Trauma Sequelae (Libro)

Andreas Maercker Editor
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.
ISBN 978-3-662-64059-3 ISBN 978-3-662-64057-9 (eBook)

https://doi.org/10.1007/978-3-662-64057-9
© 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
Preface to the Fifth Edition
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
2 Post-traumatic Stress Disorder............................................................................................. 13

Andreas Maercker and M. Augsburger
3 Complex PTSD.................................................................................................................................. 45

Andreas Maercker
4 Prolonged Grief Disorder......................................................................................................... 59

C. Killikelly and Andreas Maercker
5 Adjustment Disorder................................................................................................................... 75

R. Bachem
6 Neurobiology.................................................................................................................................... 89
C. Schmahl
7 Childhood Violence and Its Consequences................................................................... 107

A. de Haan, G. Deegener, and M. A. Landolt
8 Diagnostics and Differential Diagnostics...................................................................... 123

J. Schellong, M. Schützwohl, P. Lorenz, and S. Trautmann
9 Expert Evidence.............................................................................................................................. 153

U. Frommberger, J. Angenendt, and H. Dreßing
II Therapy
10 Early Psychological Interventions...................................................................................... 175
J. Bengel, K. Becker-Nehring, and J. Hillebrecht
11 Systematics and Effectiveness of Therapy Methods............................................... 203

A. Maercker
VIII Contents
12 Psychodynamic Treatment of People with Trauma Sequelae........................... 215

L. Wittmann and M. J. Horowitz
13 Cognitive Behavioural Therapy............................................................................................ 235

T. Ehring
14 Eye Movement Desensitization and Reprocessing (EMDR)............................... 261

O. Schubbe and A. Brink
15 Low-Threshold and Innovative Interventions............................................................. 285

Andreas Maercker
16 Treatment of Complex PTSD with STAIR/Narrative Therapy............................. 297

I. Schäfer, J. Borowski, and M. Cloitre
17 Dialectical-Behavior Therapy for Complex PTSD...................................................... 317

M. Bohus
18 Approaches of Culturally Adapted Cognitive Behavioural Therapy............ 331

D. E. Hinton
19 Psychopharmacotherapy of Trauma Sequelae........................................................... 347

M. Bauer, S. Priebe, and E. Severus
20 Therapy of Prolonged Grief Disorder............................................................................... 361

R. Rosner and H. Comtesse
21 Therapy of the Adjustment Disorder................................................................................ 375

H. Baumeister, R. Bachem, and M. Domhardt
III Specific Aspects

22 Post-traumatic Stress Disorder in Children and Adolescents........................... 393
R. Steil and R. Rosner
23 ost-traumatic Stress Disorders in Physical

P
Diseases and Medical Interventions................................................................................. 425
V. Köllner
24 Military.................................................................................................................................................. 441
K.-H. Biesold, P. Zimmermann, and K. Barre
IX
Contents
25 Torture Survivors and Traumatised Refugees............................................................ 461

M. Wenk-Ansohn, N. Stammel, and M. Böttche
26 Gerontopsychotraumatology................................................................................................ 491
M. Böttche, P. Kuwert, and C. Knaevelsrud
27 Special Features of Treatment and Self-Care for Trauma Therapists........... 507

A. Maercker
Supplementary Information
Index......................................................................................................................................................... 527
Contributors
J. Angenendt Department of Psychiatry and Psychotherapy, Psychotraumatological

Outpatient Clinic, University Medical Center Freiburg, Freiburg im Breisgau, Germany
[email protected]
M. Augsburger Division of Psychopathology and Clinical Intervention, Department of Psy-

chology, University of Zurich, Zurich, Switzerland
[email protected]
R. Bachem Psychopathology and Clinical Intervention, University of Zurich, Zurich,

Switzerland
[email protected]
K. Barre German Armed Forces Hospital Hamburg, Hamburg, Germany

[email protected]
M. Bauer Department of Psychiatry and Psychotherapy, Dresden University of Technology,

University Hospital Carl Gustav Carus Dresden, Dresden, Germany
[email protected]
H. Baumeister Department of Clinical Psychology and Psychotherapy, Institute of Psychol-

ogy and Education, Ulm University, Ulm, Germany
[email protected]
K. Becker-Nehring Education and Consulting Center, Promotional Focus on Hearing,

Stegen, Germany
[email protected]
J. Bengel Institute for Psychology, Department of Rehabilitation Psychology and

Psychotherapy, University of Freiburg, Freiburg im Breisgau, Germany
[email protected]
K. -H. Biesold German Armed Forces Hospital Hamburg, Hamburg, Germany

[email protected]
M. Bohus Heidelberg University, Heidelberg, Germany

[email protected]
J. Borowski Department of Psychiatry and Psychotherapy, University Medical Center Ham-

burg-Eppendorf, Hamburg, Germany
[email protected]
M. Böttche Center ÜBERLEBEN, Berlin, Germany

Clinical-Psychological Intervention, Freie Universität Berlin, Berlin, Germany
[email protected]
XI
Contributors
A. Brink Department of Psychotraumatology, Unfallkrankenhaus Berlin, Berlin, Germany

[email protected]
M. Cloitre VA Palo Alto Health Care System, National Center for PTSD, Menlo Park, CA,
USA
[email protected]
H. Comtesse Clinical and Biological Psychology, Catholic University Eichstätt-Ingolstadt,

Eichstätt, Germany
[email protected]
M. Domhardt Department of Clinical Psychology and Psychotherapy, Institute of Psychol-

ogy and Education, Ulm University, Ulm, Germany
[email protected]
H. Dreßing Central Institute for Mental Health, Department of Forensic Psychiatry, Clinic
for Psychiatry and Psychotherapy, Mannheim, Germany
[email protected]
T. Ehring Department of Psychology, Clinical Psychology and Psychotherapy, Ludwig-

Maximilians University of Munich, Munich, Germany
[email protected]
U. Frommberger Department of Psychiatry and Psychotherapy, University Medical Center

Freiburg, Freiburg im Breisgau, 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]
J. Hillebrecht Institute of Psychology, Department of Rehabilitation Psychology and

Psychotherapy, University of Freiburg, Freiburg im Breisgau, Germany
[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]
C. Killikelly Division of Psychopathology and Clinical Intervention, University of Zurich,

Department of Psychology, Zurich, Switzerland
[email protected]
XII Contributors
C. Knaevelsrud Clinical-Psychological Intervention, Freie Universität Berlin, Berlin,

Germany
[email protected]
V. Köllner Department of Psychosomatic Medicine, Rehabilitation Center Seehof, Federal

German Pension Agency Teltow, and Research Group Psychosomatic Rehabilitation, Charité
Universitätsmedizin Berlin, Berlin, Germany
[email protected]
P. Kuwert University Medicine Greifswald, Greifswald, Germany

[email protected]
M. A. Landolt Department of Psychology - Division of Child and Adolescent Health Psy-

chology, University of Zurich, Zurich, Switzerland
Department of Psychosomatics and Psychiatry, University Children’s Hospital Zurich, Zurich,
Switzerland
[email protected]
[email protected]
P. Lorenz Clinic and Polyclinic for Psychotherapy and Psychosomatics, Dresden University
of Technology, University Hospital Carl Gustav Carus, Dresden, Germany
[email protected]
A. Maercker Division of Psychopathology and Clinical Intervention, Department of

Psychology, University of Zurich, Zurich, Switzerland
[email protected]
S. Priebe Unit for Social and Community Psychiatry, Newham Centre for Mental Health,
Queen Mary University of London, London, UK
[email protected]
R. Rosner Clinical and Biological Psychology, Catholic University Eichstätt-Ingolstadt,

Eichstätt, Germany
[email protected]
I. Schäfer Department of Psychiatry and Psychotherapy, University Medical Center

Hamburg-Eppendorf, Hamburg, Germany
[email protected]
J. Schellong Clinic and Polyclinic for Psychotherapy and Psychosomatics, Dresden
University of Technology, University Hospital Carl Gustav Carus, Dresden, Germany
[email protected]
C. Schmahl Department of Psychosomatic Medicine and Psychotherapy, Central Institute

of Mental Health, Mannheim, Germany
[email protected]
XIII
Contributors
H. -P. Schmiedebach Campus Charité Benjamin Franklin, Institute for the History of
Medicine of the Charité – University Medicine Berlin, Berlin, Germany
[email protected]
O. Schubbe Institut für Traumatherapie Oliver Schubbe, Berlin, Germany

[email protected]
M. Schützwohl Department of Psychiatry and Psychotherapy, Dresden University of

Technology, University Hospital Carl Gustav Carus, Dresden, Germany
[email protected]
E. Severus Department of Psychiatry and Psychotherapy, Dresden University of Technology,

University Hospital Carl Gustav Carus Dresden, Dresden, Germany
[email protected]
N. Stammel Center ÜBERLEBEN, Berlin, Germany

Clinical-Psychological Intervention, Freie Universität Berlin, Berlin, Germany
[email protected]
R. Steil Institute of Psychology, Department of Clinical Psychology and Psychotherapy,

Goethe University Frankfurt, Frankfurt, Germany
[email protected]
S. Trautmann Medical School Hamburg, Am Kaiserkai 1, Hamburg, Germany

[email protected]
M. Wenk-Ansohn Center ÜBERLEBEN, Berlin, Germany

[email protected]
L. Wittmann International Psychoanalytic University, Berlin, Germany

[email protected]
P. Zimmermann Armed Forces Hospital Berlin, Berlin, Germany

[email protected]
1 I
Basics
Contents
Chapter 1 he History of Psychotraumatology – 3

T
H. -P. Schmiedebach
Chapter 2 ost-traumatic Stress Disorder – 13

P
Chapter 3 Complex PTSD – 45

Andreas Maercker
Chapter4 rolonged Grief Disorder – 59

P
Chapter 5 Adjustment Disorder – 75

R. Bachem
Chapter 6 Neurobiology – 89
C. Schmahl
Chapter 7 hildhood Violence and Its Consequences – 107

C
Chapter 8 iagnostics and Differential Diagnostics – 123

D
J. Schellong, M. Schützwohl, P. Lorenz, and S.
Trautmann
Chapter 9 Expert Evidence – 153

3 1
The History
of Psychotraumatology
H. -P. Schmiedebach
Contents
1.1 Of the Diversity of Diagnoses – 4
1.2 Nervous Disorders and War – 7
1.3 Discussion After 1945 – 9
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
Psychological reactions to shocking events 1.1 Of the Diversity of Diagnoses

1 have been known since ancient times. In the
Iliad, it is told how Achilles threw himself The London surgeon John Eric Erichsen
on the ground after the death of his friend was one of the first to causally link the
Patroclus, pulled up his hair and cried. The persistence of psychovegetative disorders
means to overcome such “nervous break- with an accident in his paper “On railway
downs” were consoling care of the affected and other injuries of the nervous system”
or common mourning performed in ritual. (Erichsen, 1866). Although he is referred to
The professional examination of trauma as the creator of the term “Railway Spine“,
sequelae, which only began in the nine- he rejected this term and spoke of a “concus-
teenth century and is linked to modern ways sion of the spine”. This spinal cord concus-
of living and working and the creation of sion was considered to be a common effect
new social and health care systems, raised of railway accidents and the consequence of
questions about the causes of the psycho- a violent impact, but it was not possible to
logical consequences and about targeted describe exactly the “molecular changes” in
therapeutic interventions. While doctors the spinal cord. Secondarily, inflammatory
and psychiatrists initially dominated these changes occur in the spinal cord which, after
debates, other professions such as lawyers a certain latency, lead to back pain, sensory
and psychologists later joined in. The dis- and movement disorders in the extremities,
cussions more or less revolved around the constipation, functional disorders in the
central question of how the relationship urogenital region, etc. The involvement of
between body and psyche developed with the brain was also given by memory, think-
regard to a physical and/or psychological ing and sleeping disorders.
trauma, which mechanisms were respon- Increased attention to these trauma
sible for the diagnosed symptoms and which sequelae at this time was determined by
individual disposition (constitution) might various cultural, scientific, social and legal
have existed. The significance of the uncon- factors (Fischer-Homberger, 1970, 1975).
scious and the will as well as the question For example, as a product of the indus-
of simulation also played a role. The names trial revolution, the railway stood for the
that changed again and again in the course overcoming of long distances at an unprec-
of these debates, such as “Railway Spine“, edented speed, as a symbol of the new
“traumatic neurosis“or “post-traumatic rhythm of modernity, which promised to
stress disorder” are indications of how make travel, exchange of goods and the
views on etiology, pathogenesis, therapy, opening up of new regions possible on an
etc. changed and how social evaluations unprecedented scale. However, the numer-
shifted. Contemporary differences in social, ous railway accidents highlighted the dan-
legal and political conditions also had a gers and the risks involved. Accordingly, a
determining influence. The development of socio-political reconciliation with the new
the last 150 years was characterized by the innovation was sought through insurance
fact that, on the one hand, the spectrum of and compensation claims. In England, the
traumatizing causes widened considerably Fatal Accidents Act had existed since 1846,
and, on the other hand, the number of pos- which made compensation claims possible
sible diagnoses decreased more and more, for the first time and which in 1864, 2 years
until finally the term “post-traumatic stress before Erichsen’s publication, also included
disorder” became established as the central the victims of railway accidents by means
diagnosis. of an additional article. In addition, around
The History of Psychotraumatology
5 1
the middle of the nineteenth century, neuro- Over the years, Oppenheim attributed an
anatomical and physiological research, with increasingly important role to psychologi-
its work on spinal reflexology, nerve elec- cal factors as the cause. He named both the
tricity (Brazier, 1988) and brain architec- fear experienced and the shock to the psyche
ture (Hagner, 2008), also provided a wealth as pathogenetic factors and explained that
of ideas for interpreting the phenomena in the physical injuries would not gain any
question with the help of these new scientific significant importance “if the pathologi-
findings. Even though Erichsen attributed a cally aged psyche in its abnormal reaction
certain role in the development of the symp- to these physical ailments did not create
toms to the fright and anxiety that can cause the permanent illness” (Oppenheim, 1892,
acute or chronic inflammation (Erichsen, p. 178). These shifts in Oppenheim’s concept
1866, pp. 47–48), and thus to a psychologi- were due to the fact that he had to deal more
cal reaction, the somatic basis was still very intensively with Jean-Martin Charcots’
much in the foreground. theories on hysteria (Micale, 1990, 2001)
Hermann Oppenheim, who had com- and had to review his own concept against
piled about 100 cases in Berlin from 1883 this background. Although Oppenheim
until his publication on traumatic neurosis understood traumatic neurosis as a sepa-
in 1889 – which mostly comprized industrial rate entity and did not want to subsume it
workers who had suffered accidents, some under hysteria as Charcot did, he concurred
of whose disorders had to be compensated that in a few cases even hysterical forms of
under the newly created accident insurance psychological alteration could be observed
scheme – also attached great importance among trauma patients (Oppenheim, 1892,
to anatomical-physiological alterations. p. 130). As a therapy, he recommended first
Possible causes included increased blood and foremost that patients should be kept
flow through the brain and “molecular” away from harmful activities and that they
changes. However, Oppenheim rejected should not be subjected to strenuous work.
myelitis as the cause of the symptoms and He attributed a high relevance to the obser-
regarded the brain as the central location of vance of rest. In some cases the treatment
the event. The attempt to establish a correla- of the head with galvanic current helped
tion between the symptoms that were detect- against headache, dizziness and insomnia, in
able during life and post-mortem changes on other patients he resorted to bromine prepa-
the basis of post-mortem examinations did rations and administered sulfonal, paralde-
not show convincing results, considering the hyde or in severe cases chloral hydrate and
relatively small number of cases. The obser- morphine (Oppenheim, 1892, pp. 189–194).
vation that certain individuals show func- As early as the 1880s, not everyone fol-
tional disorders and/or anatomical changes lowed Oppenheim’s ideas. The Leipzig neu-
after a startle event and others do not led to rologist and psychiatrist Paul Julius Möbius
the question of a special individual nature counted traumatic neurosis among hysteria
of the nervous system. Influenced by the (Möbius, 1888). Oppenheim himself con-
degeneration theory and the heredity para- tributed to the blurring of boundaries when
digm, an individual susceptibility based on he admitted that there were cases that could
a “neuropathic/psychopathic burden” was be safely described as traumatic hysteria or
assumed, that is, a disposition of the ner- traumatic neurasthenia (Oppenheim, 1892,
vous system in the form of an invisible struc- p. 9). The increasing proximity and overlap
tural and material difference, which was also between traumatic neurosis, hysteria and
considered an expression of a hereditary neurasthenia and the demarcation necessary
“inferiority”. for an assessment provoked an intensive
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
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
immediate availability of labour, neurotic already been discussed in French psychiatry

1 stations were sometimes set up near facto- before the war and to which increased atten-
ries and farms (Lerner, 2003). In this newly tion should be paid through the experiences
created system, which was based on needs of the war (Michl, 2007, pp. 253–259). In
analyses and purposeful use of resources, England, “shell-shock treatment“showed a
the doctors were integrated into a “ratio- wide spectrum in which the application of
nal” functional process in their interaction faradic currents, medication (bromine) and
with the military, ministries and companies. resting recovery were used, but depend-
With regard to the number of discharges, ing on military rank as well as the type of
the results vary from institution to institu- hospital, in which Peter Leese distinguishes
tion. About a quarter of the neurasthenia three quality levels. According to his inves-
patients were estimated to be fit for war, a tigations, the diagnosis of neurasthenia has
good 30% to be fit for garrison service, that played a more important role in English war
is, not fit for front-line service, and 16% to psychiatry than in France (Leese, 2001).
be fit for work. The figures were different War neurotic symptoms were also iden-
for the hysterical patients. Only 14% were tified in the Wehrmacht during the Second
considered fit for war, 26% for garrison use; World War, although there was also an
about 24% were classified as fit for work, but increased shift towards psychosomatic
about 22% were classified as unfit for service symptom complexes (Kloocke et al., 2005a).
(Peckl, 2014, p. 79). Since there is no medical report and the
Although there are various similarities names of the diagnoses were still very differ-
between the German and French doctors ent, hardly any valid figures are available. In
with regard to the genesis and therapy of a comparison of the different statements, a
“war neuroses”, differences are also appar- figure of 3–5% of all hospital admissions for
ent. For example, the question of pension nervous and mental disorders seems likely,
entitlements played a far less important whereby this figure also includes psychotic
role in France, although the term “sinis- disorders and thereby does not exclusively
troses de guerre” was introduced into the concern “war neurotic” cases. In an attempt
debate in 1915 when the legal situation to overcome the confusion in diagnostic
was similar (Michl, 2007, p. 214). The con- terms and to avoid terms that established a
cept of neurasthenia also received far less connection between war and psychological
attention. Basically, in France, there was a symptoms, in 1944 German doctors decided
greater interest in the psychological mecha- at the Fourth Meeting of Consultative
nisms involved in accident and war injuries, Medical Specialists to make a distinction
and the question of the connection between according to whether a somatic disorder was
mechanical and mental shocks. French doc- present or not. According to this decision,
tors attributed far greater importance to an abnormal experiential reaction, which
fear and emotions. While in Germany, an only occurred in the psychological sphere
anxious and depressive mood in individual and did not show somatisation, was distin-
patients was regarded as a predisposition guished from a psychogenic functional dis-
to various diseases, the French doctors order. In this “abnormal mental reaction”
attempted to record the fear of war in its physical phenomena such as trembling,
physical and psychological manifestations paralysis, contractures etc. occurred. With
and to determine its pathological effect regard to therapy, the methods of the First
on the entire organism. In doing so, they World War was used but supplemented by
assumed that fear could also be acquired electroconvulsive therapy, which as a new
through the effects of war. Fear built a achievement strengthened the spectrum
bridge to the emotional neuroses that had and was used in various ways. For the treat-
9 1
ment of traumatized soldiers, a graduated National Socialism and the traumatizations
system was used. In a first step, the sol- suffered in the process as well as their effects
diers were taken to relaxation rooms near on psyche and personality. The psychologi-
the front. If the symptoms did not improve cal changes triggered by fear and anxiety
after a certain time, they were taken to the are located in a complex system of refer-
next field hospital. If no satisfactory result ence. For example, in discussing traumatic
could be achieved here either, the person neurosis, a reference is made to the involve-
was transferred to a war hospital with its ment of personality layers far removed
own psychiatric department. If there was no from consciousness, in which the person is
lasting improvement here either, the patient exposed to his “complexes”. In addition,
could either be transferred to a reserve hos- the authors ask whether an approach more
pital of the Reserve Army at home or, in closely linked to the “meaning of the trau-
case of “treatment incapacity”, to a special matic experience itself ” might not lead to
department of the Reserve Army. In these a better and more realistic understanding
departments, a strict regime was applied of abnormal experience and behaviour in
in an attempt to strengthen the character and after extreme stress situations. In con-
and discipline of the person concerned in nection with the discussion of the concept
order to obtain useful soldiers for the field of psychological trauma, the extended and
army. As soon as they were admitted to the complicated connections such as, among
special unit, the sick were informed that if others, the “energetic- psychodynamic the-
they could not be reassigned to the troops, ory of the Freudian school” and finally
they were threatened with a court-martial also “existential-anthropological research”
or transfer to a concentration camp. Some are mentioned. With this, the psychologi-
of these Wehrmacht members were mur- cal trauma has come out of its “isolation”;
dered in extermination camps (Blaßneck, nevertheless, the worn-out term cannot be
2000, p. 61). completely dispensed with, since man is a
vulnerable being, in whom the lesions of
the “mental-spiritual structure” can have a
1.3 Discussion After 1945 pathogenic effect (von Baeyer et al., 1964,
p. 34). The authors deal with a broad spec-
In the German textbooks on psychiatry, the trum of possible lesions, including the
psychological trauma after 1945 has hardly burden of war, deportation and persecu-
been addressed. In the 1970s, the ICD-8 term tion, imprisonment, hunger, flight, forced
“abnormal perceptional reaction” became sterilization, social and cultural uprooting.
established for persistent psychotraumatic In 1964 at the latest, a tableau of trauma-
disorders. In the early 1990s the term “post- tisation possibilities not previously available
traumatic stress disorder” found its way into in this extent is thus named. The psychia-
textbooks (Kloocke et al., 2005b). In the trists did not, however, propose a general
early 1960s, various events took place in the diagnosis for all these disorders that could
USA at which both the consequences of the be attributed to trauma. For the diagnos-
Holocaust and the consequences of violence tic classification of the experience-reactive
in other catastrophes were discussed and consequences, chronic- reactive depression
relatively uniform symptom patterns were and paranoid malpositions were discussed.
identified regardless of the type of violence In the period that followed, the Vietnam
involved (Venzlaff et al., 2004). In 1964, War with its consequences in particular
Baeyer, Häfner and Kisker published a com- greatly supported the development of a
prehensive work that focused on the various separate psychotraumatology (Seidler, 2013,
extreme stress situations in connection with p. 10). The spectrum of triggering inju-
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).
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(pp. 85–105). Psychosozial-Verlag.
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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
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Hagner, M. (2008). Homo cerebralis. Der Wandel vom in the male: Gender, mental science, and medical
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Modernitätskritik und Krisenbewältigung in der Micale, M. S. (2001). Jean-Martin Charcot and les
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13 2
Post-traumatic Stress
Disorder
Contents
2.1 Definition of Trauma and Trauma Types – 15

2.1.1 T rauma Definition According to ICD-11 and DSM-5 – 15
2.1.2 Classification of Traumas – 16
2.2 Clinical Picture of PTSD – 18

2.2.1 S ymptom Triad of PTSD – 18
2.2.2 Additional Symptoms – 19
2.2.3 Diagnosis Assignment According to ICD-11 and DSM-5 – 21
2.2.4 Dissociation and Emotional Changes – 23
2.3 PTSD in the Context of Stress-Related Disorders – 24
2.4 Epidemiology and Course of PTSD – 25

2.4.1 E pidemiology – 25
2.4.2 Course – 25
2.5 he Development of PTSD: A Multifactorial Framework

T
Model – 26
2.5.1 isk or Protective Factors – 27
R
2.5.2 Event Factors – 28
2.5.3 Maintenance Factors – 28
2.5.4 Resources or Health Determinants – 29
2.5.5 Post-traumatic Processes and Outcomes – 29
2.6 Memory Models – 30

2.6.1 F ear Structure Model – 30
2.6.2 Dual Memory Model – 32
2.7 Cognitive Models – 34
2.7.1 ltered Cognitive Schemata – 34
A
2.7.2 Cognitive Disorder Model – 35
2.8 The Social-Interpersonal Model – 36

2.8.1 lose Relations and Society – 37
C
2.8.2 Empirical Evidence on the Social-Interpersonal Model – 38
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
2.1.2 Classification of Traumas by low predictability of further traumatic

events (Terr, 1989).
The many different traumatic events to which The status of the medically induced traumas
2 such definitions apply can be grouped or clas- has not yet been finally clarified. DSM-5 limits
sified according to various aspects. As an ori- the inclusion of medical conditions as traumatic
enting scheme, classifications into events by emphasizing that a medical situation
55 human-caused vs. random trauma, must be accompanied by a sudden catastrophic
55 short (Type I) vs. long term (Type II) event in order to be considered a traumatic event
trauma – recently extended by (e.g., waking up during surgery, anaphylactic
55 medically induced trauma (. Table 2.1;
shock; APA, 2013). Particularities of PTSD
first version in Maercker (1998)). prevalence and in the course of these traumas
are reasons for separate treatment (7 Chap. 23)

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))
Type I trauma Type II trauma Medically induced traumaa

(one-off/short-term) (multiple/long-term)
Incidental Serious traffic accidents Acute life-threatening diseases

traumas (e.g. cardiac, pulmonary
emergencies)
Job-related trauma (e.g. Technical disasters (e.g. Chronic life-threatening/severe
police, fire brigade, poison gas disasters) diseases (e.g. malignancies,
rescue services) HIV/AIDS, schizophrenia)
Short-term disasters (e.g. Long-lasting natural Medical interventions experi-
hurricane, fire) disasters (e.g. earthquakes, enced as necessary (e.g.
floods) defibrillation treatment)
Interpersonal Sexual assault (e.g. rape) Sexual and physical Complicated course of treatment
traumas violence/abuse in after assumed treatment error
(man-made) childhood and adulthood
Criminal or physical Experiencing war
violence
Civil life of violence (e.g. Hostage-taking
bank robbery)
Torture, political
imprisonment (e.g.
concentration camp
detention)
aThe status of this classification is still the subject of scientific studies
lead to the same disorder. When examining

17 2
80
Frequency in %
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,
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
2.2 Clinical Picture of PTSD
Case Study: Victim of a Criminal Attack
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.
2.2.1 Symptom Triad of PTSD Symptoms of re-experience can occur in the

form of many individual symptoms or com-
In the case example, the patient describes symp- plaints. . Table 2.2 names and describes

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.
19 2
.. Table 2.2 Individual symptoms of the symptom group re-experience
Abbreviation Explanations ICD-11- DSM-5-

diagnosis diagnosis
Intrusions/ Unwantedly recurring and stressful memories or memory x

re-experience fragments; occur spontaneously or are caused by key stimuli
Stressful Recurring dreams that contain memories or memory x x
dreams or fragments of the trauma. In nightmares, the memories can be
nightmares very distorted. Often follow the same pattern for years
Flashbacks Memory attacks, which are characterized by their suddenness x x
and liveliness. They are usually short-lived and are
accompanied by the feeling of reliving the traumatic event.
Proximity to illusions, hallucinations and dissociative states
of misunderstanding. A total loss of perception can occur
Emotional Strong emotional reaction (e.g. fear, anger) with accompany- x
stress through ing great psychological stress, if the person affected is
symbolic confronted with the traumatic event or remembers the event
triggers through key stimuli triggers (e.g. the same objects, sounds,
smells)
Physiological Involuntary bodily reactions such as sweating, trembling, x
reactions to breathing difficulties, palpitations or palpitations, nausea or
memory gastrointestinal complaints when suddenly confronted with
traumatic key stimuli and memories or fragments of
memories
2.2.1.2 Avoidance (hyperarousal). . Table 2.4 describes indi-

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

Overexcitement are predominantly assigned to the pattern of

The body reacts after a trauma, even if the disturbances of complex PTSD (7 Chap. 3).
affected persons often do not see the physical

consequences in connection with the trauma. zz Symptom Patterns in Children
The excitation threshold of the autonomic ner- For traumatized children, some abnormalities
vous system is lowered, i.e. even smaller sub- in the symptom pattern are observed, which
sequent strains lead to stronger arousal leads to the description of some specific fea-
.. Table 2.3 Individual symptoms of the symptom group avoidance
Abbreviation Explanations ICD-11 DSM-5

2
Avoidance of thoughts Conscious avoidance of thoughts and feelings that x x
and feelings remind one of the traumas (e.g. own thought-stop
attempts or self-comments: “Otherwise I will only drive
myself crazy”) Regardless of the success of the
avoidance efforts
Activity or situation Avoiding activities or situations that bring back x x
avoidance memories of the trauma (e.g. bypassing the site of the
trauma; not leaving the house at the time of day when
the trauma happened). This includes avoiding people or
conversations that are related to the traumatic event
.. Table 2.4 Individual symptoms of the symptom group perception of current threat/excitement
Abbreviation Explanations (based on DSM-5) ICD-11 DSM-5
Excessive Technical term hypervigilance: the constant feeling of not being x x

vigilance able to trust. A persistent and unrealistic feeling of danger.
Everyday situations are perceived as excessively dangerous.
This concerns both situations associated with the trauma and
unrelated situations. May (after human-induced trauma) lead to
weapons being carried for possible defence or surveillance
equipment being installed
Excessive startle After the trauma, very slight frightening, which can be x x
response triggered by slight noises and movements
Increased Slight “coming up to 180”, often outbursts of rage without a x
irritability/ clearly visible reason, for which there was no inclination before
outbursts of anger the trauma. Can often be badly judged by the person concerned
and can only be answered indirectly by asking “would your
relatives see it that way?” to explore
Self-destructive Behaviour that can be risky and thus potentially self-damaging x
behaviour (e.g. driving at excessive speed, excessive drug or alcohol
consumption, but also suicidal or self-harming behaviour). Has
been studied in the research context, especially among war
veterans
Concentration Pronounced difficulties in concentrating on simple procedures x
difficulties (e.g. reading a book, watching a film, filling in a form). It may
be clear or unclear to those affected that they have intrusive
memory flashes at such moments
Difficulty falling Post-trauma sleep disorders of both types, partly – but not x
asleep and sleeping necessarily – in connection with intrusions or stressful dreams
through or nightmares
21 2
.. 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)
55 The persons concerned are exposed to F. Duration of impairment (symptoms of

an extremely threatening or catastrophic criteria B, C, D and E) is longer than
event or series of events 1 month
2 55 Re-experiencing the traumatic event or G. The disorder causes clinically signifi-
events in the form of vivid intrusive cant stress or impairment in the social,
memories, flashbacks or nightmares occupational and other important func-
accompanied by strong and overwhelm- tional areas
ing feelings of fear or horror and strong H. Not caused by a substance (alcohol,
physical sensations or feelings of over- drugs, medication) or other medical
whelming or experiencing the same cause (illness)
intense feelings experienced during the
traumatic event 55 Additional classification
55 Avoidance of thoughts and memories of –– Dissociative subtype
the event or events, or –– Delayed start (at least 6 months
55 Avoidance of activities, situations or after the event)
persons that recall the traumatic event 55 Note
or events –– For the diagnosis of children
55 Persistent perception of an increased under 6 years of age, different
current threat, e.g. through hypervigi- descriptions of symptoms apply
lance or an increased fright response to
stimuli such as unexpected noise
55 The symptoms must persist for at least When comparing the two classification sys-
several weeks and cause significant tems, it is noticeable that the criteria for
impairment in personal, family, social, DSM-5 are more detailed and complex. The
educational, professional or other diagnostic algorithm allows for less leeway.
important areas of life In contrast, the presence of symptoms from
each of the three main groups is sufficient for
the ICD-11. Any unspecific symptoms that
overlap with other disorders are not included
Conditions for a Diagnosis of Post- in the diagnosis. This reduction to the essen-
traumatic Stress Disorder According to tial symptoms represents one aspect of the
DSM-5 (No Criteria for Children) (APA, fundamental changes to the diagnostic criteria
2015) in the ICD-11. This is intended to ensure
A. Event criterion must be fulfilled cross-cultural applicability and ease of use
B. Symptom group: Re- experience (one with the aim of maximizing clinical utility
symptom, . Table 2.2, necessary for

(Maercker et al., 2013a).
diagnosis) DSM-5 also differs in that it lists symp-
C. Symptom group: Avoidance (one toms of altered cognitions and emotional
symptom, . Table 2.3, necessary for

states (symptom group D, see 7 Sect. 2.1.2).

diagnosis) DSM-5 does not know the diagnosis of com-

D. Changes in emotional state and/or cog- plex PTSD, but the PTSD subgroup “PTSD
nitions (at least two symptoms neces- of the dissociative subtype” does.
sary) This is problematic in everyday practice if
E. Symptom group: chronic overexcita- it means that different people may receive a
tion (two symptoms, . Table 2.4, nec-

PTSD diagnosis with one diagnostic system
essary for diagnosis) but not with the other.
23 2
zz Agreement of PTSD Diagnosis According 2.2.4 Dissociation and Emotional
to ICD-11 and DSM-5
Changes
A review by Brewin et al. (2017) shows that,
depending on the classification system used, 2.2.4.1 Dissociation
the diagnostic procedure leads to significant
It is agreed that dissociative psychological
differences. In adults, PTSD rates are lower
processes play an important role in post-
when diagnosed according to the new ICD-11
traumatic symptoms. Flashbacks can be
criteria compared to ICD-10 or DSM-5. It
regarded as classical dissociation states: The
should be noted that interviews and question-
reference to reality in the here and now is lost
naires based on DSM-IV were used in these
and the affected persons feel transported back
studies. As a result, the findings may be differ-
into the traumatic event. This leads to misper-
ent if procedures specifically designed for
ceptions and misinterpretations of the sur-
ICD-11 are used. In children and adolescents,
rounding situation. The (partial) amnesia (a
on the other hand, prevalence rates according
DSM-5 criterion) is another dissociative phe-
to ICD-11 are comparable to DSM-IV and
nomenon that can improve during recovery.
DSM-5. Furthermore, only adolescents with
Within the framework of complex PTSD or the
PTSD impaired according to ICD-11 are clas-
dissociative subtype, further such symptoms
sified, who do not fulfil the criteria for diagno-
occur (7 Chap. 3).
sis according to DSM. Thus, after these initial

studies, it appears that it has been possible to 2.2.4.2 Shame and Guilt

simplify the diagnostic criteria and to counter-
A very common effect found in trauma victims
act an inflationary allocation of the diagnosis
is shame. Shame is an emotional and physical
PTSD, as criticised in ICD-10 (see Maercker
state of being exposed and the fear of being
et al., 2013a). However, other disorders that
rejected by others. Shame is encoded as both
also occur more frequently after experiencing
verbal and sensory m emories.
traumatic events should definitely be taken
Guilt refers to the feeling of being respon-
into account when making a diagnosis.
sible for what happened or not having done
Under the Magnifying Glass everything in one’s power, but also a “survivor
guilt” (e.g. self-blaming of having survived the
A consistent result of epidemiological Holocaust, “survivor guilt”, see Horowitz,
studies of traumatized persons is the high 2011 [1976])).
co-morbidity with other diagnoses. Shame and guilt have very often been
Depending on the study, it is reported that found to be maintaining factors of PTSD,
comorbid disorders are present in 50–100% regardless of the type of traumatic event and
of patients with PTSD. In most cases, with a higher probability of occurrence after
patients with PTSD have more than one experiencing multiple events (Aakvaag et al.,
other comorbid disorder (Brunello et al., 2016; Andrews et al., 2000).
2001). Inappropriate feelings of guilt on the part
of traumatised persons are subsequent attempts
by the affected persons to re-attribute (e.g. “I
am very much to blame for what happened”) in
the service of an illusion of the controllability
of the trauma cause (e.g. “If I had not acted
like this, none of this would have happened”).
However, the social feelings mentioned above
can also be induced in people who are close to
the trauma victim or have professional deal- 2.3 PTSD in the Context

ings with him or her (e.g. feelings of guilt for of Stress-Related Disorders
not being able to respond adequately to the
2 person affected). . Table 2.6 shows the neighbouring diagno-

ses of PTSD. The first two can only be diag-

2.2.4.3 Disgust
nosed in childhood and have so far only been
Shame is often accompanied by disgust. This clinically diagnosed in cases of prior complete
emotion often dominates in patients with physical and psychological neglect in infancy
PTSD as a result of sexual violence (Fairbrother and toddlers (e.g. untreated war orphans or in
& Rachman, 2004), in the form of feelings of children’s homes, see von Klitzing, 2009). The
disgust with themselves and with certain stim- other disorders of adulthood mentioned are
uli (e.g. foods whose smell, taste or texture described in the following chapters.
remind patients of the traumatic situation). In underserved regions of the world, WHO
working groups have decided to use all stress-
2.2.4.4 Anger
related disorders collectively as a diagnostic
Anger and revenge effects and thoughts have category and, where necessary, to simultane-
also often been described in traumatized per- ously target large-scale intervention pro-
sons (Olatunji et al., 2010), especially in PTSD grammes on stress, trauma and grief (Tol et al.,
after wartime operations and in many crime 2013). This is countered by the fact that the
victims (Orth & Wieland, 2006). They can respective main symptoms are psychopatho-
refer to the central actors during the trauma logically closely related:
(perpetrators) or also to persons with whom 55 PTSD and complex PTSD: symptoms of
one interacted after the trauma (e.g. “The re-experience,
emergency responders at the scene of the acci- 55 Adaptation disorder: preoccupations (men-
dent made everything worse – they were the tal arrest, 7 Chap. 5),

purest criminals”). Persistent anger can lead to 55 Persistent grief disorder: yearning and
continued hyperarousal, which also prevents longing (7 Chap. 4).

trauma processing. Findings suggest that anger

is a secondary emotion that arises as a result of
the stress of PTSD core symptoms (Orth et al., “Continuous” Instead of “Post-traumatic” Stress
Some researchers stress that the term “post-traumatic” is
2008). Glück et al. (2017) were able to show not applicable in many regions of the world. It is a con-
by means of network analysis that rumination cept that can only be applied in peaceful societies, with a
about one’s own feelings of anger plays an clear endpoint of the traumatic situation. Due to the ongo-
important role in PTSD.
PTSD and Increased Aggression

When anger develops into a willingness to take action in .. Table 2.6 Neighbouring diagnoses of PTSD
order to seek revenge, it can lead to a victim becoming in ICD-11 and DSM-5
the perpetrator himself (e.g. father of the air crash victim
who murdered an air traffic controller). A cycle of vio- ICD-11 DSM-5
lence can also be clinically proven in individual cases by
Reactive attachment Reactive attachment
expert opinion in the case of later perpetrators of violence
disorder (childhood) disorder (childhood)
traumatised in childhood and youth. This is particularly
Disinhibited social Relationship disorder
significant in fragile areas of the world where a persis-
engagement disorder with disinhibition
tent social spiral of violence can develop, which not only
(childhood) (childhood)
results in an increased risk of attacks on the family and
Complex PTSD Adjustment disorder
community but also permanently hinders the peace pro-
Adjustment disorder Acute stress disorder
cess. Corresponding findings have been made, for exam-
Persistent grief
ple, in Burundi and South Africa (Augsburger et al., 2017;
disorder
Sommer et al., 2017).
25 2
ing threat in many countries and the associated risk of 65 years of age with 3 times higher 1-year
being exposed to violent acts, the term “continuous stress” prevalence rates than among 14 to 29-year-
is more appropriate (Kaminer et al., 2013; Stevens et al.,
2013). In their paper, Maercker and Augsburger (2017)
olds (Maercker et al., 2008)
point out that the inclusion of a corresponding disturbance 55 The classification system used: higher
pattern was discussed when the ICD-11 was adopted. Due prevalence with the ICD-10 and DSM-5;
to insufficient scientific interest in this constellation, how- slightly lower prevalence with the earlier
ever, the decision was initially made against it. DSM versions and the ICD-11 (e.g. Stein
et al., 2014).
2.4 Epidemiology and Course In Germany, for example, a 1-month preva-

of PTSD lence of 1.5% for PTSD was found in a study
based on ICD-11 criteria (Maercker et al.,
2.4.1 Epidemiology 2018).
From . Table 2.7 it can be seen which are

the most frequent traumas and which traumas

The prevalence of PTSD depends among
are most likely to be associated with PTSD.
other things on the frequency of traumatic
Frequent traumas in these examinations are
events. At least for some of the traumas, it is
witnessing accidents or violence, (serious)
obvious that they vary in frequency in differ-
accidents and physical violence. However,
ent regions of the world or political areas.
these most frequent traumas are not at the
There are regions with more frequent natural
same time those which are subjectively
disasters (e.g. also some parts of the USA)
assessed as the worst trauma and after which
and countries where wars and political perse-
PTSD most frequently develops.
cution are common. Therefore, epidemiologi-
cal data on PTSD must take into account the
regional origin of the prevalence rates. A dis- List of the four most pathogenic trau-
tinction must also be made between whether mas in the study cited above
data reflect a period prevalence, e.g. 1-year 55 Captivity
prevalence, or lifetime prevalence – the latter 55 Rape (narrow definition without sexual
includes cured cases and is usually higher harassment)
than 1-year prevalence. 55 Maltreatment and sexual abuse in child-
To date, prevalence data from the USA are hood
frequently cited (National Comorbidity 55 Physical violence
Survey; Kessler et al., 2005), where a lifetime
prevalence of 6.8% was found. This is much
higher than in Europe, where an average life- >>It must be noted that epidemiological data
time prevalence of 1.9% was found (Alonso only ever provide probability data. Even in
et al., 2004). Additional factors that influence the case of a “less” pathogenic trauma, the
prevalence data full symptom picture of PTSD can emerge.
55 Gender: higher for women than for men,
e.g. in Germany 2.2% for women and 1.0%
for men (e.g. Perkonigg et al., 2000) 2.4.2 Course
55 Age groups: usually higher prevalence
rates among younger people compared to Following the experience of trauma, PTSD can
older people (Kessler et al., 1995), but in occur at any age, including childhood and old
countries with a wartime past an increase age (Maercker, 2015). If a PTSD symptom
for the “war generation”, e.g. in Germany develops, it can decrease spontaneously over
in a study from 2008 among people over the next weeks and months. A spontaneous
.. Table 2.7 Frequencies of different traumas and 1-month prevalence of PTSD after ICD-11 in a
representative German sample
2 Type Frequency of trauma (%) Frequency of disturbances

after trauma (%)
Child abuse (<14 years of age) 2.5 11.1

Rape 2.5 16.7
War experiences 3.7 6.3
Captivity/abduction 0.6 20.0
Physical violence 6.9 11.1
Serious accidents 7.7 7.4
Witness to a traumatic event 11.5 3.4
Natural disasters 3.5 7.1
Life-threatening disease 4.7 8.0
Other traumas 4.6 11.1
Multiple traumas 5.9 /
Adapted according to Maercker et al. (2018)

aMultiple entries possible
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).

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
• avoiding coping style

Results Disorders:
Risk and protection Event-related
factors factors • cognitive changes • PTSD
• Anxiety disorders
• Previous traumas Trauma severity • Depressive disorders
• Trauma duration • Dissociative disorders
• Age at time Posttraumatic processes
of trauma • Extent of damage among others
Changes in memory Psychosocial
• Lower intelligence,
consequences
education
Initial reaction Neurobiology changes • Marriage & Partnership
• Female gender • Interpretation • Education and
(risk) • Dissociation profession
but
• Personality factors
Health-promoting factors personal
growth possible
• Disclosure
• Social acknowledgment as
• victim/survivor
.. Fig. 2.2 Framework model of the etiology of trauma consequences

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.
>>If the trauma victim is in a position to see

for himself an opportunity to influence –
29 2
work) or the medical, physical and material/ pre-, peri- and other post-traumatic factors.
financial damage that has occurred. The interpersonal embedding (vs. isolation) of
the traumatised person, their possibilities to
2.5.3.2 Cognitive-Emotional communicate about what they have experi-
Changes enced (so-called “disclosure”) as well as the
Changed attitudes of trauma survivors towards recognition as trauma victims experienced by
the world and themselves are the subject of the environment are therefore very central
various psychological theories and models of (7 Sect. 2.7).

PTSD. Guilt plays a particular role here.
2.5.5 Post-traumatic Processes

2.5.4 esources or Health
R and Outcomes
Determinants
For the immediate and later trauma conse-
Resources or health-promoting factors are quences, memory changes and neurobiological
defined as those that lead to recovery after a changes are of central importance (7 Chap.
temporarily acute phase. All in all, the factors 6).

mentioned above enable those affected to bet-
ter integrate traumatic experiences into one’s 2.5.5.1 Psychosocial Consequences
own past. Secondarily, there are often considerable psy-
chosocial consequences, such as unfinished
2.5.4.1 Sense of Coherence training, job difficulties, career breaks, fre-
The psychological construct of the sense of quent separations or divorces, educational
coherence was developed in the context of problems and cross-cultural conflicts with
psychotraumatology by Antonovsky (1987). It superiors or authorities. They require means of
was intended to capture the ability to mentally psychosocial reintegration or practical social
grasp and understand what happened and to work (Soyer, 2006).
give it meaning. Persons with a well-devel-
oped sense of coherence should have good 2.5.5.2 Post-traumatic Growth
abilities to predict even terrible events on the An important phenomenon for many trauma-
basis of their understanding of the world. This tised people is that, in retrospect, they believe
construct can be assessed by a revised version that this experience set in motion a personal
of the sense of coherence questionnaire, which growth process. Viktor Frankl, a psychologist
has better psychometric characteristics than who survived a concentration camp himself,
the original questionnaire, which is flawed in already pointed this out early on (Frankl,
its methodology (Bachem & Maercker, 2018; 1973). Many traumatised people report – often
Mc Gee et al., 2018). only when asked about it – that they no want to
miss the experiences and insights they had for
2.5.4.2 Interpersonal their future life. Post-traumatic growth has
Socio-cognitive Factors been intensively investigated over the last
In the meta-analysis by Brewin et al. (2000), it decade (Calhoun & Tedeschi, 2006; Tedeschi
was found that social support – an umbrella & Calhoun, 2004; Zöllner & Maercker, 2006).
term covering various relevant processes – is
the comparatively most important predictor for The Janus Face Model of Post-traumatic Growth
As psychological processes that play a role in the devel-
the severity of PTSD, far outperforming other opment of post-traumatic growth, constructs of finding
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-
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).

shown in . Fig. 2.3, where the left side shows

The spontaneous partial activations of the
a fully developed pathological fear structure fear structure that take place in most trauma-
and the right side a deactivated fear structure tized persons – e.g. through sudden memories
(e.g. as a result of successful psychotherapy). or intrusions – do not achieve remission or
Self Self
Do one’s shopping Do one’s shopping
Evening Street Evening Street
Dark Man Dark Man
Assault Assault
Sweating Cardiac arrest Sweating Cardiac arrest
Surprise Surprise
Disgust / Disgust /
Fear Fear
Revulsion Revulsion
Danger Danger
of death of death
Cognitive (stimulus) elements Physiological reactions Emotional meanings
.. 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))
deactivation. Instead, this spontaneous activa- details on neurobiological findings can be

tion of parts of the fear structure can lead to an found in 7 Chap. 6.

increasingly distinct avoidance in the wake of The model is shown in schematic form in
2 the rise in fear. . Fig. 2.4.

There are several experimental findings

that support the validity of the assumptions of
The Two Processing Systems of Memory
the fear structure model. For example, it was
Contents According to Brewin et al.
found that patients with PTSD developed a
(2010)
selective attentional increase for trauma-
55 Representations in contextual memory
related stimuli (e.g. sounds, photographs,
(C-reps)
words) compared to persons after trauma with-
–– Verbally accessible
out PTSD and healthy controls (Litz & Keane,
memory(VAM)
1989). McNally et al. (1990) examined
–– Memories can be retrieved and
Vietnam veterans using Stroop tasks (colour
changed deliberately; they are
naming tasks). The colour of the writing in
accessible via language
which the trauma-specific terms were written
–– Memories are integrated into
was detected more slowly by patients with
other autobiographical memory
PTSD than in the control groups. It was con-
contents (past, present and future
cluded that a larger fear structure was probably
aspects): spatial and temporal
activated, which delayed switching to the
aspects are stored
actual task, naming the font color. Comparable
55 Representations in sensation-based
effects were found in women with PTSD after
memory (S-reps)
rape (Cassiday et al., 1992; Foa et al., 1991) as
–– Situationally accessible memory
well as in a recent study with war veterans in
(SAM)
the recognition of terms related to combat in
–– Storage of low-level information:
relation to other trauma-related terms without
sensory (e.g. sounds, visual
military reference (Khanna et al., 2017).
images), perceptual (e.g. changes
It has been shown in various ways that fear
in heartbeat, body temperature
or anxiety are not the only ways of activating
and pain) and affective (e.g. fear,
the trauma-related memory structure. Two
disgust)
extensions of the fear structure model were
–– No deliberate retrieval or
therefore discussed: the inclusion of anger and
description by words possible
of disgust (Chemtob et al., 1997).
–– Activation only involuntary
through trigger stimuli from the
environment without contextual
2.6.2 Dual Memory Model reference (e.g. a physically unjus-
tifiable abdominal pain)
Brewin postulated a dual representation model
of PTSD (Brewin, 2003; Brewin et al., 1996).
The starting point of this model is the assump-
Both representations of memories also occur
tion that memory has two different encoding
in healthy individuals. In encoding normal
paths and that traumatic memories are stored
memory content, an initial sensation- based
qualitatively differently than normal non-trau-
perception and temporary storage (S-reps)
matic memories. More recently, the model was
leads to a long-term encoding of memory con-
revised to adapt it to current neuroscientific
tent at higher levels (C-reps). Over time, the
findings (Brewin et al., 2010). Corresponding
S-reps then fade away and are hardly accessi-
ble.
33 2
Thoughts on th trauma, brooding

Verbally Primary and secondary emotions
accessible
system
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))
Brewin (2014) in his review illustrates empiri-

As . Fig. 2.4 illustrates, S-reps are more

cal support for the long-term but selective stor-
strongly developed than C-reps when experi- age of sensory inputs (S-reps). Furthermore,
encing a traumatic event due to the high level he shows that PTSD patients are characterized
of arousal. At the same time, connections by an improved perceptual memory but limita-
between the two systems are severely impaired. tions in episodic memory, which speaks for the
This hinders integration at the level of C-reps. functional independence of the two systems.
Flashbacks are caused by the formation of Jobson et al. (2014) could show that across dif-
S-reps without corresponding C-reps – inte- ferent cultures (study participants from
gration into autobiographical memory with Australia, Great Britain and Iran) there were
corresponding context information does not consistently deficits in autobiographical mem-
take place. The automatic and uncontrollable ory recall in persons with PTSD in contrast to
activation of the S-reps leads to the typical healthy persons.
emotionally charged detailed sensations
(Brewin, 2014; Jobson et al., 2014).
The initial premises of the model are con-
firmed by the clear phenomenological distinc-
tion between arbitrarily recallable trauma
memories and involuntary flashbacks
(Hellawell & Brewin, 2004). The different
amounts of information and processing depths
in the VAM/C-reps and the SAM/S-reps can
also be confirmed by general memory psycho-
logical findings (Brewin, 2003). For example,
2.7 Cognitive Models ►►Example 1: Changed the World Scheme

A person who has had a high degree of trust in
other people up to now (trusting world scheme),
Cognitive Schemata
2 Cognitive schemata are defined as infor-
trains a complete loss of trust in other people
through a criminal attack (new world schemes:
mation patterns represented in memory “The world is abysmally bad”, “People are
that control and organize perception and abysmally bad”). ◄
behavior. Clinically relevant schemata are
the self-scheme, which in turn can be bro-
►►Example 2: Changed Self-Image
ken down into different compartments
(multiple self-schemes, self- images or A previously self-confident person suddenly
roles), as well as the schemata of impor- experiences himself as weak and shaken by the
tant reference persons and global world trauma. His self-image after the trauma remains
schemata (or world views). for a long time: “I am weak and vulnerable.”
This self-image is in conflict with the still
remembered earlier self-image: “I am compe-
tent and stable”. ◄
2.7.1 Altered Cognitive Schemata 2.7.1.1 Cognitive-Psychodynamic

Concept
Various authors focus their etiological con- The explanatory approach of Horowitz (2011
cepts on the change from schemata to trauma [1976]) focuses on the changes in self or role
(Horowitz, 2011 [1976]; Janoff-Bulman, 1995, schemata. According to this approach, the
2015). Theories of altered cognitive schemata trauma primarily leads to a change in the self-
are based on the following PTSD symptoms in image or the structure of the roles of the person
particular. The typical shattered attitudes of affected. Horowitz assumes that the traumati-
non-traumatised persons postulated by Janoff- cally changed schemata remain activated in
Bulman (1995) have become classic. the memory until they have achieved a capac-
ity to fit in with the earlier and other schemata
through further information intake and pro-
Typical Attitudes of Non-traumatised cessing, i.e. until the new schemata can be
Persons integrated. For example 2, this means that the
55 Assumption of the own inviolability traumatically altered schemata remain acti-
55 Assumption of the world as meaningful, vated until the person affected can accept that
understandable and controllable he or she is temporarily a weak and vulnerable
55 Assumption of the self as positive and person. Details can be found in 7 Chap. 13.

valuable In the activation phase of the schematic

representations and before they have been
integrated, there are intrusions and a strong
These attitudes are changed by a traumatic emotional strain. In order to reduce this bur-
event: Traumatized persons den, Horowitz outlines, cognitive control or
55 consider themselves injured and vulnerable defence processes take effect, for example in
in the future, the form of avoidance, denial or emotional
55 see the world as hostile, incomprehensible numbness. Whenever cognitive control is not
and unjust, fully achieved, the trauma is intrusively re-
55 consider themselves damaged and experienced, which in turn leads to strong
worthless. emotional stress and thus to renewed avoid-
ance or denial.
35 2
>>According to Horowitz, restoration of explanation of persistent anxiety symptoms
health is achieved by working intensively and strong emotions such as anger, shame or
through the traumatically altered cognitive grief. They assume that chronic PTSD only
schemata. develops when the affected person processes
the traumatic event and/or its consequences in
This working through can happen indepen- such a way that he or she perceives a severe
dently and spontaneously in a patient in the current threat and damage, based on a negative
recovery process if it is not or hardly inhibited interpretation of the trauma, the specifics of
by control processes. If these control or the traumatic memory and a persistently per-
defence processes are more pronounced, only ceived threat (for details see 7 Chap. 13).

psychotherapy can bring about the normalisa-

tion or recovery process. The psychotherapeu- zz Negative Interpretation of the Trauma
tically guided working through has therefore The negative interpretation of the trauma and
two starting points: its consequences can lead to a persistent per-
55 Altered cognitive schemata (attitudes, ception of the threat and damage: This includes
beliefs), not only interpretations of the occurrence of
55 Control processes (avoidance and defence the trauma (e.g. “I am not safe anywhere”), but
tendencies). also one’s own experience and behaviour dur-
ing the trauma (e.g. “I deserve bad things to
2.7.1.2 Empirical Evidence happen to me”). Furthermore, the initial symp-
on Horowitz’s Explanatory toms are interpreted negatively (e.g. “I am
Approach dead inside”) as well as the reactions of others
after the trauma (e.g. “Nobody is there for
Of the components of Horowitz’s theory
me”).
(changes in self-regulation, control processes),
changes in cognitive schemata, in particular,
zz Specifics of Trauma Memory
have so far been empirically proven. Various
The specifics of the trauma memory and its
studies have found indicators of typical post-
embedding in other autobiographical memory
traumatic changes in self- and world cognition
structures also lead to a persistent feeling of
(Krupnick & Horowitz, 1981; Resick &
threat.
Schnicke, 1992; Roth & Lebowitz, 1988). In a
Trauma memory is characterized by the
study of traffic and crime victims, the follow-
following features:
ing self-relevant topics were found most fre-
55 The intrusive re-experience usually takes
quently through content categorizations of
place in the form of sensory impressions
patient statements (Krupnick & Horowitz,
that have a here-and-now quality and do
1981):
not convey a sense of the past as is usually
55 Frustration over one’s own vulnerability,
the case with autobiographical memories.
55 Self-reproaches,
55 There are emotions without memories, in
55 Fear of future loss of control over one’s
that people with PTSD experience physical
feelings.
reactions or emotions from the trauma
without having conscious memory of the
trauma (e.g. disgust reactions in sexually
traumatised people).
2.7.2 Cognitive Disorder Model
55 In PTSD, the autobiographical memory is
insufficiently elaborated for the traumatic
Based on clinical observations and building on
memories. Autobiographical memories are
previous models, Ehlers and Clark (2000) have
usually stored in the memory in an ordered
developed an approach to the development and
and abstracted manner and are arranged,
maintenance of chronic PTSD, focusing on the
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
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
.. Fig. 2.5 Social-interpersonal model of PTSD (Maercker & Horn, 2013)
influence the development and course of described in 7 Sect. 2.2.4 Shame, guilt, anger

PTSD. The model is summarized in . Fig. 2.5. and feelings of revenge.

Overall, the model does not claim to
replace the psychological or neurobiological
models in the narrower sense, but rather to 2.8.1 Close Relations and Society
complement them. However, it postulates that
the described interpersonal-social cognitive 2.8.1.1 Importance of Close
processes have a very high predictive power Relations
for the development of or recovery from A subjectively perceived social recognition as
PTSD. Its three blocks are schematically a trauma victim (Maercker & Müller, 2004) is
divided into two to state that not only the a protective factor in trauma processing.
affected persons change, but that they can also However, the reactions of the environment can
change their environment (e.g. shame devel- vary qualitatively and quantitatively: from the
ops in them, and at the same time, in unfavour- greatest possible support (e.g. helpful presence
able cases, they can induce shame in others). of friends) to social isolation. If traumatised
The model begins in the innermost block persons feel permanently excluded from others
with the so-called social effects, that is, feel- (“Since this thing happened I feel excluded
ings that manifest themselves in interaction from everything”; “Nobody wants to hear my
with other people, such as the emotions story anyway”) this increases their coping
problems. These processes take place bidirec-
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 mason 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-
39 2
functional disclosure in both partners dramati- surrounding society, there are still no meaning-
cally increased the extent of PTSD. ful studies.
2.8.2.2 ocial Inclusion and Cultural

S >>Of particular practical importance for
Value Orientations those affected is the possibility of disclo-
The consequences of social exclusion and sure and the social recognition they experi-
compassion fatigue have been demonstrated in ence. A lack of appreciation can contribute
experimental studies in patients with PTSD to the continued trauma consequences, as
(Nietlisbach & Maercker, 2009; Nietlisbach studies and clinical experience with vari-
et al., 2010). ous traumatised groups have shown.
A questionnaire (Maercker & Müller,
2004) is available on social recognition as vic-
tims or survivors in order to record this spe- Literature
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45 3
Complex PTSD
Andreas Maercker
Contents
3.1 Definitions, Clinical Picture and Symptoms – 46

3.1.1 T rauma Criterion – 46
3.1.2 Clinical Picture – 46
3.1.3 Diagnostic Criteria of Complex PTSD – 47
3.2 Historical Development of Diagnosis – 49
3.3 Evidence of CPTSD Diagnosis – 50
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
3.5 Differential Diagnostics – 52

3.5.1 orderline Personality Disorder – 52
B
3.5.2 Dissociative Disorders – 52
3.6 Clinical Diagnostics – 53

3.6.1 I nternational Trauma Interview (ITI) (Roberts et al., 2016) – 53
3.6.2 International Trauma Questionnaire (ITQ)
(Cloitre et al., 2018) – 54
3.7 Explanatory Models – 54

3.7.1 isk and Protection Factors – 54
R
3.7.2 Premises of a CPTSD Disorder Model – 55
Literature – 56
46 A. Maercker
3.1 efinitions, Clinical Picture

D 3.1.2 Clinical Picture
and Symptoms
Some characteristic symptoms of CPTSD
Some people who experience traumatic versus PTSD are described in the following
experiences develop a clinical presentation statements from two patients who experi-
enced trauma either in childhood or in
3 that goes beyond PTSD (7 Chap. 2).
young adulthood.
3.1.1 Trauma Criterion ►►Example 1: Experience of Sexualised

Violence in Childhood
Typically, complex post-traumatic stress dis- Report of a 23-year-old female patient who
order (CPTSD) is caused by prolonged trau- was subjected to repeated sexualised violence
matic experiences consisting of multiple or at the age of 9–14 years:
recurring traumatic events (7 Chap. 2, . 55 “For a long time, I could not talk about what
Table 2.1). The ICD-11 additionally states I experienced then. Somehow I couldn’t get
that these are usually events from which it together ... To this day I’m very angry with
escape is difficult or even impossible (e.g. my mother than with M. [her stepfather];
torture, slavery, genocide campaigns, contin- [mother] should have gotten me out of it. I
ued domestic violence, repeated sexual or still can’t feel anything when I sleep with
physical abuse in childhood). someone. The whole thing is completely
The definition in the ICD-11 deliberately screwed up for me. “
makes only prototypical statements, so 55 “I know others might call me a ‘hooker’
55 also, unique traumatic experiences can because I’m tripping into that now so often.
cause a CPTSD; I don’t know ... In the days that followed -
55 definitional problems, which are to be now I’m completely lost, I’ve already been
understood as “longer lasting”, are found somewhere in the city and brought
avoided (e.g. in the case of a one-hour home, and I don’t know anything. “Com-
hostage-taking, war actions lasting sev- pletely torn without alcohol or drugs...”
eral days), since an exact definition of 55 “I feel so dirty - direct, which is why I have
what is to be assessed as long or short in to shower so often. But somehow I am
terms of its psychological effect is not also completely dirty and depraved as a
possible due to the subjectivity of the person. I drag the others down with me in
experience of time and the different con- the mud. Yes, I also destroyed M, who was
texts of life; actually a good person, he cried a lot
55 even after prolonged or repeated trau- because of me.
matic experiences in the pathological 55 “My feelings are bullshit. I can’t do any-
case, the “classic” PTSD and not CPTSD thing with them. I’m always wrong about it.
can develop; The [people who are] good to me, I get
55 the traumas experienced can in principle incredibly aggressive and hurtful towards
occur in all phases of life, even if the them, so I only feel good when they feel bad.
majority of traumatic experiences expe- And vice versa...”
rienced in childhood or adolescence are 55 “Nobody knows what it’s like not to feel
triggers for a CPTSD; yourself. I look at my arm - it’s not mine.
55 in particular, interpersonal trauma (also: “I don’t have a body, but I don’t feel a
man-made or intentionally caused) can body...”
be a trigger for CPTSD, in contrast to 55 “I’ve been told that I’m gifted and that I
accidental trauma (. Table 2.1). could become something - and I’m trying to
Complex PTSD
47 3
do that, but I don’t think I have the inner you. But that was not there, there was such
strength to do it after all. Somehow I don’t a wall of silence, the complicity of silence.
have a nything to build on...” You continued to shut yourself in...”
(Collected by A. Maercker) ◄ (Collected by A. Maercker) ◄
►►Example 2: Political Imprisonment

A 45-year-old patient, who was imprisoned 3.1.3 iagnostic Criteria of
D
at the age of 21 for political reasons in the Complex PTSD
former (East-)German Democratic Republic
and spent two and a half years in prison, In the following, the presentation is mainly
reports: based on the ICD-11, since DSM-5 lists the
55 “I’m not like this anymore, I’ve changed. I “dissociative subtype of PTSD“as a coun-
try not to let many things get to me any- terpart to the CPTSD, which is also
more. Many things just don’t interest me described here.
anymore. But if something gets close, I
overreact, sometimes aggressively and
PTSD Core Symptoms and Disorders of
more intolerantly. If something gets me, I
Self-Organisation
have to fight for it, have my pride and my
The fault is characterized by
honour. And that causes me problems...”
55 the core PTSD symptoms of re-
55 “I have problems with anything that resem-
experiencing, avoidance and feeling
bles any kind of coercive mechanism.
of threat, and
Either you freeze in front of it and don’t
55 further symptoms, summarized as
dare to move, or you rise against it and
disturbances of self-organization:
don’t take it seriously at all. The intermedi-
–– emotional regulation problems
ate form, what would be appropriate, that’s
including dissociation tendency
what I lack. And that, of course, affects the
in stressed states
workplace. I am more unemployed than I
–– self-deprecating attitude
have a job because I cannot internalize the
–– difficulties in maintaining rela-
hierarchies. and I can’t find the right
tionships
response...”
55 “And then when I see that the [former per-
petrators] are doing well again, which
causes me such a massive tummy ache, then
ICD-11 Diagnostic Guidelines on the
I’m not responsive for two or three days,
Symptoms of CPTSD
because I have the impression that they
55 Presence of the core symptoms of
suddenly have the victory again ...”
PTSD (reliving the trauma in the
55 “I went there and talked to the rooms over
present, avoiding memories of the
... You need that for your own mental
trauma, persistent feeling of threat)
health. “You have to torture people a bit...”
55 After the onset of the stress experi-
55 “As long as I live, I will hate anything to do
ence and accompanying the PTSD
with them. I’m a fighter and that hasn’t
symptoms, development of persistent
made me many friends...”
and profound impairments in the reg-
55 “I have come to my wife at times in incom-
ulation of emotions, persistent beliefs
prehension very angry, very, very angry...”
about one’s self as inferior, inferior or
55 “You had the victim mentality, you simply
worthless, and persistent difficulties in
expected the environment to understand
48 A. Maercker
organisation must be present and the three

maintaining relationships, which are core symptoms of PTSD only to a sub-
described in more detail below syndromal extent (Maercker et al., 2018).
55 The problems of affective dysregula- In a survey study of clinic patients with
tion are characterized by increased complex PTSD on their own perception of
emotional reactivity, difficulties in the symptoms, it was shown that the patients
3 recovering from minor stress, violent initially perceived the symptoms as ego-
emotional expressions, self- syntonic, that is, they were convinced that,
endangering or self-harming behav- for example, their violent emotional reac-
ior, and a tendency to dissociative tions or dissociative states were an uninflu-
states in stressful situations. Besides, enceable character trait and thus part of
emotional numbness can occur, espe- their personality (Stadtmann et al., 2018). If
cially the lack of the ability to experi- they were able - under the guidance of thera-
ence joy or positive feelings. This pists - to recognise the connection between
includes an increased tendency to dis- the earlier traumatisation and the subse-
sociate (see below). quent symptoms, which they had accepted
55 The pronounced convictions of one- to exist for years or decades, they were often
self as inferior, inferior and worthless able to perceive these as symptoms of illness.
stand for a persistently impaired sense This made them feel less dominated by unin-
of identity. In addition, there are pro- fluenceable “forces” or automatisms.
nounced convictions of having done
something wrong in life and leading a zz Dissociative Subtype of PTSD (DSM-5)
damaged and worthless life, as well as In the “dissociative subtype”, PTSD must
permanent feelings of guilt and be present according to the DSM-5 defini-
shame. tion (7 Chap. 2), including the symptom
55 The relationship difficulties show group of cognitive changes and mood
themselves as an inability to interact changes defined only there, and in addition,
on equal terms as partners. There is a the following symptoms must be present as a
susceptibility to exaggerated views reaction to the trauma or trigger stimuli that
and expectations of a relationship recall the traumatic event:
and an inability to trust intimate rela- 55 Depersonalisation: Feelings of unreality
tionships. or detachment from one’s own body (e.g.
55 The general criterion for functional the feeling of observing the body from
impairments in personal, family, the outside) and/or
social, educational, work and other 55 Derealisation: Perception of one’s envi-
important areas is given. ronment as unreal (e.g. far away or dis-
torted).
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
CPTSD Dissociative PTSD subtype

ICD-11 DSM-5
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
due to an assessment by experts that was 3.3 Evidence of CPTSD Diagnosis

considered to be inadequate.
The diagnosis “Persistent Personality Although the precursor diagnoses of ICD-11
Change” after extreme stress from the ICD- CPTBS have been used clinically many times,
10 (code: F62.0) has been used in various their psychometric quality characteristics
expert opinions but has hardly been used in (e.g. internal consistency, reliability) remained
3 the international research literature. The weak. In a study in which the concept of
international ICD-11 working group Herman (1994) was tested in a group of for-
decided on the scientifically based introduc- mer political prisoners, for example, only a
tion of the complex post-traumatic stress low internal consistency of α = 0.55 was
disorder (Maercker et al., 2013) based on found, especially since only values above 0.80
preliminary work by Cloitre (e.g. Cloitre et are satisfactory (Maercker, 1998).
al., 2011) and the internationally expressed For the CPTSD definition of the ICD-
need for clinicians from all parts of the 11, it was found - in addition to improved
world. consistency values - that patients with “clas-
sic PTSD” as well as patients with CPTSD
>>Important can also be distinguished well from patients
It seems important that the previous with a borderline personality disorder by
PTSD (7 Chap. 2) should not be called differential diagnosis. This was shown by a
“simple PTSD” but “classic PTSD” in the latent class analysis of 280 female patients,
language of everyday clinical practice in all of whom had a history of child sexual
contrast to complex PTSD. abuse (Cloitre et al., 2014; . Fig. 3.1).
Low Symptoms PTSD CPTSD BPD

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
PTSD Dreams
PTSD Hyperarousal
Aff Dys Anger
BPD Identity
PTSD Avd Behaviour
PTSD Avd Thoughts
PTSD Startle reaction
Aff Dys Sensitive
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
3.5 Differential Diagnostics As a diagnostic guideline, it has proved

pragmatic that in cases where this distinc-
The consequences of severe and repeated tion is difficult or impossible to make, in
traumatic experiences are manifold and can particular, the therapeutic procedure deter-
manifest themselves in a wide range of dis- mines the order in which the diagnosis is
orders, including in particular affective, anx- made. If the focus is on the psychotherapy
iety, eating and substance dependence of borderline symptoms, this will be
disorders. Particularly relevant for the dif- expressed in a corresponding diagnosis; if a
ferential diagnosis of CPTSD are phase-oriented, trauma-focused procedure
55 borderline personality disorder (Border- is initiated (7 Chaps. 16 and 17), the CPTSD
line PS), diagnosis is again in the foreground.
55 dissociative disorders, especially partial
dissociative identity disorder.
3.5.2 Dissociative Disorders
3.5.1 Borderline Personality Dissociative symptomatology can be part
Disorder of the CPTSD symptomatology as
described, for example, in the form of dere-
In the case of borderline PD (according to alisation, depersonalisation, dissociative
ICD-11: Personality disorder with border- stupor or trance. Also, it is possible to alter-
line pattern), traumatic experiences can be natively consider completely own distur-
proven in the vast majority of patients in bance patterns by differential diagnosis
their medical history (approx. 80%; Sack et (ICD-11 formulations, the dissociative iden-
Complex PTSD
53 3
tity disorder and the partial dissociative antidissociative techniques are used first
identity disorder. The very rare dissociative (Boon et al., 2013; Priebe et al., 2014).
identity disorder can be more clearly distin-
guished from CPTSD, at least in its course.
In this case, the focus is on the changes in 3.6 Clinical Diagnostics
self-representation that are not reflective for
the patients themselves (see Nijenhuis, 7 Chapter 8 describes the available
2017). research tools on CPTSD, referring to ear-
lier, broader definitions such as the DES-
zz Partial Dissociative Identity Disorder NOS concept.
(PDI: New in ICD-11) In addition, the new ICD-11 specific
It is characterized by “an identity disorder clinical interview (ITI) and questionnaire
in which two or more different personality (ITQ) on PTSD and CPTSD, which are still
states (dissociative identities) are accompa- in the final stages of their psychometric
nied by pronounced discontinuities in the development, are presented here.
sense of self- and action capacity. Each per-
sonality state comprises its pattern of expe-
riencing, perceiving, feeling and relating to 3.6.1 International Trauma
oneself, the body and the environment. A Interview (ITI) (Roberts
personality state is dominant and normally et al., 2016)
functions in daily life, but is influenced by
one or more non-dominant personality The diagnostic interview was designed
states (dissociative intrusions). These intru- according to the CAPS (Clinician-
sions can be cognitive, affective, perceptual, Administered PTSD Scale; 7 Sect. 8.2.2.1).
motor or behavioral. The interview first collects information
The non-dominant personality states sel- about the traumatic event, followed by the
dom assume executive control over the con- recording of PTSD features, the re-
sciousness and functioning of the individual, experience-in-the-present symptoms (night-
but there may be occasional, limited, and mares, flashbacks: with several
transient episodes during which a pro- sub-questions, severely stressful intrusions),
nounced personality state assumes executive the avoidance symptoms (thought/feeling as
control. These personality states manifest well as behavioral avoidance), the two symp-
themselves in (transfered) behavioural and toms of persistent threat (alertness, fright-
emotional states experienced during the fulness) and the questions on the
trauma, for example, in re-enactments of symptom-related restriction of psychosocial
the traumatic memory, and episodes of self- functioning.
injury (WHO, 2018). The symptom areas of the disturbed self-
The diagnosis will again be based on the organisation are then recorded:
respective core symptoms, whereby in the 55 Emotional regulation in the two variants
case of trauma-related PDI, the focus will of
be on the alternation of adult and child self- –– Overactivation (e.g. violent expres-
presentation. The child’s conditions should sions of emotion, difficulty in recover-
be biographically related to the traumatisa- ing from minor stress),
tion (e.g. re-enact a phase during the trau- –– Deactivation (e.g. emotional numb-
matisation). In addition, the diagnosis can ing, derealisation, depersonalisation),
also be assigned if helpful in the sequence of 55 Negative self-concept (e.g. feelings of
the therapeutic procedure, for example, if worthlessness, shame),
54 A. Maercker
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 function. It has been translated into several lan-
tioning. guages (Karatzias et al., 2017).
3 The ITI ends with 9 questions on the leading

symptoms of borderline personality disor- 3.7 Explanatory Models
der, which are important for differential
diagnosis. 3.7.1 Risk and Protection Factors
There exist only valdiation data from
Sweden for the psychometric parameters of The body of knowledge on the risk and pro-
the interview (Bondjers et al., 2019). tection factors of CPTSD is constantly
expanding, although the diagnosis has only
recently been defined. The following presen-
3.6.2 International Trauma tation arranges the findings into biopsycho-
Questionnaire (ITQ) (Cloitre social factor groups.
et al., 2018)
3.7.1.1 Biological Factors
Until 2018 this questionnaire was used in Some of the extensive knowledge of disor-
longer preliminary versions for research ders for “classical PTSD” can also be trans-
purposes. The official version contains 18 ferred to CPTSD, especially when it comes
questions in addition to the traumatic event to long-term or multiple trauma. It affects
(type, period): half on PTSD core symp- brain changes, the hypothalamic-pituitary-
toms and a half on CPTSD. . Table 3.2 adrenal cortex axis, dissociation and dis-
names its items. turbed emotional regulation (7 Chap. 6).
.. Table 3.2 Arrangement of the 18 items in the International Trauma Questionnaire
PTSD criteria Re-experience Avoidance Ongoing threat
1. disturbing 2. flashbacks 3. thoughts, 4. situations, 5. vigilant 6. jumpy

nightmares feelings actions
Criteria of 7. in relationships 8. in the ability to work 9. in other important areas

psychosocial such as education, parenthood,
functioning etc.
(PTSD part)
CPTSD criteria Regulation of emotions Negative self-image Maintenance of relations
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.
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approach the emotionally damaged per- complex PTSD (CPTSD) as per ICD 11 propos-
als: A population study in Israel. Depression and
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Unveröffentlichtes Manuskript.
59 4
Prolonged Grief Disorder

Contents
4.1 Definition – 60
4.2 Development of Diagnosis – 61
4.3 Symptom Picture – 63
4.4 Distinction From Normal Grief – 64
4.5 Grief as a Cultural Phenomenon – 66
4.7 Differential Diagnosis – 67
4.8 Clinical Diagnostics – 69
Literature – 70
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)
A. Event criterion Death of a close person at least 6 months ago

B. At least one of the Strong and persistent desire(s) and longing for the deceased person
following symptoms Strong and persistent preoccupation with the deceased person or
circumstances of death
C. Some of the accessory Accompanied by intense emotional pain, for example:
symptoms Sadness
Feelings of guilt
Anger
Avoidance
Denial
Difficulties in accepting the loss
Impaired sense of identity or self (concept)
Inability to experience positive mood
Emotional numbness
Difficulties in participating in social life or activities
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
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

ago) that are not in proportion to the

the help of this instrument, it has been
bereaveds' social, cultural or religious
shown that complicated grief can be distin-
norms. Longer lasting bereavement reac-
guished from major depression and anxiety
tions that are in proportion to the cultural
disorder (Prigerson et al., 1995). In 1997,
and religious norms of the bereaved are
Prigerson’s working group, together with
called normal grief and do not receive a
other experts, specified the criteria for com-
diagnosis.
plicated grief. The resulting symptoms were
classified into two superordinate categories:
55 Impairments associated with separation
4.2 Development of Diagnosis from the deceased person (e.g. yearning
for the deceased person)
Until now, the diagnosis of a depressive dis- 55 Traumatic symptom complaints (e.g. dis-
order or an adjustment disorder has often belief about the loss).
been used as a substitute for a state of grief
requiring treatment. As will be described In the meantime, there is a multitude of cri-
below, a depressive episode after a bereave- teria for recording pathological grief reac-
ment can be distinguished from a prolonged tions as well as a number of survey
grief disorder. procedures based on different definitions of
The current definition of prolonged grief grief. The lack of consensus is reflected in
disorder is the result of worldwide research the terminology and the wide range of terms
efforts. In particular three research groups used to describe pathological grief (e.g.
(Horowitz et al., 1993; Prigerson et al., 1999; traumatic, abnormal, chronic or pathologi-
Shear et al., 2011) have contributed to the cal grief) (Wagner & Maercker, 2010). The
development of diagnostic criteria for path- concept of prolonged grief was first intro-
ological grief. In 1974, Horowitz and col- duced in 2008 as it allowed a clearer distinc-
leagues documented similarities between tion from PTSD than the concept of
symptoms of posttraumatic stress disorder traumatic grief (Prigerson et al., 2008).
(PTSD) and intense grief reactions that Finally, in 2009 an attempt was made to
were associated with significant impairment reach a common consensus with a panel of
and adaptation problems (Maercker & experts on the criteria for prolonged grief
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)
A. Event criterion Death of a loved one

B. Since death and on more than half of Strong and persistent yearning or longing for the deceased
the days at least one of the following person
symptoms occurs in clinically Intense emotional pain and intense sorrow in response to
significant manifestations for at least the death
12 months Preoccupation with the deceased
Excessive preoccupation with the circumstances of the death
C. Since death and on more than half of Difficulties in accepting the loss
the days at least 6 of the 12 symptoms Disbelief or emotional numbness
occur in clinically significant form for Difficulties in allowing positive memories of the deceased
at least 12 months person to remain
Bitterness or anger about the loss
Dysfunctional evaluations of oneself in relation to the
deceased person or death (e.g. self-reproach)
Excessive avoidance of memories of the loss
Desire to die in order to be close to the deceased person
Difficulty in trusting others since the loss
feelings of loneliness or distance from other people
Feeling that life without the deceased person is meaningless -or
empty, or the belief that one cannot function without the
deceased person
Uncertainty about one’s own role in life or a diminished
sense of identity
difficulties or reluctance to pursue interests or plans for the
future
D. Impairment criterion The symptoms lead to significant impairment in social,
professional or other functional areas or to significant
suffering
E. Congruence with socio-cultural norms The grief reaction is disproportionate or not congruent with
cultural, religious or age-related norms
63 4
The new ICD-11 criteria for prolonged 55 Intensive stress due to the (physical and
grief disorder are based on existing diagnos- emotional) separation from the deceased
tic criteria as well as the new World Health person,
Organization guidelines for the ICD-11. 55 Difficulties in accepting death
Instead of prioritizing the clinical specificity
and validity of disorders, the WHO in the People who suffer from pathological grief
new version focuses on the clinical and are often caught in a vicious circle that is
global applicability of the diagnostic criteria characterized by a strong longing for the
(Keeley et al., 2016a). Clinical applicability deceased person. This longing leads to an
is to be achieved by simplifying diagnoses so intense preoccupation with the deceased,
that they can be better communicated and which can be accompanied by several
used, and by simplifying therapy planning impairments. The core symptoms of pro-
(Keeley, 2016a; Reed et al., 2011). For fur- longed grief disorder and other additional
ther applicability, short diagnostic guide- symptom features have been statistically
lines should be used, which include the core confirmed (Prigerson et al., 2009). The anal-
features as well as additional symptom ysis showed that a diagnosis of prolonged
information (e.g. time course, cultural grief disorder requires at least 5 additional
aspects) (First et al., 2015). As can be seen emotional or cognitive symptoms in addi-
from . Table 4.1, the core characteristics
tion to the core symptom of longing (“yearn-
and a few additional criteria, as well as the ing“). Additional symptoms include the
consideration of cultural aspects, represent avoidance of memories of the deceased per-
precise and concise criteria for prolonged son, emotional numbness, anger or bitter-
grief disorder that improve the clinical and ness over the loss, an impaired sense of
global application. identity and a sense of meaninglessness.
This symptom pattern has been additionally
confirmed by network analysis (Robinaugh
4.3 Symptom Picture et al., 2014). Network analysis is a method
of empirical research that makes it possible
In general, grief is considered pathological to identify connections between different
due to two characteristics (Stroebe et al., symptoms and the strength of these connec-
2008): tions. In the study by Robinaugh et al.
55 the duration and severity of grief specific (2014), once again the intense longing for
symptoms and/or the deceased person as well as an impaired
55 significant stress or impairment in sense of identity were identified as core
important areas of life symptoms. These study results support the
new ICD-11 criteria for prolonged grief dis-
In terms of quality, however, pathological order, which include a strong longing for the
grief is no different from normal grief (Hol- deceased, preoccupation, and additional
land et al., 2009). It is not so much the symp- symptoms of emotional impairment.
tom characteristics that underlie prolonged While many bereaved may experience the
grief disorder as the intensity of the symp- symptoms described above after the loss of
toms, their clinically significant burden or a loved one, these acute grief symptoms usu-
impairment and the duration of these ally subside within the first 6 months
impairments (Maercker et al., 2013b). (. Fig. 4.1). The exact time course of the

Pathological grief reactions comprise transition from normative to pathological

two core symptoms (Maercker et al., 2013b; grief is currently the subject of intensive
Prigerson et al., 2009): research (Wakefield, 2012). According to the
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-
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).

4.5 Grief as a Cultural one of the core emotions, in Rwanda the

Phenomenon desire for retribution is perceived as appro-
priate (Bagilishya, 2000; Rosenblatt, 2008).
The experience and understanding of grief Comparative studies show that mourn-
must always be considered against the ers from China and Switzerland differ with
respective cultural background (Kast, 1999, regard to the additional symptoms of pro-
2013). Although grief is a universal reaction longed grief disorder. After the loss of their
to the death of a loved one, there are great child, Chinese parents increasingly reported
4 cultural differences in the specific grief reac- feeling that their lives were meaningless and
tions and symptoms (Stroebe & Schut, empty. Swiss parents, on the other hand, suf-
1998). These cultural variations challenge fered more often from preoccupation with
Western notions of how to distinguish path- their deceased child. Both Chinese and
ological from normal grief and current diag- Swiss parents have a strong longing and
nostic systems. A growing awareness of the desire for their deceased child. The core
importance of cultural factors in under- symptom of longing may appear to be a uni-
standing grief is reflected in the new ICD-11 versal symptom of grief, while additional
criteria for prolonged grief disorder. The symptoms such as emotional impairment
new definition refers to the cultural context vary more between cultures. Killikelly et al.
and encourages clinicians to only make a (2018) found that refugees and survivors
diagnosis if the grief response is more pro- from conflict regions often (68%) feel a
nounced than would be expected given cul- strong longing for the deceased person. The
tural and social norms. The worldwide core symptom of prolonged grief disorder is
prevalence of pathological grief reactions also widespread among refugees from East
has been confirmed in both Western coun- Timor, West Papua and Burma (Myanmar)
tries (Kersting et al., 2011; Newson et al., (Silove et al., 2017; Tay et al., 2016; Vromans
2011; Simon et al., 2007) and Asia (Fujisawa et al., 2012). Accessory symptoms such as
et al., 2010). However, expectations of how dreams of the deceased in refugees from
pathological grief differs from normal grief, Cambodia or behaviour imitating that of
symptoms, length of mourning and func- the deceased, in contrast, in Kurdish refu-
tional impairment are culture-specific. gees were culture-specific (Hall et al., 2014;
Studies found significant differences in Hinton et al., 2013).
the classification of grief reactions. In The extent of the functional impairment
Western countries, grief is often referred to caused by grief is difficult to assess across
as primarily a feeling or emotion with cultures. In the Zulu culture in South Africa,
thoughts associated. In other cultures, on for example, widows are expected to dress in
the other hand, grief is described both as an black for a year and withdraw from society.
emotion and a thought, the connection To what extent this socio-cultural norm
between which is much stronger than in leads to stress or functional impairments as
Western cultures (Rosenblatt, 2008; Wikan, a result of grief per se is unclear. The impor-
1990). In Japan, for example, grief is often tance of cultural norms and expectations is
described as “a hole in my mind and heart” also reflected in the different mourning peri-
心に穴が開く or “Kokoro ni ana ga aku” ods that are culturally considered appropri-
(Hasada, 2002). Grief seems to be under- ate. In Central Europe, the “year of
stood here as a holistic process that affects mourning” is considered appropriate. In
the mind, emotions and the body. Cultural Bali, on the other hand, the public expres-
differences also show up on an emotional sion of grief at any time is considered patho-
level. While in Western countries sadness is logical (Rosenblatt, 2008). These examples
67 4
illustrate the global significance of culture in et al., 2002; Forstmeier & Maercker, 2007;
the experience, expression, communication Nielsen et al., 2017). In a study involving
and understanding of grief. 5741 older people, 4.8% of the general pop-
ulation met the criteria for complicated grief
(ICG) (Newson et al., 2011). Besides, preva-
4.6 Epidemiology lence rates seem to be about 2 times higher
in clinically indicated persons suffering from
To date, there is a lack of large-scale popula- other mental disorders such as major depres-
tion studies that provide information on the sion or bipolar disorder (Kersting et al.,
rates of prolonged grief disorder according 2009; Simon et al., 2007). The circumstances
to ICD-11. However, previous epidemiolog- of death also play a role. After a violent or
ical studies, which have examined the preva- traumatic death, much higher prevalences
lence rates of pathological, traumatic and of about 14–76% are often found (Kristensen
complicated grief, allow estimates of the fre- et al., 2012). Disordered grief is particularly
quency of occurrence of the prolonged grief widespread among refugees with approxi-
disorder. mately 32% (Killikelly et al., 2018).
Existing large-scale studies estimate the Prevalence rates also vary in different
prevalence of prolonged grief disorder at regions of the world. The majority of stud-
around 10% (. Table 4.3). In Germany, a
ies in western countries showed prevalences
conditional prevalence of complicated of less than 10% (. Table 4.3) (He et al.,

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
.. Table 4.4 Distinction of prolonged grief disorder from a post-traumatic stress disorder and major
depression
Mental Prolonged grief disorder Post-traumatic stress Major depression

disorder disorder
Key Preoccupation with the deceased Intrusions, avoidance, Decreased interest,
Symptoms or the circumstances of death chronic hyperarousal avoidance of activity
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
aThe highlighted symptoms allow a differentiation of the disorders
(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.
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
(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
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75 5
Adjustment Disorder
R. Bachem
Contents
5.1 Definition – 76
5.2 Evolution of the Adjustment Disorder – 76

5.2.1 revious Concepts – 76
P
5.2.2 Recent Developments – 77
5.3 Symptoms of Adjustment Disorder – 77

5.3.1 iagnostic Criteria in the ICD-11 – 77
D
5.3.2 Diagnostic Criteria in the DSM-5 – 78
5.4 Problem Areas and Solutions – 78

5.4.1 djustment Disorder: Subclinical or Full Diagnosis? – 78
A
5.4.2 Differentiation From a Normal Stress Reaction – 79
5.4.3 Differentiation From Other Mental Disorders – 79
5.4.4 Subtypes Poorly Validated – 79

5.5.1 djustment Disorder According to Horowitz – 80
A
5.5.2 Crisis Model According to Caplan – 80
5.5.3 Vulnerability-Stress-Model of Adjustment Disorder – 81
5.5.4 Biological Factors – 81
5.6 Detection of Adjustment Disorder – 82

5.6.1 linical Interview – 82
C
5.6.2 Questionnaire – 83
5.7 Epidemiology, Comorbidity and Course – 83

5.7.2 Co-Morbidity – 84
5.7.3 Course and Forecast – 84
Literature – 85
76 R. Bachem
5.1 Definition as a kind of collective diagnosis for those

patients who did not meet the criteria of a
Maladaptive reactions to critical, non- more specific diagnosis such as depression
traumatic life events are called adjustment or anxiety disorder. In its 10th revision, the
disorders. Such life events can be both single ICD-10 (WHO, 1992) also included the
events such as a break-up of a relationship term adjustment disorder. Since its intro-
or loss of a job, as well as chronic stressors duction, the diagnosis of adjustment disor-
such as poverty, migration or a serious phys- der has been controversially discussed
ical illness. A critical life event (trigger of because opponents feared that normal diffi-
adjustment disorder) differs from a trau- culties in life would be pathologized (e.g.
5 matic event (trigger of post-traumatic and Fabrega & Mezzich, 1987). On the other
complex post-traumatic stress disorder) in hand, the introduction of the diagnosis of
particular by the lower intensity of the adjustment disorder allowed broader cover-
stressor. Besides, there are differences in the age and cost coverage of therapeutic inter-
dynamics and severity of the syndrome ventions by the health care system. Despite
compared with post-traumatic stress disor- small changes in further editions of the clas-
der. The symptoms of adjustment disorder sification systems (. Table 5.1), until the
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).
.. Table 5.1 Evolution of adjustment disorder in the classification systems
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 Symptoms of Adjustment

Disorder
In the ICD-11, an adjustment disorder is
still a transient disorder that develops
5.3.1 Diagnostic Criteria within 1 month after the onset of a stressor.
in the ICD-11 The symptoms should typically disappear
within 6 months unless the stressor persists
The ICD-11 understands adjustment disor- for a longer period. However, in contrast to
der as a full-fledged disorder with a symp- previous concepts, the ICD-11 adjustment
tom profile. Adjustment disorder is placed disorder is no longer treated as an exclu-
on a stress continuum, as are acute stress sion diagnosis but can occur in combina-
reaction, post-traumatic stress disorder, tion with other mental disorders, provided
complex posttraumatic stress disorder and there are substantial non-overlapping
persistent grief disorder. It is assumed that symptoms. This could be the case, for
similar symptoms are characteristic of the example, in the presence of specific pho-
stress response of adjustment disorder as for bias, panic disorder or somatic stress disor-
post-traumatic stress disorder. This concept der. In addition, the two comorbid
of adjustment disorder as a stress-response disorders must show different tempo-
syndrome was originally developed by Mardi ral development of symptoms. However, a
J. Horowitz (1973) and is consistent with the separate diagnosis of adjustment disorder
decision made by DSM-5 and ICD-11 to should not be given if critical life events
bring together all the diagnoses triggered by merely lead to an exacerbation of already
confrontation with a psychosocial stressor. existing symptoms. Finally, the last sub-
The symptoms of ICD-11 adjustment stantial change in the ICD-11 concerns the
disorder include preoccupation with the elimination of different subtypes of adjust-
stressor or its consequences and failure to ment disorder.
adapt symptoms.
78 R. Bachem
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).
The DSM-5 describes adjustment disorder

as a reaction to a critical life event, with the 5.4.1 Adjustment Disorder:
symptoms developing within 3 months Subclinical or Full
after the occurrence of the stressor. The Diagnosis?
symptoms must either be clinically signifi-
cant (beyond the response one would nor- Because adjustment disorder is treated as an
mally expect in response to the specific exclusion diagnosis, it is often used as a diag-
5 stressor) or cause significant impairment in nostic residual category for those patients who
social or professional functioning. They do not reach the threshold of another diagno-
must not be caused by another psychiatric sis (Baumeister & Kufner, 2009). Clinical stud-
diagnosis and must not be attributable to ies have attempted to investigate the severity
bereavement. Different subtypes are distin- of stress in patients with adjustment disorder
guished: and other full-fledged diagnoses and reported
55 with depressed mood, diverging results. Some studies found no dif-
55 with anxiety, ference in symptom severity between adjust-
55 with mixed anxiety and depressed mood, ment disorder and, for example, depression
55 with disturbance of conduct, (Casey et al., 2006), while other studies ranked
55 with mixed disturbance of emotions and adjustment disorder as less severe, but with
conduct. symptom burden in the middle range (Doherty
et al., 2014; Fernández et al., 2012). In a longi-
There is no minimum number of symp- tudinal analysis, patients with adjustment dis-
toms that must be present for a diagnosis of order after a serious accident showed a
adjustment disorder. In DSM-5, adjustment significantly lower quality of life, more depres-
disorder continues to be treated as a diagno- sive and anxiety symptoms than healthy per-
sis of exclusion and is not applicable when a sons, but they were less severely burdened than
comorbid mental disorder is present. those suffering from other mental disorders
(O’Donnell et al., 2016).
Particularly revealing, however, are those
5.4 Problem Areas and Solutions studies that examine adjustment disorder in
connection with suicidal behaviour. Up
In a global study involving over 5000 psy- to12-fold increased risk of suicide was found
chiatrists, adjustment disorder was named in patients with adjustment disorder (Casey
as the seventh most common diagnosis. At et al., 2015; Gradus et al., 2010).
the same time, it was rated as one of the five Furthermore, it was found that adjustment
most problematic disorders in terms of diag- disorder in suicide victims seems to be the
nostic ease of use (Evans et al., 2013; Reed most common mental disorder in some cul-
et al., 2011). The problems include the ques- tures, both among adults (Manoranjitham
tion of whether the subclinical status of et al., 2010) and adolescents (Lönnqvist
adjustment disorder is justified and the et al., 1995). Taken together, these results
unclear boundaries between pathological suggest that the diagnosis of adjustment dis-
and normal stress and between adjustment order should be granted the status of a full-
disorder and other disorders. Furthermore, fledged diagnosis.
Adjustment Disorder
79 5
5.4.2 Differentiation macological interventions than the diagno-
From a Normal Stress sis of adjustment disorder does, at least in
the earlier ICD-10 and DSM-5 conceptuali-
Reaction
sations (Grassi et al., 2007). The ICD-11
also attempts to counter this problem with
The core problem of distinguishing adjust-
the new disorder concept of adjustment dis-
ment disorder from normal stress reactions
order, since the definition of specific symp-
is due to the fact that until the appearance
toms allows for more targeted interventions.
of the ICD-11 no specific symptoms were
Study results illustrate how poorly the
defined, as is standard for most other mental
older concepts of adjustment disorder can
disorders. Critical life events trigger a stress
be distinguished from other disorders. For
reaction in most of those affected, but this
example, it was found that the prevalence of
reaction does not necessarily reach the
adjustment disorder varies greatly depend-
extent of a mental disorder. Where the bor-
ing on whether a clinical or structured inter-
der between normal and pathological stress
view is conducted. In the clinical interview,
lies, however, is difficult to determine and in
31.8% of patients were diagnosed with
the case of adjustment disorder is thus left
adjustment disorder, while 19.5% were diag-
to the clinical judgement of the diagnosti-
nosed with depression. However, a SCID
cian. The criteria of clinical significance and
interview led to a reversal of the prevalence
functional impairment can be used as guide-
rates with 7.8% adjustment disorder and
lines, which are also evaluated by the clini-
36.4% depression.
cian. The ICD-11 has addressed the problem
The extent to which the ICD-11 concept
of the inability to distinguish between nor-
improves the ability to differentiate from
mal stress and adjustment disorder through
other disorders will become apparent in
its specific symptom profile. First field stud-
clinical practice in the future and should be
ies validate this conclusion and indicate that
specifically evaluated in scientific studies.
the reliability of the ICD-11 adjustment dis-
Due to the decision to bring the symptom
order has improved compared to the previ-
profile of adjustment disorder conceptually
ous version (Reed et al., 2018). In contrast,
closer to post-traumatic stress disorder, the
these difficulties persist for DSM-5 diagnos-
differentiation from post-traumatic stress
tics.
disorder is of particular interest. A first eval-
uation study found that despite the concep-
tual similarity, the two diagnoses could be
5.4.3 Differentiation From Other
well distinguished by clinicians (Keeley
Mental Disorders et al., 2016).
Because of the significant overlap with other
subclinical and clinical disorders, especially 5.4.4 Subtypes Poorly Validated
in the area of depression symptoms, adjust-
ment disorder has been described as “too The subtypes of the former ICD-10 and the
broad to be clinically helpful” (Semprini current DSM-5 are considered empirically
et al., 2010). For example, it was found that poorly validated and have been repeatedly
people who suffer from a somatic disease criticized for their insufficient reliability
and consequently develop adjustment disor- (Baumeister & Kufner, 2009; Strain &
der often report various other syndromes Diefenbacher, 2008). The advantage in
such as somatisation, demoralisation and determining a subtype is that it contains
alexithymia. These syndromes suggest more clinical information from which interven-
specific psychotherapeutic and psychophar- tions can be derived. This is particularly
80 R. Bachem
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-

logical factors of adjustment disorder

5.5.3 Vulnerability-Stress-Model (Lorenz, Perkonigg, & Maercker, 2018b).
of Adjustment Disorder This framework model emphasizes the
importance of intrapersonal socio-affective
An explanatory model of adjustment dis- and interpersonal processes for the response
ruption in the sense of a vulnerability stress to adverse events. Loneliness and dysfunc-
model was presented by Forstmeier (2013) tional disclosure and low self-efficacy have
(. Fig. 5.1).

been identified as risk factors for adjustment
The extent of the stress experienced after disorder.
a critical life event is determined by the
nature, duration and severity of the event.
Whether or not an adjustment disorder 5.5.4 Biological Factors
develops, however, depends in particular on
the individual vulnerability factors which Little research has been done specifically on
also determine the coping attempts. the psychobiology of adjustment disorder.
According to Forstmeier (2013), particu- The biological approach (Selye, 1956), under-
larly relevant vulnerability factors for stands stress as a nonspecific response of the
adjustment disorder are cognitive inclina- body to environmental challenges and empha-
tions such as the tendencies for intrusions, sizes the importance of the hypothalamic-
avoidance, depression, anxiety and aggres- pituitary-adrenal cortex axis (HPA) in the
sion. Furthermore, comorbid or previous human stress response. Pathological symp-
82 R. Bachem
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
.. Fig. 5.1 Vulnerability-Stress model of adjustment disorder. (From Forstmeier, 2013)
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.

Composite Diagnostic International psychology.u zh.c h/en/areas/hea/psypath/

Interview (M-CIDI/DIAX; Wittchen & Research-Dissemination/self-report.html
Pfister, 1997) does not currently include
adjustment disorder, but an additional sec-
tion has been developed specifically for can- 5.7 Epidemiology, Comorbidity
cer patients (Hund et al., 2014). Furthermore, and Course
a section has been developed to measure the
adjustment disorder according to ICD- 11 5.7.1 Epidemiology
(Perkonigg et al., 2020). However, the only
interview that has been developed explicitly Adjustment disorder has been recorded in a
for the assessment of adjustment disorder is few epidemiological studies, and due to
the Diagnostic Interview for Adjustment inadequate recording in structured inter-
Disorder (DIAD; Cornelius et al., 2014), a views, prevalence rates may be underesti-
29-question interview to identify critical life mated. Furthermore, it is likely that in future
events and the psychological symptoms that studies the different concepts of adjustment
develop as a result. The DIAD has shown disorder in ICD-11 and DSM-5 will result in
first satisfactory results regarding the validity somewhat different prevalence rates.
but records them according to DSM-IV
(Cornelius et al., 2014). 5.7.1.1 Total Population
In the total population, a prevalence of
adjustment disorder of 1% was found in five
5.6.2 Questionnaire European countries (England, Ireland, Spain,
Finland, Norway) using the ICD-10 concept
At present, there are two questionnaires spe- (Ayuso-Mateos et al., 2001). Using the ICD-
cifically designed to measure adjustment 11 concept, a prevalence of 1.4% was found in
disorder: the Adjustment Disorder - New a recent representative sample of the German
Module (ADNM) and the International population, or 0.9% if functional impairment
Adjustment Disorder Questionnaire was required (Maercker et al., 2012). The sur-
(IADQ), which assess the disorder using the vey of a representative group of older people
ICD-11 criteria. The ADNM measures pre- in Switzerland (65–96 years) resulted in a
occupation and failure to adapt symptoms slightly higher prevalence of 2.3%, which is
as well as various accessory symptoms based probably related to the higher number of crit-
on 20 items (ADNM-20; Glaesmer et al., ical life events in older age (Maercker et al.,
2015). Furthermore, there is a short version 2008). Finally, in a high-risk sample of people
with 8 items (Kazlauskas et al., 2018) and a living in a former conflict area, the prevalence
screening version with 4 items (Ben-ezra of adjustment disorder was found to be
et al., 2018), which measure only the core 6–40% (Dobricki et al., 2010).
symptom areas of preoccupations and fail-
ure to adapt and also have good validity. The 5.7.1.2 Medical Facilities
IADQ assesses preoccupation and failure to Adjustment problems occur relatively fre-
adapt with 6 items and includes three items quently in liaison-consultation psychiatry.
focused on evaluating functional impair- In the total population of somatic patients,
ment (Shevlin et al., 2020). adjustment disorder was found to occur at a
84 R. Bachem
frequency of 1–2.9% (DSM-IV; Fernández 12-fold increased risk of suicide compared

et al., 2012; Semaan et al., 2001), and 9.4% to persons without adjustment disorder
among those patients with additional psy- (Gradus et al., 2010).
chological complaints (Semaan et al., 2001). Using the ICD-11 concept and allowing
Furthermore, a meta-analysis summarised for all co-morbidities, it was shown that 46%
the results of 70 studies from oncological of a group of older people with adjustment
and haematological treatment and found disorder were eligible for a co-morbid psy-
high prevalence rates of 19.4%. Among chiatric diagnosis (Maercker et al., 2008).
those in palliative treatment, the prevalence According to ICD-11, the diagnosis of
was 15.4% (Mitchell et al., 2011). Finally, in adjustment disorder can be applied together
5 the medical emergency setting, a clinical
diagnosis of adjustment disorder was made
with other mental disorders, but only if their
symptoms cannot be fully explained by the
in 31.8% of the patients who displayed self- other disorder and have a separate identifi-
harming behaviour (Taggart et al., 2006). able time course. Future research should
No figures are yet available on the preva- investigate effective co-morbidity rates in
lence of adjustment disorder according to clinical practice.
ICD-11 in the liaison setting.
5.7.1.3 Psychiatric Institutions 5.7.3 Course and Forecast

Adjustment disorders are also among the
most common diagnoses in the psychiatric By definition, an adjustment disorder devel-
setting. In the outpatient therapy setting the ops within 3 months after a stressful event
prevalence was 36% in a clinical interview, and recedes within 6 months if the stressor
while diagnosis by SCID resulted in a sig- does not persist. That adjustment disorder is
nificantly lower rate of 11% (Shear et al., a transient disorder is reflected in a high rate
2000). It can be assumed that the difference of spontaneous remissions (e.g. Baumeister
was caused by the fact that in the SCID the & Kufner, 2009). However, one of the few
adjustment disorder is treated as an exclu- longitudinal studies on the course of adjust-
sion diagnosis. A recent Asian study found a ment disorder suggests that about one-third
similar result with a prevalence of 11.5% of the patients experience a chronic progres-
when using the SCID interview in the psy- sion (O’Donnell et al., 2016). Also, this
chotherapeutic outpatient setting (Yaseen, study showed that patients with adjustment
2017). disorder relatively often develop another,
more severe mental disorder (O’Donnell
et al., 2016). Another study investigated the
5.7.2 Co-Morbidity natural course of subclinical and clinical
ICD-11 adjustment disorder symptoms
To date, the co-morbidity rates of adjust- after job loss (Lorenz, Perkonigg, &
ment disorder have rarely been investigated. Maercker, 2018c). It identified three differ-
However, it has been shown that adjustment ent patterns of progression between the
disorder often occurs together with sub- third and ninth month: Almost half of the
stance abuse (Greenberg et al., 1995; study participants showed low symp-
Kryzhanovskaya & Canterbury, 2001). tom severity, a third reported moderate
Co-occurrence with personality disorders is symptom severity and 15% experienced a
also common and has been found to pronounced symptom severity correspond-
range between 15% (Strain et al., 1998) and ing to a diagnosis of adjustment disorder
56% (Doherty et al., 2014). Besides, patients that had increased within the investigated
with adjustment disorder show an up to time frame. After a further 6 months, how-
Adjustment Disorder
85 5
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89 6
Neurobiology
C. Schmahl
Contents
6.1 Brain Changes – 90
6.2 Hypothalamus-Pituitary-Adrenal Axis – 92
6.3 Dissociation – 93
6.4 isturbed Emotion Regulation: Fear, Disgust

D
and Shame – 95
6.4.1 S tudy Results on Anxiety – 96
6.4.2 Study Results on Disgust and Shame – 96
6.5 Conditioning and Extinction of Fear – 97
6.6 Animal Models for PTSD – 99
6.7 Integration and Outlook – 100
Literature – 100
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
6.2 Hypothalamus-Pituitary- saliva or plasma. A further meta-analysis

Adrenal Axis (Morris et al., 2012), in which in contrast to
the other two studies children and adoles-
In many stress-related mental disorders such cents were also included, found decreased
as depression or PTSD, changes in the cortisol levels in PTSD patients compared
hypothalamic-pituitary-adrenal (HPA) axis to both traumatized individuals without
are discussed as a correlate or consequence psychiatric illness and non-traumatized
of the disease. individuals. Also, an effect of the temporal
Corticotropin-releasing hormone (CRH) distance to trauma was found: the longer
plays an important role in the stress response. ago the trauma was, the lower the cortisol
In animal experiments, chronic stress leads levels. This supports the long-held assump-
to an increase in CRH (Arborelius et al., tion of an initial post-traumatic hypercorti-
1999) and the administration of CRH, in solism, followed by a “blunting” of the HPA
6 turn, leads to behaviors associated with fear axis, that is, a slowly developing hypocorti-
or anxiety, for example, a decline in explor- solism (Hellhammer & Wade, 1993;
atory behavior, increased startle reflex and Bremner, 2002). Overall, the data on hypo-
reduced cleaning behavior. Since the hippo- cortisolism, therefore, remain unclear; in
campus plays an important role in inhibiting particular, it is still unclear whether it is
CRH release from the hypothalamus, a hip- related to trauma or PTSD.
pocampal reduction may indirectly contrib- Another connection between the HPA
ute to overactivity of the HPA axis. Two axis and PTSD psychopathology is the influ-
studies have actually been able to detect ence of glucocorticoids on memory func-
increased CRH concentrations in the CSF tions. Stress or treatment with
of patients with PTSD (Baker et al., 1999; glucocorticoids improves memory consoli-
Bremner et al., 1997). dation and worsens the recall of memory
Since HPA axis-mediated damage to hip- content; this could be shown in animal
pocampal neurons can occur either directly experiments. De Quervain et al. (1998) were
via glucocorticoids or indirectly via a able to show that rats find it harder to find a
glucocorticoid-induced increase in sensitiv- grid in water after an electric shock; this
ity to cytotoxic glutamate (Bremner, 2002), effect could be inhibited by an inhibitor of
the investigation of cortisol levels, in partic- cortisol synthesis (metapyrone) and imitated
ular, plays an important role in understand- in non-stressed animals by the administra-
ing morphological brain changes. Acute tion of cortisone. Aisa et al. (2007) could
stress leads to the release of cortisol, and in prove that the glucocorticoid antagonist
patients with PTSD increased cortisol mifepristone completely eliminated the
response to both non-specific (Bremner memory deficits in rats caused by a daily 3-h
et al., 2003a) and trauma-induced stress separation from the mother in the first
(Elzinga et al., 2003) has been demonstrated. 3 weeks of life. In humans, a single dose of
Some studies (e.g. Yehuda et al., 1991, cortisone reduced the number of words
1996) initially found lowered cortisol levels. remembered when given 1 h before (De
In the meantime, a large number of individ- Quervain et al., 2000). A one-week applica-
ual studies on HPA axis function in trauma- tion of 20 mg hydrocortisone led to a sig-
tized individuals and patients with PTSD nificant decrease in the accuracy of memory
are available. However, meta-analyses show recognition (McAllister-Williams & Rugg,
a mixed picture: Meewisse et al. (2007) and 2002).
Klaassens et al. (2012) could not confirm the Since PTSD is characterized by auto-
suspected basal hypocortisolism in urine, matic trauma-related memory processes that
Neurobiology
93 6
are difficult for patients to control, it is being 6.3 Dissociation
debated whether reduced cortisol secretion
could be responsible for disinhibiting the In the context of stress-related cognitive
recall of trauma memories (De Quervain, changes, we have so far only discussed an
2006). Conversely, an external administra- increased recall of trauma memories, i.e.
tion of glucocorticoids could then reduce intrusions. However, another psychopatho-
the recall of traumatic memories and thus logical pattern that is closely related to
possibly lead to a reduction of the intrusive trauma is found in PTSD, namely dissocia-
experience. In a pilot study (Aerni et al., tion (7 Chap. 2).

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
600 800 1000 1200 1400

x
.. 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)
another study, increased activity in the 6.4 Disturbed Emotion

insula and dorsolateral prefrontal cortex Regulation: Fear, Disgust
during pain stimulation and a decrease in
subjective pain sensitivity with repeated and Shame
pain stimulation was found in PTSD patients
(Strigo et al., 2010). In contrast to the exper- Due to the disturbance of emotion percep-
imental findings of reduced pain sensitivity, tion and processing in PTSD, a substantial
however, increased subjective pain percep- part of functional imaging studies deals
tion is found in patients with PTSD with neural emotion processing in these
(Asmundson et al., 2002). patients. Studies with standardized emo-
96 C. Schmahl
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

pharmacological manipulation, which can timing of traumatization can be experimen-

then be transferred to therapeutic research tally investigated here. On the psychopatho-
100 C. Schmahl
logical level, in PTSD, non-associative

memory processes (e.g. in the context of cate a clear influence of traumatiza-
recall and avoidance of trauma-associated tion.
stimuli), as well as associative memory pro- 55 The HPA axis plays an important role
cesses (e.g. in connection with a general in connection with these neural dam-
hyperarousal, irritability or emotional ages and disturbed memory for trau-
numbness), play a role (Siegmund & Wotjak, matic events.
2006). The animal model of Siegmund and 55 Research on the neuroanatomical and
Wotjak attempts to depict these two pro- neurochemical basis of dissociation
cesses, that is, conditioning and sensitization has made progress, as has the study of
processes. To record the conditioning pro- emotion regulation, not only related
cesses, the animals were placed back into the to the emotion fear.
chamber in which they had received the elec- 55 In terms of translational research,
6 tric shock at certain intervals. To measure conditioning and sensitization pro-
sensitization, unpleasantly loud sounds were cesses, in particular, play an impor-
presented in a neutral chamber. Both pro- tant role. These processes can be
cesses were measured using the “freezing” studied in parallel in animals and
reaction. In these experiments it could be humans to then transfer molecular
shown that after the electrical stimulus, both biological or pharmacological find-
an increase in the conditioned anxiety reac- ings from these models to therapy in
tion (freezing) and an increasing sensitiza- humans.
tion occurred, depending on the dose. In the
animal model described above, a reduction
of the hippocampal volume was also found Translational research will certainly become
2 months after the stressor (Golub et al., more important in the coming years. Besides,
2011). the recording of gene-environment interac-
tions, which is already more widespread in
other mental disorders, will play an impor-
6.7 Integration and Outlook tant role. This is especially important since
PTSD can be regarded as a prime example
Research on the neurobiology of PTSD has for the investigation of the interaction of
made rapid progress in recent years, which genetic factors and stress in the development
not only increases basic knowledge but can of psychopathology. Another promising
also provide important impulses for improv- research area is the interplay of psycho- and
ing therapeutic options. The overview pres- pharmacotherapy, for example, in the phar-
ents some central aspects of research in this macological influencing of extinction or
field. reconsolidation processes.
Central Aspects of Research on the

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6
107 7
Childhood Violence and Its

Consequences
Contents
7.1 Forms of Violence in Childhood – 108
7.2 Epidemiology of Childhood Violence – 109

7.2.1 hysical Violence – 109
P
7.2.2 Sexual Violence – 112
7.2.3 Emotional Violence – 112
7.2.4 Neglect – 113
7.2.5 Children as Witnesses (of Intimate Partner Violence) – 114
7.2.6 Overlap of Different Forms of Violence in Childhood – 114
7.2.7 Causes of Child Maltreatment – 115
7.3 Consequences of Violence in Childhood – 116

7.3.1 eneral Consequences of Violence in Childhood – 116
G
7.3.2 Consequences of Specific Forms of Childhood Violence – 118
7.4 Treatment Options – 118
Literature – 119
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

type of survey, number of questions). shows the frequency of child abuse in

Germany.
A major problem with prevalence rates is A survey of women with impairments/
also the high number of unreported cases, disabilities in Germany revealed a signifi-
which makes it difficult to adequately reflect cantly higher incidence of violent experi-
reality (Deutscher Kinderverein, 2017). The ences in childhood and adolescence, which
WHO (2013) describes the following preva- shows the particular vulnerability of and
lence rates for the European area: sexual danger to this group (Schröttle et al., 2012).
abuse is experienced by 13.4% of girls and Jones et al. (2012) also make it clear in their
5.7% of boys. Furthermore, 22.9% of boys global meta-analysis that children and ado-
and girls are victims of physical abuse and lescents with impairments/disabilities were
29.1% of emotional abuse. There are fewer victims of violence more often than their
European studies on neglect. The worldwide peers.
prevalence rates for physical and emotional
neglect are 16.3% and 18.4% respectively
(ibid.). A German representative survey by 7.2.1 Physical Violence
Iffland et al. (2013) reports that 12% of
respondents aged 14–90 years reported Worldwide, 22.6% (95% confidence interval:
physical abuse, 6.2% sexual abuse, 10.2% 19.6–26.1%) of adolescent and adult
emotional abuse, 13.9% emotional neglect respondents report physical abuse in their
and 48.4% physical neglect. self-
reports (Stoltenborgh, Bakermans-
.. Table 7.1 Prevalence rates of child abuse in Germany (Witt et al., 2017)
N None to minimal Low to moderate Moderate to severe Severe to extreme

N (%) N (%) N (%) N (%)
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)
Kranenburg, & van Ijzendoorn, 2013). troversy. In Germany, an amendment was

Neither gender differences nor geographical made in this respect in the Civil Code § 1631
differences were found in this meta-analysis paragraph 2 in the year 2000:
of global epidemiological studies. The vari- 55 Children have a right to a non-violent
ance in prevalence rates can be explained on upbringing.
the one hand by two sample characteristics, 55 Physical punishment, emotional violence
namely the type of sample and who was and other degrading measures are not
interviewed, children or adults, and on the permitted.
other hand by methodological moderators
such as the period of abuse, number of ques- This means that the corporal punishment of
tions, years of publication and the definition children is no longer permitted in Germany
of physical abuse. and therefore now clearly falls under the
One problem with the definition of phys- generic term physical abuse. N evertheless,
ical violence is that the corporal punishment corporal punishment is still part of educa-
of children has long been the subject of con- tion in many German families. Forsa (2011)
111 7
.. Table 7.2 Frequency of physical punishment in the last 12 months in a representative survey in
Germany
Frequencies Slap on the Slap in the Spanking Spanked with a stick or

backside face similar
Never 60% 90% 95% 100%

1 to 2 times 28% 9% 3% –
Every few 8% 1% 1% –
months
Every few weeks 4% – – –
Every few days 1% – – –
Adapted according to Forsa (2011)
conducted a representative survey among 4-year-olds, every third child experiences a

parents with at least one child up to 14 years violent upbringing, every sixth child experi-
of age. The study refers to the frequency of ences corporal punishment.
corporal punishment in the last 12 months. However, children and young people are
Overall, 40% of parents affirmed “slap on not only chastised by their parents, but also
the backside”, 10% “slap in the face” and 4% by teachers. Every second child aged
“spanking”. Nevertheless, there is a decrease 6–17 years lives in a country where corporal
compared to the study of 2006/2007, in punishment at school is not completely pro-
which 46% indicated “slap on the backside”, hibited (UNICEF, 2017).
11% “slap in the face” and 6% “spanking”.
. Table 7.2 shows how often physical pun-

»» All forms of violence against children,
however light, are unacceptable. ...
ishment was used.
Frequency, the severity of harm and intent
UNICEF describes worldwide figures on
to harm are not prerequisites for the defi-
corporal punishment in a report from 2014:
nitions of violence. States parties may
55 3 out of 10 adults believe that corporal
refer to such factors in intervention strate-
punishment is necessary to raise a child
gies in order to allow proportional
properly.
responses in the best interests of the child,
55 6 out of 10 children aged 2–14 years are
but definitions must in no way erode the
regularly physically punished by their
child’s absolute right to human dignity
caregivers.
and physical and psychological integrity
55 Almost half of all girls aged 15–19 think
by describing some forms of violence as
that a husband sometimes has the right
legally and/or socially acceptable. (UN
to beat his wife.
Committee on the Rights of the Child,
2011, p. 8)
Furthermore, UNICEF (2017) reports that
even one-year-old infants are affected by Children and young people also experience
corporal punishment worldwide. It becomes physical violence in other contexts and by
clear that 6 out of 10 children aged very different types of perpetrators. The
12–23 months experience violent methods spectrum ranges from one-off physical
of upbringing, half of them physical pun- attacks by peers or unfamiliar adults to gang
ishment, half verbal violence. In the 2 to violence, school shootings, terrorist attacks,
war and flight experiences (7 Chap. 25).

abuse and maltreatment experiences by
Different roles can also come together. Some peers. This is impressively demonstrated in a
children experience physical violence, have representative Swiss survey (Optimus Study)
to witness domestic violence and become with almost 6800 young people. It also
perpetrators themselves (UNICEF, 2014). A found a gender difference, as 40.2% of
special group of perpetrators in childhood female adolescents and 17.2% of male ado-
are child soldiers (for a comprehensive lescents reported sexual abuse. In this study,
description see Schauer & Elbert, 2010). sexual violence was broadly defined and
included events without physical contact
(exhibitionism, sexting, verbal sexual vio-
7.2.2 Sexual Violence lence, etc.). More than half of the girls
affected by sexual violence in general and
A global meta-analysis by Stoltenborgh more than 70% of the boys stated that they
et al. (2011) reports that on average 12.7% had been harassed or abused by adolescent
(95% confidence interval: 10.7–15.0%) of perpetrators of the same age (Mohler-Kuo
7 adolescents and adults stated in their self- et al., 2014). Sexual harassment via the
reports that they were victims of sexual Internet was the most frequently reported
abuse. There were differences in gender (cyber victimisation). It became clear that
(female > male) and geographical location. even sexual violence without contact (the
The lowest rates were found in Asia, the most common category of abuse), also
highest rates among female respondents in called hands-off, can have a significant nega-
Australia and male respondents in Africa tive impact on the mental health and health-
(for gender and geographical differences see related quality of life of children and
also Pereda et al., 2009). The prevalence adolescents (Landolt et al., 2016). The study
rates for sexual violence also vary consider- by Allroggen et al. (2017), which deals with
ably between studies. Barth et al. (2013) sexual violence among children and adoles-
report figures of 8–31% for girls and 3–17% cents in assisted living facilities and board-
for boys. They attribute these fluctuations to ing schools, also describes that
methodological differences. In this respect, predominantly young people of the same
they point out that, in particular, stating the age were the perpetrators. In up to 11% of
frequencies differentiated according to spe- cases, employees of the institutions were the
cific forms of sexual violence would contrib- perpetrators.
ute to more adequate results. The
Criminological Research Institute of Lower
Saxony (Stadler et al., 2012) questioned a 7.2.3 Emotional Violence
representative sample of 9175 adults (16–
40 years) about sexual abuse experiences in There is significantly less research on emo-
childhood up to and including 16 years of tional violence compared to the other types
age with a person at least 5 years older. The of maltreatment. Reasons for this include
overall rate of sexual abuse with physical the fact that emotional abuse has long been
contact was 7.4% for female respondents seen as part of the other types of maltreat-
and 1.5% for male respondents. The rates ment and that it is often a matter of long-
for exhibitionism also differed with 5.9% for term dysfunctional interactions rather than
female respondents and 1.5% for male clearly identifiable events (Glaser, 2002). It is
respondents. also very difficult to operationalise emo-
Enders (2011) criticizes the definition of tional abuse concisely. A global meta-
abuse experiences with a person at least analysis by Stoltenborgh et al. (2012) reports
5 years older, as it fails to capture many that using self-report 36.3% (95% confidence
113 7
interval 28.1–45.4%) of adolescents and of bullying and violence decreased substan-
adults are affected by emotional abuse in tially in schools in Germany. Why this is
childhood. Neither gender, geographical important becomes clear based on a study
location nor economic development level of by Lereya et al. (2015) with almost 5500
the country had any influence on the children and young people. They report that
reported prevalence rates. The aforemen- bullying has negative long-term effects on
tioned 2011 German Forsa survey shows mental health (especially anxiety, depression
that 93% of parents raised their voices in the and self-harm).
last 12 months, 85% imposed bans, 47%
ordered time off, 43% hit the table, 38%
grabbed or held their child strongly, 26% 7.2.4 Neglect
stopped talking to the child or ignored it and
19% shouted down their child (Forsa, 2011). >>Although neglect is considered one of
the most common types of childhood
Case Study: Emotional Abuse maltreatment and its consequences are
comparable to physical and sexual vio-
A 10-year-old boy lost his father to a lence, it has received much less scientific
heart attack. The mother blames him for and public attention.
the father’s death. She often stresses that
if the child didn’t exist, the father would Stoltenborgh, Bakermans-Kranenburg, van
still be alive. Even before this, the mother Ijzendoorn, and Alink (2013) report in their
met the boy predominantly hostile and worldwide meta-analysis that using self-
dismissive. In addition to pejorative feed- report 16.3% of adolescents and adults
back on any statements and on the child’s reported physical neglect (95% confidence
behaviour, there is also unreasonable interval 12.1–21.5%) and 18.4% (95% confi-
punishment (e.g. house arrest for weeks dence interval 13.0–25.4%) emotional
and television bans). neglect in childhood. There were no gender
differences.
Münder et al. (2000) called on specialists
In addition to intra-familar emotional from youth welfare offices in Germany to
abuse, children and adolescents also experi- name the risk situation that in the respective
ence emotional violence by extra-familiar case decisively contributed to the involve-
perpetrators such as coaches and teachers, ment of the family court. In half of the
strangers, for example through racist com- cases, neglect was cited as the central risk
ments, and especially in the context of bully- category, followed by emotional abuse,
ing, also by peers. Despite the increased use which was only cited as the central risk cat-
of electronic media, bullying and violence egory in 12.6%. Especially the youngest chil-
continues to occur more frequently directly dren were affected by neglect as a central
in the school context than online (Bergmann category of risk (35.2% younger than
& Baier, 2018). Nevertheless, psychological 3 years, 20.1% between 3 and 6 years). With
and sexual violence also occurs online increasing age, the proportion decreased
(ibid.). Melzer et al. (2012) describe a posi- more and more, so that it only accounted for
tive trend: From 2002 to 2010 the propor- 3.8% in the 15 to 18-year-olds (Münder
tion of perpetrators and perpetrator-victims et al., 2000 in Mutke, 2001).
7.2.5 hildren as Witnesses (of

C .. Table 7.3 Participation of children in
Intimate Partner Violence) intimate partner violence according to the
statements of women affected by violence.
Children and young people can also be indi- (Adapted from Müller & Schröttle, 2004;
multiple answers possible; case basis: all
rectly affected by violence as witnesses. In an
couple relationships reporting intimate partner
extra-familial setting or with strangers, this violence with children in the household,
can be a stressful experience. Children are N = 485)
particularly affected, however, when the vio-
lence happens in their immediate environ- Children... [%]
ment, for example, as violence between
... listened to the situation 57,1
mother and father or their respective part-
ners. Worldwide, every fourth child under ... saw the situation 50,0
the age of 5 lives with a mother who is a vic- ... got into the fight 20,6
tim of intimate partner violence (UNICEF,
... tried to defend or protect me 25,0
2017). Finkelhor et al. (2013) describe that
7 in the U.S. in 2011 22.4% (lifetime preva- ... tried to defend my partner 2,0
lence 39.2%) of 4503 children and adoles- ... were physically attacked themselves 9,8
cents aged between 1 month and 17 years
... did not notice anything 23,0
had experienced some form of violence as
witnesses in the previous year. Of these, Unclear whether the children were 11,1
aware of the situation
8.2% had witnessed family-related violence
in the previous year (lifetime prevalence Not specified 0,4
20.8%). 6.1% had witnessed violence
between parents or partners (lifetime preva-
lence of 17.3%). Even witnessing violence For example, sexual violence rarely occurs
alone, particularly in the immediate environ- alone, but often in combination with physi-
ment, has far-reaching effects on the child or cal violence (UNICEF, 2014). Experiencing
adolescent (McTavish et al., 2016). several types of violence is in turn associated
In Germany, Müller and Schröttle (2004) with a higher degree of psychiatric and
surveyed a representative sample of women health-related consequences (Arata et al.,
aged 16–85 years in regard to experiences of 2005; Hughes et al., 2017). Nevertheless, this
intimate partner violence. Every fourth multiple experience of violence is often given
woman who had lived in a partnership too little consideration in research. This is
reported that she had experienced physical reflected, for example, in insufficient meth-
(23%) or - in some cases additionally - sex- odological considerations and statistical
ual assaults (7%) by a relationship partner. evaluations (see Higgins & McCabe, 2001).
In most cases, the children had witnessed the The different forms of violence can be
violence of their parents or even got into a experienced simultaneously or consecu-
physical confrontation (. Table 7.3).
tively. Jonson-Reid et al. (2003) prospec-
tively examined for different forms of
maltreatment (sexual abuse, physical abuse,
7.2.6 verlap of Different Forms
O neglect, emotional abuse, other forms of
of Violence in Childhood maltreatment) how often and in what form
re-victimisation occurred in a period of
Children often experience a variety of differ- 54 months after the maltreatment first
ent violent experiences, which is called became known. The frequency of re-
poly-victimisation (Finkelhor et al., 2007a). victimisation for the above-mentioned forms
115 7
of maltreatment was 10.7–18.7% over this >>It has been shown that children who
period (34.7%–50.2% re-victimisation was have been abused are later at high risk of
found for those reports of maltreatment that being abused again and of experiencing
were not considered verified). other additional forms of violence,
respectively.
ase Study: The Simultaneous Occurrence
C
of Abuse and Neglect
7.2.7 Causes of Child
The police are called in because residents Maltreatment
have brought a three-year-old child into
their home who was out on his own. He is There are various theories on the causes of
only lightly clothed, even though there is child maltreatment. It is a complex bio-
snow and it is freezing cold. The child has psycho-social causal structure (see Bender &
marks from blows with a belt on torso Lösel, 2005).
and legs. It claims to have left the house
because there hasn’t been anything to eat
at home for days. Bio-Psycho-Social Stress as Causes of
This appears to be a combination of Child Maltreatment
physical abuse and neglect; neglect in 55 Individual level (e.g. characteristics
terms of inadequate care (food, clothing) of the abuser’s biography and person-
and protection of the child (being outside ality, such as a troubled childhood,
alone). mental disorders, drug or alcohol
abuse, physical disabilities, low intel-
lectual ability in combination with
However, experiencing intra-family violence lack of skills in dealing with stress
also increases the probability of experienc- and conflict resolution, lack of knowl-
ing extra-familiar violence (Cook et al., edge about child development)
2003). For example, chronic childhood vio- 55 Family level (including partner con-
lence can lead to a higher risk behaviour flicts, disrupted parent-child relation-
with regard to sexual contacts, delinquent ships, cramped housing conditions)
contact, addictive substances etc. in adoles- 55 Social/municipal level (e.g. no social
cence, which in turn can encourage violence support network of the family, high
in adolescence, such as physical confronta- crime rate in the community, deprived
tions and sexual violence (ibid.). Finkelhor area)
et al. (2007b) also describe that, regardless 55 Socio-cultural level (e.g. high poverty
of the form of violence experienced, this rate, tolerance of aggressive/violent
increased the risk of experiencing violence conflict resolution; power and rela-
again within the next year (re-victimisation). tionship gaps between the sexes)
Especially children who reported various
forms of violence were at high risk of con-
tinuing to experience violence one year later. One cause of child abuse, which is always
Lereya et al. (2015) also report a longitudi- controversially discussed, is the so-called
nal connection with experiences of bullying: cycle of abuse, which refers to the fact that
Children who had experienced maltreatment parents who have experienced child abuse
showed a higher risk of being bullied later. themselves abuse their own children later.
personal personal
familial social family social
(biological) (biological)
risks risks resources resources
risks resources
risk-increasing risk-mitigating
stress factors protective factors
• Balancing/interdependency between stress

and resources
• Degree of risk to the child’s well-being
7 • Extent of developmental disorders or
mental and physical health
.. Fig. 7.1 Bio-psycho-social model of risk and 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.
The consequences of childhood violence zz Cognitive Consequences

can vary greatly from one individual to Attention and concentration disorders, dys-
another, but often have lifelong effects functional cognitions (e.g. negative attribu-
(7 Chaps. 6 and 22). In many cases, the
tion patterns, negative schemata), language,
symptoms are much broader than the diag- learning and school difficulties.
117 7
zz Somatic and Psychosomatic
.. Table 7.4 Frequencies of mental disorders
Consequences
according to ICD-10 in children and adoles-
Headaches, breathing difficulties, eating and cents after abuse and neglect (N = 322; Ganser
sleeping disorders as well as enuresis and et al., 2016)
encopresis.
Mental disorder according to ICD-10 [%]
zz Abnormalities in Social Behaviour
Posttraumatic stress disorder 25,2
When separated from abusive parents,
abused children often show no feelings, Conduct disorders 21,4
while they manifest excessive trust in strang- Attention and hyperactivity disorders 16,2
ers. Abnormalities include withdrawal
Elimination disorders 14,0
behaviour, absence from school, hyperactiv-
ity, running away from home, aggressive Affective disorders 10,6
behaviour such as intentional destruction of Anxiety disorders 9,6
property, physical attacks (possibly with
Adjustment disorders, stress reactions 4,0
weapons) and other delinquent behaviour.
The aggressive behaviour can also be Tic disorders 2,5
directed against the parents. Beckmann Other 5,6
et al. (2017) describe that physical and ver-
bal violence by parents in childhood
increases the probability that adolescents
themselves become physically and verbally areas such as the hippocampus, amygdala,
aggressive towards their parents. prefrontal cortex and corpus callosum
(Teicher & Samson, 2013, 2016: an overview
zz Psychological Disorders in Landolt, 2012). Epigenetic mechanisms
Children and young people who have experi- are also discussed (Cicchetti et al., 2016). In
enced violence often meet the criteria of addition, age at the time of the maltreat-
mental disorders. They often exhibit comor- ment experiences and chronicity seem to
bid disorders. In addition to established diag- have an influence on neurocognitive perfor-
noses, there is also a need to develop new mance (Cowell et al., 2015). Teicher and
terminology/diagnostic criteria (“complex Samson (2016) summarise the current state
posttraumatic stress disorder”; 7 Chap. 3).
of research as follows:
A multicentre study from Germany with 55 Chronic child maltreatment can lead to
322 children and adolescents aged 4–17 years structural and functional changes in the
who had experienced abuse and neglect brain.
investigated the diagnoses of mental disor- 55 The type of maltreatment leads to differ-
ders according to ICD-10 (Ganser et al., ent effects.
2016). Almost one-third of the children and 55 Age at exposure to maltreatment has an
adolescents met the criteria of a mental dis- influence.
order. Comorbid disorders occurred in 55 The temporal connection between expe-
almost 43% of the cases. . Table 7.4 illus-
riencing violence and changes in the
trates the frequencies of mental disorders. brain is unclear (sensitive phases for spe-
cific types of maltreatment and brain
zz Neuroanatomical and Functional structures?).
Changes 55 There are gender differences.
In addition, neurobiological and brain- 55 Changes seem to be due to neuroplastic
structural changes are evident in various adaptive reactions.
55 It is not clear whether the neurobiologi- 7.3.2 Consequences of Specific

cal consequences are reversible. Forms of Childhood Violence
55 The causal mechanisms by which vio-
lence in childhood leads to changes in It is often difficult to study the consequences
the central nervous system are not yet of specific forms of maltreatment since in
sufficiently understood. many cases not only one form of maltreat-
ment has been committed and therefore the
zz Death Through Violence consequences cannot be seen in isolation.
In extreme cases, physical violence also According to Moggi (2005in Moggi, 2009,
includes the death of a child or adolescent. p. 870 f.) only some typical consequences or
According to WHO data from 2012 symptoms can be identified:
(UNICEF, 2014), almost a fifth of all mur-
der victims worldwide were under 20 years zz Physical Abuse
of age, more than half of them between 15 Injuries and organ damage such as bruises,
and 19 years of age. dents and haematomas, skeletal, soft tissue,
7 For 2016, more than 1447 deaths due to eye, brain and mouth injuries as well as
child maltreatment were assumed in the burns and scalds, which can lead to death.
USA, with younger children especially
affected, especially those under 1 year of age zz Neglect and Psychological Abuse in
(U.S. Department of Health & Human Preschool
Services, 2018). They represented by far the Developmental delays (e.g. growth and
largest group, accounting for 44% of all speech disorders, psychomotor developmen-
deceased children. Of the deceased children, tal delays) and psychosomatic symptoms
74.6% had experienced neglect and 44.2% (e.g. wetting, skin diseases) as well as abnor-
physical abuse (either exclusively or in malities in attachment behaviour.
combination with another form of maltreat-
ment; ibid.) In Europe, too, children under zz Sexual Abuse of Children
4 years of age are particularly affected Injuries in genital, anal and oral areas, preg-
(WHO, 2013). In total, at least 850 children nancies during adolescence, sexually trans-
under the age of 15 die annually from child mitted diseases and sexual behaviour that
maltreatment in Europe. Low- to middle- does not correspond to age (e.g. excessive
income countries are particularly affected, curiosity about sexuality, early sexual rela-
where 71% of deaths are registered (ibid.). tions, open masturbation or exhibitionism,
In Germany, 133 children died after mal- sexualised behaviour in social contact).
treatment in 2016; in further 78 children, an
attempted killing took place. Of these, 100
of the children killed were younger than 7.4 Treatment Options
6 years of age (Deutscher Kinderverein,
2017). Banaschak et al. (2015) attempted to With regard to the diagnosis and treatment
establish valid prevalence rates of infant of children/adolescents who have experi-
death in children from birth to the age of enced violence with a focus on the symptoms
3 years after abuse and neglect in Germany. of posttraumatic stress disorder, we refer to
Due to the incomplete data situation and the contribution by Steil and Rosner in this
the presumably high number of unreported book (7 Chap. 22). With regard to different

cases, they were ultimately unable to make methods of trauma therapy in childhood and
any representative statements. adolescence, there is a handbook by Landolt
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,
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123 8
Diagnostics and Differential
Diagnostics
J. Schellong, M. Schützwohl, P. Lorenz, and S. Trautmann
Contents
8.1 Initial Situation – 125
8.2 Structured/Standardised Interview Diagnostics – 126

8.2.1 I nterviews for Mental Disorders – 126
8.2.2 Disturbance Specific Interviews – 129
8.2.3 Evaluation of the Structured or Standardised Interviews – 130
8.3 Self-Reports – 130

8.3.1 S ymptom Questionnaire – 131
8.3.2 Instruments Assessing Traumatic Events – 135
8.3.3 Evaluation of Self-Report Instruments – 136
8.4 Other Stress-Related Disorders and Trauma

Sequelae – 137
8.4.1 cute Stress Reaction/Acute Stress Disorder – 137
A
8.4.2 Enduring Personality Change after Catastrophic
Experiences – 137
8.4.3 Adjustment Disorder – 137
8.4.4 Prolonged Grief Disorder (PGD) – 138
8.5 Differential Diagnostics – 138

8.5.1 nxiety Disorders – 139
A
8.5.2 Obsessive-Compulsive Disorders – 139
8.5.3 Depressive Disorders – 139
8.5.4 Emotionally Unstable Personality Disorder, Borderline
Type – 139
8.5.5 Dissociative Disorders – 140
8.5.6 Intermittent Explosive Disorder (IED) – 140
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
8.6 Collection of Additional Therapy-Relevant

Information – 141
8.6.1 ecording of Factors that Maintain or Determine the Course
R
of Therapy – 141
8.6.2 Assessment of Secondary Functional Impairments – 142
8.6.3 Assessment of Resources and Competences – 142
8.6.4 Diagnostics Accompanying Therapy – 144
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.
practitioners in private practice and trauma- 8.2 Structured/Standardised

specific interviews by only 3% (Haase & Interview Diagnostics
Schützwohl, 2011).
In this chapter, a comprehensive diag- Structured interviews are used to system-
nostic procedure is presented first for the atically record diagnostic criteria using pre-
diagnoses of PTSD and complex PTSD, formulated questions; if there are problems
followed by 7 Sect. 8.4 on prolonged grief

of understanding or doubts, questions can be
disorder and adjustment disorder. The struc- reformulated, explained, or supplemented. In
ture of each section corresponds largely to addition to the information provided by the
the recommendations of a commission of patients, the assessment can include all avail-
experts (Keane et al., 2000): able information. In contrast, standardised
55 The conduct of structured or stan- interviews do not leave the interviewer any
dardised interviews, originally developed freedom in the assessment, that is, questions
to ensure reliable diagnoses in research, are generally read word by word and only the
is also indispensable in clinical practice patients’ answers are coded.
(7 Sect. 8.2.1).

The following is only an overview of the
55 The frequency and intensity of symp- most important procedures:
toms should be recorded, as well as the
8 duration of the symptom burden and the
resulting psychological impairments 8.2.1 Interviews for Mental
from the patient’s perspective. The use of
Disorders
reliable and valid self-assessment proce-
dures is particularly suitable for this pur- 8.2.1.1 tructured Clinical Interview
S
pose (7 Sect. 8.3).
for DSM-IV (SCID)

55 After a potentially traumatic event, a

wide range of stress reactions can occur Until the German version of SCID-5
(7 Sect. 8.4); against this background,

(English version First et al., 2015) will
questions of differential diagnosis must be completed, the “Structured Clinical
also be discussed both in clinical practice Interview for DSM-IV” (SKID-IV; Wittchen
and in the context of expert opinions et al., 1997) will be used, which is currently
(7 Sect. 8.5).

certainly one of the most frequently used
55 In addition to classificatory diagnostics, interviews. It is utilized to record and diag-
the acquisition of further information is nose selected mental disorders as defined
necessary for therapy planning. Of par- in DSM-IV. The PTSD section allows the
ticular relevance is the recording of recording of trauma-related disorders.
maintenance factors (7 Sect. 8.6.1) and

The SCID does not offer the possibility
secondary functional impairments (e.g. of recording diagnostic criteria for acute
in the social and occupational areas; stress disorder (ASD). The following section
7 Sect. 8.6.2).

describes the basic procedure, which does
55 The recording of resources and compe- barely differ between SCID-IV and SCID-5.
tencies complements the diagnostics in The interviewer usually only conducts
the context of therapy planning (7 Sect.

the PTSD section if there is an indication of
8.6.3). the presence of PTSD from the information
55 Finally, for quality assurance purposes, available.
it is useful to provide diagnostic support The assessment begins by asking the
for the implementation of therapeutic interviewer whether the patient has ever
measures (7 Sect. 8.6.4).
experienced a traumatic event.
127 8
The following questions are then used to 2017). For copyright reasons, the new DIPS
assess the existence of a traumatic experience Open Access integrates the DSM-5 criteria
as defined by the DSM (A criterion) and to in a paraphrased short form in the protocol
determine the worst traumatic event, includ- sheet. The answers are recorded on a sepa-
ing age at the time of experience. Questions rate protocol sheet. The diagnoses deter-
are then asked about other DSM criteria. mined according to DSM-IV-TR or DSM-5
The section ends with questions about the can easily be converted into ICD-10 diag-
course and severity of the disorder. noses (Dilling & Freyberger, 2013; WHO,
The interviewer assesses the presence of 1993).
the symptoms with The PTSD section begins with a detailed
55 “?” = “Information is insufficient” assessment of the potential trauma, screen-
55 “1” = “not available”, ing questions about the current symptoms
55 “2” = “subliminal presence” or and the duration of symptoms of existing
55 “3” = “present”. post-traumatic stress reactions. In addition
to the dichotomous recording of the char-
Jump rules after completion of all ques- acteristic core symptoms of PTSD, a com-
tions on a specific diagnostic criterion make bined rating of frequency and severity must
it possible to terminate the PTSD section be given for each symptom, that is, the latter
as soon as a criterion is judged as not to be cannot be assessed independently of each
fulfilled. In the SCID, the interviewer must other. The section ends with the assessment
code the criterion and not necessarily the of the impairment experienced as well as
patient’s answer. This requires the inter- detailed questions on the temporal classifi-
viewer to make a clinical judgment. cation of the symptomatology and the life-
The administration time for the SCID time prevalence.
is given as approximately 100 minutes for
inpatients and approximately 75 minutes for >>In addition to the detection of PTSD,
outpatients. For the PTSD section, which DIPS and DIPS Open Access allow the
has proven to be a reliable and valid mod- diagnosis of a currently existing acute
ule for the diagnosis of PTSD in numerous stress disorder (ASD), whereby, here too,
empirical tests, approximately 20 minutes symptom assessments are to be made on
should be planned for traumatized patients. the described frequency/severity scale.
However, it only provides a trichotome
symptom rating (non-existent – subliminally The assessment rule in the diagnostic algo-
present – present) and a trichotome rating rithm stipulates for both PTSD and ASD
for the severity of PTSD classified as present that a symptom is diagnostically relevant
(mild – moderate – severe). when it occurs continuously (for longer
than 1 month for PTSD; Falkai et al., 2015).
8.2.1.2 Diagnostic Interview Unfortunately, there is no information on
for Mental Disorders (DIPS) the usefulness of this rule in different pop-
The “Diagnostic Interview for Mental ulations, nor is there much information on
Disorders” (DIPS; Schneider & Margraf, the test-statistical quality criteria of the
2011) is the German version of the Anxiety two sections. The interrater reliability of
Disorders Interview Schedule (ADIS, Di the PTSD section of DIPS turned out to be
Nardo et al., 1983). It combines the objec- at least good to very good (Suppiger et al.,
tive of categorical diagnostics with the col- 2008). For the PTSD section of the DIPS
lection of therapy-relevant information. The research version (F-DIPS; Margraf et al.,
DIPS was adapted to DSM-5 (DIPS Open 1996), from which the DIPS for DSM-IV
Access: Margraf, Cwik, Pflug, & Schneider, emerged, the retest reliability proved to be
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
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
complex of complex PTSD or enduring Structured procedures, if carried out

personality change after the catastrophic according to their purpose, are far less subject
experience (EPCACE), or developmental to the risk of response tendencies (Perkins
trauma disorder (DTD). The use of SIDES & Tebes, 1984). This is of particular advan-
is therefore particularly recommended for tage, for example, when, in the context of an
patients who have been victims of type II expert opinion activity, it is necessary to iden-
trauma (7 Chap. 3, 7 Sect. 8.3.1.7).
tify artificially feigned or simulated PTSD.
The interview consists of 48 questions The decision, which of the procedures
that are assigned to 27 symptoms and can presented here should be used in the context
be assigned to the 7 symptom complexes of one’s own scientific or clinical activities,
that Herman (1993) names in her definition depends largely on the practicability of the
of complex PTSD (7 Chap. 3). This means
procedures and the objective of the diagnos-
that in the SIDES, between 1 and 9 ques- tic survey.
tions must be asked for each symptom in However, the interview methods pre-
order to determine the presence of a specific sented do not contribute sufficiently to the
problem. The questions are to be answered collection of therapy-relevant informa-
on a 3-step scale (behaviour or emotion: tion. As a rule, the procedures only record
mildly – moderately – severely problematic). the occurrence of the symptoms required
8 For each symptom, criteria are defined in for diagnostic classification, whereby the
the SIDES under which conditions it is con- statements about their presence are usually
sidered “present”. only categorically documented. Topics that
In the meantime, SIDES has proven in are essential for therapy planning are not
several empirical studies to be a reliable addressed at all.
and valid method for recording the above-
mentioned symptoms (Teegen & Vogt, >>The burden on patients resulting from the
2002). exploration of traumatic events is gener-
ally limited (Jaffe et al., 2015). It is recom-
mended that interviews are carried out by
8.2.3 Evaluation of the Structured psychotherapeutically trained personnel,
or Standardised Interviews also in order to be able to employ stress-
reducing techniques if necessary (Gast
For reliable diagnostics and disorder classifi- et al., 2004).
cation, it is essential to conduct a structured
or standardized interview.
In clinical practice, standardisation 8.3 Self-Reports
is usually very well accepted by patients
(Hoyer et al., 2006). The use of these pro- Self-report instruments are particularly suit-
cedures can therefore be recommended. able for recording the frequency and intensity
However, it should be noted that although of symptoms and the resulting psychological
standardisation maximises the objectivity impairments from the patient’s perspective.
and reliability of the classification, it does The number of procedures designed spe-
not take into account certain sources of cifically for the diagnosis of post-traumatic
error such as incorrect understanding of mental disorders is now enormous. The
the question or tendencies in the answers, most important procedures for recording the
so that the validity of the diagnoses may be symptoms of PTSD are available as German
considerably reduced. translations.
131 8
8.3.1 Symptom Questionnaire In the published German version, the fre-
quency of stress reactions is recorded and
8.3.1.1 Impact-of-Event calculated on 4-level Likert scales accord-
Scale-Revised ing to the originally published mode and
the mode of the IES. However, the authors
Weiss and Marmar (1996) expanded the
of the original American version later pro-
IES and presented the “Impact of Event
posed to record not the frequency but the
Scale-Revised“(IES-R; German Maercker
extent of the stress resulting from the symp-
& Schützwohl, 1998), a procedure that addi-
toms, to code the responses on a 5-level scale
tionally takes into account items for the
and to offset them with the values 0, 1, 2, 3
assessment of hyperarousal (. Fig. 8.1).
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
1. Any reminder brought back feelings about it.

3. Other things kept making me think about it.
6. I thought about it when i didn’t mean to.
9. Pictures about it popped into my mind.
14. 1. I found myself acting or feeling like I was back at that time.
16. I had waves of strong feelings about it.
20. I had dreams about it.
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
2. I had trouble staying asleep.

4. I felt irritable and angry.
10. I was jumpy and easily startled.
15. I had trouble falling asleep.
18. I had trouble concentrating.
19. Reminders of it caused me to have physical reactions, such as sweating,
trouble breathing, nausea, or a pounding heart.
21. I felt watchful and on guard.
.. Fig. 8.1 Instruction and items of the “Impact of Event Scale-Revised” (IES-R). (Mod. according to Weiss
& Marmar, 1997)
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).
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
Have you had recurrent or intrusive distressing thoughts

or recollections about the trauma? yes no
If yes: How often did you experience this? If yes: How much did it affect you?
never 5 times per not at all very strong

week or more
often
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
3. Suddenly feelings or acting as

if the stressful experience were actually 0 1 2 3 4
happening again (as if you were actually back
there reliving it)?
.. 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.
The evaluation routine defines an item as 55 SPRINT (“Short Post-Traumatic Stress

fulfilled if it was rated 2 or higher. If one Disorder Rating Interview”; Connor &
item from symptom cluster B (questions Davidson, 2001; 8 items),
1–5), one item from cluster C (questions 55 SSS (“Short Screening Scale for DSM-
6–7), two items from D (questions 8–14), IV Posttraumatic Stress Disorder”; Bre-
and two items from cluster E (questions slau et al., 1999; Siegrist & Maercker,
15–20) are fulfilled respectively, there is clear 2010; 7 items),
evidence of PTSD. 55 PC-PTSD-5 (Primary Care PTSD for
The US American authors evaluated a DSM-5; Prins et al., 2015; German, still
cumulative score (range 0 to 80) of 33 or under validation; 5 items).
more as suspected PTSD. This was rep-
licated in the German validation study 8.3.1.7 Self-Report Instruments
(Krüger-Gottschalk et al., 2017). for Complex PTSD
55 SIDES (7 Sect. 8.2.2.2; Pelcovitz et al.,

8.3.1.5 Essen Trauma Inventory 1997) is also available as a questionnaire

The “Essener Trauma-Inventar” (ETI; version “Self-Report Inventory for Dis-
Tagay et al., 2007) is another differentiated orders of Extreme Stress” (SIDES-SR;
German-language self-report instrument Luxenberg et al., 2001; Spinazzola et al.,
8 that is available in both questionnaire and 2001). The inventory consists of 45 items
interview form and consists of 58 items. and is well suited for recording the sever-
In addition to the exploration of a large ity of symptoms for each of the 6 symp-
number of potentially traumatic events tom clusters as well as for monitoring the
in the first section, both the presence of a course of the disorder (Luxenberg et al.,
diagnosis of PTSD and ASD are recorded 2001). It is also available in two modified
in the following, in close orientation to the German language versions:
DSM- IV criteria. Beyond this categori- –– DESNOS (“Disorder of Extreme
cal diagnosis, the ETI allows the measure- Stress Not Otherwise Specified”; Hof-
ment of the expression of the 4 symptom mann et al., 1999) in the version pub-
areas of intrusion, avoidance, hyperarousal lished in the Cologne Documentation
and dissociation, and allows the severity of System for Psychotherapy and Trauma
the symptoms to be determined by means Treatment comprises 48 items (Fischer,
of a cumulative score; for this reason, the 2000; Kunzke & Güls, 2003) and the
authors emphasize the suitability of the complaint list cPTSD (Teegen et al.,
instrument for longitudinal diagnostics. 2001) with 72 items. The questionnaire
Cut-off values are provided to identify for the planned division into posttrau-
clinically abnormal values. The psychomet- matic stress disorder and complex
ric quality criteria of the ETI have so far trauma sequelae (Karatzias et al.,
proven to be good to very good (Hauffa 2017; Shevlin et al., 2018) is currently
et al., 2010; Tagay et al., 2007). only available in English.
55 The “Revised Trauma Symptom Inven-
8.3.1.6 Short Questionnaire tory” (TSI-2; Briere, 2011) is a question-
In the meantime, screening methods for the naire for recording complex post-traumatic
diagnosis of PTSD have also been published stress disorder. It has 12 clinical scales
and used in German versions. These include: (three more than in TSI-1; Briere, 1995),
55 SPAN (“Startle, Physiological arousal, some with subscales, plus 2 validity scales
Anger, Numbness”; Davidson, 2002; (atypical response behaviour, response
Meltzer-Brody et al., 1999; 4 Items), level) and 8 “critical items” to record psy-
135 8
chopathological abnormalities that poten- matic event is required for the diagnosis to
tially require rapid intervention. The be made. This can be systematically sup-
internal consistency of most scales is ported by trauma lists.
acceptable to very good (.73 to .95; Kram-
mer et al., 2017). 8.3.2.1 Trauma Lists
55 The “Screening zur komplexen Posttrau- 55 The “Life Events Checklist for DSM-5”
matischen Belastungsstörung” (SkPTBS; (LEC-5; Weathers, Blake, Schnurr, et al.,
Dorr & Bengel, 2017) differentiates (and 2013) can be used together with the PCL-5
for scoring purposes weights differently) (see above). The LEC-5 is a list of 17
its items on the A-criterion between those potentially traumatising events, for each
relevant for complex PTSD and classical of which information can be provided on
PTSD. The tool then proceeds to assess the extent of personal involvement (e.g.
further information on the event includ- whether it happened personally, witness-
ing risk and protective factors, as well as ing, etc.). This can also be expanded to
following associated symptoms in 14 include further questions to better qualify
items on a 7-pt.-scale. The authors pro- the A-criterion.
vide a PC assisted scoring. The scale 55 The “Trauma History Questionnaire”
showed good internal consistency (.91), (THQ), available in the English original
its items aligned fairly one-dimensionally (Green, 1996) and German (Maercker,
showing the scale’s homogeneousness 2002), lists in 24 items potentially trau-
(Dorr et al., 2016). Various cut-offs exist matic scenarios and allows affected per-
for different combinations of sensitivity sons to assess whether such an experience
and specificity values (Dorr et al., 2018). occurred (yes/no) and, if so, how often it
55 The International Trauma Questionnaire occurred, approximately at what age,
(ITQ; Cloitre et al., 2018) is a valid and and, if applicable, asks for a more detailed
reliable Measure of ICD-11 PTSD and description of the event.
Complex PTSD. It is freely available in the 55 There are trauma lists included in PTSD
public domain to all interested parties. It interviews and questionnaires such as
focuses on the core features of PTSD and DIAXX, PDS or ETI and more.
CPTSD employing diagnostic rules. It
consists of an introduction section for the
A-criterion followed by 6 + 3 items on 8.3.2.2 Traumatic Events
PTSD and additional 6 + 3 items on DSO in the Course of Life
(disturbances in self- organisation) on a 55 The self-report instrument “Childhood
five-point Likert-scale. The combination Trauma Questionnaire” (CTQ; Bern-
of the items defines complex PTSD. The stein & Fink, 1998) is available in Ger-
ITQ was developed to be consistent with man (Wingenfeld et al., 2010) and is
the organizing principles of the ICD-11, as suitable for retrospectively recording five
set forth by the World Health Organization forms of abuse and neglect in childhood
and is available in several languages (The and adolescence. In the long-form, it
International Trauma Consortium, 2020). consists of 70 + 3 items (the additional
ones record the tendency to trivialize), in
the short form of 25 + 3 events, whose
8.3.2 Instruments Assessing frequency of occurrence is given as a
Traumatic Events 5-level Likert scale. Sum scores can be
formed over the entire test and subscales.
In addition to the symptoms of PTSD, the 55 The questionnaire “Stressful Childhood
presence of an A-criterion, that is, a trau- Experiences” (KERF; modified German
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.

et al., 2010) were identified that best cov- 8.6.4.2).

ered its 5 dimensions on abuse and
neglect. >>The self-report instruments are all suit-
able for recording the severity of post-
8.3.2.3 Experience of Violence traumatic stress reactions, but only a few
55 The screening “Partner Violence” (PVS) procedures can separately record the fre-
(Nyberg et al., 2008) is a translation, quency and intensity of symptoms.
modification and validation of the
English-language PVS, Partner Violence A disadvantage of the instruments devel-
Screen (Feldhaus et al., 1997), which had oped specifically to detect PTSD is that they
3 items. In the German version, this was are subject to the risk of response tenden-
extended to 5 questions. It is thus well cies; they should therefore only be used in
able to identify cases of domestic vio- the context of multi-method diagnostic pro-
lence at an early stage. cedures.
55 The screening instrument “Index of The exploration of traumatic experi-
Spouse Abuse” (ISA) (Hudson & McIn- ences, as well as the psychological stress
137 8
symptoms experienced as a result, can be the traumatic event and whether it fright-
experienced as stressful in the short term ened the person affected), followed by 19
itself. However, systematic research on the items on symptoms in 5 levels. An evalu-
consequences of trauma-related surveys ation of a German-language variant
and the associated burden on respondents (Helfricht et al., 2009) is available.
shows that, as a rule, no negative effects on 55 The German version of the PAS (“Post-
those affected are to be expected in the long traumatic Adjustment Screen”, O’Donnell
term (Legerski & Bunnell, 2010). Instead, et al., 2008; German: Kröger et al., 2011),
from the perspective of the participants, the uses 10 items on a 5-point Likert scale to
positive effects of participating in studies ask for aspects that happened before, dur-
in which they provided information about ing or after a traumatic experience. These
traumatic experiences and the consequences include typical reactions, but also accom-
usually outweigh the negative effects (Jaffe panying circumstances.
et al., 2015).
8.4 Other Stress-Related 8.4.2 Enduring Personality

Disorders and Trauma Change after Catastrophic
Sequelae Experiences
Since the inclusion of PTSD in the classifi- The category of “Enduring personality
cation systems, posttraumatic stress disorder change after catastrophic experience” is
had been classified in the group of anxiety only defined in the ICD-10 (WHO, 1994)
disorders. In DSM-5 as well as in the future and is a precursor diagnosis of complex
ICD-11, stress-related disorders form a new PTSD. The disorder can be diagnosed when
group. This differentiation is also reflected the personality change, which can manifest
in the diagnostic recording. itself symptomatically, for example, in a per-
sistent hostile attitude “towards the world”,
social withdrawal or a persistent feeling of
8.4.1 cute Stress Reaction/Acute
A hopelessness, has existed for at least 2 years
Stress Disorder and is restricting functionality in a person.
In its conceptualisation, it is similar to the
The diagnostic criteria of the acute stress concepts of developmental trauma disorder
response (in DSM-5: acute stress disorder) or complex PTSD.
differ from PTSD mainly in the time crite-
ria of symptom development and duration.
Stress reactions begin earlier after the event 8.4.3 Adjustment Disorder
and are of very limited duration, especially
in the design of the ICD-10. There are proce- An adjustment disorder is diagnosed when
dures for the specific recording of the symp- a stress response occurs, the diagnostic
toms of ASD according to DSM- IV. An criteria of PTSD are not met or the stress
adaptation of the instruments according to response occurs after an event that cannot
the criteria of DSM-5 has not yet been car- be described as traumatic (e.g., termina-
ried out. tion, separation, or unemployment). In the
55 The “Acute Stress Disorder Scale” research literature, manifestations of the
(ASDS; Bryant et al., 2000) has two ini- former are often referred to as partial or
tial questions (request for a description subsyndromal PTSD. A separate empirical
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-
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-
ondary dysfunctions of PTSD, overlap 8.5.6 Intermittent Explosive

significantly with the criteria of a bor- Disorder (IED)
derline personality disorder, for example,
impulse control disturbance, anger reac- Intermittent explosive disorder (IED) is
tions, suicidal tendencies, or instability in characterized by verbal or physical aggres-
affect (Driessen et al., 2002). In addition, sive behavioural outbursts. The outbursts
it is a generally known finding that persons are not in proportion to previous psycho-
with borderline personality disorder were social stress or provocation and are not
often traumatised in their early childhood. planned (Falkai et al., 2015). In DSM-5 the
Nevertheless, it should be noted that trau- IED is listed as a separate diagnosis. In the
matisation is not causally related to bor- ICD-10, this trauma-associated symptom-
derline personality disorder. Therefore – if atology could most suitably be subsumed
the criteria of both disorders are fulfilled –under F63.8 “Other habit and impulse dis-
this should also be documented in terms of orders” or, if distrust and social withdrawal
co-morbidity. are the main focus, under F62.0 “Enduring
personality change after catastrophic expe-
rience”. Irritability and outbursts of anger
8.5.5 Dissociative Disorders
8 can also occur in the context of hyper-
arousal in PTSD, but central PTSD crite-
Dissociative symptoms can be part of post- ria such as re-experience and avoidance are
traumatic symptomatology or can exist missing in IED.
separately and complicate the symptomatol-
ogy. They are characterised by a disruption
of the normal integration of consciousness,
memory, identity, emotions, perception, 8.5.7 Intentional Production or
body image, control of motor functions, Feigning of Symptoms or
and behaviour. If the full-blown picture Disabilities
of PTSD is also present, the diagnosis of
PTSD with dissociative symptoms should be The distinction between artificially feigned
considered (Falkai et al., 2015). The follow- stress reactions, usually with unclear moti-
ing instruments are available for the assess- vation, and the presence of “real” post-
ment of dissociative symptoms: traumatic stress reactions is difficult and
55 Structured clinical interviews: requires a diagnostic procedure on several
–– “Structured clinical interview accord- levels. A differential diagnostic criterion is
ing to DSM” (SKID-D; Steinberg, that patients with this pattern of behaviour
1994; Gast et al., 2000); exhibit the symptoms of other personality
–– “Structured interview for the diagno- disorders. The use of personality diagnos-
sis of dissociative disorders” (SIDDS; tic procedures – such as SKID-II (Wittchen
Ross et al., 1989; Overkamp, 2005); et al., 1997) or the “Personality Style and
55 Self-report instruments: Disorder Inventory” (Kuhl & Kazén, 1997) –
–– “Questionnaire on dissociative symp- is therefore recommended when there is a
toms” (FDS; Freyberger et al., 1999; suspicion of artificial feigning.
Spitzer et al., 2014) or its original
English counterpart “Dissociative
Experiences Scale” (DES; Bernstein & 8.5.8 Simulation
Putnam, 1986)
–– “Cambridge Depersonalisation Scale” The possibility of simulation should be con-
(CDS; Sierra & Berrios, 2000). sidered if a (e.g. financial or forensic) benefit
141 8
can be expected from the presence of post- 8.6 Collection of Additional
traumatic stress reactions. Behaviours that Therapy-Relevant Information
indicate simulation are, for example, unco-
operative or evasive behaviour in response For therapy planning, in addition to classifi-
to requests for a detailed description of the catory diagnostics before the start of ther-
symptoms as well as the idealisation of the apy, the acquisition of further information
pre-traumatic health and social situation. is necessary. In the context of PTSD treat-
Simulation in the form of presenting non- ment, this concerns above all the recording
existent complaints is very rare; it tends to of factors that maintain or determine the
exaggerate actual symptoms (Birck, 2002), course of therapy, possible comorbid disor-
especially in certain interview contexts, for ders, and secondary functional impairments.
example, in the work context (Goodwin In addition, the assessment of pre-traumatic
et al., 2013). health, as well as available resources and
skills, deserves attention.
Information on these topics can be col-
8.5.9 rganic Diseases (E.G. Brain
O lected in the anamnestic interview. The
Injuries) following explanations focus on the presen-
tation of recording procedures that can be
Complaints similar to PTSD symptoms can used beyond that.
also occur with organic diseases. If patients
who have been proven to have been exposed
to a potentially traumatising event are 8.6.1 ecording of Factors that
R
suspected of having such symptoms – for Maintain or Determine
example, against the background of known
the Course of Therapy
somatic illnesses or other for example, neu-
ropsychological disorders – the appropriate 8.6.1.1 Questionnaire on Thoughts
specialist medical examinations should be
After Traumatic Events
considered.
and Questionnaire
on the Processing
8.5.10 Somatoform Disorders/ of Traumatic Experiences
Somatic Stress Disorders PTSD often remits in the first year after
trauma exposure and only takes a chronic
Somatoform disorders are physical com- course in some patients. Presumably,
plaints that cannot be traced back to organic interpretations, beliefs, and attitudes that
disease or cannot be traced back sufficiently. increase the extent of the burden during re-
Connections between chronic pain and experience and thus trigger and reinforce
PTSD have been shown (e.g. Fishbain et al., escape and avoidance tendencies, so that
2017). Somatoform disorders are often more habituation cannot take place, contribute
pronounced in patients with existing trauma to maintenance (Ehlers & Steil, 1995). In
than in patients without traumatic experi- order to record a wide range of such cog-
ences and the burden of such symptoms nitions, the “Posttraumatic Cognitions
increases as the post-traumatic symptoms Inventory“(PTCI, by Foa et al., 1999;
increase (Kuwert et al., 2015). German Ehlers & Boos, 1999) and the
“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
143 8
.. Table 8.1 Overview of questionnaire procedures for recording guilt, shame, and anger
Procedure Content Evaluation
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.”
and self-management skills using 66 +3 regarding therapy demand, cooperation,

items. The scales include change motiva- self-opening, and trial and error. Grawe and
tion, coping, and self-efficacy. Braun (1994) suggest using hour sheets to
55 The “Questionnaire on Current Resource record process quality, on which the patient
Realization” (RES; Trösken & Grawe, and therapist independently assess the qual-
2002) contains items on 9 scales, includ- ity of each individual therapy session. Since
ing, for example, well-being, coping with the success of therapy is closely related
everyday stress, personal strengths and to patient satisfaction (ibid.), continuous
abilities. The number of items per scale recording of patient evaluations allows early
varies from 11–21. recognition of difficulties.
55 The “resilience questionnaire” (RS-13;
Leppert et al., 2008) is the short form of >>The collection of further information is
the RS-25, which was developed in the essential for individual therapy plan-
Anglo-American area (Wagnild & ning. Questionnaires can also prove use-
Young, 1993) and validated for the ful in this context. The recording of
German- speaking area (Schumacher process quality and the effect of therapy
et al., 2005). The RS-13 has two sub- should complete the diagnostic measures
scales for measuring resilience (compe- in the course of therapy.
8 tence and acceptance).
55 The German-language inventory Brief- 8.6.4.2 Evaluation of Treatment
COPE (Knoll et al., 2005) is based on Outcome
the English-language version (Carver, The assessment of therapy effects serves to
1997) and uses 14 dimensions with two estimate the achieved therapy success or to
items each to record different coping identify the lack of thereof. Pre-post mea-
strategies in dealing with problems. surements with the self-report procedures
developed to record post-traumatic stress
reactions are a suitable way of doing this.
8.6.4 Diagnostics Accompanying In addition, the “Treatment Outcome PTSD
Therapy Scale” (TOP-8; Connor & Davidson, 1999)
is a procedure specially developed for the
It makes sense to supplement the implemen- evaluation of results. The use of TOP-8,
tation of therapeutic measures by gathering also in scientific studies, is recommended by
information on their course (process and the expert commission already mentioned
treatment evaluation) and effect (outcome above (Charney et al., 1998).
evaluation). An overview of measuring For the evaluation of treatment out-
change can be found in Stieglitz and Hiller comes, the assessment by the patient and
(2015). the therapist also proved to be useful. With
the goal attainment scaling (Roecken, 1984;
8.6.4.1 Process and Treatment Schulte, 1996), the achievement of concrete
Evaluation treatment goals defined in the context of
The process and treatment evaluation serves therapy planning can be assessed.
to record the process quality of diagnos- It is also interesting to examine whether
tic and therapeutic measures. According the changes achieved in the course of ther-
to Schulte (1996), process quality can be apy are also reflected in measures of life sat-
recorded economically by the therapist mak- isfaction and the general level of function.
ing a rating of patient behaviour after each For this purpose, a number of survey meth-
session and evaluating it on scales of −3 to ods are available which have already proven
145 8
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8
153 9
Expert Evidence
Contents
9.1 Background – 154
9.2 General Conditions – 155

9.2.1 S ocial Compensation Rules – 155
9.2.2 Basic Expert Terms – 156
9.2.3 Basic Psychotraumatological Terms – 157
9.3 Determination of Causality – 159

9.3.1 T heories of Causality (Krasney, 2001) – 159
9.3.2 Steps of the Assessment Using the Example of the Statutory
Accident Insurance – 159
9.4 articularities and Problems of the Assessment of Psy-

P
choreactive Disorders and Behaviour – 161
9.5 Methodology of the Assessment – 165

9.5.1 ountertransference – 165
C
9.5.2 Survey of the Past History – 166
9.5.3 Psychopathology and Classification – 166
9.5.4 Psychometry/Test Diagnostics – 167
9.6 ssessment of Asylum Seekers and After Political

A
Detention – 169
Literature – 170
154 U. Frommberger et al.
9.1 Background therapist, and must also critically examine

whether aggravation or even simulation may
The diagnosis of “post-traumatic stress play a role in the often assumed desire for a
disorder” (PTSD) has perhaps influenced pension, for example. The assessor is com-
and is influenced by the courts more than mitted to objectivity and neutrality. He must
any other mental disorder. The diagnosis integrate the following parameters in the
of PTSD and various diagnostic precursors expert opinion:
(e.g. “traumatic neurosis”) make it clear that 55 the general knowledge of mental disor-
an external event can causally cause a men- ders,
tal disorder. The reliability and validity of 55 the current scientific state of the art,
this diagnosis has been and continues to be 55 the psychopathological findings and bio-
called into question, especially when unjus- graphical history of the individual to be
tified claims have led to compensation and examined,
alleged misuse of the diagnosis has become 55 the legal framework.
apparent. This diagnosis and the associated
legal issues are increasingly occupying the This integrated knowledge has to be
courts. An often expressed expectation of adapted to the individual case of each
the victims is to receive recognition in the victim or survivor and critically weighed
proceedings for suffering and injustice suf- up. On the one hand, the task places high
fered. demands on the expertise of the reviewer,
9 Often, the plaintiffs are appointed a psy- but on the other hand also on his or her
chiatric or psychological expert to assess ability to integrate existing expertise, the
this subsequent disorder and the conse- information provided by the respondent
quences associated with it. Careful examina- and direct findings from the exploration,
tion and (differential) diagnosis, including a regardless of personal attitudes and opin-
precise trauma anamnesis, are therefore ions, in order to do justice to the situation
absolutely necessary. of the person to be evaluated.
Traumatic events are frequent: For exam- In the social law assessment, mental ill-
ple (type I trauma), more than 8 million acci- nesses are generally not subject to different
dents/year in Germany can have both standards than physical illnesses. Mental
physical and psychological consequences disorders are now recognised more fre-
(Angenendt, 2014). However, not only type I quently than in earlier times.
traumas such as accidents are the subject of The German AWMF Guideline 051-029
the assessment. Type II traumas such as (AWMF, 2019) can be helpful in the assess-
abuse in childhood and adolescence, which ment of trauma sequelae, the first part of
are often understood as complex PTSD, are which deals in detail with the assessment of
also increasingly being assessed (7 Chap. 3).

professional performance and the second
Psychological trauma is playing an increas- part with the causality assessment of psy-
ingly important role in socio-medical reports, chological damage consequences. It serves
as well as a reason for retirement. A consid- to improve quality, sets standards and is cur-
erable proportion of asylum seekers are con- rently being revised.
sidered traumatised. However, only a smaller Many things cannot be presented in a
proportion of those affected develop long- space-limited book contribution, or not in
term mental disorders after traumatisation, detail. Besides some basics, the focus is on
of which PTSD is only one and for which the practical and action-relevant aspects.
several differential diagnoses are possible. Therefore, this chapter can only give hints
The expert is not a party empathizer, not a and decision support in the overview. It does
Expert Evidence
155 9
not replace the study of the national litera- ity, but on the basis of the prevailing
ture on typical trauma sequelae. scientific doctrine and current classifica-
This article focuses primarily on the tions of the ICD (WHO) and the US
socio-medical assessment. Assessments of American DSM.
credibility and in criminal proceedings are
not the subject here. In this respect, refer- >>The assessor may not be able to clarify all
ence is made to further literature, for exam- the client’s questions comprehensively or
ple, Stang and Sachsse (2014). even take decisions from the client, even
if he is urged to do so. In this case, he
should make this clear.
9.2 General Conditions
The expert assessment of the psychological 9.2.1 Social Compensation Rules

(processes and/or) consequences of trauma-
tisation serves primarily as a basis for benefit A compensation scheme can not only do
decisions by the funding agencies/provision justice to the subjective, individual view-
administration or – in the event of a dis- point but must also compare with many
pute – the courts. The expert must be aware other damage consequences and put pos-
that it is not he who decides on the recogni- sible compensation in relation to each other.
tion of the consequences of damage, but the National guidelines are subject to con-
institutions to be advised. For this reason, stant revision. Indicators of German guide-
in addition to the medical-scientific findings lines contain (according to Rösner, 2008)
and criteria, the legal framework, terms and 55 Practical advice on the preparation of
definitions must also be taken into account the expert opinion,
and the expert opinions must – as far as pos- 55 Explanations of the relevant basic terms,
sible – be drafted in a manner that is under- 55 All legal terms and special terms relevant
standable to medical laypersons. In addition to the assessment,
to classifying the complaints in a psychiatric 55 Notes on the causality evaluation.
classification system, the functional impair-
ments and their effects on working life and
private life must be assessed.
The reviewer is always confronted with As a special feature of the German
his limits. He should use as many data Victims’ Compensation Act (VCA,
sources as possible, gather information and Opferentschädigungsgesetzes), the inten-
collect the current psychological findings. tional, criminal assault must have led
However, he is not free of errors and is not directly to physical or psychological
immune to possible deception. He should injury. The causal link between the act
therefore collect his findings as comprehen- and the psychological consequence is
sively as possible, describe them precisely essential for recognition under the
and discuss them. According to the legal VCA. Furthermore, the primary damage
opinion, “processes in the mental and emo- must have caused a health disorder of a
tional area of a person should be assessed, certain duration with sufficient probabil-
… as far as possible closed to a precise ity (Loytved, 2005). The damage must
examination” (Loytved, 2005, p. 151). The have occurred on national soil (land, ship
experienced reviewer can contribute to the or aircraft). For a discussion of this prob-
examination and assessment with his exper- lem, area see Stang and Sachsse (2014).
tise, even without using technical objectiv-
9.2.2 Basic Expert Terms On the other hand, it is sufficient that

the causal connection between the estab-
9.2.2.1 Chain of Cause and Effect lished facts is probable, that is, that a
critical assessment of the facts and all
A contextual assessment in civil and social
relevant medical and scientific findings
law presupposes a causal chain (a-d) deter-
shows that there is more to a causal con-
mined by 4 elements (Spellbrink, 2013):
nection than against it. (Krasney, 2001,
(a) Is the situation insured? (e.g. the way to
p. 124)
work).
(b) What is a damaging event? (to be proven 9.2.2.3 Shift of Causality
in full evidence); (liability establishing
According to Schönberger et al. (2017),
causality between the accident and the
when assessing disorders that persist over
first damage).
longer periods of time, it is also necessary
The assessor has to deal with the liability
to assess whether the cause of the symptoms
substantiating causality (i.e. the connec-
has not changed compared to the original
tion between the first damage and the
one. It is necessary to examine and weight
consequential damage):
the various factors that come into ques-
(c) What is the (primary) damage to health?
tion (so-called competing factors) (theory
(to be proven in full evidence, the so-
of essential condition). If the causes related
called “primary damage”).
to the accident have ceased to exist or have
(d) What is the (permanent) damage to
9 health? (to be proven in full: “conse-
been replaced in their quantitative signifi-
cance by others, this is called “shift of the
quential damage” or “secondary dam-
essential condition”. The consequences are
age”).
a staggering or change in the level of impair-
ment.
The administration or insurance company
must clarify the causality of the liability. 9.2.2.4 Prior Damage
It must also be examined whether a dam-
Some test persons have already developed a
aging event has caused damage to health
previous mental illness (psychological pre-
or whether pre-existing damage has been
disposition) before the trauma. It is, there-
aggravated.
fore, necessary to assess whether trauma
In social compensation law and statutory
sequelae (e.g. after an accident) that have
accident insurance, the causality that gives
been detected and diagnosed is an exacerba-
rise to liability and the causality that fills the
tion or an independent new mental disorder.
liability must be proven with a predominant
The distinction between psycho-reactive
probability.
disorders as consequences of imprisonment
9.2.2.2 Full Proof and torture as consequences of imprison-
ment and torture of damage-independent
Krasney (2001) defines full proof as follows:
neurotic disorders is also important in the
»» All facts must be fully proven, that is, the case of consequences of imprisonment and
degree of probability must be so high torture (Haenel, 2002). Stevens and Foerster
that it equals certainty. If no clear evi- (2002) describe the complex expert opin-
dence can be obtained for one of the ion problems of chronic consequences of
facts, the expert must at least be able to child abuse in the assessment according to
come to the firm conclusion, based on the German VCA and emphasise the con-
the facts established, that this is the way nections between genetic disposition, the
it was and no other way. resulting increase in the risk of psychologi-
Expert Evidence
157 9
cal trauma sequelae and the weighting of a has been shown that the classification of an
damaging event within the framework of the event as trauma in the sense of PTSD may
causality norms (Stang & Sachsse, 2014). well differ between experts.
9.2.3 Basic Psychotraumatological Classification of Traumatic Events

55 The event can
Terms
–– be a physical injury (e.g. circular
9.2.3.1 The Traumatic Event saw amputation, blunt abdominal
trauma, craniocerebral trauma) or
Even after serious, traumatising events, –– cause an exclusively psychologi-
many people do not develop manifest men- cal injury (e.g. experiencing a rob-
tal disorders. It is, therefore, necessary to bery as a cashier or a run over
explore the particular circumstances and trauma as a train driver)
contexts, the objective and, above all, the 55 The psychological consequences can
subjective ones that contributed to the develop
development of PTSD. –– immediately or shortly after the
To diagnose PTSD, it is first necessary to event, or
clarify whether the event meets the corre- –– with a time delay to the event (e.g.
sponding criteria. Different trauma defini- if the initial physical consequences
tions are used in the two currently valid of the accident are dealt with and
international diagnostic systems DSM-5 their lasting consequences become
and ICD-10 (7 Chap. 2).

apparent)
The ICD-10 lists as qualifying events –– delayed after renewed extreme
natural or man-made disasters, an act of stress or (cumulative) trauma
war, a serious accident or witness to the vio- 55 A distinction must be made between
lent death of others or even victims of tor- –– a single event (e.g. trauma type I) or
ture, terrorism, rape or other crimes. –– several events (e.g. trauma type
The DSM-5 also lists physical assault, II) cause the symptoms and
robbery, road raid or serious traffic acci- –– the significance of each individual
dents as examples. Physical abuse in child- event or which is the essential
hood, threatened or actual sexual violence, event for the symptomatology to
kidnapping, hostage-taking, captivity as a be assessed
prisoner of war are also cited as events. In 55 The weighting of the individual fac-
addition, acute medical incidents that meet tors/conditions for the development
the criteria of a traumatic event are now and maintenance of mental symp-
also included (sudden catastrophic events toms should be assessed for the fol-
such as waking up during an operation, lowing determinants,
anaphylactic shock, life-threatening bleed- –– the event itself (e.g. PTSD A cri-
ing). It is also stressed that traumatic expe- terion fulfilled?)
riences need not be limited to the listed –– the pre-morbid personality and its
experiences. coping strategies (e.g. dependent
For the reviewer, the choice of one of the personality? regressive behaviour?)
two definitions does not make things easier. –– the social environment (e.g. dis-
It is advisable to take into account possible satisfaction with the job, difficult
differences and deviations in the evaluation financial situation?)
and to discuss them critically. In practice, it
sive movements (i.e. voluntary, active

–– subjective expectations (e.g. nega- muscle movements controlled by the cere-
tive future prospects; are all conse- bral cortex). These are states of arousal
quences subjectively attributed to with often blind movement storms and
the event liable for compensation? panic-like escape, defence and attack reac-
demand for justice?) or tions. They prolong the decay phase of the
–– subjective evaluations (e.g. the terror beyond the terror experience.
employer/company is at fault and Horror is more extensive than terror and
should pay?) at the same time contains the characteristics
of horror, despair and panic. It is still a gen-
eral biological reaction; even in the case of
The consequences of DSM-5 for the assess- more intense fright, there is a normal psy-
ment of trauma sequelae are discussed by chosomatic process with physical repercus-
Denis et al. (2014) also for a social compen- sions on mental influences, which is easily
sation law. tolerated by healthy people. Severe fright
alone is therefore not a health hazard, but a
9.2.3.2 Initial Reaction to an Event vital reaction within the norm, which varies
In assessing psychological reactions to greatly from person to person. It becomes
accidents at work, courts often refer to noticeable in terms of accident law if it
the extensive work of Schönberger et al. causes an illness. Case law has recognised
9 (2017), which compiles, among other things, fright in connection with overexertion as an
the literature of psychiatrists, court deci- accident at work. The shocking effect takes
sions and commentaries. The terms fright place in the area of the vegetative nervous
and shock are used repeatedly in descrip- system (physical-vegetative reaction) and
tions of the experience and are often used represents the organic-material interrelation
synonymously. However, the terms must of the shock experience.
be distinguished and are quoted hereafter While consciousness is necessary for
Schönberger et al: the reaction to take place, the real acciden-
»» … 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.
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.
The scientific concept of causality origi-

nates from classical mechanics, is bound to 9.3.2 Steps of the Assessment
the experimental situation and thus reduces Using the Example
complexity (in vitro situation). It is rather of the Statutory Accident
not appropriate for the complex clinical- Insurance
evaluation situation. This complexity must
be related to the legal-normative concept of Using the example of statutory accident
causality (Leonhardt, 2002). insurance, the following will explain the main
steps of the assessment. The basis is a judge-
ment of the German Federal Social Court
9.3.1 Theories of Causality second Senate of 9. 5. 2006 (B2U1/05R),
(Krasney, 2001) from which is quoted in the following
55 The insured person must have been per-
“The theory of adequacy applies in civil law, forming an insured activity at the time of
especially the accident.
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,
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 addition 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

must be consulted. attempts to detect aggravation or simulation

are the “Structured Questionnaire of
zz Aggravation and Simulation Simulated Symptoms” (SFSS) and also sub-
Aggravation represents actions that are tests in the “Eysencks Personality Inventory”
intended to underline the severity of the (EPI), “Minnesota Multiphasic Personality
subjective symptoms and the possibly minor Inventory” (MMPI) (Lehrl, 2001). Stevens
objective symptoms. The simulation, on the and Merten (2007) estimate that in half of
other hand, is a deliberate misstatement all cases with compensation claims com-
(7 Sect. 8.5.8).
plaints are exaggerated or expanded. This
view does not necessarily coincide with that ◄◄

Example: Cervical Spine (Cervical)
of many trauma experts, who estimate this Acceleration Trauma
figure to be much lower. Merten (2004) calls Stevens (2006) and Eisenmenger (2008)
for the use of special symptom validation report critically on the history of the term
tests to assess neuropsychological issues. cervical spinal distortion and the problems of
This is critically discussed in the AWMF this very controversial diagnosis. Causality,
guideline for the assessment of chronic pain pathophysiology and diagnosis are highly
(2017). controversial in most of the complaints.
Mayou (1995, pp. 796 f.; translation and There is often a lack of validity, reliabil-
additions in brackets by the author) stated ity and objectivity (Poeck, 2001). “Almost
after numerous investigations and studies on without exception” the clinical, neurologi-
traffic accident injuries cal and radiological evidence of injury fails
55 “… the evidence for deliberate exaggera- (Schröter, 2008). He describes in detail the
tion of the consequences of an accident, methodology of the assessment. Stevens does
for simulation or disproportionate not regard the syndrome as a nosologically
demands is remarkably low in a study of valid construct, expects a high prevalence
almost 200 subjects…”. of aggravation and classifies it most likely
55 Only] “a small percentage of people among the somatoform disorders. The guide-
invent the burdens and disabilities and lines of the Association of Scientific Medical
others exaggerate willfully.” Societies (AWMF Guidelines) on the accel-
9 55 “Terms such as exaggeration or simula- eration trauma of the cervical spine provide
tion are rarely appropriate.” a more differentiated picture that cannot be
55 “…a large number of people receive rela- presented in detail here. ◄
tively little attention and are under-
cared-for by doctors and too little zz Existing Conflicts and Personality Traits
noticed by the compensation system.” Schönberger et al. (2009) assume that in the
presence of existing conflicts, a traumatic
In addition, Mundt (2007) reflects on the event can represent a specific stimulus in
functionality and complex processes of sim- the sense of a situation of temptation and
ulation and aggravation and gives hints for a failure. As a consequence, the pre-existing
deeper understanding of these phenomena. conflict is “shifted” to the trauma. The acci-
Philipp (2016) found in a sample of more dent event meets a latently existing neurotic
than 110 expert reports that aggravation was structure and is the final cause (= “trigger”)
a more common phenomenon, but the simu- for the manifestation of neurotic symptoms.
lation was not found in any case. Such an assessment in an individual case
requires proof that existing symptoms and
zz Disease Gain from the Diagnosis PTSD pre-traumatic structure correspond. It also
According to Meermann et al. (2008), due requires positive evidence of pre-traumatic
to its etiological component, the diagnosis conflicts or personality traits. Hypothetical,
of PTSD can also be “used” to mystify one- assumed and unproven conflicts must not
self in terms of a primary gain in disease lead to a denial of manifest trauma sequelae
(victim) identity or to instrumentalize it in in the assessment. The mere assumption
terms of a secondary gain in disease in a of conflicts independent of events or pre-
financially profitable way. morbid personality traits is not sufficient.
Expert Evidence
165 9
For these possible competing factors, too, 55 as no therapy is given here, a more pass-
expert evidence in the sense of full proof able worsening of the symptoms could
would be required. occur afterwards,
55 all information on the client has to be
zz Change Through Therapy Successes passed to the principal
Wehking et al. (2004) report from a follow- 55 affective and physiological reactions can
up of accident patients of inpatient treat- be observed during the assessment
ment. The most favourable therapy results
were achieved in inpatient treatment before There is the view of Fabra (2006) that the
the end of the first year of the accident. They only valid criterion for PTSD in the explo-
found evidence that mental disorders follow- ration of trauma must be a PTSD-typical
ing accident events can be improved even psychophysiological response. While, on the
in the chronicity stage by consistent, cause- one hand, this requirement could differenti-
related (inpatient) treatment measures. Pre- ate at least the mild from the severe cases,
existing mental disorders were found in 60% there is a clinical consensus that even in the
of the patients in the sample investigated. case of a proven severe disorder, the PTSD-
One US study found no significant dif- typical psychophysiological response does
ference in symptomatic response to inpa- not necessarily occur when, for example
tient therapy between veterans who expected 55 the subjects try to “keep their compo-
higher compensation payments and those sure” and are rather embarrassed to allow
with stable compensation payments (Belsher and show feelings and physical reactions
et al., 2012). and/or
Psychotherapy or the use of psychotro- 55 the fear of affective inundation becomes
pic drugs can bring about a lasting reduc- too great and existentially threatening so
tion in symptoms and improvement in that the effects must be fended off as self-
performance. This sustained improvement protection (isolation of effects / affective
then affects the level of impairment. blunting/numbing/dissociation),
55 the persons concerned have repeatedly
zz Time Expenditure and Remuneration confronted themselves with the trau-
The time required for an in-depth expert matic memories during trauma-focused
opinion that takes into account the aspects psychotherapy.
and requirements mentioned here is often
considerable. Unfortunately, the remunera- The validity of Fabra’s above claim is there-
tion for high-quality work is not necessarily fore questionable, and to the best of our
adequate despite adaptation. Some payers knowledge, there is no empirical evidence to
(institutions /clients) only pay very unsatis- support it. However, if such a psychophysi-
factory remuneration. ological reaction occurs during exploration,
it is helpful in terms of a clear indication of
the existence of PTSD.
9.5 Methodology
of the Assessment 9.5.1 Countertransference
At the beginning of an assessment, it may be If, on the one hand, it is the reactive psycho-
valuable to give informations to the person that logical symptoms themselves that can stand
55 test results can only be used well with in the way of an objective expert opinion,
optimal cooperation, on the other hand, it can be the attitude of
55 the willingness to exert can also be tested, the expert towards the survivor and his or
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.
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.
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
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173 II
Therapy
Contents
Chapter 10 arly Psychological Interventions – 175

E
Chapter 11 Systematics and Effectiveness of Therapy

Methods – 203
A. Maercker
Chapter 12 sychodynamic Treatment of People with

P
Trauma Sequelae – 215
Chapter 13 Cognitive Behavioural Therapy – 235

T. Ehring
Chapter 14 ye Movement Desensitization

E
and Reprocessing (EMDR) – 261
Chapter 15 ow-Threshold and Innovative

L
Interventions – 285
Andreas Maercker
Chapter 16 reatment of Complex PTSD with

T
STAIR/Narrative Therapy – 297
Chapter 17 ialectical-Behavior Therapy for Complex

D
PTSD – 317
M. Bohus
Chapter 18 pproaches of Culturally Adapted Cognitive
A
Behavioural Therapy – 331
D. E. Hinton
Chapter 19 Psychopharmacotherapy of Trauma

Sequelae – 347
Chapter 20 herapy of Prolonged Grief Disorder – 361

T
Chapter 21 herapy of the Adjustment Disorder – 375

T
175 10
Early Psychological
Interventions
Contents
10.1 Primary Prevention – 177

10.1.1 E xposure Control and Structural Prevention – 177
10.1.2 Preparation, Education, and Training – 177
10.2 Protective and Risk Factors, and Risk Symptoms – 178

10.2.1 rotective and Risk Factors – 178
P
10.2.2 Acute Stress Reaction and Acute Stress Disorder – 180
10.3 Care of Acutely Traumatized People – 182

10.3.1 sychosocial Acute Care – 183
P
10.3.2 Practical and Social Support as well as Co-care for Significant
Others – 184
10.3.3 Screening, Monitoring and Indication of Further
Treatment – 184
10.3.4 Psychoeducation – 185
10.3.5 Specific Early Interventions – 186
10.4 Psychosocial Emergency Care – 190
10.5 Outlook – 192
Literature – 193
176 J. Bengel et al.
Experiencing an emergency, a serious The frequency of traumatic events and

accident, acute and life-threatening medi- the prevalence of trauma sequelae, but
cal conditions, abuse, violence, threat- also the acute psychosocial stress of those
ening forms of stalking, kidnapping, or affected, justify preventive and early mea-
hostage- taking, a terrorist attack, a war sures. However, it is still largely open for
event, torture, or a natural disaster is which persons or groups of persons, at what
always associated with psychological stress time, in what quality, form and intensity
and an adjustment reaction. This can also and by whom the intervention is to be car-
affect eyewitnesses, relatives, survivors, ried out. For many of the existing concepts
helpers, and emergency services. The reac- and proposed measures, there are no empiri-
tion following such an event can manifest cally based indication criteria and they have
itself in an acute stress reaction (ICD), an not been sufficiently evaluated with regard
acute stress disorder (DSM) and/or in the to their effectiveness (7 Sect. 10.4; Aus-

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-
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).

A multi-level program for the prevention

of operational consequences and especially
PTSD has been developed by the US Army 10.2.1 Protective and Risk Factors
(“Comprehensive soldier fitness”, CFS; Bates
et al., 2010; Casey & Lindhorst, 2009; Rees, Protective and risk factors are usually divided
2011). The basic components provide for the into pre-traumatic, peri-traumatic and post-
promotion of resilience at the level of the traumatic factors. Contrary to earlier assump-
179 10
tions, pre-traumatic and biographical aspects the other hand, has not yet been sufficiently
show less of a correlation with the later devel- investigated; due to methodological prob-
opment of trauma sequelae than peri- and lems, the available studies do not allow clear
especially post-traumatic influences. conclusions to be drawn, except for depres-
Mental disorders in the family are asso- sion as an indicator of general psychological
ciated with an increased risk of trauma stress (Maercker & Bengel, 2017).
sequelae. This suggests genetic vulnerability As expected, regarding peri-traumatic
(Boscarino et al., 2013; Klengel et al., 2013; risk factors, the type and severity of the
Nievergelt et al., 2015; Pitman et al., 2012; event are significant, and the subjective
Van Zuiden et al., 2012). Furthermore, perception of the threat is decisive (Becker-
genes associated with fear conditioning or Nehring et al., 2012). In particular, man-
memory formation are being examined (e.g. made experiences of violence and the
KIBRA; Wilker et al., 2013). For women, a perceived threat to life are of higher risk. A
higher risk of developing trauma sequelae strong emotional reaction such as fear, help-
is found in many, although not all, stud- lessness, horror, guilt, and shame during the
ies. There is evidence that gender differ- traumatic event or immediately afterwards
ences in the neuroendocrine stress response is considered a risk factor. The question
(hypothalamic-pituitary-adrenal axis (HPA of peri-traumatic dissociation as a protec-
axis), sex hormones) are responsible for tive or risk factor is still open due to con-
this. There are no consistent findings for ceptual and methodological questions. Van
age, which could be due to a curvilinear der Velden and Wittmann (2008) argue in
relationship and the influence of develop- their meta-analysis that dissociation is not
mental phases with increased vulnerability an independent risk factor and that initial
(7 Chap. 6).
psychological problems are a better predic-
Traumatic stress also affects psycho- tor of PTSD.
biology and genes. The influence of early Post-traumatic factors cannot always be
trauma – experience-dependent neuroplasti- clearly separated from peri-traumatic fac-
city – on the entire psychobiological system tors. Acute stress disorder (ASD), but also
has been documented (Heim et al., 2000; depressive and anxiety symptoms as well as
Yehuda et al., 2010). Experiences of violence high general psychological stress are pre-
and abuse in childhood can lead to physi- dictive of trauma sequelae (Bryant, 2011;
ological and biochemical changes (7 Chap.
7 Sect. 10.2.2). However, many sufferers

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
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).
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-
sociative symptoms (7 Chap. 8). In order

instruments designed for risk assessment
to record symptoms other than ASD or after traumatic events. However, the current
PTSD symptoms shortly after traumatic state of research does not allow for a conclu-
events, some studies use the Peritraumatic sive assessment of the extent to which these
Emotions Questionnaire, which measures instruments are suitable for valid and eco-
the four subscales fear, helplessness, guilt/ nomic prediction of trauma sequelae.
shame and anger (Ehring et al., 2006;
Halligan et al., 2003).
In major catastrophic events, compre- 10.3 Care of Acutely Traumatized
hensive and professionally adequate diag- People
nostics are usually not possible due to a
large number of people potentially affected. The early psychological interventions used
In addition, the assessment of symptoms have a wide range, but their effectiveness has
directly after the event often leads to many not yet been sufficiently and fully empiri-
false positives. Persistent symptoms and suf- cally investigated (see Agorastos et al., 2011;
fering lasting for days and especially weeks Dyregrov & Regel, 2012; Kröger, 2013;
after the traumatic experience are, how- Rosenberg, 2011; Whybrow et al., 2015). The
ever, predictors of a persistent burden and central problem for an effectiveness assess-
pathological symptoms (Gray & Litz, 2005; ment is the methodological limitations of
NICE, 2005). most studies. Randomized controlled trials to
The guidelines of the International assess the effectiveness of early interventions
Society for Traumatic Stress Studies (ISTSS) are urgently needed. However, not treating
10 indicate that screening after traumatic events or treating traumatized persons as a control
should include risk factors for trauma group is ethically problematic. Furthermore,
sequelae (Balaban, 2008). Some English- due to their heterogeneity, the studies are dif-
language instruments consider well-studied ficult to compare because they differ in terms
protective and risk factors, are very econom- of trauma definition, type and severity of
ical and have better sensitivity than ASD trauma (e.g., forest fire, earthquake, experi-
diagnosis. The Posttraumatic Adjustment ence of violence), underlying symptomatol-
Scale (PAS; O’Donnell et al., 2008, 2012) ogy, form of intervention or conditions of
was developed to predict later PTSD (PAS- implementation, time of measurement and
P) and depression (PAS-D) in injured success criteria (mostly PTSD diagnosis).
patients. It consists of 10 items, has been Frequently, there is no information available
cross-validated and shows good predictive on pre-existing burdens and risk factors, on
validity. There is another screener for injured interim events and on selection in samples
patients, which is even more economical but depending on the time of assessment.
has not been cross-validated (Richmond Nevertheless, a well-founded indication
et al., 2011). With the Freiburg screening must be demanded for every early psycho-
questionnaire (FSQ; Angenendt et al., 2012; logical intervention, keeping in mind the
Stieglitz et al., 2002; see also Schneider et al., risk of negative effects of a measure. A seri-
2011), which was developed for accident vic- ous event is always an indication of early
tims, the Cologne Risk Index (KRI; Bering psychological intervention. However, direct
et al., 2005; Dunker, 2009), which is available proportionality between the severity of the
for various samples, and the screening ques- event and the need for intervention must
tionnaire on risk and protective factors after not be assumed. Particular attention must
traumatic events (S-RUST; Becker-Nehring, be paid to current cognitive processing, for
2014), there are three German- language example, the severity of the perceived threat
183 10
and attribution of blame to oneself, as well vey a change of perspective to the affected
as social support. As shown above, it is not person from being a helpless victim to an
possible to base the assessment solely on the active coper. Immediate measures following
presence of an ASD, since its variability over traumatic events were already described as
time is great and its predictive value is con- “psychological first aid” more than 50 years
troversial. Many affected persons develop ago (Drayer et al., 1954) and have since been
symptoms of a stress disorder in the first revised (Australian Psychological Society,
days and weeks, but these symptoms often 2011; Ruzek et al., 2007; Young, 2006). On
recede within the first weeks. Medium- and the basis of interviews with emergency per-
long-term trauma sequelae may also occur sonnel and accident victims, Lasogga and
without prior clinical symptoms (Bryant, Gasch (2006, p. 103 ff.) have presented rules
2011). The protective and risk factors for so-called psychological first aid for acci-
described are of great importance. dent victims (see also Lasogga & Gasch,
2011).
10.3.1 Psychosocial Acute Care

Basic Rules for Lay Helpers at the
The following describes interventions for the
Accident Site (According to Lasogga &
first days and weeks after traumatic events.
Gasch, 2006)
The general measures after critical events
55 Say that you are there and that some-
are based on the principles of crisis interven-
thing is happening!
tion and preventive psychiatric interventions
55 Shield the injured person from specta-
according to Caplan (1964) and are based
tors!
on the following goals and principles:
55 Seek careful physical contact!
55 Talk and listen!
Goals and Principles of Early
Psychological Intervention and
Prevention of the Consequences of
Stress
55 Providing protection and security, Rules for Professional Helpers
and satisfying current needs (Including Rescue Personnel) at the
55 Informing in a controlled and accept- Accident Site (According to Lasogga &
able way about the events and offering Gasch, 2006, p. 103 ff.)
the opportunity for communication 55 On the way to the place of action,
55 Informing in a controlled manner consider what you can expect and in
about possible consequences of stress what order you want to complete the
and coping strategies individual actions
55 Promoting self-efficacy 55 Get an overview first
55 Activating a social support network and 55 Tell the victim who you are and that
providing access to professional care something is happening to help them
55 Seek careful physical contact
55 Provide information on the nature of
These principles are part of the standard the injuries and the measures taken
clinical-psychological and psychiatric care. 55 Professional expertise is reassuring
However, it has not been proven that these 55 Strengthen the patient’s self-efficacy
measures can prevent the occurrence of by involving them in simple tasks
trauma sequelae. These measures aim to con-
matic events, social support proved to be a

55 Maintain the conversation with the significant protective factor in many studies
person concerned. Listen “actively” (Ozer et al., 2003) or its absence was a risk
when the person is speaking factor (Brewin et al., 2000; Trickey et al.,
55 Tell the patient if you must leave them 2012). Negative and positive social reactions
and provide “psychological substitu- are discussed as distinct processes, whereby
tion” particularly the lack of support and nega-
55 Pay attention to the relatives tive interactions such as accusations of guilt
55 Shield injured persons from specta- influence later trauma sequelae (Becker-
tors Nehring et al., 2012; Glynn et al., 2007).
55 Stressful experiences of the helper Furthermore, the perception or experience
should be processed through relax- of social interactions as helpful or unhelp-
ation techniques, individual and ful (functional support) seems to be more
group consultation significant than the size and complexity of
the network (structural support), and peri-
and post-traumatic support seems to be
These rules are derived from supportive psy- more significant than pre-traumatic support
chotherapy. Essential characteristics are the (Hepp et al., 2008; O’Donnell et al. 2010).
emotional presence, the admission of feelings The effects of the traumatic event on rela-
and the communication of security. The use tives must be clarified. With the consent of
of psychological first aid should be voluntary the affected persons, they should also receive
and adapted to the needs of the person con- comprehensive information on normal reac-
10 cerned. In particular, those affected should tions after traumatic experiences as well as
not be urged to talk about emotional reac- on the symptoms, course, and treatment of
tions immediately after the traumatic event trauma sequelae (NICE, 2005).
(ACPMH, 2013; Forbes et al., 2011; Gray &
Litz, 2005). In the event of staff shortages,
priority should be given to those persons who 10.3.3 Screening, Monitoring
cannot be released into a stable social support and Indication of Further
network. A survey of helpers after hurricanes Treatment
(Allen et al., 2010) showed that helpers did
not perceive psychological first aid (according In the acute phase following traumatic
to the Psychological First Aid Field Opera- events, the initial aim of screening is to
tions Guide by Brymer et al., 2006) as detri- identify protective and risk factors, such as
mental to those affected but as an appropriate peri-traumatic experience, post-traumatic
intervention. However, the TENTS guideline cognition, or inadequate social support,
(Bisson et al., 2010b) is against the early use rather than to identify symptoms of stress
of formal interventions for all affected people disorder. The persons affected should be
after disasters and also expresses skepticism informed about the purpose and procedure
about psychological first aid. before the screening is carried out and not
be urged to participate (Gray & Litz, 2005).
The recording of symptoms directly after the
10.3.2 Practical and Social event often leads to false positives and can
Support as well as Co-care be experienced by those affected as stress-
for Significant Others ful or at least inappropriate. A significant,
unremitting burden for several weeks after
Perceived social and practical support is gen- the traumatic event is a predictor of ongoing
erally protective of health. Even after trau- stress or chronification (Gray & Litz, 2005).
185 10
In the case of mild symptoms in the Psychotherapists Niedersachsen (Germany),
first 4 weeks after the traumatic event, for example, makes materials available
“watchful waiting” is recommended, with online in various languages (7 http://
follow-up contact to be arranged within a www.p knds.d e/index.p hp?id=139&L=0).

month (NICE, 2005). Monitoring, which However, some studies argue against the use
not only serves to establish indications, can of psychoeducational materials. Although
also improve symptoms (Foa et al., 2006). injured patients considered self-help bro-
Screening or monitoring can reveal the need chures to be useful, they did not influence
for further care. Thus, screening for pro- PTSD, anxiety and depressive symptoms or
tective and risk factors or symptoms is an quality of life (Ehlers et al., 2003; Resnick
essential component of screen-and-treat or et al., 2007; Scholes et al., 2007) or even led
screen-and-refer approaches (7 Sect. 10.4).
to more depressive symptoms 6 months after
It is important to bear in mind the avoid- the traumatic event compared to the control
ance attitude with which many patients face group (Turpin et al., 2005). The recommen-
psychotherapy. Therefore, it is important to dation of psychoeducation is based less on
follow up with patients who miss scheduled empirically proven findings than on a series
appointments (NICE, 2005). Since ASD, of assumptions (Wessely et al., 2008):
especially with good social integration, often 55 Symptoms are less frightening after pre-
shows a favorable outcome, it must always vious explanation.
be remembered that too intensive profes- 55 Presentation of the physiological or psy-
sional care can also have negative effects. A chological reactions as normal conveys a
Cochrane review shows that post-traumatic feeling of security.
symptoms are not reduced by early psycho- 55 Psychoeducation leads to early seeking
logical interventions with several sessions of professional help.
for all affected persons, that is, without 55 Dysfunctional schemata concerning the
limitation to persons at risk (Roberts et al., traumatic event, oneself, or the future
2009). Psychological interventions with sev- could be modified by psychoeducation.
eral sessions aimed at all potentially trau-
matized persons should not be provided as Wessely et al. (2008) suggest that the low
a matter of principle. or even negative effect of psychoeducation
found in some studies is due to the sensitiza-
tion of those affected and the development
10.3.4 Psychoeducation of self-fulfilling prophecies that disturb
normal recovery. The ISTSS guidelines
Psychoeducation cannot be clearly distin- (Litz & Bryant, 2008) derive from these
guished from other interventions, as it is findings that there is sufficient evidence
part of almost all specific measures follow- not to recommend information brochures
ing traumatic events. Some guidelines rec- as early intervention. Information material
ommend informing people about the usual on PTSD, which also includes destigmatiz-
reactions after traumatic events, including ing expectations of early intervention and
typical post-traumatic symptoms, the course information on support services, should be
of and treatment options for PTSD and distributed in settings where contact with
other trauma sequelae, and possible support affected persons is possible. The question
services and places to go. Written psycho- of differential effects depending on the
educational materials can be helpful in this content of the materials has not yet been
context (Gray & Litz, 2005; NICE, 2005), empirically investigated to any great extent
which can be distributed to affected persons (Beatty et al., 2010; Kenardy et al., 2008).
as self-help material. The Association of Similarly, the evaluation of web-based
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
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).
the first 10 weeks. Further case reports and

Phases of the Recent Traumatic uncontrolled studies report positive results
Episode Protocol (R-TEP; Shapiro & on various EMDR protocols, after vari-
Laub, 2008) ous traumatic events and in individual and
55 Phase 1: Recording of previous his- group settings (e.g. Fernandez et al., 2004;
tory Jarero & Artigas, 2010; Kutz et al., 2008;
55 Phase 2: Stabilization and prepara- Russell, 2006; Wesson & Gould, 2009). The
tion for exposure extent to which EMDR is suitable and indi-
55 Phase 3 and 4: Processing (assessment cated as early intervention cannot yet be
and re-processing of different epi- determined based on current data.
sodes of the traumatic event or the
subsequent period with external stim- 10.3.5.3 Psychopharmacological
ulation and change in the meaning of Intervention
the event) As a rule, drug treatment after traumatic
55 Phase 5: Embedding positive cogni- events is not necessary (7 Chap. 19).

tion Reviews (Amos et al., 2014; Morgan et al.,

55 Phase 6: Body test (test whether there 2003; Pitman & Delahanty, 2005; Kearns
is residual stress on a physical level) et al., 2012), and guidelines (ACPMH,
55 Phase 7: Closure of the meeting 2013; APA, 2004; NICE, 2005) do not docu-
55 Phase 8: Follow-up survey ment any evidence of prevention of trauma
sequelae. Slightly positive findings are only
found for hydrocortisone (Amos et al., 2014;
10 There are no studies with an adequate design Delahanty et al., 2013; Schelling et al., 2001,
for medium and long-term effectiveness as 2004, 2006; Weis et al., 2006; Zohar et al.,
early intervention. A small randomized con- 2011), but there is currently no recommen-
trolled trial conducted after an earthquake dation for everyday clinical practice; the
in Mexico found a greater reduction in contraindications additionally restrict its
post-traumatic symptoms after one session use. The SSRI sertraline (USA) and parox-
of EMDR compared to a waiting control etine (D, USA) approved for the treatment
group – however, no data is available on the of PTSD have not been systematically inves-
stability of this effect (Jarero et al., 2011). In tigated either in the prevention of trauma
a German study, EMDR was compared with sequelae or in the treatment of ASD. Other
multidimensional psychodynamic trauma SSRIs such as escitalopram have not been
therapy (MPTT) and a control condition shown to be effective in preventing PTSD
(Grothe et al., 2003). Some of the reported compared to placebo (Shalev et al., 2012;
findings suggest the effectiveness of MPTT Suliman et al., 2015).
and EMDR compared to the control group. Katzman et al. (2014) state that in
Methodological deficiencies and a very controlled trials no substance has been
broad time criterion for early intervention shown to be effective in preventing post-
are limiting factors: The traumatic experi- traumatic secondary disorders and can be
ences of the subjects were up to 4 months used reliably. Except in acute suicidal situ-
ago. The time criterion is also problematic ations, psychotropic drugs should be used
in an EMDR study following the terrorist with great restraint after traumatic events.
attacks of September 11, 2001: the interven- Psychopharmacological therapy is based on
tion took place 2–48 weeks after the event the severity of the acute post-traumatic symp-
(Silver et al., 2005). However, a decrease in toms: sedative antidepressants can be used for
symptoms is also reported for a subgroup of severe anxiety symptoms, hyperexcitability
12 affected persons who were treated within and sleep disorders. Benzodiazepines are the
189 10
drugs of choice for acute suicidal tendencies 10.3.5.4 Other Specific
and increasing suicidal thoughts but should Interventions
not be administered for longer than 1 week zz Forms of Debriefing
(Flatten et al., 2011; Gelpin et al., 1996). Psychological debriefing (hereinafter
Recent studies investigate the preven- referred to as debriefing) has its origins in
tion of trauma sequelae by pharmacological the military sector. Soldiers in World Wars
influence on the consolidation of traumatic I and II received psychological counsel-
memories and initial fear reactions or fear ling to maintain their readiness for battle
conditioning. However, most studies are (7 Chap. 24). Participants are instructed

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,

is particularly important to consider the risks 10.3.3, and 10.3.4).

of early treatment. Psychopharmacological Debriefings cannot be recommended as
early interventions aim to prevent patho- an early intervention for primarily affected
logical reactions, not to eliminate nor- persons. So far, studies and meta-analy-
mal and expected psychological reactions. ses have not been able to demonstrate a
Psychopharmaceuticals may also interfere reduction in symptoms or risk of trauma
with recovery, which in most cases occurs sequelae by debriefing immediately after
after traumatic events without professional the traumatic event. A large proportion of
support. For example, psychotropic drugs the studies and meta-analyses do not show
that lower arousal may interfere with the inte- a clear positive or significant effect on the
gration of trauma-related memories (Fletcher prevention of trauma sequelae (e.g. Antony,
et al., 2010). Prior to psychopharmacological 2010; Paterson et al., 2015; Rose et al., 2006;
therapy, somatic disorders must be explored Tuckey & Scott, 2014; Whitecross et al.,
and known. A physical disorder does not 2013; Wu et al., 2012; Young, 2012; Zehnder
necessarily exclude psychopharmacological et al., 2010). The discussion about the effec-
medication, but interactions between disorder tiveness of debriefings revolves around
and medication must be considered (Pajonk questions of the timing of the intervention,
et al., 2006). the target group, the standardized approach,
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 negation.
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-
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).

In major emergencies, an on-site presence A differentiation between the groups

(“On Scene Support Service”) of psycholo- affected – primary victims, bystanders, rela-
gists and psychotraumatologically trained tives, emergency services – is sensible and
specialists is indicated (Bengel, 2001, 2004; necessary. In major emergencies, commu-
Helmerichs, 2011; Jacobs, 1995; Lueger- nity mental health measures such as educa-
Schuster et al., 2006). The professionals tion about the consequences of stress, for
must be able to recognize ASD, excessive example, through local or national media,
demands, states of exhaustion and other outreach counselling and the activation of
consequences of stress. A central and effec- social and community resources are neces-
tive organization includes the shielding of sary (7 Sect. 10.3.5). Protection against

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
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://

www.k risenintervention-p snv.d e/psnv-

►►Example: FAQ and Adequate Answers app/). This app provides emergency services
55 “How can I tell if I’m traumatized?” with checklists and working aids (Nikendei,
55 “What are the typical problems after such 2017). Furthermore, the crisis intervention
drastic experiences?” homepage contains a list of regional PSEC
services and contact persons in Germany,
Answers: Switzerland, and Austria (7 http://www.

55 The characteristics and symptoms of a krisenintervention-psnv.de/psnv-dienste/).

stress disorder can be very diverse and
different. Not always all of the following
symptoms occur: sleep disturbances, 10.5 Outlook
nightmares, lack of concentration, physi-
cal complaints, difficulty feeling as before National and international guidelines and
or perceiving things in the environment recommendations, as well as meta-analy-
correctly, such as being numb. ses and reviews of early interventions, are
55 The event can be re-experienced sponta- available. Many of the recommendations
neously in the imagination. One feels as if are consensus among experts but are not
one is still in a threatening situation. (yet) sufficiently empirically grounded. The
55 The enjoyment of life may be reduced, complex influence of pre-, peri- and post-
contact with other people, friends or with traumatic protective and risk factors on the
the partner may be impaired. Some peo- development of trauma sequelae makes the
ple withdraw, close themselves off, seem indication of psychological early interven-
apathetic, cannot talk about what they tion difficult. Also, the type of intervention
have experienced. ◄ and the timing cannot be clearly justified by
193 10
a model and the study situation at present. of and as a result of early interventions, as
A onetime intervention will generally have well as the optimal timing of intervention,
no positive effect on severely traumatized must be made the subject of studies. Reports
persons with multiple risk factors. on experiences with psychosocial care after
The TF-CBT is the best investigated and emergencies and damage situations are
most effective form of early intervention to helpful supplements that can provide infor-
date. Since it is effective primarily after traf- mation on the organization of the PSEC in
fic accidents, while the findings are less con- major emergencies in particular, but also in
vincing in victims of violence, it is necessary everyday crisis intervention.
to investigate whether different weightings
of the modules are necessary after differ-
ent traumatic events. It is also open whether
the CBT intervention must be modified
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other acute symptoms and stress factors. J., Amella, E., Resnick, H., Muzzy, W., & Lejuez,
Furthermore, early interventions should
C. (2012). Behavioral activation and therapeutic
increasingly include elements to strengthen exposure for bereavement in older adults. The
protective factors such as social support and American Journal of Hospice & Palliative Care,
29, 13–25.
self-efficacy and to reduce risk factors. ACPMH. (2013). Australian guidelines for the treat-
However, psychological intervention ment of adults with acute stress disorder and post-
alone will usually not suffice; early inter- traumatic stress disorder. Australian Centre for
ventions must be integrated into a concept Posttraumatic Mental Health.
of trauma management. Complex and Agorastos, A., Marmar, C. R., & Otte, C. (2011).
Immediate and early behavioral interventions
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203 11
Systematics
and Effectiveness of Therapy
Methods
A. Maercker
Contents
11.1 Clinical Aspects – 204

11.1.1 S ingle (Type I) vs. Multiple (Type II) Traumas – 204
11.1.2 Classical vs. Complex PTSD – 204
11.1.3 Trauma Type – 204
11.1.4 Age – 205
11.1.5 Co-morbidity – 205
11.2 Systematic Aspects – 206

11.2.1 T ime Sequence of Therapy Elements – 206
11.2.2 Trauma Focused vs. Broad Therapeutic Approach – 206
11.2.3 Language and Cultural Adaptation for Patients from Other
Countries and Cultures – 207
11.2.4 Therapy Schools and Trauma Therapies – 208
11.3 Evidence of Effectiveness – 209
11.4 Outlook: Non-therapeutic Interventions – 210
Literature – 211
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).

sonal, intentional) and accidental (acci-

dental) trauma (7 Sect. 2.1) from a clinical

point of view. Patients who have experi- 11.1.5 Co-morbidity

enced intentional traumatisation by another
person usually show a higher degree of post- In patients with PTSD, the presence of
traumatic changes towards themselves and comorbidity is the rule rather than the excep-
others than people who have not simulta- tion. Epidemiological studies show that up
neously experienced the destructiveness of to 80% of these patients (lifetime diagnosis)
other people during their traumatisation. have other depressive, anxiety, somatoform
Childhood Trauma Trauma

Youth
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
or dependency disorders (7 Chap. 2). This

changes when the new diagnosis of complex
fact is of the utmost importance for every- PTSD is used as a basis for therapy planning.
day clinical practice, because the therapy Internationally, a phase-oriented approach
strategies to be chosen for an individual has become established for CPTSD in the
patient should always take the overall pic- corresponding guidelines (Cloitre et al.,
ture into account and make it the starting 2015), although the study situation is still
point for concrete therapy planning. insufficient for this (Maercker et al., 2019).
So far, only a few systematic studies have Therefore, it remains doubtful whether
been conducted to investigate combination the three phases mentioned remain relevant
therapies for comorbidity. This is particu- for PTSD and CPTSD and different forms
larly true for the combination of psycho- of settlement (inpatient vs. outpatient). It is
and pharmacotherapy (7 Chap. 19). More
also questionable whether the phases must
research will have to be done in the near necessarily take place one after the other,
future on the treatment of comorbid dis- or whether parallel therapeutic work on the
orders. This must take into account both three topics of safety/confidence, trauma
simultaneous and chronologically consecu- synthesis/trauma exposition and integra-
tive (sequential) treatment strategies. tion/reorientation is equally effective.
The most advanced studies to date are A pragmatic temporal division of a ther-
those on the treatment of comorbid addic- apy will acknowledge that at least the first
tion disorders. Here, several studies indicate therapy hours (including case history, assess-
that the integrated simultaneous therapy of ment, resource diagnostics, definition of ther-
PTSD and addiction disorder shows the best apy goals) as well as the last therapy hours
results (Roberts et al., 2015). (including summaries, outlooks, relapse pro-
phylaxis measures) differ from the intermedi-
ate therapy hours (therapeutic work).
11 11.2 Systematic Aspects In the following chapters on treatment,
no explicit phase classification is given for
11.2.1 ime Sequence of Therapy
T PTSD (7 Chaps. 13 and 14). For complex

Elements PTSD, a phased approach is presented in

each case (7 Chaps. 16 and 17).

In the wake of the landmark publication by

Herman (1993), the following classification
of therapy phases in PTSD became popular: 11.2.2 rauma Focused vs. Broad
T
55 Security/trust: especially stabilisation Therapeutic Approach
and affect regulation,
55 Trauma synthesis/trauma exposure, Trauma-focused procedures (or trauma-
55 Integration and reorientation. adapted procedures) in a narrower sense
are those in which the reduction of PTSD
This phase distinction was used – largely symptoms is the focus of the therapeutic
independently of treatment schools – approach. These include EMDR (7 Chap.
especially for inpatient therapy facilities.

14) as well as prolonged exposure and cogni-
However, this phase classification is not tive therapies (7 Chap. 13).

explicitly used in practice or research. It is The trauma focus of procedures can in

therefore not surprising that overviews of turn be divided into:
the empirical studies available worldwide 55 Exposure-focused therapies: Here the
show no necessity for this phase sequence focus is on reliving and retelling the trau-
(Neuner, 2008). However, this assessment matic event (. Fig. 11.2).

207 11
Affective Variations of trauma exposure

intensity
high Prolonged exposure according to Foa ( Chap. 13)
in vivo exposure (rarely indicated; Chap. 13, 27)
“Imagery Rescripting” after traumatization in childhood ( Chap. 13)
Hot-spot-narration in the context of cognitive therapy ( Chap. 13)
Eye Movement Desensitization Reprocessing ( Chap. 14)
Imaginative techniques: screen or monitor technique ( Chap. - 15)
lower Narrative exposure or online writing assignments ( Chap. 13, 16)
.. Fig. 11.2 Different forms of exposure according to their affective intensity
55 Cognition-focused therapies: Here the The results of various effectiveness meta-

focus is on changing attitudes towards analyses are presented below in 7 Sect. 11.3.

oneself, others and the environment.

55 Low-threshold interventions: These are
carried out by means of very different 11.2.3 Language and Cultural
settings (e.g. psychoeducation or peer Adaptation for Patients
groups) and media (e.g. online, app or from Other Countries
writing programs; 7 Chap. 15).

and Cultures
A broad therapeutic approach, on the other Therapies are increasingly carried out with
hand, aims to treat patients not only with patients from other countries and cultures.
regard to PTSD symptoms but also with For some time now, an informative litera-
regard to other therapeutic goals, includ- ture on PTSD therapy has been available
ing orientation towards associated symp- with the help of translators, which particu-
tom areas such as depression, anger, shame, larly addresses their specific selection for
feelings of guilt and borderline symptoms. this activity as well as the pre- and post-
However, the focus is also on strengthening treatment briefings (7 Chap. 25; Abdallah-

individual resources, up to and including Steinkopf, 2017). In addition, there is a

meaning and spiritual reorientation (Wag- growing literature on therapies that are
ner et al., 2007; Zöllner et al., 2008). carried out in the respective mother tongue
The broader approaches can usually also of patients with therapists with their own
be categorised: migration background (e.g. Kizilhan, 2010).
55 psychodynamic therapies (7 Chap. 12), The new guiding concepts of “culturally
55 inpatient treatment concepts (Wirtz & sensitive“or “cultural humiliate” therapeutic
Frommberger, 2013), attitudes express that, beyond the language
55 complementary therapeutic approaches adaptation of therapeutic procedures, more
(art, movement and creative therapies), is at stake and more comprehensive self-
55 the so-called present-oriented therapy reflection on the therapeutic procedure is
(Shea et al., 2003). required (Maercker et al., 2019).
208 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)

55 Cognitive behavioural therapy:

The reality of the application of various includes prolonged exposure accord-
psychotherapies is still dictated by the theo- ing to Foa, cognitive therapy accord-
retical therapeutic orientation of individual ing to Ehlers and Clark, cognitive
therapists or entire treatment institutions. processing therapy according to
The use of appropriate forms of therapy Resick, narrative exposure therapy
with regard to the clinical problems of according to Schauer, Elbert and
patients has not yet been based on flexible Neuner (7 Chap. 13)

empirical knowledge (“best practice”) or 55 Hypnotherapy: This played a partic-

orientation towards evidence-based guide- ularly important role in the develop-
lines (whereby the latter are not unaffected ment of trauma therapy (Brom et al.,
by scientific fashions). 1989)
This theoretical orientation remains
unsatisfactory for the progress of medical
209 11
The basis for such data summaries are
55 Humanistic-existential therapies: In studies with high methodological stan-
almost all orientations, therapeutic dards. Usually these are the 7 following
approaches have been developed, but standards.
hardly systematically investigated, for
example, in schools of Gestalt ther-
apy (Rosner & Henkel, 2010) and in Seven Standards for Data Aggregation
existential/logotherapy (Gebler & 55 Clearly defined target symptoms
Maercker, 2007) 55 Reliable and valid measurement
55 Combined methods: Genuinely for the methods
therapy of trauma sequelae, the EMDR 55 Use of blind raters (i.e., diagnostic
was developed (“Eye movement desen- assessors who do not know which
sitization and reprocessing“) according therapy condition the patients were
to Shapiro (7 Chap. 14)
assigned to)
55 Body based therapies: Complemen- 55 Training of the diagnostic assessors
tary body therapy is generally recog- 55 Manualized, replicable and specific
nised as an addition to trauma-focused therapy protocols (therapy programs)
psychotherapy (van Keuk, 2006) and 55 Random assignment to the therapy
culturally adapted therapy (7 Chap.
conditions
18); in contrast, purely body-related 55 Adherence to the therapy protocol
trauma therapy approaches (e.g. (“adherence”)
“Somatic Experiencing“; Levine,
2016) are still controversial (Metcalf
et al., 2016) . Table 11.1 is based on several of the more

recent meta-analyses for “classical” PTSD;

for complex PTSD, as described above, the
The various low-threshold procedures of current state of research is not yet sufficient
trauma follow-up therapy (7 Chap. 15) orig-
for reliable statements. If types of proce-
inate from different treatment approaches dures are not listed in the table, this means
and their existence and application proves that they cannot be assessed due to a lack of
that new developments across schools are control group studies or studies that are too
well possible. less randomised (e.g. applies to some psy-
chodynamic therapies).
The meta-analysis shows that a number
11.3 Evidence of Effectiveness of psychotherapeutic procedures can claim
proven effectiveness. In research, effect
The therapy of post-traumatic stress disor- strengths are usually classified as: >0.20 low;
ders can be regarded as a pioneer in empirical >0.50 medium; >0.80 high; >1.20 very high.
testing of the effectiveness of psychotherapy, The evidence level was assessed accord-
since a larger number of controlled therapy ing to the US health authority standards
studies have been available for years in this on the basis of various parameters on the
area than for other disorders. The results extent and quality of the available studies.
of the individual studies have been summa- It is important to note that a direct com-
rized in several meta-analyses and reviews parison of effect sizes between the meth-
(including Cusack et al., 2016; Ehring et al., ods is not possible due to the information
2014; Kuester et al., 2016; Lee et al., 2016; in . Table 11.1 for methodological reasons.

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
.. Table 11.1 Effectiveness of PTSD therapies in adulthood
Effect strengths Evidence-grade

[d or g] assessmenta
At the end of therapy (see 6-month catamnesis (compare
psychological placebo psychological placebo
condition condition)
Exposure therapy 1.01–1.27 0.80 High

Cognitive processing 1.08–1.40 0.57 Medium high
therapy
Cognitive therapies 1.33 Medium high
EMDR 0.87 1.12 (not significant) Low
Narrative exposure 1.25 Medium high
therapy (NET)
Brief eclectic therapy 0.35b Low
(BEP)
Group therapies 0.70 (Not available)
(mostly cognitive-
behavioural) c
Internet therapyd 0.66–0.83 (Not available)
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
standards: Owens et al., 2010)

b In Cusack et al., 2016, verbally indicated as “small to medium effect size”, therefore mean value of 0.20
and 0.50
c From Schwartze et al., 2017
d From Kuester et al., 2016
The application of a specific therapeutic attempt to reduce the individual suffering.

method in a patient should depend on the However, those affected will continue to live
aspects mentioned earlier in this chapter with the memories of the trauma and often
(type of trauma, classic or complex PTSD, with attitudes and values that will change
age, co-morbidities, language/cultural sensi- over time. This results in further aspects that
tivity of use). are important for dealing with traumatised
people.
11.4 Outlook: Non-therapeutic zz “Bear Witness”

Interventions Many trauma victims have the desire to
share their experiences during the trauma
Traumatic experiences can be the cause with others and thus contribute to ensur-
not only of mental disorders, but addition- ing that such disasters or crimes as they
ally of changes in the biographies of those have experienced never happen again. This
affected. The various forms of treatment desire to give testimony is common among
(including psychopharmacological ones) do victims of interpersonal violence and espe-
211 11
cially victims of state violence, repression Impressive examples of this commemora-
and torture. Chilean therapists had already tive culture are the Yad Vashem Memorial
developed the testimony method during the in Jerusalem with its lists of names, the
military dictatorship in the 1980s, in which “Vietnam War Memorial” in Washington
the therapeutic reports of the trauma were and the monument at the site of the plane
simultaneously used, for example, as testi- crash into a high-rise building in Bijlmermeer
monies for NGOs and for later prosecutions near Amsterdam. These memorials are fre-
(published under a pseudonym: Cienfuegos quently visited by survivors and grieving
& Monelli, 1983). The narrative exposi- family members.
tion of trauma (Schauer et al., 2011) was
developed from this idea and also produces
a document that can be used for criminal
prosecution if necessary.
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Abdallah-Steinkopf, B. (2017). Zusammenarbeit
zz “Finding a Mission” mit Dolmetschern. In A. Liedl, M. Böttche,
Some trauma victims are active in a charita- B. Abdallah-Steinkopff, & C. Knaevelsrud (Eds.),
ble or social association. This is often moti- Psychotherapie mit Flüchtlingen (pp. 90–107).
vated by the desire to prevent the possible Schattauer.
Bernal, G., Jiménez-Chafey, M. I., & Rodríguez,
traumatisation of other people. M. M. D. (2009). Cultural adaptation of treat-
Here are three examples. ments: A resource for considering culture in
55 Victims of criminal acts work with the evidence-based practice. Professional Psychology:
victim support organisation “White Research and Practice, 40(4), 361–368.
Ring” (Germany) as advisors for new Brom, D., Kleber, R. J., & Defares, P. B. (1989). Brief
psychotherapy for posttraumatic stress disorders.
crime victims. Journal of Consulting and Clinical Psychology, 57,
55 In the USA, mothers of children who 607–612.
have died in traffic accidents have Cienfuegos, A. J., & Monelli, C. (1983). The testimony
founded the Mothers Against Drunken of political repression as a therapeutic instrument.
Drivers Association, which publishes American Journal of Orthopsychiatry, 53, 43–51.
Cloitre, M., Courtois, C. A., Ford, J. D., Green, B. L.,
educational material and tries to influ-
Alexander, P., Briere, J., & Van der Hart, O. (2015).
ence legislation. The ISTSS expert consensus treatment guidelines
55 Formerly politically persecuted persons for complex PTSD in adults. http://www.istss.org/
work with “Amnesty International” on ISTSS_Main/media/Documents/ISTSS-E xpert-
behalf of political prisoners in other Concesnsus-G uidelines-for-C omplex-P TSD-
Updated-060315.pdf. Retrieved: 6. Aug. 2018.
countries.
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C.,
Sonis, J., Middleton, J. C., et al. (2016). Psycho-
zz Establishment of Memorials logical treatments for adults with posttraumatic
Beyond individual treatments, the involve- stress disorder: A systematic review and meta-
ment of therapists in the establishment of analysis. Clinical Psychology Review, 43, 128–141.
https://doi.org/10.1016/j.cpr.2015.10.003
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victims of trauma goes beyond individual J. M., Freitag, J., & Emmelkamp, P. M. (2014).
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55 to involve the survivors or the grieving posttraumatic stress disorder in adult survivors
surviving family members in the plan- of childhood abuse. Clinical Psychology Review,
34(8), 645–657.
ning of the place, and Gebler, F., & Maercker, A. (2007). Expressives Sch-
55 to mention the victims individually by reiben und Existentialität bei der Bewältigung
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commemoration. tionsstudie. Trauma und Gewalt, 2, 264–272.
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(2018). The influence of trauma type and timing Schnyder, U., & Rufer, M. (2007). Eine ambulante
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Heim, E., Harper, M., van’t Hoff, E., & Carsewell, K. J. R., Reston, J. T., Bass, E. B., et al. (2010).
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215 12
Psychodynamic Treatment
of People with Trauma
Sequelae
Contents
12.1 Aspects of a Psychodynamic Understanding

of Trauma – 216
12.2 Integrative Psychodynamic-Cognitive

Psychotherapy – 216
12.2.1 rototypical Case Study – 217
P
12.2.2 Excursus: Description and Development of a Narcissistic
Personality Style – 220
12.2.3 Thought and Emotion Control in Narcissistic
Personality Styles – 221
12.2.4 Therapeutic Technique: Restructuring and Stabilization – 223
12.2.5 Relationship Aspects in Narcissistic Patients – 224
12.2.6 Empirical Evidence – 225
12.3 Psychodynamical Imaginative Trauma Therapy – 225

12.3.1 I nitiation Phase – 226
12.3.2 Stabilization Phase – 226
12.3.3 Trauma Confrontation – 228
12.3.4 Integration – 229
12.3.5 Evidence – 229
12.4 Manual of Psychodynamic Trauma Therapy – 229
12.5 Summary – 231
Literature – 231
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)
When Abraham explains at the Fifth 12.2 Integrative

International Psychoanalytical Congress in Psychodynamic-Cognitive
Budapest in 1918 that part of the effect of Psychotherapy
war traumas can be explained by the loss of
the illusionary belief in one’s own inviolabil- With the description and understanding of
ity, then it is easy to recognize a forerunner stress response syndromes, this approach
of constructs such as “shattered assump- (Horowitz (1976, 2011) made decisive con-
12 tions” (Janoff-Bulman, 1992) or “posttrau- tributions to the inclusion of posttraumatic
matic cognitions” (Foa et al., 1999). stress disorder into DSM-III (APA, 1980). It
As in other schools of therapy, theory describes five phases (here in the formulation
and practice in psychoanalysis have con- by Fischer & Riedesser, 2009, pp. 97–98),
stantly evolved. This chapter presents three which trauma victims prototypically – but
selected current approaches to psychody- by no means always linearly – pass through:
namic work with trauma victims. First, how- 55 Peritraumatic exposure,
ever, some basic aspects of a psychodynamic 55 Denial,
understanding of trauma will be empha- 55 Intrusions of thoughts and memory
sized in order to facilitate the illustration of images,
the specific treatment approaches. 55 Working through,
55 Relative completion.
12.1 Aspects of a Psychodynamic For each of these phases, normal reactions

Understanding of Trauma can be described, but also pathological
extremes or chronifications can be observed.
Psychodynamic trauma theories emphasize In particular, the focus is on the oscillating
both the subjective and the processual char- movement between intrusive symptoms on
acter of traumatic experiences (Nijdam & the one hand and defensive reactions such
Wittmann, 2015). The experiences that pre- as avoidance, denial or emotional numbing
Psychodynamic Treatment of People with Trauma Sequelae
217 12
on the other. A detailed overview of con- As described, the consideration of
crete characteristics of these two opposing pre-
existing personality traits is a basic
processes on different levels of experience principle of many psychodynamic trauma-
and behavior can be found in Horowitz focused approaches. The conceptualization
(1976, Horowitz, 2011). of Horowitz (1976, Horowitz, 2011) offers
The psychodynamic-cognitive theory concrete starting points for adapting the
replaces Freud’s original concept of an treatment process to observable personality
energetic overload of the mental apparatus accentuations.
as a result of trauma (Freud, 1920) with a
concept of information overload (Horowitz
Under the Magnifying Glass: Consideration
1976, Horowitz, 2011; Horowitz & Becker,
of Personality
1972; Lazarus, 1966). Information refers
to both cognitions of internal and external Psychodynamic-cognitive psychother-
causation as well as emotions. apy does not pursue comprehensive per-
sonality changes. However, people with
Under the Magnifying Glass: Concept of different personality structures show dif-
Information Overload ferent types of resistance and relation-
ship formation during these processes.
In information overload, people remain The general techniques are therefore
in a state of constant stress or are sus- modified and applied in different techni-
ceptible to recurring stress states as long cal nuances, depending on the personal-
as the information has not been pro- ity dispositions of the patient.
cessed. The information is both repelled
and compulsively repeated until the pro-
cessing is largely complete. The emo- Of course, certain personality accentua-
tions, which are of great importance in tions (e.g. narcissistic beliefs or histrionic or
the context of stress response syndromes, obsessive-compulsive attitudes) are to some
are seen as responses to cognitive con- extent part of each personality type, and
flicts and as motives for defensive, con- some of the treatment techniques described
trol and coping behaviors. may at any time be relevant in other thera-
pies. The description of the adaptation of
the therapeutic approach to prototypical
The treatment approach of Horowitz (2003), personality types should therefore not imply
for which the significance of individual case a rigid categorization. In the following, the
formulations is emphasized, is designed in therapeutic approach will be illustrated by
phases. However, it is emphasized that these means of a case study.
phases typically overlap and are arranged
in a sequence rather for didactic purposes.
For example, treatment planning is continu- 12.2.1 Prototypical Case Study
ously reviewed and updated based on new
insights. . Table 12.1 gives an overview of
Harry is a 40-year-old dispatcher. He worked
the individual treatment steps. For a detailed his way up in a small supply company. One
description of patient- and therapist-related night, due to a lack of personnel, he drove
activities and aspects of the therapeutic an old truck himself, which contained a
relationship for each phase, see Horowitz load of steel pipes. This unsuitable vehicle
(2003). had an armored protection between the
.. Table 12.1 Phases of treatment of stress response syndromes
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).
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 observation, 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
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

become particularly important or conflic-

tual. For example, in a histrionic Harry, the
.. Table 12.2 Topics activated by an issue of sexual guilt might dominate (T3),
accident. In the first 3 topics (T1-T3) the while in a compulsive Harry, the issue of
patient sees himself as the perpetrator, in the
guilt over aggressive impulses (T2), worries
last 3 topics (O1-O3) as the victim
about neglect of duty (O2) and the image
Theme In conflict Resulting of oneself as an innocent victim (O3) might
(current with... in... dominate. To illustrate how the therapeutic
presentation) technique is adapted to the personality style,
a narcissistic personality variant is used here
Self as a perpetrator
(examples of other personality styles can be
T1 Relief ... Moral Feeling of found in Horowitz 1976, Horowitz, 2011).
that she and concepts guilt As a point of reference, an excursus on the
not he was (survivor
the victim guilt)
topic of narcissistic personality style is first
presented.
T2 ... Moral Feeling of
aggression concepts guilt
towards her
12 (because she 12.2.2 Excursus: Description
caused his and Development
problems)
of a Narcissistic Personality
T3 Sexual ... Moral Feeling of Style
ideas about concepts guilt
her
In narcissistic personality disorders, a great
Self as a victim self-love, grandiosity or idealization of
O1 Her Notion of the Fear (of other people is observed, which is based on
physical invulnerable self death and an extreme vulnerability of the own self-
injury could injury) concept. In psychoanalytic theories, the
have
happened to
vulnerability of the self has been attributed
him to difficulties during the phase of differen-
tiating the self-concept in role relationships
O2 He Responsibility Fear (of
broke rules towards the accusations)
with the mother or other early caregivers
company (Kernberg, 1975; Kohut, 1971). The pre-
dominance of narcissistic character traits in
O3 The General notions Anger
hitchhiking of innocence
one or both parents can also make a child
caused the (“the guilt lies vulnerable to difficulties in developing a
situation outside”) stable and independent self-concept, since
the parents may treat the child as if it were
221 12
one of their own functions rather than an 12.2.3 Thought and Emotion
independent existence (i.e., a self-object of Control in Narcissistic
the parents).
Personality Styles
When the habitual narcissistic satisfac-
tions drawn from being loved, receiving
If a distressing event of major importance
special treatment and admiring the self are
occurs, a deviation from the knowledge of
destroyed, depression, hypochondria, anxi-
reality should prevent the potentially cata-
ety, shame, self-destruction or anger towards
strophic state of affairs. This potential loss
any other person who can be blamed for the
of self-confidence would be associated with
bad situation can result.
intensely experienced emotions and a pain-
Kohut (1971) has described 3 coexisting
fully experienced feeling of helplessness and
but split-off self-concepts, which are often
disorientation. In order to prevent this state,
present in narcissistic personalities.
the narcissistic personality shifts the mean-
ings of events to make the self appear in a
better light. Those qualities that are good
Separated Self-Concepts in Narcissistic
are assigned to the Self (internalization).
Personality Style According to Kohut
Those that are undesirable are excluded
(1971)
from the Self by denying their existence,
55 Grandiose self, consisting of an
devaluing associated qualities, externalizing
inflated, exaggerated, exhibitionistic
and negating previous self-representations
self-image
(externalization).
55 Lowly valued, ashamed and defense-
Such fluid shifts of meaning allow the
less self-image
narcissistic personality to maintain an
55 Dangerously chaotic, destroyed, incon-
apparent consistency. However, the dis-
sistent self-image
torted meanings force further distortions
in order to survive. The resulting difficulties
give the cognitive-emotional structures a
Substitute images for (imagined) parents
subjectively experienced uncertainty. During
are maintained, which support the own self-
states of stress, gaps can occur in the avoid-
image, raise self-esteem, prevent rejection
ance of threatening ideas. As a result, anger
and serve as a mirror by allowing the grandi-
or paranoid states can occur as well as epi-
ose self to admire itself. The representations
sodes of panic, shame, or depersonalization.
of self and objects are strongly egocentric,
Self-destructive actions can be motivated
and interpersonal relationships are found
by a desire to end such stress. Likewise, a
more in the form of “I-It” than “I-Thou”
desire for secondary gain such as sympathy
relationships, as described by Buber (1959).
may occur, or playing a role as a “wounded
Issues of power and control come to the
hero”.
fore in interpersonal relationships. Narcissistic
These different patterns of a prototypi-
personalities are concerned with the possession
cal narcissistic personality can be repre-
of power to increase their own sense of com-
sented as follows, depending on whether
petence and control, or self-elevation through
they are information processing style traits,
attachment to a powerful person. At the core
personality traits, or persistent patterns of
of this desire is the use of admiration or close-
interpersonal relationships.
ness for the maintenance of self-esteem.
Typical Patterns in Narcissistic Patients –– Impoverished interpersonal rela-

55 Information processing style tionships, power orientation or
(observable in short time periods) control intentions over others
–– Shifts meanings of information that are only accessories
that could damage the self- –– Absence of “I-Thou” feelings
concept –– Social advancement or using
–– Uses denial, devaluation, and other people for positive reflec-
negation to protect the self- tion
concept –– Avoidance of self-criticism by
–– Attention is paid to sources of inciting others to unfair criticism
praise and criticism –– Dropping and devaluation of
–– Externalization of bad proper- persons who are no longer useful
ties, internalization of good prop-
erties
–– Temporary maintenance of In the case of a narcissistic Harry, the fol-
incompatible mental attitudes in lowing will look at topic O1, in which Harry
separate clusters (multiple self- talks about his intrusive images of the
images) female body in conjunction with ideas about
55 Personality traits (observable in his own susceptibility to death.
medium-term time periods, e.g. con- The idea of his possible death is incom-
versations) patible with Harry’s wishful thinking of
–– Self-centered invulnerability. The danger posed by these
–– Exaggerating or underestimating incompatible ideas is particularly great for a
the self and others narcissistic personality, who wants to main-
–– Self-elevation (or pseudo- tain an intact ideal – but in fact sensitive and
humility) in real and imagined fragile – self-image.
12 performances, in the way of To prevent these unbearable emotions
dressing or in the appearance from continuing, controls are introduced.
–– Avoiding self-deprecating situa- There are two reasons for these controls:
tions 55 Prevention of the threatening anxiety
–– Variable use of behavior depend- states and
ing on the state of self-esteem and 55 Avoiding the cognitions of fear, because
the context in the form of admitting that he is afraid would also be
–– charm, seduction qualities, a “narcissistic offence” for Harry.
efforts to control or charisma
–– superiority, arrogance, cold- This “double danger” of the narcissistic per-
ness, or retreat sonality makes therapy particularly difficult,
–– feeling of shame, panic, help- as will be discussed shortly.
lessness, hypochondriac behav- Both fears motivate defensive maneu-
ior, depersonalization, or self- vers. The idea that “someone” dies is a less
destructiveness frightening concept than that you yourself
–– envy, anger, paranoia, or will die. The topic of “having to die” is now
demands shifted from its meaning of having to die
55 Interpersonal relationships (observ- oneself to personal immortality. Instead
able in long-term patterns of patient of fear, the shift in meaning now enables
biography) a sense of triumph. The same image that
previously caused fear now leads, due to a
223 12
slight irrationalization, to a more positive focused on the therapist than on the the-
emotional experience. However, due to his matic meanings. The therapist is an impor-
defensive nature, this state is unstable and tant current source of praise or criticism.
Harry will tend to experience his anxiety The patient’s realistic or distorted observa-
state repeatedly. tions of how strongly the therapist’s interest
This denial of his own mortality deserves or disinterest is expressed will influence the
closer attention. The narcissistic Harry frees patient’s overall balance.
himself from the realities of being human by
thinking: “She is a representative of the kind zz Realistic Situation Assessment
that dies. I am of a different species.” Using During the reconstruction, the therapist
this form of narcissistic defense, Harry clas- should place special emphasis on working
sifies himself as an exception. It also means with Harry to develop realistic attributions
that he is special as an exception. of responsibility for all aspects of the event.
This kind of shift in meaning is associ- Both therapist and patient should try to
ated with a positive affect: things are bet- clarify how strongly the patient was involved
ter than expected. By shifting and undoing in each aspect of the action, i.e. what was
meanings and externalizing deadly dangers really his responsibility and what was caused
such as dying and vulnerability, a complete by external circumstances. This clarification
reversal of emotions could be achieved. involves distinguishing between what is real,
probable and fantasies. Clarification and
>>There is a double problem with the nar- restructuring undoes some of the external-
cissistic personality: Threat of avoided izations. For example, suppose a narcissistic
images and experiences as well as avoid- Harry expresses anger at the other driver
ance of admitting that something is who forced him to leave the road. This exter-
avoided. nalization of one’s own share of responsibil-
ity represents an attempt to find fault for the
death of the woman not with oneself but
12.2.4 Therapeutic Technique: solely with the driver of the opposite direc-
Restructuring tion. This is based not only on anxious ideas
and Stabilization about one’s own mistakes, but also on fear
of potentially unrealistic accusations.
How can a psychotherapist deal with such
fluid shifts of meaning? In terms of cognitive- zz Identify Responsibilities
emotional processing, a re-evaluative restruc- The restructuring includes every possible
turing is a useful tool in therapy. element of responsibility: his responsibil-
ity for taking the woman with him; his
zz Slow Action responsibility for the other cars that almost
The process should be slow; as slow as nec- collided; for driving the car off the road
essary to help Harry open up to a threat in his own manner; his responsibility for
strong enough to throw him into a state of his actions after the accident – all of this
self-destruction. During this slow process, must now be reassessed. For each issue, the
efforts are then made to re-evaluate the restructuring process will reach an end point
events and their various interpretations. where a realistic decision can be made on
the assessment of the responsibility issue,
zz Tact freeing Harry from unrealistic guilt compo-
With regard to the therapeutic relationship, nents. The review and reassessment by the
tact plays an important role. Tact is essen- therapist enables Harry to make a conscious
tial, as the narcissistic personality is more decision about his level of responsibility.
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-
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

therapist point to an idealization that tem- in regulating emotions, shaping relationships,

porarily makes up for the damage done to or altered perceptions of oneself or the per-
the self. In this case, it is necessary to wait petrator. While trauma- specific treatment
for a more secure period of time in which approaches show a clear superiority (effect
work can be done on restructuring and inte- size .87) over unspecific interventions in the
grating the stressful events. case of non-complex clinical pictures, this
Externalizations can also help a patient difference is largely lost in the case of com-
to gain sufficient emotional distance from plex clinical problems (effect size .23; Gerger
stressful issues so that he or she can bear to et al., 2014). It is therefore understandable
think about them. For example, if a feeling that separate treatment approaches have been
of disgust towards death is projected onto developed for people suffering from complex
the therapist, the crucial method is to ask trauma sequelae. One such approach is the
the patient to talk more about the therapist’s psychodynamical imaginative trauma ther-
current presumed feelings. This enables apy (PITT) by Luise Reddemann.
patients to follow their own emotional path- Before presenting central aspects of the
ways as if they were the therapist’s path- therapeutic process, the author’s remark-
ways. A direct intervention, for example in able position with regard to her concept of
the form: “You feel disgusted by death”, therapeutic attitude and human encounter
should only happen later. should be emphasized. When she advises “to
meet every new patient as if one were enter-
ing new unknown territory with a rather
12.2.6 Empirical Evidence inaccurate map” (Reddemann, 2004, p. 21),
the relativization of the importance of sup-
In a randomized controlled trial (Brom posed therapeutic expertise in relation to an
et al., 1989) the effectiveness of the presented investigative attitude becomes clear.
approach was compared with several compar-
ison conditions (trauma desensitization, hyp-
Under the Magnifying Glass: Primacy of the
notherapy, waiting group). With a pre-post
Therapeutic Relationship Over Technique
effect size of 1.14 and the strongest effects of
all procedures during the 3-month observation In the context of this form of treatment,
period after the end of therapy, the approach designed for people who are complex – and
impressively demonstrated its effectiveness. thus usually within relationships – trauma-
tized, there is a clear primacy of the thera-
peutic relationship over technique: “It is
12.3 Psychodynamical always about treating the whole person.
Imaginative Trauma Therapy And it is about the effectiveness of a rela-
tionship” (Reddemann, 2004, p. 43). In
The 11th revision of the International concrete terms, this requires on the part of
Classification of Mental Disorders (current the therapist “... tact, devotion, the willing-
tenth revision: WHO, 2004) adds the diagno- ness to make new experiences possible, and
sis of complex post-traumatic stress disorder the willingness to admit one’s own mis-
to the concept of post-traumatic stress dis- takes and, if necessary, to apologize for
order (Maercker et al., 2013). This concept, them” (Reddemann, 2004, p. 48).
which goes back to Judith Herman (Herman,
Also worth mentioning here is Reddemann's 12.3.1 Initiation Phase

(2004, p. 73) postulate that PITT therapists
should live the principles they advocate: As early as possible in the PITT process,
“Resource-oriented psychotherapy needs the explicit mandate and goal clarification
resource-oriented living therapists!”. Despite for the treatment is carried out, whereby
all the gratifying successes in trauma ther- the latter can be developed on the basis
apy, empirical research also shows the limits of the patients’ life goals. The anamnesis
of therapeutic action in view of the often should not take on the character of a trial
chronic and sometimes irreversible conse- confrontation by an unbalanced focus or
quences of traumatic events (Wittmann & emphasis on difficult aspects. This applies
Schnyder, 2014). When Reddemann (2004, not only, but especially, to the reporting of
p. 19) speaks of “healing with scars” and traumatic experiences. In this context, there
emphasizes that therapeutic work in the case are already indications of a possible over-
of trauma-related personality changes takes lap with distancing or resource-oriented
up more time – a central case study used in techniques of the stabilization phase. Here,
the PITT manual comprises about 240 ses- interventions that support the ability to
sions over a period of 3 years – she is just observe oneself or to deal with crises can be
as proactive in advocating an illusion-free used in therapy sessions or as part of home-
perception of reality as she is in advocating work. Psychoeducational work in explaining
appropriate care for severely traumatized the therapeutic procedure and the concepts
people. used also finds room here.
PITT is on the one hand a method-
integrated procedure. Thus, influences from
ego-state therapy, hypnotherapy, mindful- 12.3.2 Stabilization Phase
ness-based psychotherapy and many other
approaches can be recognized. On the other The establishment of external security can be
hand, such elements are not copied unre- considered a prerequisite for the development
12 flectively, but are integrated into a psycho- of a sense of internal security. If contact with
dynamic framework. Reddemann (2004, perpetrators exists, patients should be sup-
p. 66 ff.) illustrates this principle using the ported in developing the necessary distance,
example of cognitive work on a patient’s whereby the measures to be taken should be
self-perception. PITT does not stop at the adapted to the factors contributing to contact
cognitive refutation of a self-scheme – for with perpetrators. In one case, this may be
example in the context of a Socratic dia- clarification of which part of the patient wants
logue – but complements the cognitive to maintain contact with the offender on the
aspect with the levels of emotional mean- basis of which need structure. In another
ing and the relationship-regulating function case social psychiatric interventions may
of such schemata. The course of a PITT be required. Psychoeducative-normalizing
can be described in terms of the phases of education about traumatization, its con-
initiation, stabilization, trauma confronta- sequences, and how to deal with them can
tion, and integration. However, as with the promote patients’ self-acceptance. For this
first approach presented in this chapter, this phase, a great wealth of technical variants
does not imply a rigid but rather a flexible is described, ranging from imagination- and
sequence of phases in which the patient is mindfulness-based procedures to the use of
trusted to have the wisdom to decide what topic-specific stories or images to exercises in
he needs at a given time. body perception.
227 12
>>The basic principle here is a consistent As already indicated in the work with
activation of resources: the appropriate the inner team, PITT makes extensive use
appreciation of existing problems is of working with ego states. Reddemann
accompanied by a focus on existing com- takes a pragmatic approach to the concept
petencies and those to be developed or of the different ego parts: “... of course dif-
positive aspects. ferent people do not live in the patient. ...
The value of the concept lies in its clinical
In the following some central techniques are coherence, manageability, and simplicity”
briefly listed (for a detailed description see (Reddemann, 2004, p. 118). A description of
Reddemann, 2010). the related concept of the inner child facili-
tates understanding:
zz Safe Place
For that matter, the person goes to an imagi- »» According to our concept, the vast major-
ity of cases of violent feelings that do not
nary place that represents the highest level
seem to fit the behavior of an adult person
of security and well-being. This place is
are unresolved conflicts, injuries or trau-
designed in such a way that these qualities
mas from the past, usually from child-
are perceived with imagination in all sensory
hood. Working with injured childhood
dimensions. Through regular imaginative
parts seems to us to be a very effective
journeys to this place, the person learns to
instrument to strengthen the adult person
calm down and regenerate in difficult situ-
of today in his or her ability to function ...
ations.
(Reddemann, 2010, p. 72)
zz Inner Helpful Beings In order to maintain the functional level
Ideas of beings are developed, such as those of the adult patient in her present life and
known from fairy tales, which represent the current therapy situation, the adult
comfort, encouragement, advice, or security. ego encounters the childlike parts in the
These can be invited to the safe place for ego state work, which could be described
support. as a regression limited by the imaginative
technique. During the stabilization phase,

zz Inner Team the Ego-States work does not serve the pur-
For this purpose, the patient enters a safe pose of trauma confrontation, but rather
room in his imagination and invites people the safer accommodation and consolation
who represent him/herself in different ear- of the inner child. If the adult ego is not yet
lier and later phases of life. By asking them stable enough to take care of the inner child,
for their opinion or advice in an inner dia- inner helping beings, for example, can be
logue, the patient gains access to his inner used for this.
wisdom.
zz Work with Perpetrator Introjects
zz Vault Exercise Ehlert-Balzer (1996) has described in detail
This is a complementary imagination exer- how the psychodynamics of the traumatic
cise, working with an opposite conception, situation can lead to a situation where even
so to speak, and serves to temporarily free adult trauma victims can anchor aspects of
the mind from incriminating material. For the trauma or perpetrator like a foreign body
this purpose, memories or pictures that can- in their own ego. This can manifest itself, for
not yet be processed are locked away in a example, in accepting the perpetrator’s allo-
safe that has been presented – or in several cation of guilt. Since the superiority of the
safes if necessary. perpetrator plays a decisive role here, it is
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
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.
Under the Magnifying Glass achieved by a focusing treatment formula-

tion. The procedure described by Malan
The manual by Wittmann et al. (2017) (1965) is adapted by relating the following
describes how classical psychodynamic four levels in the form of a square:
interventions which are considered as 55 the traumatic experience and its conse-
non-disorder specific can be adapted to quences,
the individual needs of traumatized 55 important relationship experiences in the
people. It avoids the assumption that present,
the work here is fundamentally different 55 formative relationship experiences in the
from that with other patients or that the history of development,
available spectrum of interventions 55 the current therapeutic relationship.
would have to be expanded integra-
tively. This illustrates the central significance that
this approach attributes to interpersonal
experiences for personality development,
In order to ensure the flexibility of treatment for an understanding of the subjective
required from a psychodynamic perspective, traumatic experience, and for difficulties in
the manual applies the principle of param- working through the traumatic experience.
eters. Instead of prescribing which tech- The current therapeutic work can take any
nique to use, it provides criteria for deciding of the four corner points of the trauma
whether and in what form specific psycho- square as a starting point, whereby meaning
dynamic interventions could be applied. is created by connecting two or more corner
If a temporal restriction of the treatment points. This is illustrated by an example of
is considered realistic in view of the initial the work on the transference process within
situation and treatment goals, this can be the therapeutic relationship:
12 Case Study: A Patient with Complex PTSD
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.
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.
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235 13
Cognitive Behavioural
Therapy
T. Ehring
Contents
13.1 Introduction – 236
13.2 Overview – 236

13.2.1 T reatment Approaches – 236
13.2.2 Examples of Evidence-Based Cognitive-Behavioural
Therapy Programmes – 236
13.3 Cognitive-Behavioural Models of PTSD – 237

13.3.1 haracteristics of the Trauma Memory – 237
C
13.3.2 Excessive Negative Evaluations of the Trauma
and/or Its Consequences – 239
13.3.3 Dysfunctional Coping Strategies – 240
13.4 Core Treatment Components – 240

13.4.1 iagnostics and Therapy Planning – 240
D
13.4.2 Preparation for Trauma-Focused Therapy – 242
13.4.3 Modification of the Trauma Memory – 244
13.4.4 Cognitive Interventions – 252
13.4.5 Modification of Maintaining Behaviour – 255
13.4.6 Targeting Additional Problems – 257
13.4.7 Concluding Therapy and Booster Sessions – 258
13.5 Summary and Outlook – 258
Literature – 258
236 T. Ehring
13.1 Introduction 14) as the treatment of choice for PTSD

(ACPMH, 2007; American Psychological
Cognitive behavioural therapy (CBT) plays Association [APA], 2017; National
a key role in the treatment of posttraumatic Collaborating Centre for Mental Health
stress disorder (PTSD). There are a number [NCCMH], 2005; Schäfer et al.: S3 guideline
of different evidence-based treatment manu- Posttraumatic Stress Disorder).
als based on CBT, which have been reviewed
in more than 120 randomized controlled >>In the treatment of PTSD, the focus
treatment studies (Ehring et al., 2019). The should be on trauma-focused interven-
aim of this chapter is to provide an overview tions.
of trauma-focused CBT in PTSD. Due to
the large number of existing treatment man- In the presence of complex PTSD, phase-
uals, not all specific approaches can be pre- based treatment is frequently offered, in
sented in detail for reasons of space. Instead, which interventions to improve emotional
after a brief overview, the focus will be on regulation, reduce dissociation or reduce
basic principles, theoretical models and interpersonal problems are carried out prior
important treatment components that play a to trauma-focused interventions (7 Chaps.

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.
>>There are several evidence-based Both processes will be discussed in more

cognitive-behavioural treatments avail- detail below.
able for the treatment of PTSD, which
differ in their focus on exposure-oriented
vs. cognitive interventions, among other
things. So far, no systematic differences
13.3.1 Characteristics
in effectiveness between these specific of the Trauma Memory
approaches have been found.
A core characteristic of PTSD is the unin-
tentional re-experiencing of the trauma in
the form of intrusive memories, nightmares
13.3 Cognitive-Behavioural
and/or dissociative flashbacks. This re-
Models of PTSD experiencing has a number of characteristics
that distinguish it from memories of non-
The evidence-based treatment approaches traumatic events. In addition, these features
are each based on specific theoretical mod- of re-experiencing contribute significantly
els. As an example, Ehlers and Clark’s (2000) to the feeling of current threat.
cognitive model is presented in more detail
in this section. The starting point of this
theory is the observation that trauma survi-
vors with PTSD perceive a current threat, Features of PTSD Re-experiencing
although the actual threat (the trauma) is 55 Dominance of sensory impressions
already in the past. This means that even in 55 “Here and Now Quality”: Sensory
safe situations, people with PTSD often feel impressions are experienced to a
and/or behave as if they were still threat- certain extent as if they were happen-
ened, especially if current situations remind ing in this moment and not as a mem-
them of the trauma. The difficulty in experi- ory of a past event
encing the trauma as a completed event
238 T. Ehring
These processes show a certain overlap

55 Memories are accompanied by strong with the concept of peritraumatic
emotional and physical reactions sim- dissociation.
ilar to those during the trauma.
55 Memories contain the original mean- zz Inadequate Elaboration and
ing, even if additional information Contextualisation of the Trauma Memory
contradicting them was received later. As a consequence of the peritraumatic pro-
55 Memories are triggered by a variety cesses described above, the consolidated
of stimuli that were temporally asso- memory representation of the trauma dif-
ciated with the trauma (e.g. certain fers in two essential aspects from everyday
objects, colours, sounds, smells, memories and from trauma memories of
moods, personal characteristics, emo- survivors without PTSD:
tional states). 55 Perceptual information as well as the
original meanings that were present dur-
ing the trauma are also dominant in the
According to Ehlers and Clark (2000), the consolidated memory content.
following processes are responsible for this 55 Trauma memory is only inadequately
particular way in which people with PTSD linked to other autobiographical memo-
re-experience the trauma. ries, i.e., the autobiographical context is
missing in the memory representation.
zz Characteristics of Peritraumatic
Processing However, an important assumption of the
Intrusive re-experiencing occurs especially model is that these features are not charac-
when during the trauma a strong encoding teristic for the whole memory representation
of perceptual information occurs with a of the trauma, but are specific to the
simultaneous weak encoding of contextual hotspots, i.e. the worst moments experienced
or meaningful information. The authors during the trauma.
also describe this as the dominance of data-
driven processing over conceptual processing
13 (for a similar hypothesis see Brewin et al.,
2010). In addition, reduced self-referential
Case Study: Trauma Memory
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.
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).

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
Perception of current threat
Dysfunctional coping strategies Change of

maintaining
e.g. avoidance, safety behavior, excessive rumination, social withdrawal, alcohol or drug use
strategies
.. 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.
Case Study: Treatment of PTSD Following Rape
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.
13.4.2 Preparation Important Components of the Explana-

for Trauma-Focused tory Model
Therapy 55 Development of the disorder: “Why
do I have this disorder?”
13.4.2.1 Psychoeducation 55 Maintenance of the disorder: “Why
don’t the symptoms go away by them-
The aim of psychoeducation is to normalize
selves?”
the symptoms and make them understand-
55 Treatment rationale: “How can ther-
able. This usually happens in two steps:
apy help me to process the trauma and
55 Normalization of symptoms,
get rid of my symptoms?”
55 Providing an explanatory model for the
symptoms.
For detailed instructions on how to perform
zz Normalization of Symptoms
psychoeducation, the treatment manuals
Many patients with PTSD hold catastrophic
cited in 7 Sect. 13.2.2 are recommended.
beliefs about the symptoms they experience

Patients also often find it helpful if they can

(7 Sect. 13.3.2). To normalise symptoms, it
continue reading about their symptoms

is often helpful to provide the following

between sessions. Patient guidebooks can
information.
also be used for this purpose (e.g. Ehring &
Ehlers, 2018; Herbert & Wetmore, 2005).
Helpful Information About the
13 Symp toms
zz Use of Metaphors in the Development of
the Explanatory Model
55 “The symptoms are common. You’re
When developing the explanatory model
not alone in this.”
with the patient, it is important to prepare
55 “PTSD symptoms are a normal
the information in such a way that the
response to an abnormal event. It does
patient can understand it and accept it as a
not mean there’s anything wrong with
helpful explanation for their own experi-
you as a person.”
ence. It is therefore first recommended to
55 “What you experience has a name,
develop the model in the style of a Socratic
post-traumatic stress disorder, and
dialogue (see also 7 Sect. 13.4.2.2). This

there are defined criteria (ICD/

ensures that the patient is actively involved
DSM).”
in the process, checks whether the model fits
55 “The symptoms are understandable
their individual experience, and can draw
and treatable.”
the central conclusions of the model them-
selves. In addition, it is advisable to use
243 13
etaphors, for example to clarify the char-
m
acteristics of the trauma memory. result, they still have no place and
Example: Wardrobe metaphor (for a col- keep falling out)
lection of further metaphors see Priebe and 55 Deduction of the implications for
Dyer (2014)): In the context of this meta- therapy: Wardrobe must be opened
phor, memory is compared with a wardrobe intentionally, clothes must be taken
in order to develop an explanatory model out, looked at carefully, unfolded and
for intrusive re-experiencing and, in a sec- sorted into the wardrobe. Applied to
ond step, to draw conclusions for treatment. the memory of the trauma, this means
The following steps are recommended (for intentional exposure to the memory in
more detailed instructions see Ehring, 2014): treatment with the aim of processing.
Steps to Develop the Wardrobe

Meta phor 13.4.2.2 Setting the Stage
55 Joint development of differences Trauma-focused therapy is time-consuming,
between trauma memory and every- can be emotionally stressful and requires
day memories (e.g. re-experiencing in dealing with the treatment content even in-
the “here and now”; dominance of between sessions (homework). It is therefore
sensory impressions; intense feelings important to set the stage before starting
as in the past; triggered by multitude trauma-focused interventions.
of stimuli) In the view of most experts, trauma-
55 Introduction of the wardrobe meta- focused treatment should only be started if
phor: there is no current threat (e.g. domestic vio-
–– Comparison of the memory with lence; regular contact with a perpetrator
a wardrobe (Function: Classifica- who is still dangerous). It is therefore of
tion of memories) utmost importance to clarify this prerequi-
–– Memories of everyday events are site and – if necessary – to first focus on
filed in a suitable compartment; establishing security.
effect: can be consciously taken In addition, thorough planning can
out, but rarely falls out uninten- help to prevent interruptions or delays in
tionally the course of treatment (e.g. frequent can-
–– During a trauma this does not cellation of sessions). Thus, trauma-
work (happens very quickly, is focused treatment should only begin when
new, accompanied by high the patient has enough time to attend ther-
arousal); effect: clothes have no apy sessions regularly and to do home-
place in the wardrobe, fall out work between sessions. It may also be
again and again when wardrobe important to clarify practical aspects, e.g.
doors are opened. child care, holiday planning by the thera-
55 Exploration of how the patient has pist and patient or arrangements at the
dealt with trauma memories up to workplace. For patients with an irregular
now; based on wardrobe metaphor daily routines or problems with emotion
explanation why this has not helped regulation, it is also recommended that
(e.g. avoidance/suppression: clothes therapist and patient make a plan on how
are quickly thrown back into the the patient can spend the time immediately
wardrobe, door is closed shut; as a after the sessions (e.g. distraction and/or
social support).
244 T. Ehring
13.4.3 Modification of the Trauma According to Foa et al. (2014), imaginal

Memory exposure lasts about 45–60 min in the first
treatment sessions, and 30–45 min in later
A central component of most evidence-based sessions. If a session lasts much shorter, expo-
treatment approaches for PTSD are strategies sure to the same situation should be repeated
to modify the trauma memory (. Fig. 13.1).

with the same session if possible, so that the
In the following, two variants of this therapy total duration described above is achieved.
module are presented in more detail: Therapy sessions of 90–100 min should
55 imaginal exposure according to Foa therefore be scheduled, leaving enough time
et al. (2014), for the pre- and post-exposure discussion.
55 trauma memory updating in the context Imaginal exposure is repeated during the
of cognitive therapy (Ehlers, 1999). therapy sessions. If there are several trau-
matic experiences, several sessions with the
first traumatic memory should be conducted
13.4.3.1 Imaginal Exposure first. Only when a clear habituation has
The basic principle of imaginal exposure is taken place between the sessions and the
that the therapist instructs the patient to traumatic memory no longer triggers a high
exposure themselves to the memory of the level of stress does the processing of the next
trauma in their imagination with their eyes traumatic memory begin.
closed. The patient should chronologically Foa et al. (2014) also suggest that after
let the experiences happen in front of their the first 1–2 exposure sessions with the com-
inner eye and describe them. It is important plete traumatic memory, imaginal exposure
to include all aspects of the trauma and should subsequently be limited to the
one’s own reaction to it, i.e. the objective hotspots, that is to the worst moments
event, sensory impressions in all modalities, within the trauma memory, which often
thoughts, feelings, bodily sensations and correspond exactly to those parts of the
one’s own behaviour. In order to intensify trauma that are relived as intrusions, night-
the experience and initiate processing, the mares or flashbacks. The first hotspot is first
patient is instructed to describe the experi- re-activated and described in great detail
13 ence in the present tense and in the first per- (and possibly even in slow motion); this is
son singular. It is important for the repeated until habituation occurs. Then
processing that no avoidance and no safety therapist and patient turn to the next
behaviour takes place during exposure, so hotspot until all relevant hotspots have been
that the patient also includes those aspects processed in this way.
of trauma memory that are particularly In the following, the course of an expo-
stressful or embarrassing for them. sure treatment is described.
Aims of Imaginal Exposure According Preparation of the First Exposure

to Foa et al. (2014) Session (see also 7 Sect. 13.4.2)

55 Habituation within the session 55 Clarify motivation

55 Habituation between sessions 55 Setting the stage
55 Elaboration of the trauma memory: 55 Development an explanatory model
Creating a coherent narrative and treatment rationale
55 Change in trauma-related appraisals 55 In case of multiple traumas: selection
(happens spontaneously during the of the situation to start with; possible
exposure and in the debriefing) criteria:
245 13
–– Prioritize traumatic experiences –– “You are safe here. Remember,

that are often re-experienced in memories are not dangerous.”
everyday life 55 Key questions
–– Develop a hierarchy of all events –– “What is happening now?”
and prioritize events with a high –– “What do you think?”
position in this hierarchy –– “What can you see, hear, smell,
–– Thematic clustering of traumas taste? What does it look like?
and selection of the most relevant Please describe it as much detail as
cluster you can.”
–– Starting with the first and/or –– “What are you feeling?”
worst experience –– “What are you feeling in your
body? Where in your body do you
feel this?”
–– Obtain ratings of vividness and
Procedure of the First Exposure Session stress (SUDs) (0–100)
55 Remind patient of the treatment 55 Debriefing
rationale –– Provide positive feedback, rein-
55 Introduce the procedure force the patient for their effort
–– Eyes closed and hard work
–– Bring up the experience in your mind –– If necessary: help patient stabilize
and describe it from the beginning and/or to get rid of the memory
(just before the threat started) to the –– Explore thoughts and feelings
end (when the acute threat is over) about the exposure session; if
–– Description in first person singu- necessary: normalize
lar (I, me) and present tense (“as –– Explore whether habituation has
if it were happening now”) occurred
–– Inclusion of all aspects (actions/ –– Identify hotspots (for later expo-
events, thoughts, feelings, sensory sure sessions)
impressions, bodily sensations,
impulses for action)
–– It is important to allow every-
thing to come up, not to suppress Next Steps
thoughts and feelings 55 Homework: Listen to the recording
55 Explore and answer questions and of the session several times (if neces-
concerns sary: plan together, when and where)
55 Introduce the subjective units of dis- 55 In subsequent sessions: Repetition of
tress (SUD) and vividness ratings imaginal exposition, initially with the
(0–100 each) same event. After 1–2 regular exposure
55 Start recording device (for later home- sessions, possibly focus on the hot spots.
work)
55 Start imaginal exposition, thereby
–– Support the patient
–– “You are doing very well!” 13.4.3.2 Trauma Memory Updating
–– “Stay tuned.” In cognitive therapy (Ehlers, 1999), imagery
–– “I realize it’s hard for you, but is also used to modify trauma memory. In
you’re doing it very well.” contrast to prolonged exposure, however,
the focus here is not on achieving habitua-
246 T. Ehring
tion. Based on the cognitive disorder model

by Ehlers and Clark (2000) (7 Sect. 13.3.1
Trauma Memory Updating: Procedure
and . Fig. 13.1), the focus is instead on
55 1–2 sessions of imaginative exposure
updating and contextualising the trauma 55 During debriefing: Identification of
memory and to achieve an emotionally hotspots (including key appraisals
effective modification of dysfunctional peri- and associated emotions)
traumatic appraisals. 55 Cognitive restructuring of appraisals
55 Joint planning on how trauma mem-
ory can be updated
Aims of Trauma Memory Updating in
55 Re-activation of the hotspot and inte-
Cognitive Therapy
gration of updating information
55 Updating the trauma memory by
integrating new information
55 Contextualisation of the trauma
memory by linking it with other auto- When the hotspot is activated in Step 5, the
biographical events and/or clarifying update can be achieved in several ways. For
the differences between then and now example, after the hotspot is activated, the
55 Emotionally effective change in dys- patient can verbally remember important
functional appraisals corrective information (e.g. “I now know that
I did not die”; “I now know it was not my
fault”). The therapist can support the patient
In order to first get an overview of the trau- in this by assisting the verbal cognitive
matic experience and to identify the relevant restructuring of the hotspot during imagina-
hotspots, cognitive therapy initially involves tion using Socratic questioning (e.g. “You
complete imaginal exposure conducted 1–2 blame yourself that it was your fault. What do
times. In the debriefing part of each session, you know now? What else has contributed to
the therapist and patient then jointly explore it happening”) (for a detailed description of
the relevant hotspots and the appraisals and this strategy with practical examples see
emotions contained therein. In the next step, Grey et al. (2002)).
dysfunctional appraisals represented in the Alternatively, once the hotspot has been
13 hotspot are first challenged using cognitive activated, the patient may perform actions
techniques and new more helpful appraisals that conflict with the experience of the
are developed. Then therapist and patient trauma (e.g. getting up, moving) or that pro-
jointly develop a plan on how the trauma vide them with sensory evidence that contra-
memory can be updated against the back- dicts the evaluations (e.g. palpating body
ground of this new appraisal. In the final parts that were injured and have since
step, the target hotspot is re-activated with healed; looking at a photograph of them-
the help of imaginal exposure, and then the selves with other people that was taken after
a priori planned intervention to update the the trauma).
trauma memory is implemented. As with It is also possible to incorporate correc-
prolonged exposure, the session is recorded tive information into the trauma memory by
so that the patient can listen to it again as directly altering the script using imagery
homework. In addition, the exercise is (e.g. letting other people enter the scene who
repeated until there is a significant change in interact with the victim; imagining the per-
the appraisals and associated emotions. petrator in prison).
247 13
Case Study 1: Accident Survivor Mrs. R
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”).
zz Notes 55 that the patient gets up and walks around

If – as in this case example – the corrective the room to make themselves aware that
information/evaluation is clear, Step 3 (cogni- they are unharmed, or
tive restructuring outside of the imagery 55 rewrite the scene imaginatively (e.g. let
intervention) can be skipped. Alternative pos- someone enter the scene to rescue them
sibilities for updating in this case would be from the situation)
55 that after updating the hotspot, the
patient looks at a photo showing them
and their family in the new house,
Case Study 2: Surviving War
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
13.4.3.3 Further Variations zz Imagery Rescripting

of Interventions to Modify As described above, the direct alteration of
Trauma Memory trauma-related imagery is used in cognitive
zz Writing About the Traumatic Event therapy (Ehlers, 1999) as a building block to
Within the framework of cognitive process- update trauma memory. In some recent
ing therapy (König et al., 2012), structured approaches, this strategy lies at the core of
writing therapy (Sloan et al., 2011; van these treatment.
Emmerik et al., 2008) and web-based vari-
ants of trauma-focused CBT (7 Chap. 15),
Imagery Rescripting and Reprocessing
patients with PTSD are instructed to write (IRRT) (Schmucker & Köster, 2014)
about their trauma. Ehlers and Clark (2000) 55 Targets: Reduction of intrusive re-
also recommend to ask patients to write a experiencing, change of negative
trauma report in addition to the imagery- schemas as a result of early-life
based interventions described above. trauma (especially sexual and/or
physical violence in childhood)
zz Narrative Integration of the Trauma Into 55 Three phases (to be completed one
the Autobiography after the other within one session)
Narrative exposure therapy (Schauer et al., –– Imaginal exposure (7 Sect.

2011) is characterized by the fact that indi-

13 vidual traumatic experiences are not pro-
13.4.3.1).
–– Imagery rescripting I: Disem-
cessed separately, but that it aims to integrate powering the offender. Repeat
different traumatic experiences into their the exposure up to the relevant
autobiographical context through a recon- hotspot, then start rescripting.
struction of the entire life span using a nar- The therapist guides the patient
rative process. Treatment begins with the to imagine entering the scene as
recording of relevant life events and their the adult they are today and
chronological classification based on a life interacting with the perpetrator
line. The core treatment component then (and later the child). In phase 2,
consists of the chronological narration of the aim of rescripting is to disem-
the life story, whereby significant and trau- power or at least neutralize the
matic life events are dealt with in greater perpetrator and bring the child to
depth using exposure. The narrative is writ- safety. In this way, the traumatic
ten down and read out again in the next ses- memories, which are character-
sion and corrected or supplemented if ized by powerlessness and help-
needed. lessness, are to be replaced with
249 13
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
.. Table 13.1 Trigger of intrusive memory: Hug by the partner
At that time Today
Commonalities Heat of another body on my body Heat of another body on my body

Differences
Who? Strange man/offender Person I love/my partner
How? Forced/couldn’t leave Voluntarily/I can leave at any time
Where? In the street In my apartment
Weather? Summer, hot weather Autumn, cool and windy
Aim of the other person To dominate me To show me his affection
Meaning Danger No danger
them is necessary. The reduction of avoid-

impressions that only have a temporal ance is therefore an important challenge for
association with the trauma treatment. The communication of a con-
55 Deliberate discrimination between vincing rationale (7 Sect. 13.4.2) plays an

“then” and “now” important role here, as do interventions to

–– Example: PTSD after rape increase commitment, for example in the
–– Trigger of the intrusive memory: form of a detailed exploration of the advan-
hug by the partner (. Table 13.1)
tages and disadvantages of avoidance using
55 Frequent repetition: deliberate trig- list of pros and cons.
gering of stimuli, then discrimination Therapists may themselves also feel anx-
exercise (then vs. now) ious and engage in avoidance behavior in rela-
tion to imaginal exposure and may therefore
delay the start of this intervention for too
13 13.4.3.4 Difficulties and Possible long. Therapists who have little experience in
the implementation of trauma-focused inter-
Solutions
ventions also frequently report that when dif-
Special challenges can arise when carrying ficulties arise (e.g. short-term worsening of
out interventions aiming to modify the symptoms, dissociation, ambivalence on the
trauma memory (e.g. imaginal exposure). In part of the patient) they become uncertain
the following, some possible solutions to whether to continue with trauma- focused
these difficulties will be outlined. treatment. This uncertainty is understand-
able. However, it is important for successful
zz Avoidance treatment to continue the trauma- focused
One of the core symptoms of PTSD is the interventions (e.g. imaginal exposure) espe-
avoidance of traumatic memories. In the cially in these situations. It is therefore recom-
context of imaginal exposure, however, con- mended that therapists new to trauma-focused
fronting oneself to the memories of the interventions and/or encountering problems
trauma and the feelings associated with seek supervision from experienced colleagues.
251 13
this is the case, the patient’s possible fears
Key Considerations that prevent them from engaging in the
55 Although trauma-focused interven- intervention should first be explored and
tions are the first-line treatment for challenged. It may also be necessary to go
PTSD, they are used less frequently back to the treatment rational and/or engage
than is actually indicated. Anxiety in intervention to increase commitment.
and avoidance on the part of both the
patient and the therapist can play a zz Dissociation
role. Some patients experience mild dissociative
55 It is important for therapists to be symptoms during trauma-related imagery,
aware that treatments such as imagi- such as feelings of derealisation, a changed
nal exposure or cognitive therapy are perception of time or a strong “here and
effective and safe procedures with a now” quality of a memory. This is usually
sound evidence base. not problematic. However, it can be helpful
55 Registered CBT therapists with a for the therapist to normalise these symp-
qualification have all the skills needed toms and make them understandable
to carry out these interventions. How- through psychoeducation so that they are
ever, it can be useful to have experi- not experienced as threatening.
enced colleagues supervise the first On the other hand, severe dissociative
treatments. symptoms during trauma-focused interven-
tions can impair the implementation and
effectiveness of the intervention. An exam-
zz Low Vividness and/or Emotionality ple of this can be that the patient has lost
The effectiveness of imaginative strategies contact with the “here and now” and hardly
(imaginal exposure; trauma memory updat- or not at all responds to the therapist’s utter-
ing; imagery rescripting) may be limited if ances. In this case it is absolutely necessary
the patient does not succeed in developing to use strategies to control the dissociation
vivid imagery and/or if emotions of very so that the trauma-focused intervention can
low intensively only are experienced. It is be continued. However, it is important to
not always possible to tell from an observer remember that the occurrence of dissocia-
perspective how strong the vividness and tive symptoms is not a contraindication for
emotionality of imagery is; for this reason, it imaginal exposure or other trauma-focused
is recommended to have vividness (0–100) procedures. Patients with severe dissociative
and distress (0–100) assessed repeatedly dur- symptoms also benefit more from trauma-
ing imagery-based interventions. In order to focused treatments with an exposure ele-
increase vividness, it can help to slow down ment than from purely stabilising
the process and to direct patient’s attention interventions (Ehring et al., 2014; Resick
to sensory impressions in all relevant modal- et al., 2012). If dissociation occurs, trauma-
ities as well as physical sensations. However, focused treatment should therefore not be
if the problem persists, the therapist should terminated or interrupted for a longer period
explore whether this could be an expression of time, but should be continued – albeit in a
of avoidance on the part of the patient. If modified form – as soon as possible.
252 T. Ehring
important principles of these therapeutic

Dealing with Dissociation approaches will be briefly outlined.
55 Short term: dealing with severe dis- The starting point of cognitive process-
sociation during exposure ing therapy (CPT) (König et al., 2012) is the
–– Objective: To help the patient assumption that traumatic experiences can
regain orientation in space and lead to rigid beliefs (for a more detailed
time description of the processes of assimilation
–– Strategies (examples): and [over]accommodation 7 Sect. 13.3.2).

–– 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

authors suggest, among other things, that

253 13
excessive negative appraisals of the trauma zz Identification of Dysfunctional
and/or its consequences, which increase the Appraisals and Beliefs
perception of a current threat, contribute to Problematic appraisals of the trauma and/
the maintenance of PTSD. An important or its consequences to be modified in ther-
distinction is made between peritraumatic apy can be identified in various ways. They
and posttraumatic appraisals. Peritraumatic often appear in patients’ spontaneous
appraisals are interpretations that trauma expressions during the session (e.g. over-
survivors already had during the event and generalisation of danger; cognitions related
which have not been updated since then, to guilt; negative self-evaluation) and should
often despite new information being avail- then be noted for later processing. Within
able. To change these peritraumatic apprais- CPT, a list of stuck points is kept on which
als, the strategies for updating trauma all dysfunctional beliefs that are identified
memory already described in 7 Sect. in the course of treatment are noted and
13.4.3.2 are suitable. Post-traumatic apprais- targeted one after the other. During debrief-
als, on the other hand, are interpretations ing in the wake of an imaginal exposure ses-
that the trauma survivors have later devel- sion (or other interventions to modify
oped in relation to the trauma and/or its trauma memory), patients also frequently
consequences and which are to be targeted express appraisals of the trauma or its con-
with traditional cognitive interventions. To sequences that lend themselves to later pro-
this end, Ehlers and Clark propose a variety cessing. Another way of identifying
of cognitive techniques, which are described dysfunctional appraisals is to use a ques-
in more detail below. tionnaire with typical posttraumatic cogni-
tions, e.g. the Posttraumatic Cognitions
>> According to Ehlers (1999), problematic Inventory (PTCI) (Foa et al. (1999); German
post-traumatic appraisals should be tar- translation in Ehlers (1999)). Finally, dia-
geted using traditional cognitive interven- ries, for example in the form of ABC work-
tions, while dysfunctional peritraumatic sheets, are suitable to identify appraisals
appraisals should be targeted with strate- that trigger stressful feelings in everyday
gies for trauma memory updating. situations (. Fig. 13.2).

Before the therapist begins to challenge

13.4.4.2 Important Techniques dysfunctional appraisals, it is necessary to
In principle, all cognitive strategies and tech- understand the patient’s current point of
niques that appear helpful in changing dys- view (What exactly does the patient believe?
functional appraisals can be used in What had led them to hold this belief ? What
treatment with PTSD patients. While CPT – reasons/evidence do they have to hold this
similar to cognitive therapy of depression – belief ? Does the belief offer an explanation
suggests a very structured approach using a for the patient’s feelings?) It is also impor-
set of worksheets, Ehlers and Clark place a tant for many patients to experience that the
stronger emphasis on interventions of cog- therapist understands and validates their old
nitive restructuring in the session as well as point of view before they are ready to chal-
on behavioural experiments. Both lenge it.
approaches have proven to be highly effec-
tive. In the following, some techniques and >>Therefore: first understand – then
strategies will be briefly described. change!
254 T. Ehring
Date/ A. Trigger event B. Thought/belief C. Consequence

Time
Something has happend I say to myself I feel.../I do...
Monday,
August 13th.
.. Fig. 13.2 Example of an ABC worksheet
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%)
zz Challenging Beliefs with Empirical

13 Evidence
zz Challenging Beliefs with Hedonistic
A common approach to challenging dys-
Arguments
functional beliefs is to gather arguments
and/or evidence for and against the belief, While empirical thought challenging exam-
and then develop alternative views in light ines the question of whether a thought or
of the overall evidence. belief is true, another form of thought chal-
lenging focuses on the question of whether it
is helpful for the patient to have this thought
Challenging Beliefs with Empirical or belief. In this way, alternative thoughts
Evidence are to be developed that better help the
55 Formulate dysfunctional beliefs in patient to achieve her personal goals and/or
concrete terms and put them down in to leave the trauma behind.
writing
55 Have the degree of conviction of this >>Sometimes dysfunctional beliefs also
belief assessed (0–100%) have a function that must be taken into
account in the disputation.
255 13
Case Study: PTSD After a Rape as predictions and then create situations in
which these predictions can be tested.
Mrs. S. was raped by a stranger in a park Behavioural experiments often lead to faster
a year ago. Since then she has been and more lasting emotional change than
plagued by strong guilt-related cognitions pure verbal though challenging.
(“I should have prevented it”; “It only hap-
pened because I was so provocatively 13.4.4.3 Common Topics
dressed”). The guilt proved to be very In . Table 13.2 common beliefs held by

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
zz Analysis of Problematic Thinking Trauma survivors with PTSD often engage

Patterns in dysfunctional coping strategies that aim
In the context of CPT, psychoeducation on to control the perceived current threat and
problematic thinking patterns (sometimes the symptoms (7 Sect. 13.3.3). Some of

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
.. Table 13.2 Dysfunctional beliefs and possible interventions
Topic Beliefs (examples) Interventions (examples)
Guilt I’m to blame for the attacks. Psychoeducation about

I should have stopped the violence. The level of development of children (in
I should have known it would come to case of childhood trauma),
this. Behaviour in traumatic situations,
I provoked the violence by my behavior. Legal considerations
Reconstruction of the situation at that

time:
What were your reasons then?
What circumstances contributed to your
behavior at that time?
What did you know/expect at that time?
Modification of the hindsight bias

Surveys: What do others think about it?
Overgenerali- I’m not safe anywhere. Psychoeducation about
sation of I can’t trust anyone. Features of trauma memory,
danger I’m about to have another accident/ Selective attention
robbery.
Calculating probabilities
I attract misfortune.
Identification of reasoning errors:
Emotional inferences (“I feel anxious,
therefore danger must be imminent”)
Overgeneralization
Selective attention to other disasters
Behavioral experiments: What happens if

I expose myself to situations in which I
suspect danger?
13 Shame When others find out what happened to

me, they will want nothing more to do
Reconstruction of the situation at that
time:
with me. What were your reasons then?
My behaviour during the trauma shows What circumstances contributed to your
that I am weak. behavior at that time?
I am a bad person because I enjoyed the What did you know/expect at that time?
attention of the perpetrator.
Injustice/anger The world is unfair. Important: Empathy and validation
I was wronged, and no one cares.
Explore context, reduce personalization of
The person who caused the accident did
the explanation
it on purpose/wanted to harm me.
Dispute assumptions about intentions of
the other side/change of perspective
Hedonistic thought challenging (“Who
wins when I’m angry?”)
Constructive exchange instead of revenge
257 13
by the patient as homework. The progress as
In Vivo Exposure well as the effects of this change in behav-
55 During in vivo exposure as part of the iour are evaluated at the beginning of each
prolonged exposure treatment devel- session before a new plan for the coming
oped by Foa et al. (2014), the reduc- week is worked out.
tion of avoidance as well as
experiencing habituation are the zz Further Examples
main focus. Using this procedure, the Other dysfunctional behaviors include
patient should remain in the situation excessive trauma-related rumination, hyper-
until habituation has occurred. Fur- vigilance and overprotection of children/
thermore, avoidance and safety family, excessive substance use and dysfunc-
behaviour during exposure should be tional sleep patterns.
prevented.
55 In vivo exposure can also be carried
Interventions Used for the Modification
out as a behavioural experiment, the
of Maintaining Behaviour
aim of which is to test the patient’s
55 Identification of dysfunctional behav-
beliefs (e.g. “If I am not constantly on
iour and its function through func-
my guard, another accident will
tional analysis
happen”: driving a car without exces-
55 Psychoeducation about the effects of
sive checking of the rear-view mirror;
these behaviours
“Others don’t want anything more to
55 Cognitive interventions targeting
do with me when they find out what
underlying beliefs
happened to me”: telling others about
55 Cost-benefit analysis of dysfunctional
the trauma and getting feedback).
strategies
55 In the context of cognitive therapy
55 Behavioural experiments: What hap-
(Ehlers, 1999), in vivo exposure is also
pens if I replace this strategy with
used with the aim of promoting dis-
something else or leave it out?
crimination between “then” and
55 Training of alternative behaviour (e.g.
“now” (7 Sect. 13.3.3).

sleep hygiene, emotional regulation

skills, social skills)
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.
Most evidence-based treatment approaches

include so-called booster sessions after the Literature
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Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2014). Depression und Trauer. Klett Cotta.
Handbuch der Prolongierten Exposition: Sloan, D. M., Marx, B. P., & Greenberg, E. M. (2011).
Basiskonzepte und Anwendung – eine Anleitung für A test of written emotional disclosure as an inter-
Therapeuten. Probst. vention for posttraumatic stress disorder.
Grey, N., Young, K., & Holmes, E. A. (2002). Behaviour Research and Therapy, 49(4), 299–304.
Cognitive restructuring within reliving: A treat- https://doi.org/10.1016/j.brat.2011.02.001
ment for peritraumatic emotional “hotspots” in Thünker, J., & Pietrowsky, R. (2011). Alpträume: Ein
posttraumatic stress disorder. Behavioural and Therapiemanual. Hogrefe.
Cognitive Psychotherapy, 30(1), 37–56. van Emmerik, A. A. P., Kamphuis, J. H., &
Herbert, C., & Wetmore, A. (2005). Wenn Albträume Emmelkamp, P. M. G. (2008). Treating acute
wahr werden: Traumatische Ereignisse verarbeiten stress disorder and posttraumatic stress disorder
und überwinden. Huber. with cognitive behavioral therapy or structured
König, J., Resick, P. A., Karl, R., & Rosner, R. (2012). writing therapy: A randomized controlled trial.
Posttraumatische Belastungsstörung: Ein Manual Psychotherapy and Psychosomatics, 77(2), 93–100.
zur Cognitive Processing Therapy. Hogrefe. https://doi.org/10.1159/000112886
NCCMH (National Collaborating Centre for Mental Wells, A., & Sembi, S. (2004). Metacognitive therapy
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PTSD in adults and children in primary and second- doi.org/10.1016/S1077-7229(04)80053-1
ary care. National Institute for Clinical Excellence.
261 14
Eye Movement
Desensitization
and Reprocessing (EMDR)
Contents
14.2 The 8 Phases of EMDR – 263

14.2.1 hase 1: Client History and Treatment Planning – 263
P
14.2.2 Phase 2: Stabilisation and Preparation for EMDR – 266
14.2.3 Phase 3: Assessment of the Target Situation – 270
14.2.4 Phase 4: Reprocessing with External Stimulation – 271
14.2.5 Phase 5: Installation – 273
14.2.6 Phase 6: Body Scan – 275
14.2.7 Phase 7: Closure of the Meeting – 275
14.2.8 Phase 8: Follow-Up and Reintegration – 276
14.3 How Does EMDR Work? – 276
14.4 Effectiveness Studies – 277
14.5 EMDR-Based Enhancements – 279
Literature – 280
262 O. Schubbe and A. Brink
14.1 Introduction EMDR has been developing dynamically

ever since. Developments in trauma therapy
EMDR stands for “Eye Movement are reflected in the design of the 8 EMDR
Desensitization and Reprocessing”. This phases. EMDR is being used for a wider
eight-phase treatment concept describes the range of applications. The understanding
full process of trauma treatment. As first that EMDR can be used to process dysfunc-
described in 1889 by Janet (1973 [1889]) and tional memory opens the possibility of using
as recommended in the current treatment EMDR beyond the diagnosis of
guidelines for PTSD (Flatten et al., 2001), PTSD. Thus, EMDR can also be used to
EMDR treatment begins with trauma- process sub-traumatic experiences of origin
specific history taking, treatment planning that have led to dysfunctional beliefs or a
and stabilization. Only after sufficient stabi- phobia, for example. Frequently, new fields
lization, the traumatic memory can be proof application are emerging. To increase the
cessed. For each processing session, a acceptance and the range of applications,
stressful memory is selected and processed more options to interweave resources into
in five steps: Assessment, desensitization, the processing phase and to balance between
installation, body scan and closure. In the resources and trauma processing have been
best-case scenario, the traumatic memory
created. As EMDR is an empirically based
has lost its stressful quality at the end of
procedure, theoretical considerations and
therapy, and the client’s quality of life has
models were developed further in accor-
improved significantly.
dance with the advancing knowledge.
Client History Francine Shapiro set up a rather eco-
EMDR was empirically developed by Francine nomical working model, the AIP model. Its
Shapiro. She experimented with the use of eye move- terminology comes from computer science
ments for the resolution of traumatic memories. In
and appears quite technical (Shapiro, 2001,
1985, she published her findings on the significance
of eye movements for the installation of positive ego 2018). On a closer look, however, this model
states (Shapiro, 1985). In 1988 she examined the effec- reflects the humanistic approach according
tiveness of her approach in her dissertation (Shapiro, to which a person unfolds under good con-
1988). The basic structure of EMDR is based on the ditions and develops deeply individual solu-
phase model of trauma therapy: stabilization, trauma
processing, and reintegration (Janet, 1973 [1889]). Then tions and healing methods. The core of
her intern Mark C. Russels and her developed the con- EMDR is a process that is initiated and
14 cept of “Reprocessing”. From this she later developed accompanied in such a way that it offers
a theory model, the “Adaptive Information Processing” optimal processing conditions. It is worth
model. Her meditation teachers Ondrea and Stephen
Levine shaped her understanding of what happens putting the model into a larger context in
when memories are processed. In Vipassana medita- order to be able to explore it in depth.
tion she learned the Lightstream Technique, which she EMDR is intended for combination with
included in her textbook for treating residual physical other established therapeutic procedures.
stress. There are also numerous influences from hyp-
notherapy, Milton Erickson and his students. The best
There is a mutual basis for EMDR with psy-
known of these are Milton Erickson’s VAKOG system, choanalytically oriented approaches, as
which is reflected in the imagination technique “Safe EMDR gives glimpses into the unconscious
Place Exercise”, as well as studies by John Grinder on process. Changes can be brought about by
the effectiveness of eye movements in trauma sequelae.
The SUD (Subjective Units of Distress) scale (1–10)
processing original traumatic events as well
according to Joseph Wolpe is used to measure the as current maintaining conditions. EMDR
degree of stress and for before-and-after comparison. utilizes the process of “free association” as a
Eye Movement Desensitization and Reprocessing (EMDR)
263 14
vehicle for integration of traumatic memo-
ries (Wöller & Kruse, 2014). EMDR as Procedure in 8 Phases
EMDR is compatible with the princi- (According to Shapiro)
ples of behavioural therapy: It places great Phase 1: Client history and treatment
value on a clear understanding of symp- planning
tom maintaining conditions, on informed Phase 2: Stabilisation and preparation
consent, on the integration of resources, and for EMDR
on the differentiation of cognitive general- Phase 3: Assessment of the target sit-
izations. The phases of EMDR represent a uation
solution focused structure. The typical Phase 4: Desensitization and repro-
EMDR session starts with one traumatic cessing with external stimulation
memory, patients’ everyday posttraumatic Phase 5: Installation of the positive
triggers or symptoms, or with a future tem- cognition within the target situation
plate, e.g. catastrophic expectations, which Phase 6: Body scan
are thereto selected. Before confrontation, Phase 7: Closure of the session
the therapist asks for the major hotspot of Phase 8: Follow-up in the following
the event, the worst moment, or an image session
that represents the event. Trauma confron-
tation in sensu is a core element of
EMDR. Following the confrontation in 14.2.1 hase 1: Client History
P
sensu, an in vivo confrontation can be nec- and Treatment Planning
essary for reality testing (Linden &
Hautzinger, 2011). 14.2.1.1 Initial Interview
Like any other individual therapy, EMDR
begins with the initial consultation. This
14.2 The 8 Phases of EMDR serves as the first contact. Optimally, it helps
with establishing a therapeutic relationship
Along the traditional concept for trauma and mutual trust. As usual, it is necessary to
treatment, EMDR starts with an assessment ask why the patient is seeking therapy at this
phase and a phase focusing on the patient’s particular time, what their living conditions
stability and quality of life. After these first are, and which problems are bothering
two phases, the subsequent EMDR sessions them. It should be asked whether the patient
guide through exposure, desensitization and has previous experience with psychother-
reprocessing. The information from the apy, and for therapeutic goals. Further ques-
assessment phase, specifically on traumatic tions relate to the motivation for therapy,
events and biographical resources, is used whether the client is under pressure, or
for treatment planning. The resource orien- whether coercion has been exerted to enter
tation of EMDR make it a gentle approach treatment. The emphasis on wishes, motiva-
(Sack, 2010). The work on stressors is always tion and a defined therapeutic goal deter-
embedded in at least as many resources. mines the direction and layout of
Four of the following phases (1, 2, 7, and the treatment plan.
8) correspond with general treatment stan- At this point of EMDR therapy, the
dards. The middle phases 3–6 are specific to symptoms need to be assessed. The thera-
EMDR (Schubbe & Gruyters, 2018). pist records the biographical context, in
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.
265 14
.. 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.
afterwards or alternating. 14.2.2).

There are two methods we particularly Working with a timeline offers another
recommend: the first is creating a list, and possibility for specific assessment of trauma
the second is working with a timeline. When history. A timeline of one’s life can be laid
creating a list, it is advisable to fill in only out in the therapy room (e.g. with a rope),
one keyword for the event on each line, which supports viewing one’s life from
together with a number for the respective above, and gives an overview from today’s
age. Finally, at the end of each line, a num- point of view. Thus, interrelations can be
ber from 0 to 10 is added for the degree of detected, for example a connection between
stress, i.e. for the degree of perceived stress a stressful phase of life and the development
when remembering in the present. Such a of special resources.
list may also makes amnesic periods of life When working with the timeline one can
perceptible (. Table 14.1).
use the “Stones and flowers” principle. The
Coping questions and stabilization exer- traumas and burdens can be arranged with
cises have proven to be useful for stabiliza- stones along one side of the timeline and the
tion after the client’s trauma history. resources can be placed along the other side
Afterwards the resources can be assessed with flowers or stars.
in form of a list. The list of positive life More recent developments in EMDR
experiences is intended to draw the patient’s already begin the introduction of bilateral
attention back to positive topics after talk- stimulation in this phase, however it is only
ing about their trauma history and serves – used to deepen and install positive resources
in preparation for EMDR – to systematically (Rost, 2016).
14.2.1.4 Treatment Planning planning in complex traumatized patients

The treatment planning is based on the was developed by Kitchur (2005). She rec-
recording the client’s trauma history. This ommends to form thematic groups accord-
includes estimating which and how much ing to various criteria, and to bring them
stabilisation is necessary in the context of into a certain treatment order. The treat-
amplifying existing resources and development topics should be chosen in such a way
ing new ones. In addition, topics for the that they are emotionally accessible, but do
EMDR-processing work can be selected - not overtax the client’s ability to regulate
either from the list or the collected stones. their emotions (affect rule). Completely
A typical EMDR processing session accessible memories should be processed
begins by focusing on a carefully chosen ini- before fragmented or partially amnesic
tial target. memories (rule of coherence). This is done
With mono-traumas, the choice of in order to not surprise and overwhelm the
this target is obvious. However, it must also patient at the beginning with memory frag-
be examined whether there exist earlier ments that become conscious anew. In
events in the client’s biography which might Kitchur’s approach the chronology rule is
be emotionally charged in a similar manner. subordinated.
This earlier incidents in the background
have to be targeted before the later mono- >>Early planning of treatment and thus
trauma. initial topics for the EMDR process
Patients with complex trauma have dif- leads to a transparent, well-structured
ferent traumatic memories and varying ini- course of therapy. It also forms the basis
tial themes. These can come in considerable for the subsequent stabilisation phase.
abundance, therefore they should be pro-
cessed in several sessions. The planning of
the EMDR process thus becomes an essen- 14.2.2 hase 2: Stabilisation
P
tial step within the overall treatment and and Preparation for EMDR
should be approached very carefully and in
close atunement with the patient. The stabilisation phase occupies an individ-
The chronology rule was established by ually adapted space within the EMDR-
Shapiro as the most important rule. Phrases process. For mentally stable patients who
like “First things first” or “Past – Present – experienced a mono-trauma as adults (e.g.,
14 Future” characterise the so-called standard the motorcyclist after an accident, whose
protocol. They remind us to process early trauma history can be found in the
traumatic memories before later ones. . Table 14.1 no extensive stabilisation

Traumatic memories experienced early in phase is required). In this case, it is sufficient

life can be updated for processing without to devise the stabilization as a direct prepa-
triggering later memories, but not vice versa. ration for the EMDR-processing. It is also
The advantage of starting with the earliest sufficient to practice only one stabiliza-
memories is also that the distress of later tion method for safely switching into a
events is reduced on its own, while such a resourceful state, and to practice another
generalisation is not being observed vice method for internal distancing and contain-
versa (Greenwald & Schmitt, 2008). ment of stressful experiences. Also, patients
However, Shapiro found limitations of this with a very distressing biography, who have
methodology in complex traumatized been able to develop an extremely creative
patients with a wide range of issues. The and resourceful life (e.g., artists or musi-
most detailed concept for EMDR treatment cians, who have found an additional expres-
267 14
sion for their traumatisation in their music, relaxation CDs or pleasant manual
creativity), do not need an extensive stabili- activities, have a deepening effect on relax-
sation phase. In contrast, this is the most ation.
important and time-consuming therapeutic In addition, the patient should learn
step in EMDR for patients with low strategies for dealing with intrusive memo-
resources. ries, nightmares and psychological crises.
As preparation for EMDR confronta- There are numerous strategies and exer-
tional work, it should be remembered that cises that have proven to be effective. In
this should not be carried out as long as addition to methods for orienting oneself
unprocessed memory content cannot be to the present in space and time, one exam-
combined with the resources necessary for ple is the screen technique, the imagination
processing. To the extent that traumatic of a screen. Patients learn to project their
memory content is avoided and dissoci- intrusions onto this imagined screen and
ated in everyday life, the day-to-day then control them with an imagined remote
resources available are difficult to access control (Brink, 2014). The method of epi-
during the processing of traumatic mem- sodic contextualization (Ehlers, 2010) has
ory content. been proven to be very successful. Here,
patients are trained to embed chronologi-
cally the fragments of memory, which are
(resurfacing in their intrusions or night-
In the second phase of EMDR it is part mares in such a way that a good memory
of the concept to systematically support precedes the memory fragment, which is in
associative access to inner resources and turn followed by a good later memory.
to bring the patient into contact with the Such a resourceful embedding makes it
present and possible solutions. The effect easier to relax and oftentimes the fre-
of EMDR can be understood through quency of intrusions and nightmares
the fact that during trauma processing decreases significantly. In order to deal
new associative connections between with crises that are often experienced as
traumatic contents and resources are inexplicable at the beginning, it is common
created. practice in trauma therapy with EMDR to
create a list of possible triggers and to help
the patient to identify them gradually. For
each trigger it should be contemplated if
14.2.2.1 Stabilisation and how it can be avoided, or how it can
The patient should learn to reduce the basic best be dealt with. Working with such a list
level of his or her internal distress. improves self-perception and self-care and
Movement-oriented methods are often bet- helps to systematically replace harmful
ter suited for this than quiet relaxation avoidance strategies such as addiction or
methods. To reduce tension and stress, ele- self-harm.
ments from Qi Gong, Tài Chi, Yoga, trauma
and tension release exercise (TRE), expres-
sive breathing exercises with forced exhala- Under the Magnifying Glass: Keeping an
tion, as well as any form of endurance sports “Emergency Case” Ready
are recommended. Only when these expres-
For unstable patients and patients, who
sive and movement-oriented methods bear
have suffered multiple trauma, a so-
fruit can relaxation methods such as pro-
called emergency case with stepwise
gressive muscle relaxation, autogenic train-
strategies for stress relief is created:
ing, painting, making music, listening to
explanations. When choosing EMDR as

55 well-practiced reorientation tech- treatment, the choice of timing is crucial.
niques The general and EMDR-specific criteria of
55 techniques for distancing oneself a trauma confrontation must be taken into
from stressful thoughts and feelings account.
such as the film stop technique or the
vault exercise zz Timing
55 a selection of cherished objects, In order to be able to assess whether the
favourite music, self-help literature “resource mix” is already sufficient for the
55 addresses and phone numbers of upcoming trauma treatment and if it fits
friends perfectly, the therapist should check whether
55 (if applicable) medication the patient
55 telephone number of a previously
carefully selected hospital 55 is currently able to manage his or her
everyday life independently (everyday
test)
55 has an inner idea of a safe place (safe
14.2.2.2 Indication place test),
and Contraindication 55 can calm down after an intensive conver-
The first phases of EMDR can be started sation about traumatic memories (con-
without considering any contraindications versation test)
beyond normal patient education. This edu- 55 is able to clearly identify the limits of his
cation should include the fact that psycho- or her resilience (testing self-perception
therapy can lead to changes and side effects, and therapeutic confidence).
and that phases can also occur, in which the
subjective wellbeing worsens. In preparation for EMDR processing, it
When planning the confronting EMDR should be remembered that processing
phases, further considerations regarding the should not be initiated as long as unpro-
indication or contraindication are necessary. cessed memory content cannot be connected
These concern the choice of timing, the gen- to the resources required for processing. For
eral use of a trauma-confronting procedure this purpose, it should be checked whether
and EMDR-specific criteria. enough resources could be (re-)activated in
14 In order to prepare the EMDR process, the first therapy phase, in order to suffi-
it is important to examine the therapeutic ciently promote the inner stability of the
mandate for both - for the topics to be patient. These resources should also be indi-
worked on and for the method to be used. If vidually appropriate. The patient should be
the mandate is connected to ambivalent feel- able to master everyday life independently
ings, the symptoms can still have an impor- and to deal with surfacing traumatic memo-
tant function for the inner balance. Then ries. This includes being able to calm oneself
alternative strategies need to be developed while experiencing overwhelming emotions
for the symptoms in order to reliably estab- and to be able to discern the junction to dis-
lish this inner balance. It is also possible that sociation and to signal these in therapy.
the ambivalence towards the task is an
expression of avoidance symptoms. In this zz Contraindications for Trauma
case, it is advisable to support the patient Confronting Procedures
firstly in dealing with this fear by using other EMDR trauma confrontation is contrain-
methods, to motivate him patiently for dicated in all cases where insufficient psy-
EMDR and to reduce fears by appropriate chological, social or medical stability is a
269 14
fundamental argument against trauma failure as well as phobic fears of exposing
exposure. These can be all states of acute oneself to a situation that cannot be com-
psychological instability and lack of acces- pletely planned from the outset, are major
sibility in therapeutic contact: psychotic obstacles on the patient side and should be
tendencies, acute suicidal tendencies, influ- taken very seriously by the therapist.
ence of drugs, alcohol or sedating medica- Sensitive preparation, self-determination
tion. In medical risk situations such as an and the greatest possible choice and con-
unstable heart disease or high-risk preg- trol make it easier for patients to get
nancy, EMDR should only be conducted involved in the unknown process. It can be
in a safe medical setting. In the case of practised in a playful way, that the thera-
patients suffering from epileptic, pseudo- pist immediately stops upon the stop sig-
epileptic attacks or asthma attacks, it nal: no means no, limits are always
should be discussed, after a consultation appreciated. Metaphors can also help the
with a physician, what the psychotherapist patient to confide in the therapist (7 Sect.
and patient can do in the event of a seizure. 14.2.2.3).

Mental retardation and neurological disor- EMDR can be performed with various
ders might limit the effectiveness of bilateral stimulations. Therefore, eye prob-
EMDR, but do not pose a risk. A trauma lems or photosensitive epilepsy are no
confrontation should normally not be car- obstacle when tactile or acoustic stimulation
ried out if contact with the perpetrator is used.
continues.
In the case of dissociative symptoms,
Checklist for Working with EMDR
EMDR is only indicated to the extent that it
55 Is there a stable and trusting working
is possible to keep the patient in an associ-
relationship?
ated state during trauma processing or to
55 Am I prepared to see the patient
quickly return to the present. Dissociative
through the entire process?
symptoms should be assessed using for
55 Have the stressors objectively ended?
example the FDS questionnaire (Freyberger
55 Do the stressors create an emotional
et al., 2005).
and sensual reaction?
In the case of children, the family con-
55 Can sufficient physical resilience be
text and existing bans on speaking must be
assumed?
taken into account. Before trauma confron-
55 Is there sufficient mental stability and
tation, very careful preparatory work involv-
ability for self-regulation?
ing the whole system is necessary. As a rule
55 Is there enough energy available in
of thumb, no EMDR processing topics that
everyday life for profound emotional
are taboo in the family should be chosen.
processes?
Bans on speaking should be dissolved in a
55 Can a symptom gain be excluded?
family discussion before trauma exposure,
55 Have the EMDR targets been defined?
unless a child has addressed it by own initia-
55 Is there enough time to finish the ses-
tive in therapy: In this case it is also correct
sion well?
to respond to it and to merely keep an eye on
(If one of the questions has to be
the conflict of loyalties.
answered in the negative, this point needs
to be clarified before starting EMDR).
zz EMDR-Specific Contraindications
The EMDR process presupposes that the
therapist and the patient can collectively Statements in Court
engage in a self-organizing process. An In ongoing legal proceedings, it should be borne in
excessive need for control, strong fears of mind that patients’ statements in court are sometimes
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.
14.2.2.3 Explanation of EMDR 14.2.3 hase 3: Assessment

P
and Specific of the Target Situation
Psychoeducation
EMDR should definitely be explained so The client’s history, treatment plan and indi-
that patients know what they are consenting cation for EMDR have now been completed.
to. Some patients need detailed information EMDR has already been explained to the
and possibly further reading. Whereas for patient and he has given his consent. He or
other patients short and concise explana- she is familiar with the “safe place” exercise
tions are sufficient. This explanation could and the stop signal. The sitting position is
for instance be as following: synchronized with the chosen form of bilat-
eral stimulation. Only then does the typical
▶▶ Example: Explanatory Conversation EMDR session (phases 3–6) begin.
In phase 3, the patient explores the worst
14 T: “When a trauma happens, all memory
information is—so to speak—locked up in moment (hotspot)of the selected initial situ-
the nervous system, connected with the ation. The patient assesses this worst
original images, thoughts, feelings and body moment on several levels. This refreshes the
reactions. The trapped memory is separated inner perception of the dysfunctionally
from the biographically appropriate solution,
stored memory on several levels. In addi-
external stimuli however can trigger
corresponding feelings. EMDR seems to tion, it serves the process assessment, so that
make the trapped information accessible for one can record changes in the processing
processing again, so that the memory can be state at the end of the session and in the cat-
better integrated internally and is therefore amnesis.
less easily triggered from the outside.”
In order to increase familiarity with bilat- Levels of Inner Perception

eral stimulation, it is beneficial to try out Narrative of the situation
different visual, acoustic and tactile options Inner sensory perception (usually an
and to communicate the different alterna- image)
tives. Most often, the visual stimulation is Generalized belief about oneself
271 14
P: “I feel powerless and scared to death.”

1–3 triggered emotions (often several)
physical sensations that accompany T: “On a scale of 0–10, with 0 being no bad
feelings and 10 being the worst possible
these emotions. feeling, how strong is that feeling for you
now?”
P: “Nine.”
Scales Used T: “Where do you feel that in your body?

The “Subjective Units of Distress” (SUD) Where can you locate it?”
for estimating the perceived stress P: “There is a tightness in the throat.”
The “Validity of Cognition” (VoC) T: “You have done very well; we now have
for assessing the validity of the desired everything we need/that is important to
belief about oneself start the EMDR process. Now please
imagine the flames again, think ‘I am
helpless against the flames/I am at the
mercy of the flames’, feel the tightness in
▶▶ Example: Phase 3 your throat and watch whatever comes up.
Anything can appear, you can just observe
T: “Do you agree to work on the memory of whatever comes up. Are you ready?”
the helicopter crash today?”
P: “Okay.”
P: “Yes.”
T: “Good!”
T: “What image represents the worst part of
this incident?” ◄
P: “The flames.”
T: “The flames, okay. What negative belief
about yourself does this picture elicit 14.2.4 Phase 4: Reprocessing
today?” with External Stimulation
P: “I am at the mercy of the flames.”
T: “When you imagine the flames, what would
you rather think about yourself today?”
The phase of reprocessing is also called
P: “What do you mean?” processing, EMDR process or EMDR
T: “When you recall the memory of the flames confrontation. The therapist leads the
from today’s perspective – is there patient into emotional contact with the
something positive you can think about memory’s most disturbing image, with
yourself?” the negative cognition and the stressful
P: “I can protect myself.” body sensation and then begins a series
T: “When you imagine the flames, how true
of bilateral stimulations.
does the phrase ‘I can protect myself’ feel
at the moment on a scale of 1–7, where 1
stands for completely false and 7 for
The therapist ensures that the patient focuses
completely true?” his attention on both the external bilateral
stimulation and the unprocessed memory
P: “Two.”
content. He or she ensures that the resources
T: “When you imagine the flames and say the necessary for the solution remain accessible
words ‘I am helpless against the flames/I at the same time. The therapist does as many
am at the mercy of the flames’, what
emotions come up/do you notice now?”
stimulation sets as are needed to signifi-
cantly reduce the stress. A set lasts until the
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-
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

therapeutic interweave are listed with exam-

ples.
.. Table 14.2 Therapeutic interweave
Form of interweave Example
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)
.. Table 14.2 (continued)
Form of interweave Example
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?”
◄
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
◄
getting into the car, the patient should first

take a short walk or rest after the session. tion. The suitability of the positive
cognition as well as the degree of
14.2.8 hase 8: Follow-Up
P stress give clear information about the
patient’s condition relative to his
and Reintegration
dream or nightmare.
After confrontational sessions, one of the first
questions in a follow-up session is whether
anything new has emerged since the EMDR 14.3 How Does EMDR Work?
session with regard to the initial target.
The therapist should state the target of The AIP model (Adaptive Information
the last session and ask again about the Processing Model) is a simple theoretical
degree of subjective stress. In this way the model. Shapiro (2001) assumes an innate
therapist can check if the initial theme of ability to process traumatic memory con-
the last session has been completely pro- tent. The information associated with the
cessed. In some cases, the theme has been trauma must be transferred from the
completed, in others new memory material trauma network to adaptive networks. In
has appeared. Occasionally, patients report the adaptive networks the trauma can be
particularly vivid dreams after EMDR ses- processed and reconnected. Comparable to
sions, which then usually contain very valu- the concepts of assimilation and accommo-
able information about topics still to be dation according to Piaget (1947), those
worked on and symbolizations useful for affected by trauma attempt to integrate
processing. new experiences into existing patterns
(assimilation) or they try to enlarge existing
What Can Be Processed with EMDR? schemata (accommodation). Traumatic sit-
55 Stressful memories – memories that uations are difficult to categorize because
are still vividly present in the back of they exceed anything imaginable.
the patient’s mind in today’s life and Unprocessed networks are disconnected.
that affect everyday life. These contain generalized beliefs, sensory
55 Emerging memories: During the pro- unprocessed memory images, stressful
cessing, associatively connected mem- emotions and body correlates that appear
14 ories, often linked by a bridge of as symptoms. The symptoms are not
affect, seem to become accessible regarded as the cause of disorders, but as
again, regardless of whether they were consequences of dysfunctionally stored
previously remembered or not. Impor- information. The AIP model can explain
tant distressing memories that emerge dissociation better than the former fear
spontaneously can become the next structure model (Maercker & Rosner,
topic of a further EMDR session. 2006). For treatment with EMDR, the dys-
55 Nightmares: Dream content is partic- functionally stored information is identi-
ularly suitable for deepening an fied, recalled and made accessible for
already initiated EMDR process in processing again. The memory information
one of the follow-up sessions. In this is integrated, and as a consequence adap-
case, the therapist also inquires after tive changes of ego states, cognitions and
the worst moment the negative cogni- behavioral patterns occur.
tion when remembering the dream, Additionally, there are also various edu-
the feeling as well as the body sensa- cational, behavioral and neurological
hypotheses on the effect of EMDR. They
277 14
try to explain how EMDR stimulates the The quantitative studies also show signifi-
processing of information. There are several cant improvements in the treatment of trau-
processes, which presumably play a role: matized patients with EMDR. The available
limiting overexcitation by dividing one’s research results were summarized by
attention, synchronizing brain activity, the Münker-Kramer (2017) and in various
orientation reflex and an integration process meta-analyses (e.g. by Davidson and Parker
similar to dream sleep. (2001)). Watts et al. (2013), Rothbaum et al.
(2005) as well as Bisson and Andrew (2007)
were able to show that EMDR is one of the
14.4 Effectiveness Studies most effective forms of treatment for
PTSD – alongside exposure training and
The efficacy of EMDR has already been cognitive behavioural therapy (CBT).
quantitatively assessed in many randomized The meta-analysis by Bisson et al. (2013)
controlled studies and in some qualitative confirmed that EMDR and CBT continued
studies. Edmond et al. (2004) analysed the to have a better effect than other therapy
content of the statements of 59 women trau- methods 4 months after the end of treatment.
matised by sexualised violence. In several studies, EMDR not only works
The group treated with EMDR was just as well as other therapy methods, but
compared with a control group that received also more quickly (Ironson et al., 2002;
a common form of method-integrative psy- Marcus et al., 1997, 2004; Power et al.,
chotherapy. After integrative therapy, these 2002). Such a result was even found in stud-
women described a better ability to deal ies where there the patients did homework
with the trauma consequences: “I have now on top of the exposure treatment, but not
gathered some helpful tools I have learned with EMDR (Lee et al., 2002; Power et al.,
how to feel better; things I can do before I see 2002).
the therapist again.” Or: “The panic’s gone Similar results were obtained by a meta-
and I can still feel fear and anxiety, but none analysis that examined the effectiveness of
that paralyses me. Now I know that I can EMDR with children (Rodenburg et al.,
make decisions for myself.” 2009). EMDR and CBT proved to be the
After EMDR, patients described more most effective treatment methods for trau-
profound changes: “Instead of going from matised children. The EMDR-treatment of
the outer layers of an onion to the core, as is children with PTSD was also verified by
done in conventional psychotherapy, EMDR Ahmad et al. (2007) and Diehle et al. (2015).
allows you to go straight to the core. It solves Again, EMDR proved to be effective in
the issue at the core, and then the changes every case, even with children who had pre-
penetrate through all layers back to the outer- viously not responded to other treatments
most layer.” Another patient put it this way: (Chemtob et al., 2002).
“I think it goes directly to the cellular level … EMDR-treatment is also effective if
for me it goes deeper than talking about it, it PTSD is combined with comorbid disor-
goes right to the center and frees it … for me ders. In a review (Valiente-Gómez et al.,
it was like scraping out and removing every- 2017) these comorbid conditions are dis-
thing because it no longer belongs there.” cussed in detail.
EMDR has also been shown to be effec-
>>The statements of patients with EMDR tive in treating patients with PTSD and psy-
indicate that EMDR achieves a more chotic disorders (van den Berg et al., 2015),
complete trauma resolution, whereas the PTSD and borderline disorders (Brown &
comparative group values the Shapiro, 2006; Mosquera et al., 2014),
relationship to the therapist more. PTSD and pseudoepileptic seizures
(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)
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).
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).
zz 5. Bauer, M., & Priebe, S. (1997).

Resource-EMDR: More and more EMDR Psychopharmakotherapie. In A. Maercker (Ed.),
Therapie der posttraumatischen
methods aim to use bilateral stimulation Belastungsstörungen (pp. 179–190). Springer.
and other EMDR elements outside of the Bisson, J., & Andrew, M. (2007). Psychological treat-
trauma confrontation, e.g., to better install ment of post-traumatic stress disorder (PTSD).
and increase the impact of stabilization Cochrane Database of Systematic Reviews, (3),
exercises. Rost (2016) provides a compre- CD003388.
Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R.,
hensive overview of this. The best-known & Lewis, C. (2013). Psychological therapies for
procedures are the “absorption technique” chronic post-traumatic stress disorder (PTSD) in
(Hofmann, 2004a) and “resource develop- adults. Cochrane Database of Systematic Reviews,
ment and installation” (RDI; Leeds & Korn, 2013(12), CD003388.
2002). In summary, these processes are Böhm, K. (2015). Obsessive compulsive disorder and
EMDR. In M. Luber (Ed.), Eye movement desen-
based on the idea of supporting processing sitization and reprocessing (EMDR) therapy
by making resources more accessible. scripted protocols and summery sheets: Treating
trauma, anxiety and mood-related conditions (2nd
zz 6. ed.). Springer.
New methods were developed from the Brink, A. (2014). Selbstkontrolle und emotionale
Distanz gewinnen – Die Nutzung von Bildschirm
EMDR tradition. With the Imagery und Fernbedienung. In K. Priebe & A. Dyer
Rescripting and Reprocessing Therapy, (Eds.), Metaphern, Geschichten und Symbole in der
Mervyn Smucker developed a treatment Traumatherapie. Hogrefe.
approach that extends the behavioral imag- Broad, R. D., & Wheeler, K. (2006). An adult with
ery rescripting by adding elements of gestalt childhood medical trauma treated with psycho-
analytic psychotherapy and EMDR: A case study.
therapy and the element of reprocessing Perspectives in Psychiatric Care, 42(2), 95–105.
from EMDR (Smucker & Vetter, 1997). Brown, S., & Shapiro, F. (2006). EMDR in the treat-
Brainspotting emerged from Somatic ment of borderline personality disorder. Clinical
Experiencing and EMDR in conjunction Case Studies, 5(5), 403–420.
with a method defined by David Grand Burkhardt, L. (2016). Behandlung der dissoziativen
Identitätsstörung mit EMDR. In C. Rost (Ed.),
(2003) for controlling attention via the line EMDR zwischen Struktur und Kreativität.
of sight. Attention and direction of gaze are Bewährte Abläufe und neue Entwicklungen
closely related – up to common functional (pp. 251–266). Junfermann.
areas in the parietal, frontal, and temporal Carlson, J. G., Chemtob, C. M., Rusnak, K., Hedlund,
lobes (Corbetta et al., 1998). N. L., & Muraoka, M. Y. (1998). Eye movement
14 desensitization and reprocessing (EMDR):
Treatment for combat-related posttraumatic stress
disorder. Journal of Traumatic Stress, 11(1), 3–24.
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14
285 15
Low-Threshold
and Innovative Interventions
Andreas Maercker
Contents
15.2 Stepped Care and Psychoeducation – 286
15.3 Positive-Psychological Interventions – 288

15.3.1 esilience and Mental Fitness – 288
R
15.3.2 Forgiveness Interventions – 289
15.4 Web-Based Interventions and Serious Games – 290
15.5 Community-Based and Peer Programmes – 292
15.6 Guided Autobiographical Writing – 293
Literature – 294
286 A. Maercker
15.1 Introduction sive disorders. The approach of stepped care

is initially based on different degrees of sever-
In addition to the conventional psychother- ity of the clinical picture; these are usually
apeutic methods, further alternatives have divided into “mild”, “moderate”, “severe”
been developed in the international context and “life-threatening”. Alternatively, acute
over the last decades to help traumatised degrees of severity such as early, moderate,
victims. In this chapter, these interventions chronic and escalating stages are also differ-
are summarised as low-threshold procedures entiated.
defined in such a way that those seeking help The following prerequisites belong to the
usually seek them outside the established stepped care approach (van Straten et al.,
health care system (although there is also 2015):
overlap with more recent approaches within 55 Evidence-based treatment methods of
the health care system; 7 Sect. 15.2). This

varying intensity are available.
is also linked to the fact that the use of an 55 Adequate diagnostics are carried out as a
intervention is not dependent on the pres- basis for treatment selection.
ence of a diagnosis. Those affected may also 55 A systematic assessment of the course
have so-called sub-syndromal conditions and results is carried out.
(i.e. not all the symptoms necessary for a
diagnosis are fully present), or it may be a The therapeutic interventions of the stepped
matter of individual prevention including care approach are generally characterised as
better processing of the experience. follows:
Low-threshold interventions usually 55 Begin with a treatment option of the
stem directly from research and health care lowest intensity with a good prognosis
for risk groups, for example when they are for the patient to benefit from it.
developed by institutions such as the mili- 55 Ability to take a “step up” or a “step
tary (resilience programmes), involve higher down” with customized treatment
investment costs (web-based interventions) options
or are disseminated by aid organisations
(community-based programmes). As will be . Table 15.1 shows the evidence-based

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

options and self-care). patients work with at least two therapeutic/

interventive contact persons during this
The psychoeducational programme can time and requires transparent implementa-
be carried out in individual or group set- tion and basic knowledge of the respective
tings under the guidance of professionals, parallel procedure from all sides.
including the professional groups of com- For depression treatment, where addi-
plementary therapists (e.g. art therapists, tional interventions are most frequently
kinesitherapists). The manual contains used internationally, some important results
detailed instructions for therapists with and indications are now available from eval-
sample formulations, in which possible diffi- uations:
culties and challenges during (group) imple- 55 Additional interventions significantly
mentation are addressed. It is also aimed at improve the overall progress in recovery
patients with other native language back- (Kooistra et al., 2016).
grounds, for whom German-language con- 55 The majority of therapists of a basic
tent often remains difficult to understand procedure are reluctant to advise and
at first. In line with the approach of staged recommend additional interventions to
care, participation in this psychoeducation their patients (Berger et al., 2017)
may be sufficient for some patients; for oth- 55 Additional interventions are also indi-
ers, more intensive phases of (individual) cated in addition to inpatient treatment
psychotherapy follow. (Kordy et al., 2016).
288 A. Maercker
15.3 Positive-Psychological certain low-threshold programs for emer-

Interventions gency and military personnel. This aspect of
acceptance has to do with the fact that men
The intervention programmes presented from such occupational groups find it very
here are the result of collaboration between difficult to engage in psychological interven-
“positive psychology” – a field of humanis- tions or psychotherapy that are experienced
tic psychology – and psychotraumatology. as “unmanly” (7 Sect. 15.5; see Pieper

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.

15.3.1 Resilience and Mental Trauma Resilience Training” by Arnetz

Fitness et al. (2009) became best known for emer-
gency services (military, police, paramed-
The target concepts of “resilience” and ics). This modular program serves to deal
“mental fitness” are closely related and have with potentially traumatic situations. In 10
developed apart. Despite its high standing weekly sessions of 2 h each, the focus is on
in public discourse, “resilience” is a concept 55 the learning of relaxation techniques,
that has been poorly defined from a scientific 55 guided imaginations of potentially trau-
point of view up to now, as there are many matic events,
different, mutually incompatible definitions, 55 the acquisition of adaptive coping strate-
so that there are many criticisms of this gies in the confrontation with these
15 concept (e.g. Stamm & Halberkann, 2015). events.
Resilience can approximately be defined as:
The positive evaluation results indicate, in
»» … the maintenance of normal, i.e. previ- comparison to other, usually much shorter
ous, mental functioning, even after con-
programmes, that such programmes work
frontation with extreme stress conditions
most effectively with repeated sessions to
or potentially traumatic events, without
achieve a better effect, since these psycho-
the manifestation of mental illness or
logical habituation/habituation processes
restrictions in terms of functional level
can cause trauma-relevant stimuli.
that severely impair the well-being of the
Another modular program, the US
individual concerned. (Kleim & Kalisch,
“Comprehensive Soldier Fitness” program,
2018, p. 754)
was designed to be even more comprehensive
Mental fitness is a term that was coined for (Seligman & Fowler, 2011). The focus was
the purpose of improving the acceptance of on the individual promotion of resilience,
289 15
.. 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
Programmes according to Enright and 15.4 Web-Based Interventions

other authors have since been applied to and Serious Games
people affected by domestic violence, politi-
cal violence and other problems of inter- Many terms have become established for
personal conflict, for example, those of the interventions described below: online,
addicted patients. Online forms of forgive- internet, e-mental health, telepsychiatric,
ness interventions have also been developed virtual reality or app-based interventions as
(Stammel & Knaevelsrud, 2009). well as “computerized cognitive behavioral
Evaluations of forgiveness interventions therapy”. What all these programmes have
show that most of these programmes have in common is that they make use of the pos-
so far been conducted with people who have sibilities of the new digital technologies for
not been traumatised in the strict sense (but health promotion measures. Serious games,
people who had experienced adversity) and on the other hand, originally emerged from
that a reduction in PTSD symptoms has the digital entertainment industry and from
almost never been investigated. Therefore, educational games, which were then also
the results should only be applied with cau- used in the health sector.
tion to trauma patients. Specifically, it was Data protection plays a special role for
found that depressive symptoms changed to the web-based interventions. For this rea-
a low to medium extent (effect strengths of son, the application of these programs in the
0.37), programmes over 12 sessions worked health care sector is strongly regulated. It is
better than shorter ones and individual important that personal data are protected
programmes worked better than group pro- in the best possible technological way, for
grammes (Akhtar & Barlow, 2018). In one example by firewalls and filtering technolo-
evaluated online programme for a mixed gies, for which providers are responsible.
group of patients, no improvement in Another problem is the sustainability
depression was found (PTSD not studied) of developments. In the field of e-mental
(Nation et al., 2018). health, new offers were created in rapid suc-
cession, often only financed for their proj-
Under the Magnifying Glass ect phase and then not sustainable even if
the proof of effectiveness was positive. This
Overall, it can be said that, as fascinating has to do with implementation and licensing
as the approaches of positive psychology fees, which are of a magnitude comparable
for intervention programmes may seem, to the acquisition of large medical equip-
there is little evidence for their successful ment (Maercker et al., 2015). For this rea-
15 application in the field of trauma son, only a few examples are given below,
sequelae. A fundamental problem seems each of which has remained available for a
to be that traumatized (and prolonged long time until today.
grievers) have a need to address their
negative feelings and sensitivities before zz CoachPTBS App
the issues of strength and resilience are The CoachPTBS app (available free of
addressed. charge as Android and iOS version) pro-
vides information on trauma sequelae and
291 15
the consequences of use. It consists of mod- the client with individualized feedback on
ules for information, self-assessment and their progress and remaining problems.
offers various exercises such as “emergency MTR has been reviewed in several stud-
case” (in case of a symptom escalation), ies, both in the US and in China (including
relaxation exercises, “own strengthening people with very low levels of education),
spell” etc. The original English version and has been shown to be as effective in
comes from the US military (Kuhn et al., reducing PTSD symptoms as standard con-
2018). The use of this English-language app sulting room therapies. Moreover, MTR was
has been demonstrated in evaluation studies even slightly superior in terms of the extent
in the USA: of self-efficacy conviction achieved among
55 a reduction of PTSD and other symp- users (Steinmetz et al., 2012; Wang et al.,
toms after one and 3 months, 2013).
55 a use intensity – effect relationship,
55 the effectiveness as an additional inter- zz Interapy
vention to conventional trauma therapy Interapy is the longest existing web-based
in US military hospitals (summarised in procedure in the PTSD field (since 1995:
Kuhn et al., 2018). 7 http://www.interapy.nl), developed by

the Dutch psychotherapist Alfred Lange.

zz MyTraumaRecovery Since 2005, this service has also been avail-
MyTraumaRecovery (MTR) is a self-help able in German (7 http://www.online-

program in English and Chinese that is psychotherapie.uzh.ch). The therapy is

worked on by the clients themselves without based on a cognitive-behavioural approach
contact with a therapist (Steinmetz et al., and is limited to 5 weeks with 10 patient-
2012; Wang et al., 2013). It begins with an therapist contacts. The treatment takes
introductory and explanatory video. The place entirely within a strongly structured
program consists of several modules that website. This offer is low-threshold, espe-
can be worked on one after the other or cially due to its use from home, its ano-
in parallel. It is recommended to work on nymity to the outside world (the therapist
the program for a total of at least 30 min expects to know the client’s regular name,
per session, but no longer than 60 min. In however, and uses it during therapy), and
contrast to the usual trauma-focused ther- the greater time flexibility for the client as
apy (7 Chaps. 11 and 13), the first module
to when one of the writing tasks is carried
of the program is the module on mutual out (more detailed description in Maercker
social support, and trauma confrontation et al., 2015, p. 3 ff.).
is avoided throughout the program. The The intervention consists of 3 phases,
other modules are: relaxation, self-talk, each preceded by a detailed psychoeduca-
dealing with triggers, coping with problems tion. At the beginning of each phase, the
and seeking professional help. Each of the patient and therapist plan on which days
modules begins with a self-test, in which the and at what time the patients will complete
initial level of skills in this area is examined. the writing tasks (essays), with the therapists
This is followed by structured plans for indi- answering the patient after one working day
vidual aspects of the module, in which the at the latest. The therapy is divided into 3
participants can record the personal benefits phases:
of the new behaviour, obstacles and means 55 Self-confrontation with the most painful
of overcoming them. The program is par- memories, thoughts and feelings: This
ticularly effective because of the many auto- phase consists of a total of 4 essays, each
matically generated feedbacks that provide of which is agreed to take 45–60 min. In
292 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
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).
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ing intervention, which is described in more for the promotion of mental well-being: A system-
detail in 7 Chap. 26. Writing interventions

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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,
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7(1), 1–25. centered care transitions after injury hospitaliza-
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(pp. 61–76). Springer VS. 2017.1354621
15
297 16
Treatment of Complex PTSD

with STAIR/Narrative
Therapy
Contents
16.1 I mportance of Emotion Regulation

and Interpersonal Skills – 298
16.2 Interpersonal Development – 300
16.3 Overview of the Treatment Programme – 301

16.3.1 odule 1: Emotional Regulation and Interpersonal Skills – 301
M
16.3.2 Module 2: Creation of Narratives – 303
16.4 Implementation of STAIR in Group Format – 305

16.4.1 E xpansion of the Concepts for Emotion Regulation – 306
16.4.2 Concept of Compassion for Oneself and Others – 307
16.4.3 Processes in the Group – 308
16.4.4 Dealing with Security, Trust and Control – 308
16.4.5 Handling Shame – 309
16.5 Application to Young People – 309

16.5.1 daptation of Interventions – 310
A
16.5.2 Consideration of Aspects of Developmental Psychology – 310
16.6 Research Findings on STAIR Narrative Therapy – 311
16.7 Outlook and Further Developments – 313
Literature – 315
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.
16.2 Interpersonal Development small number of schemes that they tend to

apply inflexibly in different situations and to
Parents, siblings and other important child- different interaction partners. For example,
hood caregivers also represent the first mod- if they were confronted with hypothetical
els for interpersonal relationships. These situations in which benevolent behaviour by
early relationship experiences serve as tem- others was most likely, they still expected
plates for future relationships and have a sig- cool, hostile and controlling behaviour from
nificant influence on one’s own behaviour others (Cloitre et al., 2002).
and expectations of interpersonal relation-
ships. An important aspect of this is that >>Problems in interpersonal relationships
children are dependent on their caregivers as are often related to patterns formed by
a source of security and care. When abuse early negative relationship experiences.
experiences occur in these key early relation- They shape the expectations of affected
ships, the basic assumption may emerge that persons in interpersonal relationships
relationships are fundamentally hostile, that and their behaviour in them.
vulnerability leads to exploitation and inti-
macy leads to suffering and betrayal. As a The study also found that the nature of the
result, adults often report serious interper- relationship did not seem to have any influ-
sonal difficulties, such as dealing with criti- ence on the expectations of the persons con-
cism, accepting the opinions of others and cerned. Irrespective of whether the
standing up for their own needs. For exam- relationship was with a mother, father, other
ple, a study of women undergoing treatment family caregivers or the best friend, affected
found that the majority had significant dif- persons reacted similarly and without reac-
ficulties in living intimacy, that they experi- tions being appropriate to the respective
enced themselves as either too controlling or person and situation. This type of overgen-
too submissive, or that they found it difficult eralization may be explained by the fact that
to establish and maintain contact with oth- the healthy development of social compe-
ers (Cloitre et al., 1997). Such problems may tences includes instruction about and aware-
be contributors to the tendency to abruptly ness that effective and appropriate social
terminate both employment and personal responses depend on the context and the
relationships. Interpersonal patterns that persons involved. A child learns in the
have developed through experiences of course of its development to distinguish
abuse in early relationships can be particu- where aggressive behaviour is appropriate
larly evident when emotionally charged situ- (e.g. when romping in the playground) and
ations require the ability to manage conflict where not (e.g. when playing with a small
or find balance in relationships. The inter- sibling), or when obedience to an adult is
16 personal patterns of those affected can then appropriate (e.g. to a teacher at school) and
when not (e.g. to a stranger in the park).
lead to the expectation that others will
behave coldly, controlling or distanced Parents help their children to develop this
towards them (Cloitre et al., 2002). In the specific knowledge by constantly pointing
sense of a forward defence, this can then out the differences in interpersonal expecta-
lead to behaviour patterns whose aim is to tions within and outside the family and by
avoid the negative interactions that affected enabling children to explore their emotional
persons fear, or it can be a re-staging of reactions in such different interpersonal sit-
interpersonal roles from their family of ori- uations. The ability to react in a differenti-
gin. Overall, those affected have a relatively ated way in different interpersonal situations
301 16
may therefore also be insufficiently devel- ability to recognise and differentiate feelings
oped in persons undergoing treatment due and to regulate them in such a way that they
to experiences of abuse. serve overriding needs. The STAIR module
In STAIR Narrative Therapy, a strong distinguishes between 3 core areas of emo-
focus is placed on enabling patients to tional competencies:
expand the interpersonal schemata available 55 Conscious perception of emotions,
to them and use them in a context sensitive 55 Emotional regulation,
manner. This is also promoted by therapist- 55 Use of emotions for personally signifi-
patient interaction during treatment, and cant goals.
patients should be made aware that such
interaction models are context-dependent. One of the first interventions of STAIR is to
Different types of relationships (e.g. at work, systematically explore how feelings can be
in an intimate relationship or in the parent- named, what intensity they have and in what
child relationship) require different expecta- context they occur. During treatment,
tions, behaviour and reactions. An important expressing and classifying feelings again and
goal of treatment is therefore to enable again is also an important prerequisite for
patients to have relationship experiences the client to be able to develop a coherent
that are different from those in abusive rela- narrative of his or her personal life story
tionships and to develop greater sensitivity during the course of therapy. Difficulties
to the different types and contexts of rela- with emotional regulation are attributed to
tionships. the physical, cognitive and behavioural sys-
tems underlying it. This also makes it clear
which approaches can be chosen for training
16.3 Overview of the Treatment emotional skills.
Programme
Approaches to Working on Emotions
STAIR Narrative Therapy is a treatment 55 Physical strategies (e.g. breathing
program consisting of 16 sessions. The first exercises, physical activity)
module (STAIR) consists of sessions 1–8 55 Cognitive strategies (e.g. altered inner
and focuses on changes in the areas of emo- dialogues, guided attention)
tional regulation and interpersonal skills. 55 behavioural strategies, especially in
The second module (Narrative Therapy) the area of social contacts (e.g. asking
consists of sessions 9–16 and focuses on the friends for help, talking about feelings
processing of traumatic experiences with the with others)
help of trauma narratives. During this ther-
apy phase, skills training is also continued in
relation to the still existing everyday prob- To this end, the coping strategies already
lems of the patients. available to patients at each level will be col-
lected, with the aim of strengthening and
expanding them. The overall aim is to com-
16.3.1 odule 1: Emotional
M pile a selection of coping strategies that
Regulation reflect these three areas so that physical sen-
and Interpersonal Skills sations, thoughts and actions positively
influence each other and contribute to better
For the structure of module 1 . Table 16.1.
modulated emotional experiences. Further-
The first sessions of the STAIR module more, the concept of stress tolerance and
focus on emotional competences, i.e. the related skills in treatment are addressed to
.. Table 16.1 Module 1 (STAIR)
Subject of the meeting Content of the meeting
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
enable patients to better pursue personally In subsequent sessions, a key interven-

meaningful goals. When patients are better tion is to identify and change interpersonal
able to identify and deal with their emotional patterns. Interpersonal schemata arise in
reactions during the course of treatment, early life phases in interaction with impor-
they can allow themselves to experience tant caregivers. They reflect ideas about one-
16 stressful emotions in a well-dosed manner self and others as well as assumptions about
that serve an important purpose or personal how relationships work. Typical examples
goal or that are simply unavoidably linked to of such assumptions are “If I do what I am
certain life experiences. They learn to weigh told I will be loved” or “If I ask for the satis-
up the desired goal and the emotional bur- faction of my needs I will be rejected”.
den that is likely to be associated with it, as Interpersonal patterns that were appropriate
well as their own abilities to deal with it, and in childhood may cause problems in adult-
to decide whether they want to turn towards hood and may lead to unintentional repeti-
the goal despite the expected burden. tion of negative relationship patterns.
303 16
In the course of treatment, such inter- emotional regulation and to the changes in
personal schemes are systematically identi- feelings caused by the alternative schemes.
fied using appropriate working materials.
Questions on the Modification of
Questions for the Identification of Sche mata
Schemes 55 What are my goals in this situation?
55 What happened in this situation? 55 What else could I feel and think about
Who was involved? me?
55 What did I feel and think about 55 What else could I assume about the
myself ? other person? How could they think,
55 What did I suspect, how the other feel or react?
person thinks/feels/reacts to me? 55 What else could I do?
55 What did I do? What was the result?
16.3.2 odule 2: Creation

M
In the next step, alternative schemes are of Narratives
examined and tested within the protective
framework of the therapy (e.g. “If I don’t The work in the second module (narrative
ask for my needs to be met, my friends will therapy) is based on a modified version of
never know what I want”). Whether these prolonged exposure (PE). It serves to create
schemes can be consolidated is often related narratives of the traumatic experiences
to the improvements achieved in the area of (. Table 16.2).

.. Table 16.2 Module 2 (narrative therapy)
Subject of the meeting Content of the meeting
Session 9 Planning and motivation building; information on the purpose of working on

Introduction to working memories, description of the procedure; creation of a memory hierarchy
with narratives
Session 10 Repetition of information on the meaning of the narrative work; practice
Narratives from the first with neutral memory; record the first narrative on a traumatic memory and
memory listen to it together; examine assumptions about yourself and others
contained in it; validation and support of the learning process by the
therapist
Session 11 Explore emotional state; evaluate the work on the last memory; perform
Continuing the work on narrative (of the same or a different memory); identify schemata contained
memories therein and continue work on them; perform role-plays in relation to
alternative schemata
Session 12–15 Continue to select appropriate memories, addressing emotional areas beyond
Working on other fear (e.g. shame, grief and loss); identify and work through patterns
emotional areas associated with shame and loss; provide clear, appreciative feedback
Meeting 16 Summarize progress on skills and patterns of self and others; discuss relapse
Closing risks; plan next steps, provide resources and recommendations
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.
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
16.4 Implementation of STAIR

Some patients find it difficult to limit them- in Group Format
selves in the description of their memory. In
this case, therapists should try to gently Meanwhile the STAIR module of STAIR
guide them to talk less about the events. Narrative Therapy is also available in an
Other patients, on the other hand, find it dif- extended group version. According to the
ficult to report accurate information about individual therapeutic treatment, the goals
their memories at all and find only brief or of the group treatment with STAIR are to
vague fragments. It is then important to tell learn how to deal with negative and stressful
them back that this is a common phenome- feelings and to improve interpersonal skills
non and that it will not prevent them from and thus your own relationships. In this
benefiting from the narrative work. Many of phase, patients should be supported in rec-
those affected have a long and complicated ognising and naming their own feelings and
trauma history, which can make it difficult experiencing their own influence on their
to make a selection of memories. Patients feelings. In addition, they are instructed to
can quickly feel overwhelmed as a result. In recognise relationship patterns learned early
this case they should be relieved by the ther- on and to change them in such a way that
apists, who should explain to them that not they can shape their relationships as they
every memory has to be taken into account, wish.
but those that are experienced as most sig- Within the framework of group treat-
nificant for the present. ment, 2-hour sessions are held once a week
When narrative work increasingly in their original form over a period of
focuses on the memories that are the great- 12 weeks. After discussing the content,
est burden to patients, appropriate responses, structure and framework of the group (such
including dissociative phenomena, may as the treatment contract and group rules)
occur. If there is a tendency to dissociative with the patients in session 1, 5 sessions on
emotion regulation and 5 sessions on work-

ing on interpersonal skills follow. The 12th Levels in Emotion Surfing
session is scheduled for balance and fare- 55 Perception of the body level (“Where
well. As with individual treatment, the over- exactly do I feel the feeling?”)
all length of the session can be flexibly 55 Perception of the thought level
adjusted to different settings and needs and (“What am I thinking right now?”)
can be extended beyond the number of 12 55 Perception of the behavioural level
sessions. (“What am I doing right now?”)
Structure of the Group Meetings

If the feeling is perceived attentively, the
55 Overview of the current session
subsequent steps are about accepting one-
(“timetable”) and repetition of the
self and the feeling just experienced without
group rules
evaluating it and without having to change
55 Debriefing of the exercises between
it. Patients are encouraged to allow them-
sessions
selves this feeling. The aim of emotion surf-
55 Brief summary of the previous ses-
ing is for them to perceive that feelings have
sion and review of discussed strate-
a “peak” and a “turning point”, that is they
gies
are subject to a completely natural change,
55 Introduction to the new topic and
without having to “go into battle” with
presentation of new strategies
them.
55 Preliminary discussion of the exer-
cises between sessions
>>The skill “emotion surfing“helps patients
to accept feelings for what they are –
namely only feelings and not facts.
16.4.1 Expansion of the Concepts
for Emotion Regulation The skill “Feelings as messengers” addition-
ally focuses on the deeper understanding of
In addition to learning skills for the percep- feelings and the functions behind them.
tion and modulation of emotions, two fur- Emotions are an important resource, we
ther important aspects of emotion regulation need them for an effective life. If we succeed
are included in the group concept: firstly, the in understanding our feelings, they help us,
acceptance of feelings (skill “emotion surf- for example, to make decisions or act in a
ing“) and secondly, the recognition of the certain direction. As a result of traumatisa-
needs that may be behind them (skill “feel- tion, feelings are often “switched off ” or
ings as messengers”). experienced as excessive and overwhelming.
The skill “Emotion Surfing“is about
16 being more attentive with your feelings.
This limits our ability to think and act and
distorts our perception of ourselves and
Patients are instructed to focus their atten- others. Those affected therefore often find it
tion on their experience in the current very difficult to trust their feelings – this
moment and to concentrate on the 3 differ- ability is to be regained with this skill.
ent levels of experience. Patients can learn what information our
307 16
feelings tell us and what they tell us back Following on from this, a meditation on self-
about our wishes, goals, likes and dislikes. compassion is carried out to support the
perception of the associated feelings,
>>The skill “Feelings as messengers” helps thoughts and body reactions and to practice
patients to regain confidence in their self-turning.
feelings and to recognize needs that lie
behind their feelings. ►►Example: Meditation for Self-Compassion
55 “Concentrate on your breathing for a few
minutes. Close your eyes and perceive only
16.4.2 Concept of Compassion your breath. Take a deep breath slowly.
Hold it. Slowly exhale again, allowing all
for Oneself and Others the air to escape from your lungs. Repeat
for a few minutes: Breathe in, hold it,
In order to achieve a generally benevolent exhale slowly.
approach to oneself, one’s own feelings, but 55 Now let a picture of yourself emerge in
also to others in relationships, the concept your imagination. Take a good and close
of (self-)compassion has also been included look at yourself. Focus on the positive parts
in the group treatment. In this therapy of yourself, such as satisfaction, joy, lustful
phase, it should be made clear to those feelings, positive beliefs, beautiful experi-
affected how much easier life with them- ences and memories.
selves and others becomes if they manage to 55 What do you perceive?”
adopt an appreciative attitude, reduce expec- 55 “Now focus on the parts you associate neg-
ative things with, such as emotional pain,
tations and demands and “allow” them-
fears, sadness, negative beliefs, traumatic
selves and others more. experiences.
After a theoretical introduction to the 55 What do you perceive?”
concept of compassion, the group uses 55 “Now imagine that these two parts inside
worksheets to discuss what patients allow of you are fighting with each other. It is a
themselves and others to do and where it is long and very exhausting fight that starts
still difficult to feel compassion. With the anew every day and has been going on for
help of appropriate materials, this is worked many years.
out in relevant areas such as “making mis- 55 What do you perceive?
takes”, “accepting help”, “doing something 55 “Now imagine that you allow the positive
good for yourself ”, “being insecure” or and negative parts of yourself to stop fight-
ing and instead coexist side by side.
“being proud”. Afterwards, the group par-
55 What do you perceive? “
ticipants are encouraged to imagine what it 55 “Focus on how the performance feels to
would be like to have more compassion with you. “
themselves or with others and what effect 55 “Look at all your holdings as they are,
this could have on their thoughts, feelings without evaluating them.” ◄
and behaviour.
The aim of this treatment module is to
>>Many patients find it particularly diffi- obtain a more realistic assessment of one’s
cult to feel sympathy for themselves. At own difficulties, stress limits and challenges,
this point, the corresponding schemes but also to be able to better accept one’s own
can be worked out again (e.g. “If I allow progress and successes, such as the increase
myself to ask for help, then ...”). in competence within the group.
16.4.3 Processes in the Group get understanding and support“or “When I

ask for help, I am taken seriously and my
The positive effect factors of group thera- problems are easier to solve”). This type of
pies can be used well, especially with regard corrective interaction usually contributes to
to the training of skills. Patients can give group cohesion, enables new relationship
each other mutual support, for example by and bonding experiences for the partici-
assessing for themselves in which situations pants, and there can be immediate learning
which type of skill can be used sensibly. In of interpersonal skills. At the same time,
addition, the group offers a protected “exer- working in a group can also present special
cise framework” in order to try out and challenges against the background of the
practice specific skills directly. This can take patients’ interpersonal schemata. Uncer-
place through guided role-plays, but also tainties, fears of trust and loss of control as
through the dynamics developing within the well as feelings of shame should be given
group, which can be taken up by the thera- special attention.
pist and made useful for working on skills.
>>Various aspects of the group setting 16.4.4 Dealing with Security, Trust

prove to be beneficial for working with and Control
the STAIR module, such as the possibil-
ity of receiving immediate feedback For many of those affected, it is a great chal-
from other participants and learning on lenge to communicate with other people at
the model. all. Many of them have had the experience
of being ignored, rejected or punished as
By validating the difficulties of each indi- soon as they reveal themselves and their
vidual in the group, patients directly experi- needs. It is difficult for them to share their
ence corrective experiences which in turn experiences, for example because of fear of
can strengthen the new, healing patterns uncontrollable and threatening conse-
(e.g. “When I open up and show weakness, I quences.
Case Study: Influence of Interpersonal Schemes on the Client’s Experience in the Group
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.”
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.”
By providing an appropriate framework and here (e.g. emotion surfing, self-compassion

working continuously on the interpersonal or the like).
schemata, patients can experience directly in
the process that they have possibilities to >>Feelings of shame are frequent among
influence and are not exposed to any danger those affected and must be explicitly
when they practice their new behaviour and taken into account in the group setting,
relationship patterns. e.g. by disputing the underlying schemes.
In addition, the therapist should always

express his or her own appreciation for the
16.4.5 Handling Shame patients and enable them to expand their
competencies within the group and at the
In therapeutic work with traumatised peo- same time have positive experiences with
ple, various forms of shame also play a role. their fellow human beings.
Internalized feelings of shame, often
express themselves in massive devaluation
of the own person. Externalised feelings of 16.5 Application to Young People
shame, on the other hand, manifest them-
selves in the conviction of being devalued The treatment concept for adolescents is
by others, for example at the moment when similar in structure to the adult version. It is
those affected report their biographical also a 12-week group programme to pro-
experiences. It is accordingly important to mote emotional and social skills. Strategies
take up and work on shame-related sche- for dealing with feelings are also presented
mata and to modify the meaning of the and in a second step the skills for shaping
trauma for the value of oneself. In addition, interpersonal relationships are taught. In
of course, the previously learned strategies the following, the differences to the adult
for emotion regulation can also be used version will be discussed in particular.
16.5.1 Adaptation 16.5.2 Consideration of Aspects

of Interventions of Developmental
Psychology
The therapy materials of the STAIR-A are
modified according to age. The presentation Adolescence is a very important phase of life
of concepts and tasks have been adapted so in terms of the development of emotional
that they are more tangible for young people and social skills. Both learning appropriate
and correspond to their living environment. strategies for dealing with one’s own emo-
Typical situations from the everyday life of tional states and developing the skills needed
adolescents are taken up in which difficulties to enter into and shape relationships are
may arise, e.g. at school, at home with their important developmental tasks in adoles-
parents or within the peer group. The work- cence. Traumatic experiences before and
sheets on appropriate communication strat- during this time can directly undermine
egies include the following very concrete these developmental tasks and strongly
example situations: impair the development of assertive compe-
tencies. As a consequence, affected young
►►Example: Communication Strategies people often find it difficult to react appro-
“Your classmate Anna says mean things about priately to life events or to cope with stressful
Nora. Nora is one of your best friends since experiences. A focus on promoting resilience
first grade – how could you react to Anna? is therefore an important component of psy-
What could you say?” chotherapeutic work with young people. It is
“You meet Robert and Maria after school. of great importance to support them effi-
They’re planning a party for the coming ciently in coping with their everyday life and
weekend. Maria asks you to make the invita- thus help them to achieve an adequate ability
tions, decorate the party room and provide all to function. STAIR-A focuses exactly on
the food – how could you respond to Maria’s this. Emotional and social skills serve as pro-
request? What could you say to her?” ◄ tective factors and make it easier for young
people to access external and internal
Overall, compared to the procedure for resources (using relationships, being able to
adult patients, a greater focus is placed on calm themselves, etc.). They learn to identify
concrete changes at the behavioural level. their own goals and to achieve them with
The adolescents are supported in formulat- appropriate problem-solving strategies and
ing tangible goals for each treatment mod- skills for stress tolerance.
ule, such as “I would like to manage to keep
my room cleaner”, “I would like to be late for >>Resilience in the sense of the ability to
school less often”, “I would like to have fewer cope with crises with the help of internal
16 tantrums when I argue with my sister” etc. and external resources and to grow from
The intended involvement of caregivers them is a central protective factor against
is also a great help in this respect. In order to the consequences of current and future
better understand the experiences and critical life events.
behaviour of the adolescents and to be able
to deal with them in the sense of treatment, Faith in oneself and in positive coping strat-
parents, caregivers or other caregivers are egies has a great influence on the develop-
invited to separate sessions in which, in addi- ment of self-efficacy. The experience of
tion to psychoeducational elements, appro- self-efficacy determines the extent to which a
priate coping strategies are also taught. person is convinced that they have the neces-
311 16
sary skills and strategies to cope with a chal- 16.6 esearch Findings on STAIR
R
lenge. Many young people who have been or Narrative Therapy
are exposed to traumatic experiences assume
that external factors such as “fate”, “luck”, Studies on the effectiveness of the treatment
“chance” or the influence of other people program have been conducted with different
determine what happens (to them). This is patient groups. Three randomized con-
often accompanied by feelings of helpless- trolled trials (RCT) have been conducted in
ness, sadness or anger and the use of mal- adult patients with experiences of violence
adaptive coping strategies. Another focus is in childhood (Cloitre et al., 2002, 2010;
therefore on promoting self-efficacy. To this Oprel et al., 2021) and one open trial study
end, the young people are given the oppor- of a flexible application of STAIR Narrative
tunity to have corrective experiences within Therapy among survivors of the terrorist
the framework of group treatment. They attacks of September 11th (Levitt et al.,
experience that they are up to certain tasks, 2007). The results speak for the effectiveness
receive support from the other patients and of the program in terms of a reduction in
observe them in successfully coping with PTSD symptoms and improvements in emo-
their own goals. Therapists should always tional and social functioning. Several stud-
take care to positively mark and validate ies have investigated the use of STAIR
even small changes. alone. An RCT comparing STAIR to treat-
Similarly, work on interpersonal schemes ment as usual (TAU) in VA primary care
focuses in particular on the modification of found significant reductions in PTSD,
young people’s control convictions, i.e. the depression, emotion regulation and social
convictions that they have an influence on functioning (Jain et al., 2020). A compara-
themselves, their lives and their own future tive study of STAIR group versus TAU
and that they can make a difference. For among individuals with PTSD and chronic
example, the control convictions of a 13-year- mental illness (Trappler & Newville, 2007)
old boy before and after the modification by found significant reductions in PTSD, psy-
the schema work could be: “If I show myself chotic symptoms and behavioral agitation
weak, the others use this to hurt or harm me” and de-activation. Appropriate to concerns
(before), or “I can decide to whom I show about delivering treatment over distance
myself weak, and there are people who then during times where face-to-face contact is
like me anyway and even support me” (after). impossible (e.g., environmental events such
as the COVID-19 pandemic), STAIR deliv-
>>The promotion of internal control con- ered via telemental health to 10 women
victions within the framework of the Veterans with military sexual trauma (MST)
scheme work promotes the perception of found significant reductions in PTSD and
one’s own possibilities of influence with related symptoms as well as improvement in
regard to personal goals as well as future emotion regulation and interpersonal func-
challenges and crises. tioning (Weiss et al., 2018). Two studies
using group STAIR were conducted in ado-
The treatment concept of STAIR-A is there- lescents, one an open trial study in an inpa-
fore not only focused on the reduction of tient setting (Gudino et al., 2014) and the
PTSD symptoms or depressive and anxious other a comparative study of the group ver-
symptoms, but above all on the development sion in a school context (Gudino et al.,
of personal strength and belief in oneself, 2016). Both studies showed a reduction in
which supports adolescents in overcoming symptoms and significant improvements in
current and future difficulties. coping strategies. We provide details regard-
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.
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
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
315 16
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317 17
Dialectical-Behavior Therapy
for Complex PTSD
M. Bohus
Contents
17.2 The Model – 319
17.3 Basics and Principles – 322
17.4 Treatment Overview – 324
17.5 Proof of Effectiveness – 328
Literature – 329
318 M. Bohus
17.1 Introduction How should we treat patients with

chronic suicidality, self-injury, and severe
DBT-PTSD is rooted in Seattle, dissociative symptoms, intrusions and flash-
USA. There, in the hospitable home of backs, who suffered from self-contempt,
Marsha Linehan, therapy researchers and deep rooted shame and guilt and self-hate?
developers of Dialectical Behavior Therapy To resolve this stalemate, we first decided
(DBT) met for their annual stocktaking: (we wrote the year 2005) to enrich DBT with
What is effective about DBT for patients trauma-specific interventions, especially in-
with borderline personality disorders, and sensu exposure, and to try out the new pro-
where are the outstanding problems and tocol in the residential setting at CI
weaknesses? Mannheim. In Germany, complex treatment
One problem in particular was all too programs over 12 weeks under residential
obvious: several analyses (e.g., Harned et al., conditions are funded by insurance compa-
2008) showed that standard DBT had very nies. Here, we had a well-trained DBT team,
little impact on improving comorbid PTSD established structures, and therefore a cer-
in the population of borderline patients. tain degree of safety and could treat patients
After 1 year of treatment, only about 10% with severe behavioral control with exposure
of those affected, showed significant reduc- based interventions.
tions in symtomatology. Because about two- To make a long story short- our suspi-
thirds of all borderline patients report cions were not confirmed: we found no exac-
childhood sexual abuse, and about half of erbation of suicidal ideation, suicidal acts,
all clinically treated borderline patients have self-injury, or aggressive breakthroughs dur-
manifest PTSD, we could not simply pass ing exposure (Krüger et al., 2014). Rather,
over this issue. the vast majority of patients expressed con-
In some ways, DBT was blocking its siderable relief that someone finally dared to
own way. Nearly all patients with border- process their traumatic experiences. And we
line disorder and comorbid PTSD report were deeply touched and fascinated by the
chronic suicidal ideations and a variety of rapid successes and profound changes that
dysfunctional behaviors, such as self-injury could be achieved through targeted trauma
that are successfully used to end aversive therapy, also – and especially – with these
tension, negative emotions, and also intru- seriously ill sufferers (Bohus et al., 2013).
sions and dissociative states. Intuitively, we On this basis, we felt encouraged to refine
assumed that focusing on trauma-relevant and enrich the treatment concept step by
emotions in the context of therapy would step in the following years in order to do jus-
lead to an increase in stress levels, and thus tice to as many facets of this disorder as pos-
to an increase in uncontrollable threatening sible. For a long time now, at the Central
behavior patterns. The dogma postulated Institute in Mannheim, we have not only
by M. Linehan was therefore logically that been treating borderline patients, but in the
the patient should first learn to control dys- meantime far more than a thousand affected
17 functional behavior with the help of skills persons who suffered from the sequelae of
in therapy stage I, before the focus was then interpersonal violence in childhood and
placed on trauma-relevant content in ther- adolescence as complex PTSD. As a result,
apy stage II. On the other hand, many we have also had to significantly expand the
patients had great difficulty relinquishing treatment manual and gear it specifically to
these behaviors as long as they were tor- the multi-layered coping with traumatic
mented by intrusions and flashbacks and experiences. Today, the patient manual has
did not profit from standard DBT. grown to about 300 pages. It includes a wide
Dialectical-Behavior Therapy for Complex PTSD
319 17
range of heurisms and interventions that ual or physical experience of violence with
can be adapted for a patient’s individual all its shades, and second, the social rejec-
treatment. DBT-PTSD is therefore tion or “traumatic invalidation” by close
considered a “blended treatment” as a com- family members (care-givers). These two
bination of therapist-guided treatment and trauma-associated experiences trigger very
self-help manual. different emotional patterns and behavior.
Inpatient treatment programs are safe, In addition, patients with complex PTSD
highly effective, work quickly, but consume are characterized by trauma-specific mental
high resources and are hardly available out- and behavioral coping strategies that ulti-
side the European countries. Therefore, we mately result in prototypical basic assump-
decided to adapt the manual to outpatient tions about oneself and the world, mature
conditions and to evaluate it (Bohus et al., into identity, or self-concept, and thus deter-
2020; see also 7 Sect. 17.5 in this chapter).
mine future experience and behavior (see
For pragmatic reasons, we dispensed with . Fig. 17.1).

the usual DBT skills group in this program

and put the responsibility for teaching skills zz Trauma-Associated Primary Experience
to control dissociation and high stress, to During traumatization, sensory, physiologi-
develop mindfulness, compassion, and self- cal, cognitive and emotional impressions are
esteem in the hands of the individual thera- stored in the form of a mental trauma net-
pist and the respective patients. The data work. In terms of content, pain, physiologi-
prove us right – after 45 hours of individual cal arousal, confusion, and feelings of
therapy, the “Intent to Treat (ITT)” analyses powerlessness, fear, disgust, humiliation,
of a large RCT showed about the same and shame play the important roles here.
results as under 3 months inpatient condi- This trauma network is depicted in the inner
tions. Nevertheless, this format cannot claim circle of the diagram of . Fig. 17.1.

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.
17.2 The Model zz Traumatic Invalidation

Often it is not possible for the affected per-
We hypothesize that most patients with son to share the traumatic experiences, and
complex PTSD experience two different the corresponding feelings with important
types of traumatization: first, repeated sex- attachment figures and to get the appropri-
320 M. Bohus
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
.. Fig. 17.1 Model of complex PTSD
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.
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
time by someone very close to me. This Individual Variance

actually happened, and these memories
are painful. Yet I am able to create a Preparations
meaningful life.”
7. Identifying and de-actualizing cognitive,
emotional, and behavioral automatisms
in daily life: “Although it will take a while
for the old patterns to completely disap-
pear, nevertheless, I can now begin to In-sensu
shape my life according to my values and Exposure
goals.”
8. Building social structures that correspond
to the new view of oneself and the world:
“I can and I need to reorder some aspects
of my life now. I won’t let people treat me
so badly anymore – I deserve respect.” Post-Processing
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
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
shaped very actively and consciously and

used for a variety of change processes remain in hell if we do not help them
through targeted therapeutic behavior. The to motivate themselves to walk the
basis of a trusting working relationship is a new path.
therapeutic attitude, which in the DBT- 6. Clients with cPTSD deserve – like all
PTSD is based on common basic assump- other people – a compassionate and
tions of the treatment team. supportive attitude, even if they
We assume that the following basic sometimes cause considerable difficul-
assumptions are correct and helpful when ties for themselves and others.
working with childhood and adolescent vic- 7. Clients with cPTSD need to try out
tims of sexualised and physical violence who new behavior in the social context,
suffer from complex PTSD: and sometimes the social context is
part of the problem.
8. Clients cannot fail in DBT-PTBS.
Basic Assumptions 9. Therapists working with victims of
1. The overall goal of DBT-PTBS is to abuse need support and self-
help the clients to live a life worth liv- compassion.
ing. Even when many patients do not
have a concrete idea of what this
should look like at the beginning of The consultation-team helps the therapists
treatment. to motivate themselves, to define the treat-
2. The overall attitude of DBT-PTSD is ment goals, to stay with the manual and to
compassion: The wisdom that suffer- balance acceptance and change.
ing and failure is part of the shared
human experience; the willingness to
share and carry the traumatic experi- 17.4 Treatment Overview
ences and the suffering of our clients;
the conviction and encourage to moti- The outpatient program for DBT-PTSD
vate our clients to overcome the comprises up to 45 sessions of individual
sequelae of their traumatic experiences. therapy, usually weekly, while the residential
3. Mindfulness teaches us to take a bal- treatment program runs 12 weeks. However,
anced approach to one’s negative outpatient treatment can be condensed and
emotions so that feelings are neither carried out over a shorter period of time. The
suppressed nor exaggerated. Negative program is divided into seven thematic treat-
thoughts and feelings are observed ment phases (see . Fig. 17.3), with each

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.
325 17
Event-Based Foci Treatment-Phases Treatment - Modules
(Example)
0
• Pre-Treatment
1
• Commitment
1. Severe crisis generating 2

• Trauma-Model and Motivation
behavior 3.1 Antidissociative Skills
• Skills und Cognitive Elements e.g. 3.2 Distress - Tolerance
2. Therapy destructive 3
behavior 3.3 Emotion-Regulation
• Skills Based Exposure 3.4 How to Work with Guilt
3. Therapie interferring 4
3.5 How to Work with Shame
behavior • Radical Acceptance
5
6 • Towards a Life Worth Living
7 • Farewell and Post-Treatment
.. Fig. 17.3 Modular structure of DBT-PTSD
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
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-
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
18.2 Guiding Principles of the CA-CBT – 332

18.2.1 ulturally-Adapted Trauma Exposure – 332
C
18.2.2 Multiplex Model and Emotion Exposure – 334
18.2.3 Techniques for the Regulation of Emotions – 336
18.2.4 Inclusion of Cultural or Religious Healing Traditions
of the Patients – 339
18.2.5 Interoceptive Exposure as a Culturally Adapted
CBT Technique – 340
18.2.6 Worries and Generalized Anxiety Disorder – 341
18.2.7 Coping with Catastrophic Beliefs – 341
18.2.8 Consideration of Culture-Bound Syndromes – 341
18.2.9 Somatic Symptoms – 342
18.2.10 Treatment of Sleep-Related Problems – 000
18.2.11 Culturally Significant Rites of Passage – 342
18.3 Conclusion – 344
Literature – 344
332 D. E. Hinton
18.1 Introduction are also treated. In order to achieve these

treatment goals, the CA-VBT, in contrast to
This chapter describes key aspects of a cul- other treatment approaches, uses specifically
ture-sensitive cognitive behavioural therapy developed emotional exposure and tech-
for traumatised persons from non-Western niques for regulating emotions such as med-
cultures. For this purpose, a specific proce- itation and yoga-like stretching. This is
dure has been developed, which is called intended to achieve improved psychological
“culturally adapted cognitive behavioural flexibility in the long term (7 Sect. 18.2.3).

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).

So far, the team of the author has used the

CA-CBT for patients of Latin American
and Asian origin (Hinton et al., 2004, 2005a,
18.2 Guiding Principles
2009b, 2011a). Furthermore, the CA-CBT
has been used in worldwide collaborative of the CA-CBT
projects, for example, with Afghan refugees
in Germany as well as with Egyptian, Turk- 18.2.1 Culturally-Adapted Trauma
ish and indigenous South African patients Exposure
(Acarturk et al., 2018; Jalal et al., 2017,
2018; Kananian et al., 2017). Exposure procedures play an important role
The CA-CBT differs in various aspects in PTSD as repeated confrontations with
from common CBT treatment approaches traumatic memories (7 Chaps. 12 and 14).

(7 Chaps. 12 and 14) in order to meet the

This usually involves the repeated evocation
challenges of culturally diverse patient of traumatic memories with all sensory
groups. Its contents are presented in easily modalities by means of plastic re-experience
understandable language so that they can be and the associated high level of emotional
understood by people with minimal educa- activation. For various reasons, this type of
tion and language skills. The CA-CBT exposure may not be ideal for traumatised
18 includes various adapted forms of exposure, people from non-Western cultures. Firstly,
each more or less involving a focus on body the risk of a worsening of symptoms has
sensations. In addition, symptoms related to been described several times, which can lead
PTSD such as worries and panic attacks are to therapy discontinuation (Lester et al.,
treated, the reduction of anger and rage is 2010). Secondly, the theoretical assumptions
aimed at and comorbid anxiety disorders regarding the mode of action of exposure
Approaches of Culturally Adapted Cognitive Behavioural Therapy
333 18
.. Table 18.1 Sequence of the CA-CBT meetings and key components of the sessions
Session Session title Exposure form Stretching Mindfulness

number followed by practice exercise at the exercise at the
of the indexed end of the session end of the
protocol session
1 Education about trauma Emotion (e.g. fear) X X

sequelae
2 Muscle relaxation and Emotion (e.g. fear) X X
stretching using a visualiza-
tion
3 Applied stretching with Emotion (e.g. fear) X X
visualization protocol
4 Flashback protocol Emotion (e.g. fear) X X
5 Education about trauma Emotion and trauma X X
sequelae and about the
changeable catastrophic
assumptions
6 Interoceptive exposure I: Emotion and trauma X X
Circular head movement
7 Interoceptive exposure II: Emotion and trauma X X
hyperventilation
8 Education about breathing Emotion and trauma X X
and its use for relaxation
9 Sleep disturbance Emotion and trauma X X
10 Generalised anxiety disorder Emotion and trauma X X
11 Anger/fury Emotion and X X
especially anger
12 Neck, shoulder and Emotion and X X
headache related dysphoria especially anger
and panic
13 Other somatic symptoms Emotion and X X
and the associated panic especially anger
14 Culture-bound syndromes in Emotion and X X
connection with trauma- especially fear
related emotions: Final
report
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
Hofmann, 2008). Thirdly, therapy pro- zz Interoceptive Exposure

grammes have increasingly begun to teach For this purpose, certain bodily perceptions
patients suitable techniques for regulating (e.g. dizziness) are used and these are linked
their emotions before exposure in order to to new positive associations, which are
reduce their level of arousal, as otherwise intended to replace the association with the
the exposure becomes difficult for them to trauma as well as the catastrophic assump-
bear (7 Chaps. 16 and 17).
tions. Creating such positive new associations
In addition, exposure should not only be increases the acceptance and effectiveness of
carried out for traumatic events (and the the intervention (7 Sect. 18.2.5).

thoughts and feelings associated with them),

but also for physical sensations (Hinton
et al., 2008; Otto & Hinton, 2006; Wald & 18.2.2 Multiplex Model
Taylor, 2007, 2008). Such interoceptive expo- and Emotion Exposure
sure is particularly important for patients
with Trauma patients from different cultures
55 conspicuous somatic complaints, often experience not only fear and shame
55 including catastrophic assumptions but also anger, general anxiety and worry
about these complaints, (Hinton et al., 2009c, 2010). The multiplex
55 distinct associations between trauma model of the many modalities of PTSD
and physical sensations (i.e. the trauma development shows (. Fig. 18.1) that these

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.
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
.. Fig. 18.1 Multiplex model for the development of PTSD
zz Derived Meaning for Emotional zz Emotional Exposure

Exposure In the CA-CBT certain emotions are evoked
The confrontation with intense emotions is in the most vivid way possible. Some of
an important element of treatment, through these emotions are induced during the con-
which patients learn to endure emotions and scious recall of traumatic memories at the
apply more adaptive strategies in dealing beginning of the sessions. Other emotions,
with these emotions. Emotional exposure is i.e. fear, anger and worry, are triggered by
easy to perform in different cultures, espe- asking patients about their experiences with
cially when combined with exercises to a particular emotion that has recently
improve emotional regulation. Emotional occurred. In particular, it is asked which
exposure is understood as both the confron- events triggered the emotion and which
tation with negative emotions and the pro- body perceptions were associated with this
motion and experience of positive emotions emotion. After an emotion has been evoked
such as compassion and loving kindness (ele- in this way during a CA-CBT session, exer-
ments of mindfulness; see Singer & Bolz, cises for the regulation of emotions are
2013). applied, whereby the patients consciously
336 D. E. Hinton
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.
sessions 5–10, it is possible to move on to 18.2.3.2], which could replace images of a

combined exposures to anxiety on the one physical catastrophe). If this substitution
hand and trauma on the other, followed by succeeds, this can be understood in the sense
the development of hourly indexed proto- of psychological flexibility (here: visual flex-
cols. Later sessions (11–14) focus more on ibility).
triggers for anger or resentment if this is the
patient’s primary concern – this would then 18.2.3.1 Psychological Flexibility:
be recorded in writing through indexed Basics
anger/rage protocols. Psychological flexibility – defined as the
ability to distance oneself from current ways
zz Therapeutic Goals of thinking and to consider alternative ways
The aim is to enable patients increasingly to of thinking (Kashdan, 2010) – is a meta-
apply techniques for emotion regulation and level processing method that CA-CBT tries
acceptance. These techniques can be applied to establish as a standard processing method.
whenever the trauma is remembered or Compared to the previously existing psy-
other dysphoric states are experienced. chopathology, psychological flexibility cre-
Through the written induced protocol, ates a new adaptive way of processing, which
patients connect new and adaptive experi- replaces the feeling of threat and thus
ences with the trauma memory (e.g. their enables emotion regulation that is discon-
own ability to act, self-confidence, unin- nected from the trauma consequences
volved observation, loving kindness, com- (Hinton & Kirmayer, 2017; Hinton et al.,
passion). Dysfunctional modes such as 2013; Kashdan, 2010; Kok & Fredrickson,
pondering or ruminating about problems, 2010).
for example, change into the mode of mind- In addition, psychological flexibility is
fulness (e.g. to current impressions such as an important skill for people from different
leaves moving in the wind, the colour of cultures who are faced with a variety of
clouds, the feeling that the body is moving adjustments and who are expected to recon-
through the room or paying attention to the cile their own and the new culture and
flow of breath). acquire a new language. To this end, con-
temporary cultural theory uses the terms
18 “postcolonial hybridity” and “bricolage”,
18.2.3 Techniques for the which express the difficult condition of
Regulation of Emotions immigrants to construct identity (see
Bhabha, 2000).
Emotional exposure with anxiety is done at The CA-CBT aims to increase psycho-
the beginning of most sessions, after patients logical flexibility in many ways. On the one
describe a recent situation in which they hand, this is achieved by teaching emotional
337 18
detachment, a major aspect of emotional One of the basic principles of the CA-
flexibility, and by practicing the naming and CBT is the “multisystemic network model”,
distancing of affects. On the other hand, which summarises the involved processes of
flexibility is increased through emotional psychological flexibility and which is shown
and trauma exposure, as patients distance in the appendix in . Fig. 18.2. It refers to

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
Processing mode: attention to the sensory Activation of the biologically associated

experience of the present moment state of the VNS (vegetative nervous system):
warm limbs, slowed breathing, etc...,
The associated psychological

assessment: the feeling for new
possibilities, for many options for Activation of a mood:
action, the ability to adapt to relaxation, euphoria
challenges, hope; relaxation
and not being overtaxed
Somatic state: Associated biographical

Associated Muscle relaxation and memory: memory of positive
predisposition mobility of the joints events caused by muscle
for action: prosocial, relaxation and physical
active engagement flexibility
Associated images: (1) Nature images: a flexible branch; a leaf moving

Associated metaphors: in the wind; symbolic images of rice, which is considered to be
flexibility, options for action, articulated like the hand; (2) man-made environmental images;
looseness; the feeling of a candle flame or incense moving in the wind; (3) type of greeting:
possibility, multiple hands in lotus form followed by a bend; (4) ritual act: bowing in the
movements temple; (5) dance forms: Dance that emphasizes flexible movements
of hands and fingers and the curvature of fingers and arms; instruction
Associated self-statements: to dancers to have a “soft hand” obtained by bending the hand into
I am relaxed; I can adapt; a bow, bending the ankles, and placing the hand in the morning dew,
I can handle things. especially the one that lies on lemon grass (a plant with curved leaves);
(6) Dress: headdress of dancers (e.g. Angkor Wat dancers); tassels; other
clothing; (7) aesthetic ideals: one should be soft and flexible (tduen
phluen); and (8) moral Imaginations in the visual language: the need
to be flexible (tduen phluen) and not “rigid” (rung) as in the proverb
“upright and rigid like the rice handle without grain, bent like the
one with grain loaded rice stalk” (ngeuy sko, aon da kroeup).
.. Fig. 18.2 Multisystemic network model

338 D. E. Hinton
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
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
sion (. Table 18.1). The essential Buddhist

trauma flashbacks in order to determine the
principle “equanimity” (“upekkha”) is also typical way patients deal with suffering.
part of the treatment and stands for the Healing rituals from the respective cul-
practice of distancing oneself from emo- ture can also serve to improve the regulation
tions and spiritual content and viewing them of emotions: for Buddhist patients, for
like clouds in the sky. For Buddhist patients, example, rubbing lustral water into the skin
these practices can be described with the or listening to Buddhist music; for American
terms used in its tradition, emphasizing that indigenous groups, participation in tradi-
the performance of these practices is “meri- tional ceremonies such as the sweat lodge
torious” and that this “merit” can be shared can be helpful. Ideally, therapeutic meta-
with oneself and others. This understanding phors, causal explanations (e.g. “historical
of merit can enhance the sense of action trauma”), understanding of healing and
competence and can significantly reduce sui- ideas about ontology (i.e. the nature of
cidal tendencies and depression. When being) from the relevant cultural tradition
patients feel a sense of guilt for survival, should be integrated into the treatment. For
they can be reminded of the culturally deter- further discussion on the inclusion of tradi-
mined duty to commit themselves to the per- tional healing in treatments, see Gone (2009,
son for whom they feel guilty at least once a 2010).
year to ensure the good rebirth and mental
health of the deceased.
In order to promote psychological flexi- 18.2.5 Interoceptive Exposure
bility among Christian patients from Latin as a Culturally Adapted
America, the image of the flame of a sacrifi- CBT Technique
cial candle in the breeze is used and it is
emphasized that this movement is a reminder During the interoceptive exposure of a CA-
to remain flexible. As indicated above, CBT, positive reassociations of body per-
Christian images are used in the Loving- ceptions to culturally appropriate images
Kindness meditation. It is also recom- are made.
mended that Christian patients from Latin Cambodian patients can be instructed to
America use other religious techniques of imagine various traditional “games” during
emotion regulation, such as opening the a circular head movement exercise: for
Bible at random to read a passage or reciting example, an exercise in which a person is
a rosary (if the patients are Catholic). For asked to walk in a circle while holding a
patients from so-called Pentecostal churches, scarf (“lea geunsaeng”), or another exercise
speaking in tongues with its different voice in which the person hums and runs after a
ranges can serve as a reminder and show stick that has been thrown into the distance,
that there are many ways to God and thus making it impossible to breathe. Latin
many ways to act and feel. American patients are asked to imagine tra-
The use of culturally influenced proverbs ditional exercises that cause dizziness: the
can make it easier to cope with negative “piñata” game, in which the eyes are blind-
emotions. In the anger exposure part of the folded, or the “galliñita ciega” game. In
18 treatment (3rd phase, . Table 18.1), a
these exercises, the person is turned around
Cambodian proverb can be used to teach until he or she becomes dizzy. In these exer-
how to control anger outbursts: “If you con- cises, the dizziness negatively perceived by
trol your anger once, you gain a hundred the trauma is reassociated with the newly
days of happiness”. It specifically asks how connoted positive memories of the tradi-
patients deal with fear, anger and stressful tional game.
341 18
18.2.6 Worries and Generalized symptoms, including their ideas about how
Anxiety Disorder the symptoms are physically produced. On
the other hand, patients are asked about
The reduction of uncontrollable worries is a their fears about the danger emanating from
central treatment goal for patients from dif- these symptoms.
ferent cultures. Refugees and people from Patients with a Cambodian background
ethnic minorities often worry about their liv- often fear that dizziness indicates the onset
ing conditions (they live in dangerous areas of a “khyâl” attack (culture-bound stress
and are often confronted with financial syndrome, literally “wind attack”) (Hinton
problems and other burdens). Trauma vic- et al., 2010). Latin American patients report
tims often have a tendency to be difficult to that shakiness of limbs or racing thoughts
detach from their worries and tend to over- could indicate a problem of their “nervios”
excite, which often turns into panic attacks. or a threatening “ataque de nervios”
This tendency can be described as “arousal (culture- bound stress syndrome with psy-
inducibility”, which corresponds to the gen- chophysical decompensation).
erally increased sensitivity to stress that is Any PTSD symptom, such as nightmares
often present in trauma patients (Harkness or startle, can lead to such catastrophic
et al., 2015). Arousal induced by anxiety can assumptions. People from many cultures
lead to catastrophic assumptions and the re- fear that the re-experiencing of trauma is
experience of the trauma. Concern also accompanied by the threat of “insanity”.
causes a state of excessive vigilance against Others fear that the re-experience of trauma
all possible threats. The CA-CBT addresses is the result of persecution by dangerous
issues of concern, makes catastrophic spirits of the dead.
assumptions about the negative effects of
the concerns, and determines whether the zz Startle
concern triggers a re-experience of the People from some cultures see frightfulness
trauma or a panic attack. Getting to know as a power to drive out souls and cause death
the patient’s worrying issues strengthens the or serious illness (e.g. Latin American and
empathic connection between patient and Southeast Asian populations; for a review
therapist and thus improves the therapeutic see Hinton & Lewis-Fernández, 2010a, b).
relationship. Within the framework of CA- Again, other cultures believe that frightful-
CBT, other special techniques for reducing ness indicates a dangerous “weakness” of
anxiety can be applied, such as meditation, the heart, which causes general cardiac
which has proven to be effective in gener- hyperreactivity leading to death.
alised anxiety disorder (Roemer et al., 2008)
and in PTSD (Follette et al., 2006).
18.2.8 Consideration
of Culture-Bound
18.2.7 Coping with Catastrophic Syndromes
Beliefs
Usually the last therapy session is dedicated
In . Fig. 18.1 on the multiplex model, the to the assessment and treatment of anxiety

role of catastrophic beliefs of patients in the and PTSD-related “culture-bound syn-

development of PTSD, general excitability dromes” (a concept from transcultural psy-
and somatic symptoms is shown. In the CA- chiatry). Patients often attribute their PTSD
CBT, patients are asked about their under- and anxiety symptoms to a culture-bound
standing of what causes the anxiety syndrome, such as the khyâl or nervios
342 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).

trigger a vicious circle that causes further

somatic symptoms and worsens PTSD
(. Fig. 18.1). The appendix shows in 18.2.11 Culturally Significant

. Table 18.2 how somatic symptoms can be

Rites of Passage
treated with a CA-CBT.
18 Certain cultures practice “purification” or
transition rituals, such as the steam bath
18.2.10 Treatment of Sleep- ritual among Southeast Asians or in certain
Related Problems indigenous cultures (Silver & Wilson, 1988).
At the end of a CA-CBT, patients from the
In the CA-CBT, one session deals specifi- respective cultures can be encouraged to
cally with sleep-related problems, including perform these rituals, if they identify with
343 18
.. Table 18.2 How the CA-CBT reduces somatic symptoms
Treatment Techniques to achieve the treatment target

target
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
mediates certain sensations, i.e. creates new Worries and GAD

positive associations of sensations.
18.3 Conclusion
This chapter has illustrated how CBT can be

adapted for patients from different cultures Arousal,
panic and
and has provided many examples. The dif-
somatic
ferent guiding ideas for the culture-sensitive symptoms
treatment of these traumatized populations
were presented and several basic models Panic disorder PTSD
were described that can be used to design
treatment. From these materials, the con- .. Fig. 18.3 Arousal triad
crete treatment manuals for refugees and
ethnic minorities from very different cul-
of anxiety and the dangers of somatic and
tures described at the beginning were then
psychological anxiety symptoms, the arousal
put together in concrete terms, which - as
triad seems to be particularly pronounced in
reported above - made it possible to achieve
fugitives and ethnic minorities. Often these
good effectiveness and low therapy discon-
symptoms are caused by culture-bound syn-
tinuation rates.
dromes (e.g. Khyâl attacks in Cambodian
populations; neurasthenia in Chinese popu-
lations; nervios and ataque de nervios in
Annex Latin American populations).
. Table 18.2 shows in the overview how

Node Network Model CA-CBT reduces somatic symptoms.
. Figure 18.2: This node-network model

(i.e. all linguistically marked fields on the Literature

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18
347 19
Psychopharmacotherapy
of Trauma Sequelae
Contents
19.1 The Role of Psychopharmacotherapy in PTSD – 348
19.2 I ndications and Practical Guidelines

for Psychopharmacotherapy – 348
19.2.1 T arget Symptomatology – 349
19.2.2 Practical Implementation – 349
19.3 Empirical Evidence – 350

19.3.1 ntidepressants – 350
A
19.3.2 Tranquillizers/Anxiolytics – 353
19.3.3 Anticonvulsants and Lithium – 354
19.3.4 Antipsychotics – 355
19.3.5 Alternatives – 355
19.4 Psychopharmacotherapy of Further Trauma

Sequelae – 356
19.5 Concluding Considerations – 357
Literature – 358
348 M. Bauer et al.
19.1 The Role However, progress has been made in the

of Psychopharmacotherapy past 15 years in establishing more efficient
pharmacotherapeutic treatments for PTSD
in PTSD
with the help of placebo-controlled studies
(Hageman et al., 2001; Berger et al., 2009;
Psychopharmacotherapy has a subordinate
Ipser & Stein, 2012; Watts et al., 2013; Vil-
role compared to psychotherapeutic pro-
larreal et al., 2016). Thus, paroxetine has
cedures in the treatment of posttraumatic
now been approved in Germany and parox-
stress disorder (PTSD), the most clinically
etine and sertraline in the USA for the treat-
relevant trauma sequelae in the literature
ment of PTSD, and numerous randomised
and clinical practice. Compared to the
placebo-controlled studies have also been
relatively large number of publications on
published for other active substances from
posttraumatic disorders and their psycho-
the group of SSRIs that have shown effi-
therapeutic treatment, there are compara-
cacy (Stein et al., 2006; Ipser & Stein, 2012).
tively few studies on the therapeutic use of
However, more recent meta-analyses have
psychotropic substances (Ebbinghaus et al.,
concluded that the effect sizes (extent of the
1996; Ipser & Stein, 2012; Hoskins et al.,
effect) for antidepressants in this indication
2015).
are rather small (Hoskins et al., 2015; Cipri-
ani et al., 2017). Nevertheless, pharmacolog-
Under the Magnifying Glass ical therapy in PTSD may be effective and
considered as part of the treatment.
In Germany, the antidepressant parox-
etine from the group of selective serotonin
reuptake inhibitors (SSRI) is currently 19.2 Indications and Practical
the only active substance approved for the
Guidelines
treatment of posttraumatic stress disor-
der. However, the current study situation
for Psychopharmacotherapy
also shows indications for the efficacy
of other drugs, especially those from the
More recent findings suggest that phar-
SSRI group. In the USA, sertraline from
macotherapy could prevent or reverse the
the same group is also approved for the
development of dysfunctions in PTSD
treatment of PTSD.
(Bonne et al., 2004; Charney et al., 1993).
First of all, the question arises at which
symptomatology and at which point in time
Although the diagnosis of posttraumatic of treatment of a patient with PTSD phar-
stress disorder (PTSD) was included as a macotherapy should be considered:
separate diagnostic category in the “Diag- 55 The use of psychotropic drugs should be
nostic and Statistical Manual of Mental considered especially for PTSD syn-
Disorders” (DSM-III; American Psychiatric dromes with pronounced clinical symp-
Association, 1980) as early as 1980 (Gersons toms.
& Denis, 1996), the first controlled studies on 55 Pharmacotherapy carried out initially
the use of psychotropic drugs in PTSD did at the beginning of treatment could
not appear until the late 1980s. One reason be advantageous in order to enable or
for the hesitant use of psychotropic drugs to facilitate access to psychotherapy for the
19 date may be that only in recent years biolog- patient.
ical models of the etiology of posttraumatic 55 An indication for drug therapy may also
disorders have been increasingly developed exist if psychotherapeutic efforts have
(Bonne et al., 2004; Charney et al., 1993). been unsuccessful or if patients are par-
Psychopharmacotherapy of Trauma Sequelae
349 19
ticularly open-minded about treatment 55 Pressure to remember (intrusions, night-
with psychotropic drugs, while they tend mares, reverberations, stress caused by
to reject other approaches. triggers, physiological reactions to mem-
ory);
Before starting drug therapy, a careful diag- 55 Avoidance/emotional deafness (avoid-
nostic assessment of the patient is neces- ance of thoughts and feelings, avoidance
sary. Possible concomitant mental illnesses of activities or situations, amnesia, reduc-
(comorbidity) must be identified (7 Chap. tion of interests, feeling of alienation,
11). If other significant mental disorders are limited scope of affect, limited future);
present at the same time, these must be taken 55 Chronic excessive arousal (difficulty fall-
into account in psychopharmacotherapy – ing asleep and staying asleep, increased
as a rule direct and, if necessary, primary irritability, concentration difficulties,
treatment of these concomitant disorders hypervigilance, excessive startle response).
should be considered.
In addition, it must always be checked In addition, pharmacotherapy shows good
whether and with what effect the patient has efficacy in the following common comorbid
already taken or is currently taking medica- disorders:
tion for PTSD symptoms. Both over-the- 55 Depression,
counter as well as prescription sedatives and 55 Panic attacks, anxiety,
sleeping pills are often taken as S (7 Sect. 55 Psychotic experiences (delusions, percep-
19.3.2), often in combination with or as an tion disorders, hallucinations).
alternative to alcohol (Brady et al., 2000).
In principle a drug-free interval should
be established for patients with PTSD who 19.2.2 Practical Implementation
are taking psychotropic substances before
starting any psychopharmacotherapy in For patients who do not have specific psy-
order to better assess the initial symptoms chiatric comorbidity (e.g. psychotic illness),
and later effects and side effects. Primary a therapeutic trial with the active substance
combination treatments, which experience paroxetine, which is approved for the treat-
has shown to be common in patients with ment of PTSD in Germany, is initially indi-
PTSD, are not recommended in individual cated. If there is a contraindication to the
cases. administration of paroxetine, another anti-
depressant from the SSRI group should be
>>Although patients with PTSD often have selected. Which drug is chosen from the
a wide range of symptoms, any drug large group of antidepressants may depend
treatment should preferably be started as on numerous factors in individual cases,
monotherapy. In the later course of treat- including the experience of the respon-
ment and if the response to monotherapy sible physician in the treatment with the
is inadequate, simultaneous treatment respective substances and possibly specific
with several psychotropic drugs should previous experiences of the patient.
be considered.
>>Antidepressants of the SSRI type are
the most suitable, as the effectiveness of
19.2.1 Target Symptomatology this group of antidepressants in PTSD is
best proven (Ipser & Stein, 2012; Cipriani
The literature available today suggests that et al., 2017). Moreover, SSRIs have a
pharmacotherapy is effective against the 3 more favourable side effect profile than
symptom groups of PTSD. These include: tricyclic and tetracyclic antidepressants.
350 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
19.3 Empirical Evidence The group of antidepressants is useful for

treating many different psychiatric disor-
There are a number of open uncontrolled ders. However, the treatment of depressive
studies on the use of various psychotro- disorders is the main indication for antide-
pic substances in patients with PTSD that pressants, which have been tried and tested
report mostly good therapeutic success for over 40 years. Other indications for the
(Davidson, 2006; van der Kolk & Greenberg, use of antidepressants include anxiety and
1987). However, the number of systematic, panic syndromes, obsessive compulsive dis-
controlled pharmacological studies is com- orders and pain syndromes.
paratively small, given the relatively high
prevalence of this pathology (Stein et al., 19.3.1.1 SSRI and Other
2006). In the controlled trials, antidepres- Serotonergic
sants of different substance groups (SSRIs, Antidepressants
norepinephrine reuptake inhibitors, tricy- SSRIs are a group of antidepressants that
clic antidepressants, MAO inhibitors) were have gained great importance in the treat-
tested almost exclusively. The best data are ment of depressive disorders in recent years
available for the SSRI group. Here, efficacy and are now the most frequently prescribed
for the substances sertraline, paroxetine and antidepressants worldwide (Bauer et al.,
fluoxetine could be proven in both short 2013). In addition, SSRIs are also suc-
19
351 19
.. Table 19.1 Guidelines for the use of psychotropic drugs in posttraumatic disorders
Substance Examples (generics) Daily dose, therapy Special indications

group duration
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
SSNRI Venlafaxine 75–225 mg Depression, panic attacks,
anxiety
Duloxetine 30–120 mg
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
Valproate, carbamazepine Dosage according to Depression, panic attacks,
serum level anxiety
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
Atypical antipsychotics
Risperidone 1–4 mg Psychotic symptoms
Olanzapine 2.5–20 mg
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
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).
19.3.2 Tranquillizers/Anxiolytics Before starting benzodiazepine therapy, it

is essential that the patient is informed by
19.3.2.1 Benzodiazepines a doctor about the risks of dependence and
Benzodiazepines are among the most com- withdrawal symptoms if the drugs are taken
monly used psychotropic drugs. Their main over a long period of time. Some patients
indications are the treatment of anxiety, with benzodiazepine abuse or dependence
tension and agitation, and the treatment of report this spontaneously in a reluctant
354 M. Bauer et al.
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
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.
To some extent, primary/prospective lol, escitalopram, temazepam or gabapentin

(before trauma) and secondary/retrospec- in preventing PTSD, but which, like another
tive (after trauma, but before manifesta- meta-analysis (Sijbrandij et al., 2015), found
tion of PTSD) preventive pharmacological evidence for the efficacy of hydrocortisone
approaches are also pursued. Up to now, in the development of PTSD. A recent ran-
the administration of hydrocortisone has domised controlled trial also found evidence
mainly been investigated in high-risk popu- for the efficacy of intranasally administered
lations (e.g. patients in intensive care units; oxytocin in preventing PTSD in the sub-
Steckler & Risbrough, 2012). group of patients with a high PTSD symp-
tom burden in the Clinician-Administered
PTSD Scale (CAPS), whereas no significant
19.4 Psychopharmacotherapy difference was found in the overall patient
of Further Trauma Sequelae population (van Zuiden et al., 2017).
In view of the (narrow) data situa-
In addition to post-traumatic stress disor- tion described above, what should be
der (PTSD), the current diagnostic criteria done in everyday clinical practice if symp-
(ICD-10, DSM-5) include other disorders toms of an acute stress reaction such as
that can follow trauma more or less directly. sleep disturbance with recurring stressful
The “acute stress reaction” is particularly trauma-associated dreams are present and
worth mentioning here as a direct trauma associated with significant impairment,
sequelae disorder, which differs from PTSD and if the person affected requests medical
in that the pattern of symptoms, which is help? One possibility could be to use atypi-
comparable to that of PTSD, usually occurs cal antipsychotics such as olanzapine (Carey
directly after the trauma, lasts at least et al., 2012), which have proven successful
3 days and must be remitted within 1 month in PTSD treatment with regard to these
of the trauma – otherwise the diagnosis of symptoms, off-label and then, depending on
an acute stress reaction must be changed to the clinical symptoms, to gradually reduce
that of PTSD – provided that, in addition them again in a timely manner, before the
to the time criterion, its other criteria are often encountered adverse side effects such
also met. as weight gain become clinically relevant. It
Against the background of the data is also worth discussing whether approved
available, the WHO’s “Guidelines for the treatment options such as sertraline or par-
Management of Conditions Specifically oxetine should be used during the acute
Related to Stress” of 2013 recommend that stress response when it is foreseeable that the
neither benzodiazepines nor antidepressants symptoms will not remit within 1 month after
should be offered to children, adolescents or the trauma. Such a procedure could also be
adults during the first month after a poten- discussed in cases in which the symptoms of
tially traumatic event in order to relieve the acute stress response partly persist over
the symptoms of an acute stress response, the period of 1 month after the trauma and
(even) if they are associated with signifi- are significantly impairing, but the complete
cant impairment in daily life (WHO, 2013). criteria of PTSD are not fulfilled, so that the
Despite the low quality of evidence, the diagnosis of an adaptation disorder must be
WHO recommendation on benzodiazepines assigned here. In such a case, however, the
is clear (“Strength of recommendation: use of the drugs sertraline and paroxetine,
19 strong”) and also applies to trauma-related which are approved for PTSD, would then
insomnia. This recommendation is consis- be off-label – unless the criteria for a depres-
tent with a Cochrane analysis (Amos et al., sive episode, with trauma as a risk factor for
2014) which found no benefit of proprano- this, were simultaneously met.
357 19
In addition to the acute stress reaction physiology of these disorders may provide
and PTSD, the “persistent personality dis- new insights for treatment. According to
order after extreme stress” in the context of the current state of knowledge, however,
direct trauma sequelae must also be men- psychopharmacotherapy represents a use-
tioned (ICD-10: F62.0). According to the ful addition to the overall treatment plan for
ICD-10 there is a “persistent personality posttraumatic disorders, which is particu-
change lasting at least 2 years” after “a stress larly indicated in severe PTSD syndromes
of catastrophic extent”. Here it is demanded with hyperexcitability, panic attacks and
that the stress “must be extreme”, so that depressive symptoms, if possible in com-
“the vulnerability of the person concerned bination with psychotherapy. First choice
need not be considered as an explanation drugs for posttraumatic stress disorder are
for the profound effect on the personality”. antidepressants from the SSRI group (e.g.
The disorder is characterized “by a hostile sertraline, paroxetine) or pharmacologically
or distrustful attitude towards the world, similar substances (e.g. mirtazapine, venla-
social withdrawal, feelings of emptiness or faxine, duloxetine). They show good efficacy
hopelessness, a chronic feeling of tension as with regard to all 3 symptom clusters with
in the case of constant threat and feelings good tolerability. If these drugs are ineffec-
of alienation”. PTSD (ICD-10: F43.1) can tive or intolerable, the use of other antide-
precede the personality change. In the ICD- pressant classes (tricyclic antidepressants
11, however, this disorder no longer appears, or MAO inhibitors) should be considered.
but is transferred to the concept of “complex “Mood stabilizers (lithium, anticonvulsants)
post-traumatic stress disorder” (Giourou are another alternative, which can also be
et al., 2018). In order to be diagnosed, the prescribed in combination with an antide-
diagnostic criteria of PTSD must have been pressant in the sense of augmentation. In
present at some point in the course of the the case of particularly severe courses or
disease; in addition, however, the disorder is the occurrence of psychotic symptoms, the
characterised by severe and profound prob- use of an atypical neuroleptic should also be
lems of affect regulation, a profound convic- considered. A pharmacotherapeutic treat-
tion that one’s own self is inferior, damaged ment attempt should last at least 8–12 weeks
or worthless, and persistent difficulties in (. Table 19.1) and, if the therapy is success-

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.
19.5 Concluding Considerations If psychopharmacological (co-)treatment is

given, it will lead in individual cases to sev-
PTSD as well as the other trauma sequelae eral practitioners being responsible for the
described above are diseases that are diffi- same patient (e.g. family doctor, psychother-
cult to treat with psychotropic medications. apist and psychiatric specialist). Such a con-
Further studies on the etiology and patho- stellation may have to be accepted in order
358 M. Bauer et al.
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therapy; however, it requires clear agree- tives to antidepressants in posttraumatic stress
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361 20
Therapy of Prolonged Grief

Disorder
Contents
20.1 Systematics – 362
20.2 Therapeutic Approaches – 363

20.2.1 omplicated Grief Treatment – 363
C
20.2.2 Cognitive Behavioural Therapy – 365
20.2.3 Cognitive Therapy with Confrontation – 366
20.2.4 Integrative Cognitive Behavioural Therapy – 366
20.2.5 Internet-Based Cognitive Behavioural Therapy – 369
20.2.6 Further Therapeutic Approaches for Prolonged
Grief Disorder – 370
20.3 Effectiveness – 370
Literature – 371
362 R. Rosner and H. Comtesse
20.1 Systematics of grief symptoms particularly when they

include techniques for confronting avoided
Psychotherapeutic interventions for pro- loss-related memories or situations and for
longed grief disorder (PGD) must be distin- cognitive work on grief-related dysfunctional
guished from non-specific interventions for cognitions or feelings of guilt. As a starting
normal grief. Non-specific interventions are point, it is useful to classify these treatment
directed at all bereaved (universal preven- approaches on the basis of the therapeutic
tion) or high-risk groups (e.g. bereaved par- methods used in each case (. Table 20.1). At

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.
.. Table 20.1 Schematic classification of cognitive-behavioural therapy approaches in cases of

persistent grief disorder
Therapy methods
Therapeutic approach confrontation Cognitive Other therapeutic methods
of grief restructuring
Complicated Grief Treatment (Shear + − Techniques of interpersonal

et al., 2001) therapy
Cognitive behavioural therapy + + Behaviour activation
(Boelen et al., 2007)
Cognitive therapy with confrontation + + −
(Bryant et al., 2014)
Integrative cognitive behavioural + + Techniques of systemic
therapy (Rosner, Pfoh, et al., 2015) therapy and Gestalt therapy
Internet-based cognitive behavioural + + Social sharing
therapy (Wagner et al., 2005)
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.
To this end, techniques of cognitive-behav- which focuses on avoidance behaviour with

ioural therapy treatment of p ost-traumatic regard to loss-related situations or activities.
stress disorder according to Foa and Roth- Successful exposure leads to a more coher-
baum (2001) are combined with elements of ent and complete narration of the loss event.
interpersonal therapy (IPT). CGT consists This in turn leads to a reduction in confu-
of 4 therapy phases with a total of 14–18 sion about death and ultimately to accep-
double sessions (Shear et al., 2001, 2005). tance of the event. Guilt, shame and other
In phase 1, the relationship to the emotions and cognitions that are unpleasant
deceased person, circumstances of death for the patient and that appear during the
and grief symptoms are first described in exposure are thus reassessed.
detail. Furthermore, individual treatment Another problem is the excessive pre-
goals and ways to achieve them are devel- occupation with the circumstances of the
oped together with the patient. The authors loss and memories of the deceased person.
(Shear et al., 2011) emphasize that some While this behaviour protects against pain-
bereaved are reluctant to undergo therapy ful feelings of grief, it prevents patients from
and therefore do not follow the treatment engaging in social activities and relation-
rationale. For this reason, aspects of motiva- ships again. In this case, the exposure exer-
tional interviewing are used to uncover and cises aim to acknowledge the reality of loss,
resolve possible ambivalence. This approach separation anxieties and feelings of guilt.
is maintained throughout the entire ther- Another aim of the treatment is to build up
apy. Since patients with PGD often isolate positive and comforting memories of the
themselves from friends and relatives, a deceased person in order to achieve a reas-
close person is included in one of the ses- sessment of the loss. Sometimes these posi-
sions who also participates in some of the tive memories develop spontaneously after
exposure exercises. This procedure is used the exposure exercises, sometimes they need
to strengthen or restore the social support to be therapeutically stimulated. In the latter
system. case, the therapist asks the patient to bring
The second phase of CGT lasts about pictures of the deceased. Memories are dis-
6 sessions and contains the actual active cussed and the therapist emphasizes positive
treatment of the core symptoms of PGD. and comforting aspects.
Exposure in sensu is used here (based on In phase 3, the therapeutic goals achieved
Foa & Rothbaum, 2001), which usually so far will be recapitulated, and in phase 4,
refers to the actual loss (e.g. ideas about exposure will be continued or IPT interven-
how the accident might have happened, how tions related to role transitions will be used.
the deceased suffered shortly before death) In a first efficacy study, Shear et al. (2005)
or the circumstances of death (e.g. receipt used IPT as a control condition. 95 patients
of the death notice, funeral). The individ- were randomized to the CGT or IPT condi-
ual exposures are repeated again and again tion. The comparison of the two treatments
within a short period of time until the emo- showed high drop-out rates (around 26%
tional intensity of the experience diminishes in both conditions). The completer analy-
(see Foa & Rothbaum, 2001). While the first sis showed a superiority of CGT. However,
exposures may be stressful for the patient, only 51% of the participants benefited from
the stress usually decreases relatively quickly the intervention. CGT for bereaved seniors
and the exposure is repeated only for the was evaluated using the same design (Shear
most intensively experienced thoughts and et al., 2014). The results also showed a sig-
memories. Furthermore, this exposure is nificant reduction in grief symptoms in
20 combined with a behavioural change inter- this specific bereavement group. In another
vention, similar to a confrontation in vivo, controlled study, the efficacy of CGT in
365 20
combination with pharmacological treat- 55 anxious (e.g. in relation to situations that
ment was evaluated (Shear et al., 2016). 395 remind one of loss) and depressive avoid-
patients were randomized in 4 conditions: ance styles (e.g. social isolation).
Citalopram, placebo, CGT + citalopram
and CGT + placebo. CGT + placebo was From this, Boelen et al. (2007) derived the
superior to the placebo only condition. goals for their cognitive behavioural therapy
The combination CGT and citalopram of PGD. Central to this are the three pro-
was not superior to the CGT only condi- cesses mentioned above, which have to be
tion. Citalopram was not superior to pla- dealt with in the therapy: Elaboration and
cebo. Only comorbid depressive symptoms integration of the loss, dysfunctional beliefs
improved significantly when psychotherapy and/or interpretations, and anxious and/or
was combined with citalopram. Supiano depressive avoidance behavior.
and Luptak (2013) adapted CGT for a At the beginning of the therapy a num-
group setting. 39 persons were randomized ber of grief specific information is collected,
to either the CGT group (CGGT) or a sup- such as whether the loss is perceived as tem-
portive group therapy. CGGT was superior porary or permanent, what characteristics
in the controlled comparison (d = 1.34). the intrusions have, or what maladaptive
The CGGT drop-out rate was 51% and that cognitions are present. In addition, psycho-
in the supportive group 25%. As possible education and normalisation of the grief
mediators of the treatment success of CGT, symptoms are carried out. It is important
the reduction of feelings of guilt, nega- for the treatment to determine which of the
tive thoughts about the future and avoid- three processes are how pronounced and
ance behaviour are discussed, whereby the how they maintain the grief symptoms. The
reduction of the latter could be identified process that makes the greatest contribution
as a mediator (Glickman et al., 2017). All to maintaining the symptoms is chosen as
in all, CGT is currently the most inves- the focus of treatment. To address a lack of
tigated therapeutic method. However, in integration into autobiographical memory,
most of the studies of this working group, the authors choose exposure in sensu (simi-
an interview measure that differs from the lar to Foa & Rothbaum, 2001). In order to
other studies was used (Clinical Global avoid emotional overload, the therapists pro-
Impressions Scale), so that comparability ceed in a gradual manner and also use writ-
with the effectiveness of other interventions ing tasks. In the case of anxious avoidance
is difficult. behaviour, exposure is carried out in vivo.
If there is an excessive preoccupation with
the loss (e.g. pronounced rumination about
20.2.2 Cognitive Behavioural the reasons or circumstances of the loss),
Therapy which prevents acceptance of the reality of
the loss, exposure with reaction prevention
Boelen et al. (2006) proposed a cognitive is used. A behavioural activation is used to
model of PGD, according to which 3 pro- reduce depressive avoidance behaviour. If
cesses are assumed to be central to the devel- dysfunctional beliefs are paramount, the
opment and maintenance of PGD: usual methods of cognitive restructuring
55 low elaboration and integration of the according to Beck (1979) are used.
loss into autobiographical memory; Boelen et al. (2007) investigated their
55 negative misinterpretations of one’s own intervention in a randomized controlled
grief reaction or dysfunctional global trial involving 54 bereaved persons. They
beliefs (e.g. a negative picture of the were assigned to either cognitive behav-
future without the deceased person); ioural therapy (CBT) or supportive therapy.
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
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
Avoidance Excessive confrontation/

preoccupation
Symptom reduction:
Less loneliness
Less longing
Less pain
Emotional restrictions Functional restrictions
External Memories of death and loss External

trigger (internal tigger) trigger
Hopelessness/
Helplessness
.. Fig. 20.1 Model of prolonged grief. (From Rosner, Pfoh, et al., 2015; courtesy of Hogrefe Publishers)
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
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
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-
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).

at-risk groups achieved small or no effects at In general, research on the effectiveness

post (d = 0.14) and follow-up (d = 0.03). of PGD suffers from the previous diver-
In their meta-analysis, Wittouck et al. sity of terms and the lack of differentiation
(2011) only considered interventions address- between normal and prolonged grief. The
ing prolonged grief symptoms. The authors use of the same diagnostic criteria and
included 14 controlled studies and differenti- structured clinical interviews (Prigerson
ated between psychotherapeutic interventions et al., 2009) is indispensable for establish-
(k = 5) and prevention programmes (k = 9). ing indications and evaluating the success
Again, non-specific interventions had no of treatment. To date, however, only a few
effect (d = 0.03). Therapeutic interventions efficacy studies have considered the presence
also showed a moderate effect after the end of of PGD as an inclusion criterion.
treatment (d = 0.53). Four of the 5 treatment
studies achieved a significant reduction in
prolonged grief symptoms. All 4 studies were Literature
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375 21
Therapy of the Adjustment
Disorder
Contents
21.1 Nosology of Adjustment Disorder – 376

21.2 Indication – 376
21.3 Overarching Therapeutic Strategies – 376
21.4 Stepped Care Approach – 377
21.5 Psychosocial Interventions with Low Intensity – 378
21.5.1 S elf-Help and Bibliotherapy – 379
21.5.2 Group Therapy and Self-Help Groups – 379
21.5.3 Mindfulness, Meditation and Relaxation – 379
21.5.4 Internet-Based Interventions – 380
21.5.5 Behavioral Activation – 380
21.6 Psychotherapeutic Interventions – 381

21.6.1 ognitive Behavioral Therapy – 381
C
21.6.2 Psychodynamic Psychotherapies – 382
21.6.3 Client-Centered Therapy – 382
21.6.4 Eye Movement Desensitization and Reprocessing (EMDR) – 383
21.6.5 Other Psychotherapeutic Interventions – 383
21.7 Psychopharmacological Interventions – 384

21.7.1 erbal Remedies – 384
H
21.7.2 Benzodiazepine and Anxiolytics – 384
21.7.3 Antidepressants – 384
21.8 Perspectives – 385
Literature – 386
376 H. Baumeister et al.
Adjustment disorder is among the most The diagnostic criteria of an adjust-

21 frequently diagnosed mental disorders ment disorder according to the DSM-5 dif-
worldwide (Evans et al., 2013; Reed et al., fer considerably from the proposals of the
2011). Adjustment disorder alone as well diagnostic criteria for the upcoming ICD-
as together with other trauma- and stress- 11, since they are based on different etio-
related disorders is associated with consider- logical and nosological models (7 Chap. 5).

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).

to be of lesser intensity than those preced-

ing post-traumatic stress disorders (PTSD),
there is some evidence that traumatic events 21.3 Overarching Therapeutic
can also trigger adjustment disorder instead Strategies
of PTSD (Casey, 2009, 2014). It is assumed
that the relationship between a stressor (trig- Most psychological and psychotherapeutic
gering critical events such as loss of employ- interventions for adjustment disorder share
ment, marital row or burglary) and the three main commonalities (Casey, 2009;
severity of the symptomatology is not linear, Strain & Diefenbacher, 2008):
since different moderators such as vulner- 55 Elimination or mitigation of (the sources
ability, individual factors, genetic predispo- of) stress,
sitions or subjective evaluations can impact 55 Improvement of coping and adaptation,
this relationship (Baumeister et al., 2009). 55 Symptom reduction and behavioral
Accordingly, the occurrence of symptoms change.
as a consequence of a triggering stressor can
be considered as an interaction of stressor- zz Elimination or Mitigation of Stress
related variables with personal, environmen- Psychosocial interventions aim to support
tal and biological factors in the sense of a patients in reducing the effects of the stressor
diathesis-stress model (Baumeister et al., or, if possible, to comprehensively eliminate
2009; Casey & Bailey, 2011) (7 Chap. 5).
the triggering event and its consequences.
Therapy of the Adjustment Disorder
377 21
For example, the negative effects of job loss therapeutic intervention (Carta et al., 2009;
might disappear, when the person is able to Casey, 2014; Domhardt & Baumeister,
find a new job. If, however, a stressor is per- 2018; Strain & Diefenbacher, 2008). This
sistent and not modifiable (e.g., progressive rather clinical recommendation refers to the
cancer), measures should be targeted that potentially volatile nature of the disorder
can mitigate the effects of the stressor and and to cost-benefit considerations of more
improve the level of functioning and quality invasive treatments for mental disorders that
of life (e.g., ensuring social support). often remit over time without intervention.
Accordingly, Bower and Gilbody (2005)
zz Improvement of Coping Strategies and have proposed a stepped care approach for
Adaptation (sub)clinical disorders on the continuum
Psychosocial interventions also aim to between a normal stress response and a men-
improve coping of patients and improve tal disorder. Such a stepped care approach
adaptation. For instance, cognitive methods may ensure that affected individuals receive
include the identification of dysfunctional the least invasive, but sufficient supportive
thoughts and the development of functional intervention to relieve distress and improve
cognitions and strategies. At the behavioral levels of functioning.
level, patients can be guided to take up (pos- As a potentially transient disorder – the
itive) activities and be supported in experi- DSM-5 describes a resolution of symptoms
encing self-efficacy. within 6 months after the elimination of the
stressor or its consequences (APA, 2013) –
zz Symptom Reduction and Behavioral watchful waiting may be sufficient as the
Change sole strategy for some patients (step 1).
In order to reduce the level of stress and However, considering the complexity of the
improve the level of functioning in the long course of mental disorders, it is clear that
term, a reduction of symptoms and the further intervention options are required in
development of functional behaviors should such a stepped care approach (. Fig. 21.1).

be considered as additional important ther- This becomes obvious when considering

apeutic objectives. The required therapeutic the risk of chronicity and progression once
strategies in this area will vary depending on adjustment disorder symptoms are present
the underlying nosological model. In con- as well as the fact that stressors and its con-
ceptualizing adjustment disorder in terms sequences might not terminate completely.
of a subclinical form of PTSD, exposure In step 2, low-intensity psychosocial
and coping procedures will play a role, for interventions with a favorable risk-benefit
example, in order to be able to process intru- ratio such as bibliotherapy, behavioral acti-
sive thoughts and images (see 7 Chap. 13).
vation or Internet-based interventions are
In the case of an adjustment disorder mixed proposed (Baumeister, 2012; van Straten
with depression and anxiety (APA, 2013), et al., 2015). “Low intensity” can refer here
corresponding evidence-based treatment to both the limited resources of the health
approaches for depressive and anxiety disor- care system and expertise in mental health
ders should be part of the intervention. needed (i.e. limited time and effort for health
care providers; interventions may also be
provided by less qualified or even trained lay
21.4 Stepped Care Approach people) as well as limited costs for patients
(in terms of time, financial resources, side
There is a broad consensus that the first-line effects or adverse events).
treatment of adjustment disorders should For patients who do not adequately
be a (short-term) psychological or psycho- respond to the interventions offered in the
Level 4
21 Inpatient treatment
Level 3
Psychotherapy and/
or pharmacotherapy
Level 2
Low-frequency/low-
Level 1 intensity psychological
Watchful waiting interventions
e.g. bibliotherapy, e.g. cognitive

behavioral activation behavioral therapy, e.g. psychiatric or
e.g. supervision by or internet-based psychodynamic psychotherapeutic
general practitioner interventions therapies hospital
.. Fig. 21.1 Stepped care approach for adjustment disorder
first two steps, further treatment options 21.5 Psychosocial Interventions

in the form of outpatient psychotherapy with Low Intensity
and/or pharmacotherapy are available in a
third step. For patients with high symptom From a health policy perspective, psychoso-
severity (e.g. with acute suicidal tendencies), cial interventions of low intensity and com-
inpatient psycho- and pharmacological plexity offer various advantages. First, these
treatment options are considered in a fourth interventions require fewer resources, as they
step within the stepped care approach for require less therapeutic time and may even
adjustment disorder. be implemented by less specialized health
The following overview of the evidence care providers (Baumeister, 2017; Richards
of psychological, psychotherapeutic and et al., 2016). Second, some of these inter-
pharmacological interventions for adjust- ventions are found to be as effective as more
ment disorder follows the categorization intensive treatment methods, such as behav-
of low intensity to intensive interventions ioral activation approaches realized by lay
within this stepped care approach. Since persons (Richards et al., 2016) and guided
the stepped care approach and the differ- Internet-based interventions (Andersson
ent steps are derived from research on other et al., 2014), which seem to be not inferior
mental disorders (Bower & Gilbody, 2005; to the treatment of depressive disorders with
van Straten et al., 2015) and have not yet cognitive behavioral therapy (CBT) offered
been explicitly validated for adjustment dis- face-to-face. Please note, however, that the
order, it should be considered merely as a evidence-base for these low-intensity inter-
heuristic for categorizing the different psy- ventions has a predominant focus on symp-
chosocial and pharmacological interven- tom improvement, while the evidence on
tions. An elaborated stepped-care model adverse events is insufficient so far. Third,
would require detailed information for each low-threshold psychosocial interventions
level, rules for ascending or descending offer the option of closing the gap between
between the different steps and evidence- treatment needs and the scarcity of evidence-
based differentiations concerning patient based treatment provisions through their
subgroups and clinical courses. scalability and potentially high reach. This
379 21
could be particularly important in relation (Mitchell et al., 2011). Since the benefit of
to adjustment disorder, as in some develop- self-help groups and group therapy for can-
ing countries these stress-related disorders cer patients is well documented (Spiegel
are most often associated with completed et al., 2007; Spiegel, 2012), these interven-
suicides (Manoranjitham et al., 2010). tions could possibly also be of help for
patients with somatic diseases and comorbid
adjustment disorder. Indeed, Rüsch et al.
21.5.1 Self-Help (2017) revealed that a specific cognitive-
and Bibliotherapy behavioral group therapy for patients with
somatic disease and comorbid depressive or
A self-help intervention for adjustment dis- adjustment disorder resulted in fewer symp-
orders based on the trauma sequelae con- toms of depression and a higher quality of
cept for the ICD-11 has been developed life. Furthermore, the positive impact of peer
by Maercker and colleagues, which can be support and support groups on mental health
implemented both as bibliotherapy (Bachem and well-being of patients with somatic dis-
& Maercker, 2016) and as an Internet-based eases can be considered as well documented
intervention (Maercker et al., 2015). The (Davidson et al., 2012; Mahlke et al., 2014).
CBT oriented self-help manual was designed
specifically for victims of domestic burglary
and comprises various modules (screening, 21.5.3 Mindfulness, Meditation
psychoeducation, optional referral to on- and Relaxation
site psychotherapy, self-perception, cop-
ing, activation and recovery), which are As a generic and transdiagnostic approach,
designed after evidence-based interventions relaxation techniques can be applied equally
for PTSD, anxiety disorders and depression to the different subtypes of adjustment
(Moser et al., 2019). The effectiveness of disorders according to DSM-5, although
this 4-week self-help intervention was suc- they may be more relevant for the subtype
cessfully evaluated against a waiting list con- of adjustment disorder with depressive
trol group in a randomized controlled trial symptoms, as indicated by a systematic
(RCT) with home invasion victims with clin- review (Shah et al., 2014). Bos et al. (2014)
ical or subclinical symptoms of adjustment were able to show that individual mindful-
disorder (Bachem & Maercker, 2016). As ness training was associated with symptom
such, this study is in line with the evidence improvement and increased quality of life in
on bibliotherapy and self-help in other patients with adjustment disorders. Positive
mental disorders (Gregory et al., 2004) and effects of mindfulness training could also
points to the potential of bibliotherapy and be found in group format (Sundquist et al.,
other self-help interventions as a first active 2015). Similarly, Srivastava et al. (2011)
intervention step after watchful waiting for showed that yoga meditation techniques can
patients with adjustment disorders. effectively reduce symptoms of adjustment
disorder with anxiety or depression. In addi-
tion, Jojic and Leposavic (2005a, b) evalu-
21.5.2 Group Therapy ated the effectiveness of autogenic training
and Self-Help Groups in adolescents and adults with adjustment
disorder and found that this relaxation
A meta-analytical review has shown that technique could positively influence physi-
the prevalence rate of adjustment disorder ological measures, both at the end of the
among patients with cancer is close to 20% intervention and at a 6-month follow-up.
21.5.4 Internet-Based research question for future studies. A

21 Interventions systematic review indicates that Internet-
based interventions with human support
The effectiveness of Internet- and mobile- are more effective than unguided interven-
based interventions for various mental dis- tions (Baumeister et al., 2014). However,
orders is well documented (Domhardt et al., from a health economic and health policy
2018). In addition, these Internet-based perspective, unguided “pure” self-help inter-
interventions are considered to have various ventions may possess a relevant role – espe-
advantages, like potential cost-effectiveness cially in the situation of limited health care
(Paganini et al., 2018) and high accessibil- resources – as a significant cost-effective sec-
ity (Domhardt et al., 2018). Internet-based ond treatment option within a stepped care
interventions might prove particularly use- approach, given lower intervention costs
ful in the treatment of adjustment disorder (Baumeister et al., 2014).
due to the clear life event linkage, the poten-
tially transient nature and the subthreshold
definition of adjustment disorder (Maercker 21.5.5 Behavioral Activation
et al., 2015).
The first Internet-based intervention Behavioral activation has been shown to be
developed specifically for adjustment disor- an effective treatment for depressive disor-
ders is based on the virtual reality program ders (Ekers et al., 2014), with a potential
“EMMA’s world” (Botella et al., 2006). In for advantageous cost-effectiveness in direct
this blended therapy approach, virtual real- comparison to CBT (Richards et al., 2016).
ity components from PTSD therapy and With some symptomatic overlap between
positive psychology were combined with on- adjustment and depressive disorders (Casey,
site psychotherapy sessions. First results of a 2001), behavioral activation approaches
case study indicate the applicability and use- may also be a promising treatment option
fulness of this intervention (Andreu-Mateu for adjustment disorder, breaking through
et al., 2012). The same research group has dysfunctional coping strategies and social
further developed virtual reality interven- withdrawal and gaining positive environ-
tions to include Internet-based personalized mental reinforcements. In a Cochrane
homework materials specifically for adjust- Review (Arends et al., 2012), it was shown
ment disorder (Quero et al., 2012). Skruibis that almost half of the treatment approaches
et al. (2016) have developed an Internet- targeting return to work in adjustment dis-
based intervention for adjustment disor- order patients have behavioral activation
der based on the trauma sequelae concept, components. Van der Klink et al. (2003), for
which is divided into four modules: relax- example, successfully integrated behavioral
ation, time management, mindfulness and activation components alongside behav-
relationships. The intervention called BADI ior therapy techniques in their treatment
(Brief Adjustment Disorder Intervention) approach to reduce sick day leaves due to
has been successfully validated in a first adjustment disorder.
RCT (Eimontas et al., 2017). In summary, there is some evidence for
The Internet-based interventions imple- the effectiveness of low-intensity psychoso-
mented so far vary considerably with regard cial interventions for adjustment disorder.
to their target population, technical imple- However, further research needs to show
mentation and accompanying therapeutic whether the assumed advantages in terms
support. Hereby, the question of how much of cost-effectiveness and greater reach of
guidance is required will be an important these low-threshold interventions for adjust-
381 21
ment disorder actually proves to be true difficulties can be addressed with treatment
(Baumeister, 2014; Proctor et al., 2009). strategies that are specifically adapted to the
problem at hand (such as sleep and concen-
tration difficulties or reduced self-esteem)
21.6 Psychotherapeutic (Bachem & Maercker, 2016). In adjust-
Interventions ment disorder with disturbance of emotions
and conduct, which is diagnosed primarily
Psychotherapeutic interventions ought to be in children and adolescents, parental and
based on the underlying nosological model problem-solving training can be important
of adjustment disorders, since the respec- components of treatment, analogous to evi-
tive symptomatology can vary considerably dence-based interventions for conduct disor-
between subtypes. In a modular treatment der in childhood and adolescence (Kazdin,
approach, elements from evidence-based 2016).
psychotherapeutic procedures for depres- Depending on the indication, further
sion, anxiety disorders or PTSD can be a generic therapeutic strategies for adjustment
central component of these interventions disorders may address suicidal ideation
(Bengel & Hubert, 2010), which can addition- and behavior as well as self-harm behavior,
ally incorporate stress-related interventions. resorting to individual resources of patients,
For adjustment disorder with depressive developing improved emotional regulation
mood, relevant therapeutic strategies can be strategies and problem-solving skills (Bengel
derived from CBT or interpersonal therapy, & Hubert, 2010; Casey, 2009; Strain &
as recommended in the respective national Diefenbacher, 2008). In addition, in all idio-
guidelines for unipolar depression (e.g. syncratic manifestations of adjustment dis-
DGPPN et al., 2015). Behavioral activa- order, as mentioned above, the elimination
tion, establishing supportive social contacts or – if this is not possible – mitigation of
and cognitive restructuring of dysfunctional the stressor can be a central component of
beliefs can also be important in adjust- psychotherapy. Furthermore, the discussion
ment disorder with depressive symptoms. of the subjective assessment of the stressor
Exposure therapy (Olatunji et al., 2010) and can play an important role in the psycho-
relaxation therapy (Manzoni et al., 2008) therapeutic process of adjustment disorders,
have been shown to be effective for vari- especially when the stressors are permanent
ous anxiety disorders. Therefore, given the (or even progressive) as in chronic medical
symptomatic overlap, it seems appropriate conditions.
to integrate behavioral exposure and relax-
ation techniques as a central component of
psychotherapeutic interventions for adjust- 21.6.1 Cognitive Behavioral
ment disorder with anxiety. These can be Therapy
supplemented by strategies aimed at achiev-
ing therapeutic changes in cognitive and In various mental disorders and indications,
behavioral patterns (such as tackling of CBT has the overarching therapeutic goals
avoidance behavior). When conceptualized of improving the level of functioning, as
as a subclinical form of PTSD (Maercker well as the reduction or remission of symp-
et al., 2007, 2013), psychotherapeutic inter- toms (Hofmann et al., 2012). Hereby, CBT
ventions should address key symptoms such uses a range of different cognitive, behav-
as intrusive preoccupation with the stressor ioral and emotion-focused techniques, all
and inability to adapt. Intrusions can be of which are intended to support the patient
treated by imaginative exposure; adaptation (in terms of self-management) in modifying
dysfunctional cognitions and maladaptive To date, the evidence on the effective-

21 behavioral patterns (Hofmann et al., 2012). ness of cognitive-behavioral psychotherapy
Currently, CBT-oriented approaches for specifically for adjustment disorder cannot
the treatment of adjustment disorder were keep pace with the strong empirical evidence
specifically developed to address a range of base of CBT for other mental disorders (e.g.
different stressors, such as cancer (Cluver Hofmann et al., 2012). However, ongoing
et al., 2005; Schuyler, 2004) or domestic bur- RCTs will contribute to improve the evi-
glary (Bachem & Maercker, 2016) and have dence base for CBT-oriented psychothera-
been successfully evaluated in different pop- peutic approaches for adjustment disorder
ulations such as military service candidates (Maercker et al., 2015; Skruibis et al., 2016).
(Nardi et al., 1994) or geriatric patients
(Frankel, 2001). The modular design of
various CBT manuals, which were devel- 21.6.2 Psychodynamic
oped specifically for adjustment disorder, is Psychotherapies
often equally suited for the implementation
in individual or group settings (e.g. Reschke, Psychodynamic approaches operate on a
2011). continuum of interpretation and support,
In the above mentioned Cochrane Review and comprise a number of manualized psy-
by Arends et al. (2012), a total of nine RCTs chotherapies (Leichsenring et al., 2015).
were included (Bakker et al., 2007; Blonk Interpretative interventions aim to improve
et al., 2006; Brouwers et al., 2006; Rebergen patient insight into desires, affects, object
et al., 2009; Stenlund et al., 2009; van der relationships and defense mechanisms
Klink et al., 2003; van Oostrom et al., 2010; (Leichsenring et al., 2015). Supportive inter-
de Vente et al., 2008; Willert et al., 2011), ventions primarily aim to strengthen the
which evaluated the effectiveness of inter- therapeutic relationship, reach agreement
ventions targeting return to work in the on therapeutic goals and improve psychoso-
event of maladjustment. The authors of this cial skills - among other therapeutic aspects
systematic review concluded that the spe- (Leichsenring et al., 2015). In total, psycho-
cific cognitive-behavioral interventions did dynamic short-term therapies have proven
not significantly reduce the time to return their effectiveness in four different studies
to work (Arends et al., 2012). In contrast, with patients with adjustment disorders
problem-solving therapeutic approaches sig- (Ben-Itzhak et al., 2012; Kramer et al., 2010,
nificantly reduced the time to return to work 2015; Maina et al., 2005).
part-time, but not full-time at the time of
the one-year follow-up (Arends et al., 2012).
Three of these problem-solving therapies 21.6.3 Client-Centered Therapy
were extended by behavioral activation com-
ponents (Brouwers et al., 2006; Rebergen Altenhöfer et al. (2007) examined the effec-
et al., 2009; van der Klink et al., 2003) and tiveness of client-centered short-term ther-
additionally enriched by CBT components apy (12 sessions) for adjustment disorder
(Rebergen et al., 2009), so that it seems in an outpatient setting with 50 patients
justified to group these problem- solving who had either lost a close person or had
approaches together with CBT as a more experienced serious negative experiences at
intensive psychotherapeutic intervention. work or university. The results of this non-
Nevertheless, in other contexts, stand-alone randomized study indicated that there was a
problem-solving approaches are mostly con- significant improvement both at the end of
ceived as low-intensity interventions (e.g. treatment (Altenhöfer et al., 2007) and at a
van Straten et al., 2015). 2-year follow-up (Gorschenek et al., 2008).
383 21
21.6.4 Eye Movement in a quasi-experimental design an interven-
Desensitization tion called “mirror therapy”, which was
especially developed for patients with a
and Reprocessing (EMDR)
heart attack and adjustment disorder. This
intervention seeks to integrate various tech-
Given the current conceptualization of
niques (psychosomatic introspection and
adjustment disorder as a stress-related
mindfulness, acceptance and self-esteem,
sequelae disorder, it appears promising to
neurolinguistic techniques as well as mir-
approach the symptomatology of adjust-
ror confrontation exercises and self-care)
ment disorder (especially intrusive preoccu-
in a holistic way. In this study, patients in
pation with the stressor) in a similar way as
the intervention group showed significantly
it is pursued in posttraumatic stress disorder,
fewer symptoms of adjustment disorder
for example in the form of Eye Movement
compared to three different control condi-
Desensitization and Reprocessing (EMDR;
tions at the end of treatment. After half a
7 Chap. 14). Mihelich (2000), for instance,
year, patients in the “mirror therapy” group

examined the effects of two treatment ses-

had fewer adjustment disorder symptoms
sions of EMDR in a serial case study com-
than patients on the waiting list, but did
pared with two exposure sessions in nine
not show improved values compared to the
patients with adjustment disorder. This
two active control conditions. A psycho-
study showed that patients with adjust-
therapeutic approach (“body-mind-spirit
ment disorder (and anxiety or mixed anxi-
therapy”, BMS) by Chan (2001) integrated
ety and depression) benefited from EMDR,
approaches of Western medicine with con-
whereas patients with adjustment disorder
cepts and procedures of traditional Chinese
and depressed mood did not benefit from
medicine and Far Eastern philosophy. In a
EMDR treatment (Mihelich, 2000). In a
study, Hsiao et al. (2014) were able to show
randomized controlled trial with 90 students
that this “BMS” therapy led to a positive
without mental disorders, Cvetek (2008)
change in cortisol levels as well as a decrease
showed that three hours of treatment of
in suicidal ideations in patients with adjust-
an EMDR intervention led to significantly
ment disorder and depressed mood.
lower values on the Impact of Event Scale
Overall, the evidence base for psycho-
compared to both active listening and wait-
social and psychotherapeutic interventions
ing control conditions.
for adjustment disorder appears limited,
especially when compared to the empirical
state of knowledge for other common men-
21.6.5 Other Psychotherapeutic tal disorders (Fonagy, 2015; e.g. Hofmann
Interventions et al., 2012). To date, CBT, problem-solving
therapy, relaxation techniques and psycho-
Adjustment disorder often occurs in patients dynamic short-term therapy have evinced
with (chronic) medical conditions (Mitchell the most comprehensive empirical support.
et al., 2011). Treatment approaches that aim The effectiveness of EMDR and “BMS”
to cure the medical condition or alleviate its therapy has been supported by an RCT. As
symptoms (and thus simultaneously address a limitation, it must be mentioned that some
the stressor that causes the adjustment dis- of the presented studies have considerable
order) should also have a positive impact methodological weaknesses (including het-
on the symptomatology associated with erogeneous patient groups, no randomiza-
the adjustment disorder. Thus, González- tion or small sample sizes) and can therefore
Jaimes and Turnbull-Plaza (2003) evaluated only be interpreted in a limited way.
21.7 Psychopharmacological & Kieser, 1997), gingko bilboa (Woelk et al.,

21 Interventions 2007) and valerian (Bourin et al., 1997) were
superior to placebo treatment in patients
Psychotherapy is the method of choice for with pronounced anxiety symptoms.
the treatment of adjustment disorder (Strain
& Friedman, 2015). Nevertheless, psycho-
tropic drugs are used in clinical practice with 21.7.2 Benzodiazepine
increasing frequency. A study conducted in and Anxiolytics
the US found that while 22% of patients
with adjustment disorder were prescribed Among psychotropic drugs, the best empiri-
antidepressants in 1996, this figure had risen cal evidence has been found for the use of
to 39% in 2005 (Olfson & Marcus, 2009). etifoxine, a non-benzodiazepine anxiolytic,
This is in stark contrast to the fact that to be equivalent to the benzodiazepines
randomized controlled trials on the effec- lorazepam and alprazolam in two double-
tiveness of psychotropic drugs in adjust- blind randomized controlled trials with
ment disorder treatment are extremely rare. patients with adjustment disorder and anxi-
For example, there are no recommendations ety symptoms (Nguyen et al., 2006; Stein,
regarding the dosage or duration of use 2015). Etifoxine also revealed the important
of psychotropic drugs (Casey et al., 2013). clinical advantage of fewer side effects.
This may be related to the fact that the trig- An older study showed that the benzo-
gers of adjustment disorders are very het- diazepine lormetazepam was superior to a
erogeneous, both in terms of the type and placebo control condition (de Leo, 1989).
in terms of the severity and duration. It is Alprazolam (Ansseau et al., 1996) and loraz-
therefore difficult to define homogeneous epam (Nguyen et al., 2006) also proved to
target groups and at the same time make be effective. Finally, two further studies with
general statements on the effectiveness of randomised controlled design showed that
psychotropic drugs. trazodone was more effective than cloraz-
Little is known about the psychobiol- epam in patients with adjustment disorder
ogy of adjustment disorder and thus the with a cancer diagnosis (Razavi et al., 1999)
rational for using psychopharmacological and HIV-positive patients with adjustment
interventions is unclear (Casey et al., 2013). disorder (de Wit et al., 1999). However, due
However, on the syndromal level of adjust- to the high addictive potential the usage of
ment disorder, for example when symptoms benzodiazepines is not recommended for
of depression or anxiety are present, there patients with adjustment disorder.
may be potential benefits with various sub-
stances. Psychopharmacological treatment
may be useful if the psychotherapeutic inter- 21.7.3 Antidepressants
vention was not able to reduce symptoms
(Bachem & Casey, 2018). Interestingly, there are currently no studies
that explicitly investigated the effectiveness
of antidepressants in adjustment disorders
21.7.1 Herbal Remedies with depressive symptoms (Casey et al.,
2013). In a retrospective case study with
Various studies have investigated the effec- patients with either depression or adjust-
tiveness of herbal tranquilizers in the treatment disorder treated by general practi-
ment of adjustment disorder. For example, tioners, SSRIs were shown to lead to a
it was shown that the use of kava kava (Volz clinically significant reduction of symp-
385 21
toms (Hameed et al., 2005). No particular tial for the further development of future
antidepressant was superior to the others. treatment approaches (Kazdin, 2007).
According to the study, patients with adjust- Future studies should take into account
ment disorder responded twice as often to recommendations for research on change
the drug compared to depressive patients, mechanisms (e.g., Lemmens et al., 2016) and
although it should be noted that sponta- investigate theoretically derived therapeutic
neous remissions are also more frequent techniques that are central to the respective
in adjustment disorder and that this might therapeutic approach.
be a misdirected causal attribution of the Research efforts in this field have long
observed improvement in symptoms. suffered from the lack of a concise model
of adjustment disorder and the respec-
tive diagnostic instruments based on it.
21.8 Perspectives The conceptualizations of the ICD-11 will
most probably lead to a higher discrimi-
In view of the limited empirical evidence, nant validity of the disorder category, espe-
there is a need for further efficacy and cially in the differentiation from depressive
replication studies on psychological and disorders (Maercker et al., 2015). Newer
psychotherapeutic interventions specifically diagnostic tools for adjustment disorder
designed for adjustment disorder and evalu- such as the “Adjustment Disorder – New
ated using homogeneous patient cohorts. Module” (ADNM; Einsle et al., 2010;
Future studies should also focus on inter- Lorenz et al., 2016) for self-disclosure will
ventions for children and adolescents, given allow future research to create more homo-
the high incidence of adjustment disorder geneous patient samples with adjustment
in this age group (Casey & Bailey, 2011) disorder, which may contribute to increase
and only one published study so far (Jojic the reliability of epidemiological studies
& Leposavic, 2005a). Longitudinal study (Baumeister et al., 2009).
designs could also help to identify patterns With regard to current clinical practice
of change in individual stressors, to uncover in the treatment of adjustment disorder,
resilience and remission rates and transi- information from the health care system
tions to other mental disorders over time would be urgently needed to assess the
(Domhardt et al., 2015), since adjustment extent to which there is underuse, overuse
disorders are known to be a significant risk or misuse of health care services for patients
factor for the development of other mental with adjustment disorder. For example, the
disorders, especially in children and adoles- frequent prescription of psychotropic drugs
cents (Andreasen & Hoenk, 1982). as initial treatment practice for patients
Psychotherapy research of adjustment with subclinical or mild mental disorders
disorder as a transient disorder is particu- is disputed (Baumeister, 2012). In a study,
larly challenging, since positive changes in Fernández et al. (2012) were able to show
intervention studies without a control group that this question is probably also relevant
might be merely due to spontaneous remis- in the area of adjustment disorder, as in
sion or the expected disease course, espe- 37% of cases patients with adjustment dis-
cially when the stressor is no longer present. order were prescribed psychopharmaco-
Consequently, process research in this field logical drugs by their general practitioner.
should pay particular attention for evalu- However, given the limited availability and
ating a direct and immediate link between accessibility of evidence-based treatment
an intervention component and symptom options in most countries worldwide, the
change, since a deeper understanding of the question of how to improve the overall
underlying mechanisms of change is essen- situation of (mental) health care is likely
to be more pressing. As shown above, low- Disorders, 227, 243–253. https://doi.org/10.1016/j.

21 threshold psychosocial interventions such jad.2017.10.034
Bachem, R., & Maercker, A. (2016). Self-help inter-
as bibliotherapy or Internet-based interventions for adjustment disorder problems: A ran-
ventions, with their potential for scalability, domized waiting-list controlled study in a sample
could play an important role in reducing the of burglary victims. Cognitive Behavior Therapy,
gap between treatment demand and supply. 45, 397–413. https://doi.org/10.1080/16506073.20
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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 22 ost-traumatic Stress Disorder in Children

P
and Adolescents – 393
Chapter 23 P
ost-traumatic Stress Disorders in Physical
Diseases and Medical Interventions – 425
V. Köllner
Chapter 24 Military – 441

Chapter 25 T
orture Survivors and Traumatised
Refugees – 461
Chapter 26 Gerontopsychotraumatology – 491

Chapter 27 S
pecial Features of Treatment and Self-Care
for Trauma Therapists – 507
A. Maercker
393 22
Disorder in Children
and Adolescents
Contents
22.1 pecifics of the Symptoms of PTSD in Children

S
and Adolescents – 395
22.1.1 dequacy of the Diagnostic Criteria of PTSD for Children – 395
A
22.1.2 Course of PTSD in Childhood and Adolescence – 396
22.1.3 Differential Diagnostics – 396
22.1.4 Prevalence of PTSD in Childhood and Adolescence – 397
22.1.5 Significance of Gender, Age and Type of Trauma – 397
22.1.6 Comorbid Disorders – 398
22.2 sychological Models and Hypotheses

P
on the Particularities of Traumatisation
in Early Life – 399
22.2.1 T he Cognitive Model According to Ehlers and Clark – 399
22.2.2 Psychobiological and Neuroendocrinological Models – 400
22.2.3 The Developmental Psychopathological Model According
to Pynoos – 400
22.3 Role of Parents – 400
22.4 Risk Factors – 402
22.5 Diagnosis of PTSD in Childhood and Adolescence – 403
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
trauma (7 Chap. 8). Examples are

It is assumed that the ICD-10 criteria 55 affective disorders,

have so far led to overdiagnosis of the 55 other anxiety disorders (such as separa-
disorder. First studies comparing the tion anxiety),
prevalence rates suggest that the more 55 psychotic disorders,
restrictively formulated criteria of the 55 the borderline personality disorder.
ICD-11 will lead to a significantly lower
number of PTSD diagnoses in children They must also be distinguished from adjust-
and adolescents compared to an assessment disorder and the consequences of
ment according to the revised DSM-IV head injuries (according to this, however,
or ICD-10 criteria (Sachser & Goldbeck, long-lasting symptoms such as irritability,
2016). anxiety, etc. should be checked for psycho-
logical causes). A distinction must also be
made between PTSD and persistent grief, for
which, however, no defined criteria for child-
22.1.2 Course of PTSD hood are yet available (7 Chap. 20).

in Childhood Some of the overarousal symptoms, such

and Adolescence as irritability, outbursts of rage and difficul-
ties concentrating, may erroneously lead to
Longitudinal studies on the untreated course the diagnosis of a disorder from the group
of PTSD are rare, but at least for a subgroup of hyperkinetic or aggressive disorders,
they indicate a high stability of symptoms. strong trauma-related intrusions or severe
Recent studies formulate trajectories that dissociations may erroneously be considered
characterize different courses of PTSD: For to be psychotic symptoms, avoidance of cer-
example, Osofsky et al. (2015) found four tain foods caused by strong trauma-related
trajectories in the course of 4 years following feelings of disgust may be considered an eat-
natural disasters (hurricane, oil spill): 52% ing disorder.
of the more than 4000 children examined
(3–12 years) showed stable low symptoms, >>It is essential to prove whether symptoms
a second group showed a strong regression which appear to be related to comorbid
of symptoms (21%), a third group showed disorders might be trauma- related and
increasingly more symptoms (18%) and a therefore understood as symptom of
fourth group showed stable high symptoms PTSD.
397 22
22.1.4 Prevalence of PTSD Under the Magnifying Glass
in Childhood
Children with a certain pre-traumatic
and Adolescence psychopathology have an increased risk
of trauma: For example, it can be
First, it should be noted that there is little
assumed that children with ADHD
reliable epidemiological data on children
(attention deficit/hyperactivity disorder),
under 12 years of age. The probability of
conduct disorder, or substance abuse dis-
experiencing a potentially traumatising event
order are more likely to experience a
as a child or adolescent varies from region
potentially traumatic event than children
to region and is particularly high in regions
and adolescents without this disorder.
with frequent natural disasters and social or
This is consistent with the very high life-
political conflicts (7 Chaps. 1 and 2).
time prevalence of PTSD (30%) in a

In a meta-analysis, which also included

group of 15–19 year olds with substance
non-representative studies (n = 3563), the
dependence (Deykin & Buka, 1997).
incidence rate for PTSD after trauma in chil-
dren and adolescents aged 2–18 years was
15.9%. The highest prevalence rates were
22.1.5 ignificance of Gender, Age
S
found after interpersonal traumatic events
(25.2%), with 9.7% of respondents develop- and Type of Trauma
ing PTSD after non-interpersonal trauma
zz Gender
(Alisic et al., 2014). The incidence rate was
highest among interpersonally traumatised The risk of experiencing a potentially trau-
girls (32.9%). A representative survey of US matic event is increased for girls, especially
adolescents aged 13–17 years showed that in the area of sexualised violence, as is the
62% of the adolescents had experienced a risk of developing PTSD. A meta-analysis
traumatic event and found a lifetime preva- of traumatised children and adolescents
lence of PTSD of 4.7% (McLaughlin et al., aged 2–18 years showed that 20.8% of trau-
2013). In a Swiss study (Landolt et al., matised girls developed PTSD symptoms,
2013), 56% of the surveyed students aged compared to 11.1% of boys (Alisic et al.,
14–16 years reported having experienced 2014). Girls who had experienced interper-
traumatic events. The criteria for current sonal trauma had the highest risk of devel-
PTSD according to DSM-IV criteria were oping PTSD (32.9%), whereas boys had the
met by 4.2% of all respondents. In all 3 stud- lowest risk after non-interpersonal trauma
ies, girls were affected by PTSD more than (8.4%) (Alisic et al., 2014).
twice as often as boys.
>>The prevalence of trauma seems to be
particularly high among psychiatric inpa- There are clear gender differences in both
tients and adolescents. the lifetime prevalence and incidence of
PTSD. Representative epidemiological
Lipschitz et al. (1999) found that 93% of studies found that girls are more likely to
74 adolescents hospitalized in a psychiatric develop PTSD as a result of a traumatic
clinic reported at least one traumatic event. event than boys. Significantly more girls
About 32% fulfilled the criteria of PTSD than boys and more women than men
according to DSM-III-R. PTSD in adoles- had a lifetime diagnosis of PTSD (e.g.
cence is quite common as compared to other Landolt et al., 2013).
mental disorders.
zz Age 55 internalizing and externalizing behav-

The risk of developing PTSD decreased ioral problems,
both in studies in adults and in studies in 55 poorer academic performance,
22 adolescents and children with increasing 55 thoughts of suicide and suicide attempts,
age at trauma (Ellis et al., 1998; Essau et al., 55 interpersonal difficulties,
1999; Kessler et al., 1995; Trickey et al., 55 physical complaints.
2012). A younger age when experiencing
trauma is generally cited as a risk factor for Depression, drug abuse and somatoform
the development of PTSD, although sys- disorders are comorbid to PTSD in about
tematic studies in children under 6 years of 20–30% of affected children and adolescents
age are still pending (Trickey et al., 2012). and cause considerable distress to them
(Essau et al., 1999).
zz Type of Traumatisation Giaconia et al. (1995) found retrospec-
Experiencing sexual violence generally carries tively that 30% of adolescents with the life-
a 6–7 times higher risk of PTSD compared to time diagnosis of PTSD suffered from major
other forms of traumatisation: 80% and 50% depression and 38% from alcohol depen-
of all affected older adolescents or young dence in the last year before the survey.
adults developed PTSD after experiencing
sexual violence (Cuffe et al., 1998; Giaconia
et al., 1995; 7 Chap. 7). Corresponding

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.
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).

These cognitive factors also predetermine Under the Magnifying Glass

the severity of PTSD symptoms in children
(Pynoos et al., 1987; Schwartz & Kowalski, In summary, it can be said that children,
1991; Yule & Williams, 1990). Steil et al. due to the lack of a long-term perspective,
(2001) found, for example, in a prospective catalyse possible consequences of the
study of 24 children who had been involved trauma even more and misinterpret their
in a traffic accident, that the extent of cog- own symptoms as permanent damage.
nitive avoidance in the child and the extent Some traumatised children no longer
of dysfunctional assessment of what had expect to live long enough to reach adult-
happened could well predict the child’s later hood at all.
PTSD symptoms.
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.
22.3 Role of Parents

22.2.3 The Developmental
Psychopathological Model
According to Pynoos
Parents and caregivers play a crucial role
Pynoos et al. (1995, 1996) rightly criticized as important interaction partners and
that the interaction between development models for adaptive or dysfunctional cop-
and traumatization has so far not received ing in the post-traumatic adaptation of
sufficient attention in general models of adolescents (Alisic et al., 2011).
PTSD. In a developmental psychological
401 22
For example, children derive their interpre- Generally significant are current and previ-
tation of the traumatic event and its con- ous psychological illnesses of the parents.
sequences from the reactions of their close Steil et al. (2001) found, for example, in a
caregivers. The parents provide the child prospective study of 7 to 16-year-old victims
with emotional security and structural sta- of traffic accidents, that a psychological dis-
bility. If, for example, the parents of a child order of the parent who spent most time
who has experienced sexual abuse are not with the child prior to the trauma predicted
able to communicate with the child about it, the diagnostic status of the child 2 months
the child may feel rejected and degraded. On after the trauma.
the other hand, if the parents compensate
for their own feelings of guilt after a traffic
accident by spoiling the child, the child may
feel incompetent and “sick”, even though he There is sufficient empirical evidence that
or she is well after the trauma. the use of strategies to control intrusions
such as rumination or thought suppres-
Under the Magnifying Glass sion (Ehlers & Steil, 1995; Steil, 1997;
Steil & Ehlers, 2000) can directly aggra-
Parents can systematically reinforce help- vate the symptoms of PTSD (thought
ful and harmful strategies of the child in suppression, for example, increases the
dealing with the traumatic memory. In a likelihood of the unwanted thoughts
recent meta-analysis by Williamson et al. occurring) or prevent the patient from
(2017) of 9 to 16-year-olds, parental dealing with the trauma.
behaviour towards the child (overprotec-
tion; hostility; support; warmth) contrib-
uted significantly to the variance in the It is expected that parents’ dysfunctional
severity of PTSD symptoms. cognitions about the trauma, its conse-
quences and how to cope with it will be
important for the development of post-
Unfavourable model learning or other unfa- traumatic symptoms in adolescents. Ellis
vourable learning strategies emanating from et al. (1998) found that 40% of the 45-year-
the parents can be used to explain (in addi- old children they examined after a traffic
tion to genetic hypotheses) findings on the accident showed increased parental protec-
association of parental and child psycho- tivity towards the child. For example, if the
pathology after trauma. Deblinger, Taub, parents want to protect the child from the
et al. (1997) and Deblinger et al. (1999b) stressful memories or in an excessive way
found, for example, that in children who from renewed danger, they may contribute
had experienced sexual abuse, maternal rat- to maintaining the dysfunctional avoidance
ings of externalising symptoms of the child of trauma-relevant stimuli (Williamson
and the child’s PTSD symptoms were higher et al., 2017). In various studies, parental
the more the mothers experienced their symptoms of avoidance behaviour and
own general psychopathological symptoms dysfunctional cognitions regarding trauma
(especially depression). Maternal rejection have been associated with increased PTSD
experienced by the child was linked to the symptoms in children (see e.g. Deblinger
severity of the child’s depressive symptoms. et al., 1999b; Laor et al., 1997).
Under the Magnifying Glass 55 pre-traumatic mental morbidity,

55 severity of stress,
When parents and children have experi- 55 perceived danger to life,
22 enced trauma together, parents who 55 loss of resources in the family (such as
develop PTSD themselves appear to be the destruction of the house),
less successful in helping their children 55 development of acute stress disorder
cope with the consequences (Laor et al., (ASD),
1997; Rossman et al., 1997). A meta- 55 dysfunctional coping strategies,
analysis by Alisic et al. (2011) found that 55 lack of social support,
PTSD of a parent was a major risk fac- 55 further stressful life events following
tor for developing PTSD in children. traumatisation.
Younger age at trauma and female gender

The age of the child may moderate the con- are also considered risk factors. As expla-
nection between maternal and infantile psy- nations for the gender difference, biologi-
chopathology as a result of traumatization. cal differences, different role expectations,
Wolmer et al. (2000) found in a prospective different cognitive assessments of trauma
study on the consequences of SCUD missile and possibly differences in the reporting
attacks on the Israeli population during the of symptoms are discussed (Gavranidou &
Gulf War an association between infantile Rosner, 2003; Kruczek & Salsman, 2006).
PTSD symptoms and maternal psycho- When assessing the particularly stable and
pathology, which was particularly high in consistent risk factor of pre-traumatic mental
6-year-old children, lower in 7-year-olds and morbidity, it must be borne in mind that this
no longer statistically significant in 8-year- may also be associated with a higher risk of
olds. trauma: children with ADHD, conduct disor-
It is possible that the parents’ style of der or substance abuse may experience trauma
communication with the child influences the more frequently than healthy children.
child’s autobiographical memory (Tessler & In a meta-analysis (N = 64 studies) of a
Nelson, 1994): Thus (as soon as the child total of 32,238 subjects, risk factors for the
has acquired the necessary linguistic skills) development of PTSD after trauma were
a parental elaborate communication style investigated in adolescents aged 6–18 years
and active efforts to make the traumatic (Trickey et al., 2012). The following risk
events understandable for the child could factors for the development of PTSD were
promote the embedding of stressful events identified:
in the autobiographical memory or concept- 55 female sex,
controlled data processing. 55 younger age,
55 membership of an ethnic minority,
55 low intelligence and a low socio-eco-
22.4 Risk Factors nomic status,
55 comorbid anxiety disorder, comorbid
Steil and Rosner (2008) give an overview depression.
of risk factors and groups. Kultalahti and
Rosner (2008) summarized in a literature Likewise, critical life events and problems
review about 60 studies that examined risk prior to the traumatic event, parental prob-
factors in children after single traumatic lems, low social support, a low level of func-
events. The following risk factors were found tioning in the family and social withdrawal
to be particularly significant increased the risk of PTSD.
403 22
22.5 Diagnosis of PTSD child and parents and of interviewing the
in Childhood child itself (7 Chap. 7). It is also problem-

atic that children may find it very difficult

and Adolescence
to talk about what they have experienced
and their psychological symptoms – they do
When diagnosing the consequences of trau-
not want to make the parents or the family
matisation in a child, 3 areas must be con-
feel worried (Perrin et al., 2000; Deblinger,
sidered:
Helfin, & Clark, 1997).
55 pre-traumatic functional level of the
child,
55 the traumatic event itself, Under the Magnifying Glass
55 and its consequences for the child and its
The diagnosis of traumatisation in early
environment.
childhood poses problems. Although
there is empirical evidence of non-verbal
All available sources of information should
memory in relation to traumatic events
be used for this purpose: Child and parents,
before the age of 2, the earliest verbally
teachers, observation of behaviour at school
accessible autobiographical memories
or in the home, medical records and infor-
are found on average only at around
mation, and reports from witnesses (Thorn-
3 years of age and only in fragmented
ton, 2000). To clarify the diagnosis of PTSD
form (Pillemer, 1998).
in children, the use of structured interviews
is generally recommended (Steil & Rosner,
2008). Symptoms such as intrusions can The autobiographical memory of children
only be assessed from the child’s subjective seems to be prone to distortion and sug-
viewpoint. Symptoms that can be better gestion (Eisen et al., 2007). Even specially
objectified, such as increased irritability or trained psychologists could not reliably dis-
aggressiveness, anxiety or regressive behav- tinguish between children’s narratives based
iour, are also open to outside assessment by on true experiences and those based on pre-
parents, teachers or the diagnostician. vious suggestion (Ceci et al., 1994).
>>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
Authors Name of the instrument Applicable Psychometric characteristics Remarks

from [in
years]
Structured interviews with the child/youth

Landolt et al. (2003) Child Post-traumatic Stress 6 Reliability of the English Not related to ICD or DSM, some of the
(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
22 405
Following Thornton (2000), the follow- 55 Surveys of children and parents/carers

ing diagnostic guideline results: 55 Central aspects
55 Diagnostic guide –– Changes in motor, cognitive and other
22 55 Survey only with the child performance with traumatisation
55 Central aspects –– Functional level of the child (school,
–– Current and previous diagnosis(s) of family, social contacts)
the child after DSM or ICD (includ- –– Previous traumatisation of child and
ing PTSD) parents/carers
–– Present general psychopathological –– Stimuli that may trigger memories of
symptomatology the trauma
–– Determination of the degree of sever- –– Secondary emotions and dysfunc-
ity by self-assessment of the child tional cognitions associated with the
–– Objectives/subjective characteristics trauma and its consequences
of the trauma –– Strategies of cognitive avoidance of
–– Grief over family members/friends traumatic memories
–– Cognitive performance level –– Self-damaging behaviour in the child,
55 Peripheral aspects drug use, suicidal tendencies
–– Self-image –– Parental reactions to the child’s symp-
–– Interest toms
–– Social skills 55 Peripheral aspects
55 Survey only with parents/carers –– Important life events before and after
55 Central aspects traumatisation
–– Current and previous diagnosis(s) of –– Parental style of upbringing and
the child and parents according to social support the child receives
DSM or ICD 55 Surveys parents/carers and other sources
–– Present general psychopathological 55 Central aspects:
symptomatology –– Objective characteristics of the trauma
–– Determination of the severity level by (sequence of events, injuries etc.)
assessment of the parents
–– Demographic information The interviews on stress disorders in child-
–– Medical case history hood and adolescence can be considered
–– Behaviour and development of the an international standard (IBS-KJ; Steil &
child in the motor, cognitive, social Füchsel, 2006), a modified German transla-
and emotional field tion of the “Clinician Administered PTSD
55 Peripheral aspects Scale for Children and Adolescents” (CAPS-
–– Parental view of traumatisation CA). This instrument provides
55 Collection exclusively from other sources 55 Information on the presence of the diag-
55 Central aspects noses PTSD and ASD,
–– Medical case history 55 Summary scores on the frequency and
–– Behaviour and development of the intensity of post-traumatic symptoms,
child in the motor, cognitive, social 55 Calculations of frequency and intensity
and emotional field for the individual symptom clusters.
55 Peripheral aspects
–– Social support that the child receives The diagnosis of possible comorbid disor-
–– Social skills of the child ders can be carried out with relevant instru-
407 22
ments. A German-language version of this Cognitive behavioural therapy (CBT) is inter-
interview adapted to the criteria of DSM-5 nationally considered the treatment of choice
is being prepared by a working group led by for adults – together with treatment with
Cedric Sachser. “Eye Movement Desensitization and Repro-
cessing” (EMDR; 7 Chap. 14) – and its

>>When presenting the traumatic events, effectiveness is considered empirically proven

the child should first have the opportu- (see the corresponding chapters in this book).
nity to tell the story himself before the In controlled and randomized studies, it also
therapist asks detailed questions about achieved very promising results in children
the events. and adolescents and can be considered the
method of choice according to the current
In younger children, the traumatic experi- state of knowledge. There is an impressive
ences can be recorded by asking the child to number of controlled and randomised stud-
draw a picture to which he or she can tell ies on CBT in the consequences of trauma-
a story, or by re-enacting the events with tisation in childhood. . Table 22.2 provides

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
.. Table 22.2 Overview of effectiveness studies on CPT in childhood PTSD
Study Trauma Sample Treatment conditions Variables Results

Number of meetings examined
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
exposure vs. standard group

therapy
10 sessions over 10 weeks
Celano et al. Sexual abuse; N = 32 girls Individual supportive therapy in Child: General Improvement in both
(1996) Abuse was is between 1 and Age: 8–13 years combination with treatment of distress, PTSD groups; no difference
26 months ago M = 10.5 years the female caregiver vs. symptoms between the groups
cognitive intervention (based on Mother: support
the Finkelhor model) in and attribution
combination with treatment of
the female caregiver
8 sessions over 8 weeks
Chemtob et al. Natural disaster; N = 214 CBT group intervention vs. PTSD symptoms Individual CBT = Group
(2002) 2 years later 152 girls, 97 boys CBT-individual intervention vs. intervention CBT > Wait
Age: 6–12 years Wait list list
M = 8.2 years 4 sessions in 4 weeks
Cohen et al. Sexual abuse plus other N = 203 children Trauma-focused CBT (Tf-CBT) Children: PTSD Tf-CBT > Child-centred
(2004); Deblinger trauma; on average N = 189 reference vs. child-centred therapy symptoms, therapy
et al. (2006) 12 months after last abuse persons 12 double lessons (one for child, depression,
Age: 8–14 years one for reference person) general distress
M = 10.8 years Parents:
depression,
emotional
reaction,
parenting style
Cohen and Sexual abuse, not longer N = 67 Tf-CBT for child and parent vs. General distress, Tf-CBT > nondirective
Mannarino than 6 months since end of 42% boys, 58% non-directive supportive care PTSD symptoms supportive treatment
(1996a, 1997) trauma girls 12 sessions
Age: 2–7 years
M = 4.7 years
Cohen and Sexual abuse; within N = 49 Tf-CBT child and parents vs. General distress, Tf-CBT > nondirective
Mannarino 6 months of the last event 15 boys, 34 girls non-directive supportive care PTSD symptoms supportive treatment
(1998) Age: 7–14 years 12 sessions
M = 11.1 years
Cohen et al. Sexual abuse; N = 82 Tf-CBT vs. child-centred PTSD symp- Tf-CBT > Child-centred
(2005) Time since trauma not 56 girls, 26 boys supportive therapy toms, depres- supportive intervention
reported Age: 8–15 years 12 sessions sion, anxiety,
M = 11.4 years sexualised
behaviour
Deblinger et al. Sexual abuse N = 90 Tf-CBT with parents vs. PTSD symp- Tf-CBT with parents = Tf-
(1996); Deblinger 17% boys, 83% Tf-CBT in child vs. toms, depres- CBT with child = Tf-CBT
et al. (1999a) girls Tf-CBT with parents and child vs. sion, general with parents and child >
Age: 7–13 years Standard advice distress Standard advice
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)
Study Trauma Sample Treatment conditions Variables Results

Number of meetings examined
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
Gilboa- Singular traumatisation N = 38 Developmentally Adapted PTSD symp- PE > PT

Schechtman et al. (accidents, sexual or 24 girls, 14 boys Prolonged Exposure (PE) vs. toms, depres-
(2010) physical experience of Age: Psychodynamic Therapy (PT) sion, global
violence); M = 14.05 years functional level
18.5 months since trauma
Cohen et al. Violence of partner against N = 124 Tf-CBT vs. PTSD symp- Tf-CBT > Treatment as
(2011) mother; 61 boys, 63 girls Treatment as usual toms, anxiety, usual
time since trauma not Age: 8 sessions depression
reported M = 9.6 years
de Roos et al. Singular trauma (explo- N = 40 CBT vs. PTSD symp- CBT = EMDR
(2011) sion); 44.23% Girls EMDR toms, anxiety,
6 months since trauma Age: 14–18 years 4 sessions each depression
Scheeringa et al. Both multiple and single N = 31 TF-CBT vs. PTSD symp- CBT > Wait list
(2011) trauma (accidents, death of 33.8% Girls Wait list toms, depres-
a close person, illness, Age: 3–6 years 12 sessions sion, anxiety
sexual or physical violence); M = 5.3 years
time since trauma not
reported
Nixon et al. Singular trauma; N = 33 CBT vs. PTSD symp- CBT = CT
(2012) 20 months since trauma Age: CT without exposure toms, depres-
M = 11 years 9 sessions each sion, anxiety
Schottelkorb War traumatization; N = 31 CBT vs. PTSD symptoms CBT = play therapy
et al. (2012) time since trauma not Age: 6–13 years Play therapy
reported 17 sessions each
McMullen et al. War traumatization; N = 48 TF-CBT vs. PTSD symp- CBT > Wait list
(2013) time since trauma not Only boys Wait list toms, depres-
reported Age: 13–17 years 17 sessions sion, anxiety
M = 15.8 years
Jensen et al. Both multiple and single N = 156 TF-CBT vs. PTSD symp- Tf-CBT > Treatment as
(2014) trauma (accidents, death of 124 girls, 32 boys Treatment as usual toms, depres- usual
a close person, illness, Age: 12–15 sessions sion, anxiety
sexual or physical violence); M = 15 years
reported
Diehle et al. Both multiple and singular N = 48 TF-CBT vs. PTSD symp- Tf-CBT = EMDR
(2015) traumatisation (accidents, 18 boys, 30 girls EMDR toms, depres-
illness, sexual or physical Age: 8–18 years 12 sessions each sion, anxiety
experience of violence); M = 12.9 years)
reported
O’Callaghan et al. War traumatisation N = 50 CBT vs. PTSD CBT = psychosocial interven-
(2015) Age: 8–17 years Psychosocial intervention tion
M = 14 years 9 sessions each
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
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.
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.
22.6.2 Overview A traumatic event always activates the

of Psychotherapeutic attachment system. It is therefore advis-
able for the practitioner to point out the
Intervention Methods
22 child’s needs to parents and other caregiv-
ers and to support them as much as possible.
Only a small proportion of children and
If an ASD is diagnosed, the use of one of
adolescents affected by PTSD appear to
the proven CBT manuals is recommended.
receive psychological or psychiatric help
There is still a research gap in the review
(e.g. only 24% of adolescents with PTSD in
of psychotherapeutic interventions for the
the study by Essau et al., 1999). It is possible
treatment of ASD in children and adoles-
that neither they nor their parents perceive
cents. Therefore, the use of the “Critical
the typical symptoms as consequences of the
Incident Stress Debriefing” or “Psychologi-
traumatic experience in need of treatment.
cal Debriefing“in children and adolescents
Therefore, it is suggested (e.g. in the context
with ASD is not recommended.
of the care of the physical injuries or in the
context of care provided by other agencies) 22.6.2.2 Interventions
that children and adolescents and their par-
for a Diagnosed PTSD
ents should be actively offered treatment.
The manual of the working group around
>>In the case of childhood disorders or Cohen et al. (2009) is described here, which
behavioural problems, a possible trauma- contains all elements of the proven trauma-
tisation should always be considered as a focused cognitive behavioral therapy. For
cause of the symptoms. this manual, a free German-language learn-
ing program for child and adolescent psy-
22.6.2.1 Interventions in the Acute chotherapists is available (7 https://tfkvt.

Phase ku.de/), which is enriched with example vid-

eos and worksheets on the respective topics.
Under the Magnifying Glass The manual focuses on the consequences
of child abuse violence and consists of the
In the phase immediately following trau- following components:
matisation, it is recommended that chil- 55 Psychoeducation and promotion of the
dren and adolescents be closely observed parents’ educational skills,
in order to be able to initiate appropriate 55 Relaxation,
intervention if symptoms do not recede 55 Affect regulation,
or develop with a delay. 55 Identification and processing of dysfunc-
tional cognitions (appropriate interpre-
In this observation phase directly after the tation and classification of the event),
event, general supportive interventions are 55 Developing a trauma narrative (imagina-
quite useful and are well accepted by the tive reliving – in-sensu exposure),
affected persons and their families. 55 Exposure in vivo with stimuli that trigger
the symptoms (trauma triggers),
>> Everything that conveys security is favour- 55 Joint parent–child sessions (involvement
able for children and young people, e.g. of the parents as therapists),
55 Establishing contact with caregivers, 55 Promoting future safety.
55 Resuming everyday routines (e.g.
reading a story and cuddling together The child and a (non-offending) caregiver
before bedtime), initially participate in in separate sessions;
55 Considering basic needs for food and joint sessions are planned towards the end
sleep. of the therapy. Although all components
415 22
are directly related to the treatment of 55 on the one hand to react flexibly to
post-traumatic symptoms, the trauma nar- changes and
rative and in vivo exposure can be clearly 55 on the other hand, to continue to imple-
identified as a phase of trauma process- ment a consistent style of education.
ing. Cohen et al. (2006) assume that about
12–16 sessions are needed for the entire If educational skills were already limited
programme. beforehand, it is particularly difficult to
develop new behaviour patterns, especially
>>The basis of the intervention is the estab- when children and adolescents react to the
lishment of a good therapeutic relation- event with aggressive behaviour and tan-
ship. trums.
The teaching of basic skills for the care-
Empathy and active listening are as much a giver in their concrete applications to the
part of this as the willingness to listen to very affected child has proven to be helpful here.
incriminating or even cruel content, and to Central to this is the use of:
signal to the child/youth that the therapist 55 praise and reward, but also
can “bear” the whole story. The background 55 selective attention and time-out.
to this is that the parents of traumatised
children are often traumatised themselves zz Relaxation
(e.g. by experiencing the event together or by Furthermore, the children and adolescents
feeling guilty about misjudging a situation), learn to relax, in particular to reduce the
and the child/adolescent feels that the care- symptoms of overarousal. Possible relax-
giver may be overwhelmed by the disclosure ation techniques are:
of all the details. 55 controlled breathing,
zz Psychoeducation 55 meditation,
55 progressive muscle relaxation.
Particularly supportive for the parent–child
In psychoeducation, information on the relationship and for the child to gain com-
frequency, forms and consequences of petence can be the request that the child
childhood abuse is given at the beginning teaches the parent the respective relaxation
of therapy. method.
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
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
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
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.
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(2002). Brief treatment for elementary school
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425 23
Disorders in Physical
Diseases and Medical
Interventions
V. Köllner
Contents
23.1 Physical Disease as a Traumatic Event – 426
23.2 Differential Diagnosis – 427
23.3 Epidemiology, Predictors and Course – 428

23.3.2 Predictors for the Occurrence of PTSD – 430
23.3.3 Course – 430
23.4 Somatic Clinical Presentations – 431

23.4.1 T ransplantation and Intensive care Medicine – 431
23.4.2 Interactions Between PTSD and Heart Disease – 432
23.4.3 Tumor Diseases – 433
23.4.4 Chronic Pain – 434
23.4.5 Gynaecology and Obstetrics – 435
23.4.6 Relatives of People with Life-Threatening Illnesses – 435
23.5 Treatment – 436
Literature – 437
426 V. Köllner
23.1 Physical Disease which describes a continuum of reactions to

as a Traumatic Event stressful and traumatic life events from the
normal stress response through time-limited
With the introduction of a revised trauma disorder patterns such as adjustment disor-
definition of DSM-IV (APA, 1994; 7 Chap.

der to PTSD and complex PTSD. Until
recently, studies on physical disease patterns
23 2), categories of potentially traumatic expe-
riences were expanded and it was explicitly have paid too little attention to this differen-
made possible to consider a severe physical tial diagnostic spectrum, and the focus has
illness as a potentially traumatic event. As usually been on PTSD alone. For cancer
a result, early research on trauma sequelae patients, it was pointed out that the adjust-
was conducted in the second half of the ment disorder in particular has so far
1990s, particularly in transplantation and received too little attention in research,
intensive care medicine, cardiology and although this disorder plays a major clinical
oncology. With some delay, the psychologi- role here (Mehnert & Koch, 2007; Kangas,
cal burden on the relatives of these patients 2013).
also attracted attention.
In the new DSM-5 and ICD-11 classifi- >>The new version of the trauma definition
cation systems, physical illness is no longer in DSM-IV made it possible to view a
explicitly mentioned as an example of a serious physical illness as a traumatic
traumatic event, but is also not excluded. A event. This is also possible after DSM-5
significant difference to the DSM-IV defini- and ICD-11. In addition, the other clini-
tion is the elimination of the A2 criterion in cal presentations from the spectrum of
the trauma definition, i.e. the subjective per- stress-related disorders must be taken
ception of fear, helplessness or horror into account. Clinically, the adjustment
(7 Chap. 2). ICD-11 defines trauma as an

disorder is of particular importance.
event or series of events of exceptional
threat or catastrophic extend (WHO, 2018), In his schematic classification of traumatic
while DSM-5 calls for “confrontation with events, Maercker (2009) introduced medi-
actual or threatened death, serious injury or cally caused traumas as a separate category
sexual violence“(APA, 2015). This implies alongside Type I and Type II traumas and
that even severe physical illnesses do not formulated further research needs for this
always meet the trauma criteria of ICD-11 trauma category. One concept that high-
and DSM-5, but only if dramatic episodes lights the differences between medical and
with a real threat of death occur in the other traumas is the model of the “endur-
course of the disease. However, this is often ing somatic threat” (EST) by Edmondson
the case with many diseases, such as cancer (2014). This concept describes the following
or heart disease. conceptually and clinically relevant features
Up to now, studies on the prevalence of of medical trauma:
PTSD after physical illness have largely been 55 While in PTSD, the trauma is located
conducted according to DSM-IV criteria. outside the affected person, in PTSD
Studies on the prevalence according to the caused by illness the traumatic event is
new systems are still largely lacking. A study usually located inside the body.
by Andrykowski et al. (2015), which com- 55 While traumas are usually in the past
pared DSM-IV with DSM-5 in patients with (and the end of the real threat is a pre-
bronchial carcinoma, found a higher preva- requisite for the beginning of a trauma
lence according to the DSM-5 criteria (57% confrontation), the threat usually lasts
vs. 37%). The ICD-11 introduced a new dis- during a traumatization by a physical
order category “Disorders related to stress”, illness, because the basic pathophysio-

Post-traumatic Stress Disorders in Physical Diseases and Medical Interventions
427 23
logical process in the body is still virulent 23.2 Differential Diagnosis
(e.g. arteriosclerosis) or at least cannot
be excluded (e.g. the presence of malig- The acute stress reaction according to ICD-
nant cells in the body). In most cases, the 10 (F43.0) includes intrusions, avoidance
traumatic event represents an acute exar- behaviour, vegetative overexcitation and
zebation of a chronic disease. The fear of anxiety symptoms. The acute stress disorder
those affected is therefore directed according to DSM-5 additionally empha-
towards the future. sizes dissociative symptoms such as dereali-
55 There are also significant differences in sation and depersonalisation. For example,
the nature and consequences of avoid- patients often describe themselves as hav-
ance behavior and hyperarousal symp- ing felt like in a film after receiving a can-
toms. The internal stimuli of the disease cer diagnosis: “That wasn’t me who was just
(e.g. palpitations) are amplified by hyper- told she had cancer.” The symptoms appear
arousal and cannot usually be completely immediately after the traumatic situation
avoided. However, treatment measures and usually subside after hours or days.
reminiscent of the disease are often Because of this transience of symptoms and
avoided, such as examination appoint- because it can be seen as a normal reaction
ments or the taking of medication. This, to a traumatic event, it is no longer included
like the physiological effects of hyper- in the ICD-11. Since an acute stress reac-
arouesal, leads in the worst case to an tion and especially dissociative symptoms
actual increase in mortality, i.e. to a are associated with an increased risk of
renewed real threat. PTSD (Flatten et al., 2003; Kangas et al.,
2005), corresponding symptoms should be
The EST model appears to be a promising recorded and the affected persons should be
framework concept to investigate the con- monitored in order to be able to offer ther-
ditions of onset, course and treatment of apy in time if necessary. In the scientific con-
stress-related diseases in the course of physi- text, acute stress disorder is relevant because
cal illness. An association between PTSD a latency of 1 month after the traumatic
triggered by heart disease and fear of dis- event must be waited for in order to be able
ease progression has already been demon- to make a diagnosis of PTSD. Otherwise,
strated (Fait et al., 2018). there is a risk of incorrectly high PTSD
prevalence rates being recorded by count-
Under the Magnifying Glass ing acute stress reactions (Mehnert & Koch,
2007). However, acute stress reactions are a
Physical diseases, when considered as predictor for the later onset of PTSD, i.e. the
traumas, have some special characteris- affected patients should be monitored in this
tics described by the concept of “Enduring respect.
somatic threat”. For example, the source The procedure for diagnosing PTSD
of the threat is internal rather than exter- (F43.1) described in 7 Chap. 8 also applies

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
(Einsle et al., 2012), while questionnaires are 23.3 Epidemiology, Predictors

suitable for both screening and follow-up. and Course
In research reports, especially in patients
with severe physical diseases, the distur- 23.3.1 Epidemiology
bance pattern of subsyndromal PTSD is
increasingly reported (Krauseneck et al.,
23 2005). Here, essential symptoms of PTSD
There are only few studies on the prevalence
of acute stress reactions in physical diseases.
are present, but the diagnostic criteria are
For tumor patients, prevalences between 2.4%
not fully met. A negative influence on the
(Mehnert & Koch, 2007) and 25% (Flatten
quality of life of those affected can also be
et al., 2003) are given. After acute myocardial
demonstrated for these subsyndromal disor-
infarction, Roberge et al. (2008) found an acute
ders (Köllner et al., 2007; Shelby et al.,
stress reaction in 4% of the affected patients,
2008). Diagnostically, they should be classi-
after acute respiratory failure (ARDS)
fied as adjustment disorders (F43.2)
with long-term ventilation up to 44% were
(Schroth & Köllner, 2018).
described (Davydow, Desai, et al., 2008a). In a
The reformulation of the concept of
systematic review of 64 original papers, which
adjustment disorder in the ICD-11 (Maercker
very carefully distinguished between PTSD
et al., 2013; Bachem & Casey, 2017) provides
and acute exercise response, Mehnert et al.
the possibility of better diagnosing stress-
(2013) found an adjusted point prevalence for
related symptoms resulting from physical ill-
the acute exercise response of 4.8%.
nesses below the threshold of PTSD, not least
The problem is that not all studies specify
because it was developed on a sample of phys-
an exact time of data collection and do not
ically ill people (Maercker et al., 2007). Two
make an exact distinction between stress
core symptoms were newly introduced: preoc-
response and PTSD. Such a distinction is not
cupation and failure to adapt, both of which
always easy, however, because multiple trau-
are very well suited to describe stress reactions
matic situations can occur in the course of a
in physical disorders in addition to depressive
chronic disease. For example, artificial respira-
and anxiety symptoms. For screening for mal-
tion and a stay in an intensive care unit (ITS)
adaptation after ICD-11, the ADNM-20 is
can last several months in the case of ARDS,
now available as a questionnaire, which still
or in the case of a tumor disease, both the noti-
needs to be validated in patients with physical
fication of the initial diagnosis and the message
disorders (Lorenz et al., 2016).
of metastases can trigger dissociative symp-
toms or intrusions. It is therefore not always
Under the Magnifying Glass possible to define the beginning and end of the
traumatic experience precisely. In addition,
Especially in a medical context, patients during surgery or other medical interventions,
rarely report their PTSD symptoms spon- the traumatic event usually occurs with
taneously. Even in patients known from advance notice. While a crime or natural disas-
the psychosomatic consultation liaison ter usually comes as a surprise, the date of an
service, sometimes it was only the system- operation is known several weeks in advance.
atic survey within the framework of a
study that revealed clinically relevant >>In follow-up studies, it has been shown
PTSD. Patients with potentially trau- that the stress caused by intrusion or
matic events in the course of their disease hyperarousal before surgery is highest in
should therefore be systematically order to decrease after surgery and
screened for the presence of an adjust- remain low in most patients over the long
ment disorder or PTSD. term (Köllner et al., 2002; Köllner, Krauß,
et al., 2004b, Jacobs 2015).
429 23
. Table 23.1 shows the frequency of PTSD
that confirmed the diagnosis with a
and (if recorded) adjustment disorder in dif- structured interview.
ferent diseases or medical procedures. The 55 Studies that distinguished between
following relationships become apparent PTSD related to the underlying somatic
when looking closer at the studies: disease and PTSD caused by other life
55 Studies that only used questionnaires events reported low levels of disease-
reported higher prevalences than studies related PTSD.
.. Table 23.1 Frequency of PTSD and (if recorded) adjustment disorder after different clinical presen-
tations or medical procedures
Illness/medical procedure Prevalence Study
Patients after a stay in intensive 5–65% PTSD Jackson et al. (2007)

care unit due to critical illness
(especially long-term ventilation)
Patients with heart disease 0–38% PTSD Spindler and
Pedersen (2005)
Patients after infarction event 12% (0–32%) PTSD related to heart disease Edmondson et al.
(meta-analysis of 24 studies) (2012)
Patients 5.5 (1–10) years after 14.3% PTSD and 22.2% adjustment disorder Schurig et al. (2008)
surgical replacement of the aortic in surgery under emergency conditions
arch (surgery in deep hypother-
6.2%/7.6% for surgery under elective
mia)
conditions
Patients after organ transplanta- Total PTSD: Questionnaire survey: 0–46%, Dawydow et al. (2015)
tion (Tx, system review of 23 clin. interview: 1–16%
studies)
Tx-related PTSD in the clin. interview: 10–17%
Patients 3 years after heart 20.8% adjustment failure Dew et al. (2001)
transplantation
17.0% PTSD (each related to Tx)
Patients before and after lung Waiting list: 25% PTSD Jacobs et al. (2015)
transplantation
After Tx: 6,25% PTSD
Patients with tumor disease (syst. Point prevalence: PTSD 2.6 Mehnert et al. (2013)
review of 64 original papers using
Adjustment disorder 12.5%
structured interviews)
Metanalysis of 25 studies (21 of Questionnaire surveys: 7.3–13.8 Abbey et al. (2015)
them on breast cancer) on
Studies with structured interviews: 12.6%
cancer-related PTSD
lifetime and 6.4% point prevalence PTSD
Women 1 year after vaginal 4.2% PTSD Sentilhes et al.
delivery (2017)
3% PTSD Söderquist et al.
(2006)
Women 3 months after miscar- 38% suspected PTSD after questionnaire Farren et al. (2016)
riage, prospective controlled study survey (PDS) compared to 0% PTSD in the
control group without miscarriage.
430 V. Köllner
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)
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-
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-
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
ease rather than objective factors of the TRAUMA

course of the disease. A comparison of ado-
lescents after cancer with a healthy control
group showed that stress-related syndromes
Dysfunctional
(adjustment disorder, PTSD) were signifi- cognitive style
cantly more frequent at 18.6% compared to
23 7.3% (Schrag et al., 2008). Predictors here
/re-experiencing
were the type of cancer and treatment, the PTSD

age of onset of the disease and mental disor- Cycle
ders prior to the cancer.
Hyperarousal/
Avoidance/
Tension
Inactivity
23.4.4 Chronic Pain
Chronic pain is a common symptom in post-

traumatic stress disorder. A prevalence of Pain
Cycle
up to 75% has been demonstrated in torture
victims with PTSD. The pain may be related
to nerve or tissue damage caused by the Catastrophic Feeling
trauma, but more often it occurs indepen- thoughts/ of pain
Fear-Avoidance
dently. It may occur as whole-body pain (e.g.
Beliefs
fibromyalgia syndrome; Häuser et al., 2013)
or localised in relation to the trauma. They .. Fig. 23.1 The perpetual avoidance model of the
can occur in the short term - then often in link between chronic pain and PTSD. (From Liedl &
connection with intrusions - or as perma- Knaevelsrud, 2008)
nent pain (overview in Bischoff et al., 2016).
The interaction between chronic pain opiate use in chronic pain patients (Phifer
and PTSD is the subject of more intensive et al., 2011).
research. Liedl and Knaevelsrud (2008) An example of the importance of PTSD
describe the relationship between pain and in the chronification of pain and impaired
PTSD using the “perpetual avoidance functioning is chronic pain syndromes fol-
model” (. Fig. 23.1), which describes the
lowing acceleration trauma of the cervical
relationship mainly via avoidance behaviour spine (especially after rear-end collisions).
and hyperarousal. Accordingly, they are Stress-related symptoms in the sense of an
developing a behavioral therapeutic treat- acute stress response were detectable in 13%
ment concept that includes biofeedback to of those affected and were associated with
reduce hyperarousal and physical activation chronic pain and poorer occupational reha-
to reduce avoidance behavior. Pain that is bilitation over the long term (Kongsted
reminiscent of the trauma can trigger intru- et al., 2008). A close connection was found
sions, but conversely it can also be a symp- between a poor rehabilitation outcome and
tom of the intrusive. Stress in the (early) the development of an anxiety disorder or
biography can lead to increased pain sensi- PTSD (Sterling et al., 2011). Dunne et al.
tivity independent of the full-blown presen- (2012) were able to show that PTSD-specific
tation of PTSD, which is called pain-induced cognitive-behavioural therapy also led to a
hyperalgesia and which has also been dem- reduction in the impairment caused by pain
onstrated in animal experiments (Egloff and to an improvement in functional ability.
et al., 2014). Comorbid PTSD is associated Unfortunately, the comorbidity of pain
with higher pain impairment and higher and PTSD is still often overlooked when
435 23
pain therapists do not ask about trauma and the relationship with the child, regular
and/or psychotherapists tend to consider screening seems to be advisable in order to
pain as a domain of somatic practitioners. be able to offer timely therapeutic support.
This is unfavourable because PTSD patients Four months after termination of preg-
with chronic pain benefit better from com- nancy due to fetal abnormalities, 44% of
bined treatment approaches that include 217 mothers and 22% of 169 fathers exam-
activating body-oriented therapy with ined suffered from conspicuously increased
alternation between activation and relax- exposure to PTSD symptoms. Predictors
ation of the muscles and biofeedback in included pronounced doubt during the deci-
addition to trauma confrontation (Bischoff sion to terminate the pregnancy, inadequate
et al., 2016). support from the partner, low age, advanced
pregnancy and religiousness (Korenromp
et al., 2007).
Chronic pain is a common symptom in

PTSD and should be considered in an 23.4.6 Relatives of People
overall treatment plan. In addition to with Life-Threatening
trauma confrontation, sports and exer- Illnesses
cise therapy, relaxation training and bio-
feedback are helpful for these patients, While initially only the patients were the
as well as psychoeducation on chronic focus of scientific interest, in recent years it
pain and methods of pain psychother- has become apparent that, especially after
apy, if necessary. very invasive procedures in the field of high-
tech medicine, relatives have shown higher
levels of stress and PTSD prevalence than
23.4.5 Gynaecology the patients themselves. Dew et al. (2004)
and Obstetrics found 22.5% PTSD and 34.5% adjustment
disorders in relatives (“caregivers”) of the
Besides breast cancer, a complicated birth sample of heart transplant patients described
was discussed as a possible trigger for above. Also in the long-term course after
PTSD. Söderquist et al. (2006) found in a stem cell transplantation, a higher symp-
longitudinal study in 1640 women a birth- tom burden was found in the partners than
related PTSD in 3% of cases, which mostly in the patients (Lautenschläger et al., 2003).
remained stable over 11 months. Predictors Bunzel et al. (2007) found no PTSD in any
were increased anxiety and intrusive imagi- of the patients examined (male 36, female
nations even before birth, previous mental 2) who had received an artificial heart, but
illness and obstetric complications, vaginal in 27% of the partners (female 26, male 1).
delivery with instrumental support or emer- A possible explanation for these findings is
gency dissection, and reports of a negative that the patients are more likely to be men
relationship with obstetric staff. Sentilhes and the relatives women, who have a higher
et al. (2017) came up with a comparable vulnerability to PTSD. Another possible
prevalence of 4.4%, with the question asked explanation is that images of the interven-
on day 2 postpartum about bad memories tion and the patient’s situation afterwards
of the birth having a high predictive value. are more likely to be perceived by the rela-
Even though the prevalence of PTSD after tives than by the patient himself, who may
birth is rather low, in view of the consider- be repressing the current threat and more
able negative consequences for the mother likely to perceive the supportive aspects of
436 V. Köllner
the intervention. In addition, social support psychotherapeutic support and education

is offered primarily to the patient and less to should be offered analogous to the proce-
the relatives. dure for acute stress reactions, but advise
Parents of children with cancer are also against a trauma-focused approach. Kangas
highly exposed (Bruce, 2006; Cordova et al., et al. (2013) found a similar result with a
2017). Yalug et al. (2008) found PTSD con- 7-hour CBT in 35 psychologically highly
23 firmed in the SCID in 34.6% of 104 parents stressed patients shortly after diagnosis of
examined, with mothers more frequently cancer in the ENT area. Again, CBT was
affected than fathers. Other predictors were not superior to active control, but there was
the previous loss of a family member, a a tendency in the small sample to fewer
worse prognosis and more invasive treat- patients with clinically relevant PTSD after
ment of the child, mental illness in the pre- CBT.
vious history and a higher level of Duncan et al. (2007) were able to demon-
education. Increased PTSD rates were also strate in a small, uncontrolled pilot study a
found in children of parents and siblings of positive effect of guided written disclosure
children with cancer (overview in Cordova on PTSD symptoms - but not on depres-
et al., 2017). sion - in parents of children with cancer. In
a controlled, randomized study in patients
>>Relatives of patients with life-threatening with PTSD 1–3 years after stem cell trans-
diseases or invasive interventions seem plantation, a CBT performed by telephone
to suffer from PTSD at least as often as over 10 sessions resulted in a significant
the patients themselves. They should be reduction of disease-related intrusions,
included in appropriate care programmes avoidance behavior and depression com-
and offered support when needed. pared to standard oncological therapy
(DuHamel et al., 2010). In patients with
heart disease, therapists are often inhibited
23.5 Treatment from using exposure because of the concern
that the associated stress will trigger an
Although there are now well over 100 stud- acute cardiac event. However, Shemesh et al.
ies on the prevalence of PTSD and adjust- (2011) were able to prove in a randomised
ment disorder in physical diseases and study (comparison between confrontation in
their unfavourable effects on disease pro- sensu and psychoeducation) that trauma
gression, mortality and quality of life have confrontation neither led to relevant pulse
been clearly demonstrated, there have been or blood pressure increases during the ses-
very few studies on treatment in this patient sions (on average only 0.5 mmHg more than
group to date, albeit with a clear upward in the control condition, in the 95% confi-
trend in recent years. dence interval a maximum difference of
Von Känel et al. (2018) were able to show 7.1 mmHg, which is also clinically harmless)
in a randomized study of 190 patients who nor to increased cardiac events or even
experienced high distress during an acute deaths in the long-term course. However, a
coronary syndrome that early psychoso- significant improvement in PTSD symptoms
matic counseling of 1 hour in the first 2 days was found in the subgroup of highly stressed
seems to lead to a reduction in the PTSD patients.
rate over the long term. Contrary to the ini- The results of these studies and clinical
tial hypothesis, however, a trauma-focused experience suggest that the same procedures
approach did not prove superior to a more are effective and should be used to treat
psychoeducative general “stress counsel- patients in the medical context for which
ing”. The authors conclude from this that there is evidence of efficacy in PTSD overall.
437 23
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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.
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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).
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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-
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posttraumatic stress disorder resulting from car- atric Hematology/Oncology, 25, 27–38.
441 24
Military
Soldiers on Military Missions
Contents
24.1 Background – 442

24.1.1 Extended Range of Tasks of Armed Forces – 442
24.1.2 Challenges for Emergency Medicine – 442
24.2 History of War Traumatizations – 443

24.2.1 An Overview – 443
24.2.2 Changing Manifestations – 443
24.3 Stress Reactions in the Military Environment – 445

24.3.1 Forms of Deploymen: National/International – 445
24.3.2 Epidemiology and Pathogenesis – 446
24.4 Prevention – 447
24.5 herapy Within the Framework of the Federal Armed

T
Forces – 449
24.5.1 Therapeutic Facilities in Federal Armed Forces Hospitals – 449
24.5.2 Trauma Therapy in a Federal Armed Forces Hospital Based
on Case Studies – 451
24.6 Supply Law for Soldiers of the Federal Armed Forces – 456

24.6.1 Damage to Military Service – 456
24.6.2 German Act on Employee Benefits – 456
24.6.3 Deployment Reuse Act
(Einsatz-Weiterverwendungsgesetz) – 457
24.6.4 Appraisal of Damage Caused by Military Service – 457
Literature – 458
442 K.-H. Biesold et al.
24.1 Background in the Mediterranean (Operation SOPHIA)

and at the Horn of Africa (OAE/Atalanta) to
24.1.1 xtended Range of Tasks
E secure sea routes. At the end of 2017, a total
of Armed Forces of approximately 3700 German soldiers are
deployed abroad, of which around 300 are
women (BMVg, 2000, 2004).
This chapter is based mainly on the exam-
ple of the German military. With the end
of the “Cold War” at the end of the 1980s,
24 the world political situation changed fun-
24.1.2 Challenges for Emergency
damentally, and as a result, after German Medicine
reunification, the political decision was
made to assume more international respon- Due to the tasks resulting from the new
sibility. This led to considerable changes in deployment principles for the Federal
foreign and security policy and thus also in Armed Forces in the transformation process
the everyday military life of soldiers. of the armed forces, changes in the organisa-
Since the early 1990s, the Federal Armed tion of the medical service and medical care
Forces has been participating in international also became necessary. In modern military
peacekeeping, military operations and UN medicine of the twenty-first century, there
observer missions as part of its expanded range are 3 major subject areas that dominate
of tasks. The foreign missions began with operational medicine:
the UN mission in Cambodia in 1992/1993 55 Emergency medicine and emergency sur-
(United Nations Transitional Authority in gery with the optimization of fast life-
Cambodia, UNTAC), where a field hospital saving measures in the “platinum 10
was operated in the capital Phnom Penh for minutes” and the “golden hour” up to
the total of approximately 20,000 UN sol- the modern developments of “damage-
diers and UN staff deployed in the country control-surgery” and “medical evacua-
as well as the local civilian population. From tion” with an optimized rescue chain
March 1993 to 1994, this was followed by a from the place of action to the home
mission to support the peace-keeping UN country.
operation UNOSOM in Somalia. From 55 Hygiene and infectiology with research
1994 to 2008, the Federal Armed Forces into global health risks using “medical
also provided a small contingent for a UN intelligence” and the application of cur-
Observer Mission in Georgia (UNOMIG). rent tropical medicine diagnostic and
The mission in Bosnia-Herzegovina (SFOR/ therapy standards.
EUFOR) began in December 1996 and ended 55 Psychotraumatology with preventive,
in 2012. In Kosovo (KFOR) – a mission that diagnostic and therapeutic strategies to
has been running since June 1999 – 456 sol- maintain or restore mental health after
diers are currently (as of December 2017) military operations. While emergency
deployed. Since December 2001, the main medicine, emergency surgery and infecti-
focus of the military commitment abroad ology primarily serve the prevention of
has been the Afghanistan mission (ISAF), health damage or the optimal treatment
with currently still about 1100 soldiers in of injuries during the mission, the psy-
the “Resolute Support” mission. Further chological effects after experiencing
soldiers are deployed in Mali (MINUSMA, extreme stress often only become appar-
1100 soldiers), in Jordan (Counter DAESH), ent after the end of the mission,
in Sudan (UNMISS/UNAMID), at sea off sometimes with months or years of

Lebanon (UNIFIL), as part of refugee aid latency.
Military
443 24
Physical traumatisation is usually imme- end of the nineteenth century. In 1871, Da
diately visible and its extent can usually be Costa described a psychosomatic complex
quickly grasped. of symptoms including heart pain, palpi-
tations, fatigue, dizziness, and shortness of
breath, which he observed in soldiers during
the American Civil War and which was later
The consequences of psychological inju- named after him (Da Costa Syndrome). In
ries are often not registered by those this context, other terms such as “soldier’s
affected, or are not accepted due to stig- heart”, “irritable heart” and “effort syn-
matisation fears and are still not suffi- drome” were also coined.
ciently recognised by superiors, comrades
24.2.2.2 War Trembler, “Shell
and also by the doctors treating them.
This makes it more difficult to register the
Shock”, Trench Neurosis
patients and sometimes prevents timely After an initial enthusiasm for war, the sol-
and adequate therapeutic assistance. diers in World War I quickly experienced a
large number of psychological traumas due
to their confrontation with the cruel real-
24.2 History of War ity of war. There were countless casualties
in the trench warfare on the Western Front,
Traumatizations and with the use of new weapons such as
machine guns and poison gas, the following
24.2.1 An Overview complaints increasingly occurred:
55 Psychogenic movement disorders (“war
The history of psychotraumatology is closely tremors”),
linked to the history of military conflicts. For 55 Paralysis and amnesia,
centuries, wars have always brought great suf- 55 Twilight conditions,
fering to people – civilians and soldiers – and 55 Confusion,
have led to manifold psychological damage. 55 Speech disorders,
Although the psychosocial conse- 55 Blindness,
quences of wartime experiences have been 55 Numbness.
known for centuries, as with other psycho-
psychosomatic clinical pictures, a change These symptoms were initially attributed to
in symptoms or a change in the form of the effect of the grenade bombardment and
appearance has been observed over the were referred to as “shell-shock”. However,
decades. Sometimes even the impression is the “war neurotics” were not recognised as
created that every era, every war produces a sick people in Germany, but were consid-
new, its own “syndrome”. ered to be hereditary and constitutionally
less resilient. The methods of treatment
(electric shocks, “Kaufmann cure”, ice
24.2.2 Changing Manifestations water baths, violence, isolation) were in part
cruel and served to drive the soldiers back to
24.2.2.1 Da Costa Syndrome the front. In England, France and the USA,
The first medical scientific publications on attempts were made to select suitable men
the psychosocial and health consequences for the front and psychogenic disorders were
of psychological traumatisation as a result either treated close to the front or the sol-
of war experiences in soldiers date from diers were brought back home and treated in
the time of the wars of secession at the special facilities (Shephard, 2000).
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.
24.2.2.6 Gulf War Syndrome

After the end of the Second Gulf War in
24.3 Stress Reactions
1991 (Kuwait and Iraq), many of the soldiers
complained of the occurrence of numerous in the Military Environment
unspecific physical symptoms such as
55 Joint and muscle pain, 24.3.1 Forms of Deploymen:
55 Unusual fatigue and exhaustion, National/International
55 Memory problems,
55 Depression, Today, soldiers in NATO forces are not only
55 Disorders of cognitive and emotional deployed in armed military conflicts, but
functions. often also in international peace-keeping
and combat operations under UN mandate
Doctors summarized these symptoms in and, for example, under NATO or EU lead-
1994 under the term “Gulf War Syndrome”. ership.
The cause was unclear, and suspected trig- However, as recent history has shown,
gers included the numerous preparatory the boundaries between the various mili-
vaccinations, exposure to nerve gas, inges- tary forms of deployment are not sharp and
tion of insect repellents, toxic gas releases sometimes disappear. In April 2003, after
from burning oil wells or uranium muni- only a few weeks, the American Government
tions. These hypotheses on the genesis of the declared the war in Iraq to be over, after
disease could only be partially proven, and it the invasion was completed, the Iraqi army
is assumed that the disease is partly caused had capitulated and Saddam Hussein’s
by exogenous factors. However, there is also regime had been overthrown. However,
controversial discussion as to whether and the US forces suffered the greatest num-
to what extent psychogenic reactions to war ber of wounded and killed soldiers in the
experiences with predominantly somato- “stabilisation phase” of the following years.
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 mission 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
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.
Phase 1 Phase 2 Phase 3

Deployment preparation Deployment Deployment follow-up
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
.. Fig. 24.1 Three-phase, three-level concept
zz The Three-Phase, Three-Level Concept of can contribute to raising the awareness of

Stress Management those potentially affected before a possible
The supporting pillars of the concept are the strain and can be the starting point for fur-
three-phase model and the three-level con- ther primary prevention measures. However,
cept of stress management (. Fig. 24.1). screening can also facilitate early detection
The three-phase model describes the three of diseases after exposure and motivate those
stages (= phases) of the assignment: prepa- potentially affected to take up therapeutic
ration, implementation and follow-up. The treatment promptly. However, it should not
three-level concept is divided into the stages be used to select vulnerable soldiers or exclude
(= levels) of psychosocial support, which is them from foreign missions. Otherwise, a
applied depending on the type and extent of high rate of defence and dissimulation could
the stressful events. be expected (Wesemann et al., 2018).
Intervention level 1 (especially assis- In the Federal Armed Forces, the impor-
tance from comrades and superiors) is more tance of such measures has been increasingly
important in the course of the mission than recognized in recent years and implemen-
in the preparation and follow-up phases, tation has begun under the leadership of
since the everyday psychosocial support the Psychological Service. A psychological
from partners, family, friends and acquain- screening was designed for a planned start
tances is not available there or can only be in 2018, which in the long term every sol-
accessed to a limited extent via remote com- dier should receive when he is recruited and
munication media. However, it also plays then repeatedly during his service, especially
an important role in the preparation and before and after foreign deployments.
follow-up of an assignment in coping with Where there is suspicion of psychologi-
uncertainty about what is to come and in cal stress for soldiers, which arises during
reintegration into the everyday life at home screening, but also in the case of imminent
that is no longer familiar. stressors such as foreign deployments, the
Various innovative approaches in recent Federal Armed Forces is increasingly work-
years complement the basic concept of pre- ing on the development of effective primary
vention described above. These start at vari- prevention measures.
ous points in the care landscape: a broad Education (psychoeducation) plays a
routine screening of psychological symptoms central role in the primary prevention of the
Military
449 24
Federal Armed Forces. This is mainly pro- lead to stigmatisation fears and thus make
vided by the “troop psychologists” working it difficult and delay contact with the help
in larger units. In addition, there are other system.
elements, the effectiveness of which has Thus, in secondary prevention, the new
not yet been studied to any great extent. media again offer themselves as the first con-
Measures of stress preparation through vir- tact option. These are supplemented by per-
tual exercises, coupled with procedures of sonal counselling services such as the 24/7
active relaxation as well as the improvement telephone hotline of the Psychotrauma Centre
of social skills, seem to be the most suit- (0800-5887957) (Zimmermann et al., 2013).
able in order to be able to make good use Since mid-2016, a smartphone app
of social reference systems even in the event (“Coach PTSD”) has been able to provide
of stress. A supportive social environment the above-mentioned prevention elements
has been shown in numerous studies to be in an easily accessible form, especially for
an essential element of disease prevention. younger patients. It was developed by the
PTZ and the TU Dresden and has already
been downloaded several thousand times in
the year of its release.
The use of modern media seems to be a Intensified and extended formats for sec-
suitable approach to offer prevention in a ondary prevention are also very popular,
standardised way and from a learning especially the 2- to 3-week preventive cures.
theory point of view in an effective and Following the increased occurrence of mis-
motivation-increasing manner. The Psy- sion stressors, these can be applied for unbu-
chological Service of the German Armed reaucratically and carried out in civilian
Forces has developed the computer-based clinics at the expense of the Federal Armed
blended learning platform CHARLY in Forces. They do not claim to provide profes-
cooperation with civilian partners. In a sional psychotherapy, but can contribute to
1.5-day group seminar, the participants strengthening resources and thus to prevent-
are taught the above-mentioned preven- ing illness. They also convey recognition and
tive elements in a multimedia and playful esteem for the participating soldiers on the
manner. In cooperation with the PTZ, an part of their employer and therefore have a
effectiveness study was carried out among high level of acceptance. The participants
medical personnel. In a randomized, con- consider sports and movement-related offer-
trolled longitudinal design, a comparison ings in particular to be important and help-
with routine stress training resulted in a ful (Zimmermann et al., 2015b).
significantly lower symptom burden for
the CHARLY group after a mission in
Afghanistan (Wesemann et al., 2016). 24.5 Therapy Within
the Framework of the Federal
After exposure to stressful events, secondary Armed Forces
prevention methods can influence the pro-
cess of processing or disease development. 24.5.1 Therapeutic Facilities
Here again, psychoeducation seems to be of in Federal Armed Forces
great importance. This should be offered on Hospitals
a low-threshold basis and, if necessary, also
anonymously, since, particularly in hierar- Years of experience in the therapy of sol-
chical systems such as the military, feelings diers with mission-related mental disorders
of shame accompany the disease process, have shown that soldiers often prefer to be
treated in Federal Armed Forces facilities, of concomitant diseases (comorbidities)

since there is specific knowledge available (Alliger-Horn et al., 2014, 2015).
about the everyday military requirements, In a broader sense, personal value orien-
mission stress and trauma. However, the tations as well as moral injuries in the context
German Armed Forces currently have only of the traumatic situation, whose influence
4 hospitals where in-patient trauma therapy on the severity and form of symptoms has
can be offered (Berlin, Hamburg, Koblenz, already been described, must also be taken
Ulm). For this reason, outpatient, semi- into account in this context. In a recently
24 inpatient and inpatient offers of the civilian published study on the course of qualified
care landscape are also regularly used. withdrawal among alcohol- dependent sol-
diers, for example, a strong expression of
the value “tradition”, which characterizes
a high value of traditional social norms
A close-meshed regionalized supply, and habits, contributed to a significantly
which can at the same time also contrib- improved therapy outcome (Zimmermann
ute a profound knowledge of the mili- et al., 2015a).
tary field of life, is not available. Due to In order to respond to these observations
a lack of experience with war- with appropriate therapy, a 3-week group
traumatised soldiers in the civilian sec- programme was introduced at the Federal
tor, intensive therapeutic and scientific Armed Forces Psychotrauma Centre, which
cooperation with military authorities is was specially designed for soldiers with
necessary. mission-related mental illnesses and moral
injuries. This programme includes classic ele-
ments of psychosocial stabilisation, but also
In recent years, outpatient and inpatient topics such as self-care and self-compassion.
treatment settings have developed in the Building on this, value orientations and
German Armed Forces, which have been their change in the context of operational
specially adapted to the needs and specific experiences are reflected upon. Violations of
characteristics of military patients (Zim- moral standards by others (e.g. superiors) or
mermann et al., 2016). In order to document by the patients themselves are discussed in a
treatment quality in line with the current group setting. Group cohesion and mutual
state of scientific knowledge, it was neces- understanding provide protection against
sary to evaluate these settings with regard to excessive feelings of guilt or shame. The
the quality of outcomes. course concludes with a social competence
The trauma therapeutic procedure training, which focuses on the verbalisation
EMDR (Eye Movement Desensitization of experiences in the social environment.
and Reprocessing) has proven to be par- A first pilot evaluation of 20 participants
ticularly suitable and effective for soldiers: showed that the phenomenon of shame,
controlled studies have shown high effect which often contributes significantly to the
strengths (Alliger-Horn et al., 2015; Köhler psychological strain of this group of people
et al., 2017). However, the therapy results and can lead to delays in the therapeutic pro-
varied due to various influencing factors, cess, can be influenced significantly positively.
which have since been increasingly taken This has an effect above all on the dimen-
into account in the planning of therapeutic sions of aggressiveness towards oneself and
processes. In the foreground are the num- others as well as social withdrawal as a result
ber of traumas experienced and the extent of shame (Alliger-Horn et al., 2018).
Military
451 24
Under the Magnifying Glass 24.5.2 Trauma Therapy
in a Federal Armed Forces
The involvement of relatives in the treat-
ment process is of great importance for
Hospital Based on Case
successful healing. Numerous studies have Studies
shown that social support is a key factor in
the mental well-being of people under 24.5.2.1 General Conditions
stress, also and especially in a military The treatment of patients with traumatic dis-
context. A systematic literature analysis orders is carried out according to the guidelines
showed that social support from the social of the German-speaking Society for Psy-
environment of military forces, from the chotraumatology (Deutschsprachige Gesell-
comrades’ circle, but also from the family schaft für Psychotraumatologie, DeGPT) and
reference system has a significant protec- the Association of Scientific Medical Societ-
tive influence on the course of mission- ies (AWMF Guidelines). Janet’s step-by-step
related psychological trauma sequelae in model is generally accepted as a valid stan-
soldiers (Waltereit et al., 2013). dard. Thereafter, the therapy proceeds in 3
phases (detailed 7 Sect. 24.5.2.3):

55 Stabilization phase (relationship build-

In the Federal Armed Forces hospitals, ing and stabilization),
work for relatives is offered as an outpa- 55 Processing phase (trauma processing),
tient open group or as a block event lasting 55 Integration phase (integration and reori-
several days. The work is supportive and entation).
focuses on psychoeducation and communi-
cation structures within the family. Through The avoidance of the trauma experience
the pastoral care project of the Protestant should be abolished and replaced by coping
Church Office (ASEM) and the Soldiers and experiences.
Veterans Foundation of the German Armed The fact that this takes place in a military
Forces Association, 3-day to 1-week events environment has many implications:
are supported financially, in terms of per- 55 The dislocated origin of the patients from
sonnel and content. According to a recent all over Germany limits the contact to the
study, this has reduced the psychological personal environment of the patients.
burden on family members in particular, 55 The duration of the stay is often longer,
while at the same time improving their qual- as the aim is to restore a level of function
ity of life and their sense of mutual support appropriate to the service. On the other
(Wesemann et al., 2015). hand, the often positive resource situa-
tion of military patients (stable psycho-
Under the Magnifying Glass social environment, etc.) can favour a
speedy therapeutic procedure.
An innovative therapeutic approach is the 55 Care is provided in a “company medical”
support of relatives’ work through horse- system, with corresponding advantages
supported interventions according to the and disadvantages in terms of relation-
EAGALA method. An open pilot study ship management. On the one hand,
conducted by the Psychotrauma Centre patients appreciate the therapists’ knowl-
has shown that these seminars have a sig- edge of the system and their work; on the
nificant positive effect on the psychological other hand, as part of the treatment pro-
well-being of couples with post-traumatic cess, expert opinions are required time
disorders (Köhler et al., 2017). and again, for example regarding the
necessity of a transfer close to home,
renewed participation in an assignment, on the further procedure at the appropriate

etc. In some cases, a separation of thera- time (Barre & Biesold, 2001).
peutic and expert functions is necessary.
55 In many cases interval therapy is neces- 24.5.2.3 Therapeutic Approach
sary. This is achieved by appropriate The therapeutic procedure comprises 3
interim dismissals and resumption of phases:
treatment. 55 Stabilization phase,
55 Processing phase,
24 24.5.2.2 Conditions of Admission 55 Integration phase.
In-patient trauma therapy is mainly provided
for soldiers with mission-related or work- 1. Stabilisation phase
related trauma. These are mainly patients
with disorders that can be assigned to type The psychological traumatisation arises from
I traumas. However, even after an intensive the vital discrepancy between threatening
preliminary diagnostic phase, the possibil- situational factors and individual coping
ity cannot be ruled out that earlier traumas options, which is accompanied by feelings of
will become apparent in the therapeutic pro- helplessness and defenceless abandonment.
cess, which will then require a significantly Especially members of high-risk professions
higher therapeutic effort in all dimensions. with their self-image oriented towards func-
According to experience, this is frequently tionality and resilience perceive this as a dis-
the case with female soldiers who, for exam- turbing loss of control over themselves and
ple, have earlier intimacy traumas. In most their life situation. They lose confidence in
cases, patients with complex trauma that is their ability to maintain control and therefore
not related to their duty are referred to exter- often live in fear that superiors and comrades
nal outpatient or inpatient treatment. In the might notice their unstable condition and
case of acute trauma, a decision is made in lose respect for them. A lot of energy is spent
accordance with the usual guidelines as to on maintaining the facade of “normality”.
whether acute trauma therapy is appropriate In a vicious circle of failed coping attempts,
or whether, after crisis intervention and con- many of those affected get deeper and deeper
sultation, the self-healing process should be into a symptom swirl from which they are no
awaited in the further course of the case, in longer able to free themselves alone. The fol-
order to then make a well-founded decision lowing example vividly illustrates this.
Case Study: Mission-Traumatised Female Paramedic
“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 relations 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.
zz External Stress Factors zz Third Integration Phase

Assistance with external stress factors that In the final phase of therapy, the aim is to
would require a lot of mental energy dur- rethink the significance of the trauma for the
ing the stabilization phase (funeral, pending self-image and world view in order to develop
court proceedings, expectation of punish- new future perspectives (trauma integration).
ment, financial hardship, unprovided for Under certain circumstances, new career
relatives, etc.) requires the involvement of and life perspectives must be developed, for
social services and military pastoral care. example, if continued use as a soldier is no
24 2. Processing phase longer possible for health reasons. Especially
in such cases, trauma therapy can encoun-
In the processing phase, trauma processing ter resistance that is difficult to overcome.
takes place, which in the German Armed Soldiers trust that they will be supported
Forces Hospitals is carried out exclusively by their commanding officer if they suffer
in individual therapy. The following therapy damage while performing their duty. If this
methods are used: expectation is disappointed, e.g. because a
55 “EMDR” (Shapiro, 1998; 7 Chap. 14), mission-related PTSD with a corresponding
55 Elements of cognitive behavioural therapy deterioration in the level of function does
(Heiland & Maercker, 2000; 7 Chap. 13), not lead to the hoped-for acceptance as a
55 Imaginative resource installation and professional soldier, this can lead to deep bit-
Imagery Rescripting and Reprocessing terness, which can lead to a chronification of
Therapy (IRRT). PTSD. The person affected feels that his or
her commitment and thus his or her person
In the meantime, controlled studies of the are devalued, especially in relation to com-
Psychotrauma Centre have shown a sig- rades who were not in the mission. He reacts
nificant effectiveness of these procedures with depression, hatred and psychosomatic
(Alliger-Horn et al., 2015; Köhler et al., disorders. To the burden of the traumatising
2017). situation is added the bitter feeling of having
been betrayed (Shay, 1998).
In the processing phase, it is important,
on the basis of an inner stability strength- In the integration phase, the patient
ened by resource installation, to enable a must be supported to sacrifice grief, to
confrontation and work through the most accept losses without resigning, to allow
stressful aspects of the traumatic experi- forgiveness and self-forgiveness, thus
ence, to overcome avoidance and to put giving room to “traumatic growth”.
the experience into an adaptive and ratio-
nal perspective. This should also take into
account the specifics of the peritraumatic In this phase, albeit closely linked to the
operational environment (space alien to trauma confrontation, the processing of per-
the culture, role models in the deployment sonal value orientations and their change in
as helper and fighter, etc.). the course of the assignment as well as possible
moral violations also play an important role.
Military
455 24
Case Study: Change in Value Orientations and Development of Moral Injury
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.
Case Study: Sequence of a Trauma Therapy
Cause for Introduction him desperately and, seeking help, had

The soldier, 26 years old, is presented because stretched out both hands to him. The boy was
he collapsed with crying fits after his return then carried away through the “sluice”.
from the mission at home. He had expressed
panicky fear of going to the barracks. Until Experience Processing
then, the patient was a well-motivated and The patient had the feeling of having failed
well-judged soldier. Exceptional previous and “abandoned” the boy. “I should have done
burdens and illnesses could not be deter- something” was the self-reproachful attitude
mined. The patient was assigned to a supply he developed. He tried to distract himself
unit. In his function, he had a lot of contact and, although he had hardly drunk any alco-
with the field hospital. hol until then, he now drank up to 10 bottles
of beer and 1/2 bottle of whisky per day. He
Traumatic Event had not asked for help on the spot for fear of
In the fourth week of deployment, he had being repatriated!
been given the task of handing in the standby
planning to the emergency department. It Therapy
was at this very moment that an ambulance After a preparatory meeting, in which stabili-
drove up at high speed and brought a small sation measures were largely dispensed with,
boy lying on a stretcher, whose legs had been the disruption was dealt with in an EMDR
torn off, presumably in a mine accident. This meeting over the next hour. The patient
led to an encounter in which the child’s gaze focused on the presentation of the little boy
met that of the soldier. The boy had looked at and the outstretched arms. This was associ-
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.
24.6 Supply Law for Soldiers Soldier Pensions Act (Soldatenversorgungsgesetz

; SVG)
of the Federal Armed Forces Damage to military service (WDB) is damage to health
caused by the performance of military service, by an
24.6.1 Damage to Military Service accident suffered during the performance of military
service or by circumstances peculiar to military service
(§ 81(1) SVG).
Federal Armed Forces soldiers who suffer For the recognition of a health disorder as a result
damage to their health during their period of damage caused by military service, the probability
of service can claim a military service of the causal connection is sufficient. If the probabil-
injury, provided that the degree of injury ity required for the recognition of a health disorder as
a result of damage during military service is not given
(see 7 Chap. 9) is not only temporary but

because there is uncertainty in medical science about
also at least 25%. As a consequence after the the cause of the identified illness, the health disorder
end of their military service, they may, on can be recognised as a result of damage during mili-
application, receive care, including medical tary service with the consent of the Federal Ministry
treatment. of Labour and Social Affairs; consent can be granted
generally (§ 81(6) SVG).
>>The early presentation of active and for-

mer soldiers to the Federal Armed
Forces Social Service (7 http://www.

24.6.2 erman Act on Employee
G
personal.bundeswehr.de) as soon as they Benefits
are suspected of having a mental illness
caused by their deployment is crucial for The Law on the Regulation of Benefits for
the smooth running of the application Special Foreign Deployments (Gesetz zur
procedure and for the later allocation of Regelung der Versorgung bei besonderen Aus-
benefits. landsverwendungen; EinsatzVersorgungsge-
Military
457 24
setz [Deployment Supply Act], EinsatzVG) integration into working life as permanently
of December 2004 and the Law on the as possible, they receive the necessary pro-
Improvement of Benefits (Einsatzversor- fessional qualifications. The law applies
gungs-Verbesserungsgesetz, EinsatzVVerbG) retroactively to all mission victims who suf-
of December 2011 adapted the pension law fered their injury after 1992.
to the new requirements of foreign deploy-
ments.
The core of these laws is the concept of 24.6.4 Appraisal of Damage
“accident on the job”. This covers any dam- Caused by Military Service
age to a soldier’s health that he/she suffers
during military operations abroad (“spe- The medical expert’s first task is to deter-
cial deployment abroad”) as a result of an mine which (mental) disorders are present
accident at work or the special conditions in in the proband and whether these health
the area of deployment. If this operational conditions are related to military service
accident leads to a GdS of at least 50%, the (causality question; 7 Chap. 9). If this can

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.
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459 24
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461 25
Torture Survivors
and Traumatised Refugees
Contents
25.1 pidemiological Aspects and Types

E
of Traumatisation – 462
25.1.1 T orture – 462
25.1.2 War Trauma – 464
25.1.3 Stress Due to Flight and Persistent Strains in the Host
Countries – 464
25.2 sychological Consequences of Traumatisation

P
and Flight – 465
25.2.1 osttraumatic Stress Disorder – 465
P
25.2.2 Complex Post-Traumatic Stress Disorder (CPTSD) – 465
25.2.3 Prolonged Grief Disorder (PGD) – 465
25.2.4 Adjustment Disorder – 466
25.3 Need for Psychosocial and Therapeutic Care – 466
25.4 Psychotherapy with Torture Victims and Refugees – 468

25.4.1 Steps of Trauma-Oriented Treatment for Victims of Torture – 469
25.5 Therapeutic Work in a Transcultural Setting – 480

25.5.1 T ranscultural Encounter in Psychotherapy – 480
25.5.2 Communication with Interpreters – 481
25.5.3 Therapist–Patient Relationship – 483
25.5.4 Vicarious Traumatisation – 483
25.6 Concluding Remarks – 484
Literature – 485
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).
>>Torture is a systematic and intentional

Specific Aspects of Systematic Torture damage to the personality of the victim
55 By other people planned and inten- and ultimately aims to damage the core
tionally of the personality (Drozdek & Wilson,
55 The vital threat 2004; Maier & Schnyder, 2007).
55 Extreme humiliation
55 Prolonged and repeated exposure It means a humiliation and degradation
over long periods deeply affecting the personality structure
55 Inability to act, helplessness and and social relationships; it influences fam-
dependence ily, society and subsequent generations
55 Possible betrayal of companions, exis- (Kira, 2002; Weierstall et al., 2011). Stud-
tential threat to family members or ies on the second and third generation of
political friends Holocaust survivors (Kellermann, 2001), in
55 Feelings of guilt (especially when wit- Iraq (Fritzemeyer, 2017) and with refugees
nessing the torture of others, death of from Iraq and Lebanon (Daud et al., 2005),
show that torture can create a transgenera-
tional problem. In addition to the individual 55 Sequence 1: Beginning of persecution

consequences, the effects of traumatisation characterised by increasing repression or
in the social system, especially in the fam- a war situation;
ily, must therefore be considered. Children 55 Sequence 2: Time of persecution until
can be parentified and overburdened, and flight, i.e. a phase with a high risk of
parents may keep children close to them- traumatic events;
selves because of their own fears and restrict 55 Sequence 3: Phase after the end of the
their range of movement or show aggressive persecution.
outbursts.
It was shown that sequence 3 is crucial for
25 25.1.2 War Trauma
the course of mental disorders. The course of
the disorder is highly dependent on contex-
tual factors after the traumatic experiences.
Refugees have often experienced prolonged In the case of traumatised refugees, this is
and repeated traumatisation caused by the phase in exile. In this phase, so-called
other persons. This “type” of traumatic post-migration stressors have a consider-
events (see specification of traumatic events able influence on psychopathology (Porter &
according to Maercker, 2009) is associated Haslam, 2005). Due to the political situation
with an increased probability of develop- in many EU countries (e.g. Dublin proce-
ing trauma sequelae. A “dose–response dure), refugees are confronted with increas-
effect” was found, which shows that a higher ingly long-term and serious post-migration
number of war traumas is associated with stressors. In Germany, for example, the
increased distress and a higher probability stricter asylum laws that have been in force
of diagnosing trauma sequelae (Steel et al., since 2016 (see BAMF, 2018) have led to the
2009). War traumas often include not only increased number of residence titles with
the experience of bombing and attacks with restricted rights (e.g. subsidiary protection)
weapons, but also torture-like systematic and higher rejection rates, resulting in lon-
violence – often in the form of sexualised ger asylum appeal processes. These legal
violence. decisions have an impact on the living situ-
ation of the refugees in terms of their social
situation (e.g. restricted family reunification,
25.1.3 Stress Due to Flight longer stay in refugee shelters). The future
and Persistent Strains prospects remain uncertain, and a feeling
in the Host Countries of constant dependence arises. It has been
shown that post- migration stressors such
In most cases, refugees have experienced as uncertainty about residence (Nickerson
potentially traumatic situations not only et al., 2011b), fear of deportation (Herlihy
in their country of origin but also during et al., 2002) and the hearing process itself
their flight and are in a persistent stress situ- (Schock et al., 2015) are associated with an
ation in the host country. These sequential increase in PTSD symptoms. It should be
traumatisations have a significant impact noted that there are first indications that new
on the development of trauma sequelae. traumatisation and post-migration stress-
The model of sequential traumatisation ors in the host country have a comparable
(Keilson, 1979) continues to be helpful for influence on the increase in psychopathology
understanding the development of mental (Schock et al., 2016). Retraumatising expe-
disorders in torture victims and traumatised riences (7 Sect. 25.4.1.7) contribute to the

refugees. Keilson distinguishes 3 traumatic fact that a processing or recovery process is

sequences: impeded (Brandmaier & Ahrndt, 2012; Car-
465 25
swell et al., 2011; Herlihy & Turner, 2007) and made trauma, Herman (1992) coined the
a chronification of trauma-reactive disorders term “complex PTSD” (7 Chap. 3). The

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,
which is characterised by a persistent mental 25.3 Need for Psychosocial

attachment (or persistent longing) in rela- and Therapeutic Care
tion to the deceased person, as well as a deep
emotional suffering. The duration of this Due to the severe psychological burden
grief goes beyond the respective culturally caused by traumatic experiences in the
or religiously accepted grieving phase, but country of origin and during flight, as well
extends at least over a period of 6 months. as the often continuing impact of serious
Exact prevalence rates of PGD (accord- post-migration stressors, the earliest possible
ing to ICD-11) in refugees are still missing. access to adequate health care at various lev-
Older studies, however, indicate that this els (i.e. social, medical, psychological) is rec-
25 disorder occurs frequently (31–54%; Craig
et al., 2008; Momartin et al., 2004).
ommended. Therapeutic services should be
adapted to the needs of the respective legal
and social context and phases of the migra-
tion process. . Figure 25.1 shows different
Adjustment Disorder

25.2.4 levels of health care, based on the interven-

tion pyramid for humanitarian disasters –
In terms of differential diagnosis, an adjust- IASC Guidelines (Inter-Agency Standing
ment disorder (ICD-10 F 43.2, Dilling et al., Committee, 2007), a graduated approach to
2011) should also be considered for refugees mental health and psychological support rec-
who have experienced a stressful phase of ommended by the UNHCR, here adapted to
life in their home country and during their the conditions in a country with a developed
flight and who are simultaneously in the health care system (Wenk-Ansohn, 2017).
phase of adaptation in exile (Sluzki, 1979). With the model of care levels, it is important
This diagnosis, often used as a “residual that, if necessary, an allocation can be made
category”, will be newly and more clearly from one care level to the other in the sense
defined in ICD-11 (7 Chap. 5). Here, the

of a “stepped care model” (NICE Guidelines,
dysfunctional symptomatology is triggered NICE, 2009); parallel, coordinated thera-
by the presence of a psychosocial stressor peutic interventions at the different levels are
(or loss of resources). For the cohort of often also useful.
torture victims and refugees, this loss of It should be emphasised that adequate
resources is manifold and serious (including material and social basic care, i.e. covering
loss of social structure, loss of family, loss “basic needs”, are the basic prerequisite for
of financial and social status). For example, medical and psychotherapeutic measures to
refugees in the host country may experience be effective.
symptoms of maladaptation, with symp-
toms of anxiety and depression and men- >>Achieving secure living conditions is a
tal preoccupation, as well as difficulties in prerequisite for psychological stabilisa-
coping with a new situation, with or with- tion after traumatic experiences.
out PTSD. Prevalence rates on adjustment
disorder in refugees and victims of torture The following framework conditions are
are scarce. An older study shows prevalence central to cope with traumatic experiences:
rates of 6–40% among refugees in post- 55 Security,
conflict regions (Dobricke et al., 2010). 55 Sufficient material conditions,
467 25
Necessary: Prerequisite: Financing
networking of the and pool of interpreters
professions, social specially trained for
work accompanying Psychotherapy psychotherapy
therapy
Psychiatric treatment
Psychosocial counseling and support

Low-threshold offers:
psychosocial counselling, everyday practical Assistance,

adequate accommodation, group offers, integration-promoting
social activities, German courses, access to education, occupation
and work, monitoring the well-being of childred
Psychiatric/psychotherapeutic diagnostics and indication
Identification of special needs and if needed report for asylum-related issues
Somatic primary care and information on psychosocial health
If there is evidence of experience of violence or
psychological symptoms: Access to health and psychosocial care
.. Fig. 25.1 Elements of adequate health care for refugees (see Wenk-Ansohn, 2017)
55 Social recognition, refugees are not identified in the initial asy-

55 Possibility of social contact and autono- lum procedure or by the health system. These
mous action, refugees are often for years in the middle of
55 Hope and future prospects. legal proceedings with uncertain future pros-
pects. In view of this situation, the qualified
Most traumatised refugees do not have a expert assessment of trauma- related and
secure residence when they are admitted for other mental health problems in refugees
treatment, that often lasts for years. Because or the preparation of an expert statement/
of their psychological symptoms, trauma- psychological or medico-legal report (mlr)
tised refugees are often not able to present for refugees undergoing treatment is of great
their persecution in a “complete, consistent, importance.
detailed and vivid” manner, as demanded The diagnosis of trauma sequelae can,
by the authorities in the asylum procedure if necessary, support the statements on a
(Birck, 2002). So far, the early identification political prosecution, describe the need for
of vulnerable groups by independent, spe- treatment and, if serious health risks are to
cially trained health professionals has only be expected in the case of forced return, sup-
taken place in some regions of Germany, as port the recognition of obstacles to depor-
is actually required for the implementation tation (Haenel & Wenk-Ansohn, 2004;
of the Reception Directive of the European Wenk-Ansohn et al., 2013; Scheef-Maier &
Union (Europäische Union, 2013). Overall, Haenel, 2017). In 2003, the German Medical
a large proportion of particularly vulnerable Association released standards for assess-
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-
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).
Phase 1 Phase 2 Phase 3 Phase 4 Phase 5

Orientation/ Stabilisation Focus on Focus on Farewell
Basic measures Past Future
Building trust Resources Triggers, Self-esteem Integration
(biographical and nightmares
current) Dealing with Work
Diagnostics Narrative of conflicts
biography Information/ traumatic Relapse
psychoeducation Social prevention
expert-statement/ relations
medico-legal report Symptom control/ In-depth Review
skills processing Options for
25 Information
Coping with Transformation
action Aftercare
Clarifying of goals everyday life Future Crisis

Possible medication Mourning prospects intervention
Diagnostic Phase Therapeutic phase Aftercare

Accompanying clinical social work
Establishing of a Accompaniment of Integration course

sustainable asylum procedures Integration
relationship Professional
Initiating social support opportunities Work
Social clin. history
Strengthening personal Advanced education Aftercare
Situation of and social resources
the children Future perspectives Crises
Support of the family intervention
Basic interventions if necessary, further
systems
(lawyer, accompaniment during
accommodation Language courses residence procedures
mobility)
.. Fig. 25.2 Therapy phases – components of trauma-oriented treatment (phase model). (Modified according
to Meichenbaum, 1994; Drozdek & Wilson, 2004)
25.4.1.1 Initial Interview

A detailed initial conversation in the first 55 Current stressors
session with the support of an interpreter 55 Social situation/residence situation; is
(Wenk-Ansohn, 2017) is recommended in a lawyer involved
order to decide together with the patient 55 Motivation to contact the treatment
whether psychotherapeutic treatment is facility; preliminary information
likely to be helpful for the special needs. 55 Previous diagnostics/treatments
55 Suspected diagnosis – no diagnosis –
other problem?
Initial Interview: Setting with a 55 Unstable life situation or other exter-
Professional Interpreter nal factors in the foreground?
Topics to ask about and for consideration 55 Therapy motivation?
of the interviewer: 55 Treatment indication (general – cur-
55 Complaints rent)?
55 Key biographical data – potentially 55 What type of action/treatment is
traumatic background likely to be indicated? Which mea-
471 25
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
Case Study: Mr. S., Syrian Refugee
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-
25 complaints, he reports that he can hardly

concentrate during the German course, is
oned and had experienced torture. Since then
he would have had nightmares.
restless, irritable, cannot fall asleep for hours Regarding the current situation, he
and then wakes up again and again, drenched reports that he is in the process of re-opening
in sweat. Asked about bad dreams, he affirms his asylum procedure after having been
and mentions that the same horrible contents granted only subsidiary protection. A major
occur again and again. Even during the day problem, he said, is that he has not been
sometimes “these images” would come into granted international protection and thus
his mind, “sometimes I have the feeling that I may not be able to bring his family together
am still in Syria”. Asked about triggers for for years.
25.4.1.2 Acute Treatment Versus expert statement (also called medico-legal

Long-Term Treatment report) will be prepared for the proceeding
The need for treatment and thus the thera- regarding the right of residence, in order to
peutic procedure differ, depending on the support a stabilisation of the external situa-
phase of migration and the associated pri- tion as soon as possible.
mary stressors. Experience in recent years Individual sessions can be combined with
has shown that it makes sense to initially group sessions for acute treatment. Such
offer acute or short-term therapy (duration acute treatment can have the effect of achiev-
approx. 6–9 months) to newly arrived refu- ing psychosocial stabilisation and a recovery
gees or refugees still living in a very unstable process can begin. The chronification of psy-
social and residence situation (Wenk-Ansohn, chological symptoms is reduced and paths
2017). Taking into account emergency psy- towards rehabilitation and integration into
chological and trauma therapy aspects, such the host society are made possible. A longi-
treatment offers immediate psychotherapeu- tudinal study with patients in an acute pro-
tic help, which is combined with psychiatric gramme shows a significant improvement in
medication and social work support if nec- symptoms of PTSD, anxiety and depression
essary. After a diagnostic phase, in which (Wenk-Ansohn et al., 2018). At the end of
an initial narrative of the biography is also the acute treatment, it can be clarified with
developed in an overview, psychotherapeutic the patients whether further trauma-focused
interventions usually focus on dealing with treatment is indicated and preferred at the
current stress and trauma-associated trig- current stage of the migration process or
gers as well as dealing with symptoms with whether other steps are more important,
psychoeducational (Liedl et al., 2010) and such as participation in vocational prepa-
skills-oriented elements (Koch et al., 2017). ration training. In the case of chronically
If necessary, after the diagnostic phase, an complex traumatised persons and in the case
473 25
of already relatively stable residence condi- In addition to clinical diagnostics, this
tions, a long-term psychotherapy process first stage of treatment includes an assess-
should rather be intended from the begin- ment of the previous course of symptoms
ning, which also aims, after an initial phase and psychological test diagnostics. Like-
of trust-building and stabilisation, to process wise, the reconstruction of the biography
the traumas as far as possible, develop cop- including the traumatic events should be
ing strategies and open up new perspectives. worked out in this phase, as far as this is
Particularly in cases of violent loss or disap- possible and ethically justifiable at this
pearance of close relatives, after sexualised time – and necessary for a possible report.
torture or wartime violence (Wenk-Ansohn, This procedure presupposes careful han-
2002), or when dealing with perpetrators, dling (Pielmaier & Maercker, 2012) as well
treatment is often lengthy. Also in the case as good skills in early recognition and in
of pre-traumatic psychological problems, dealing with dissociative reactions and
longer psychotherapeutic treatment is often must be accompanied by initial thera-
necessary (Wenk-Ansohn, 2017). peutic support and psychoeducational
interventions. The pressure of having to
25.4.1.3 Diagnostics and Basic prepare an expert statement/psychological
Measures or medico-legal report for submission to
the authorities is problematic for the early
phase of the interaction and the thera-
Components of the Diagnostic Phase peutic relationship and is associated with
(5–10 Sessions) After Admission professional and ethical problems (Gur-
55 Clinical psychological and if neces- ris, 2003c). At the same time, however, this
sary psychiatric diagnostics also offers the possibility of a first ver-
55 If required, general medical diagnos- balization (“first disclosure”) and thus an
tics and documentation of eventual important step for the treatment (Gangsei
physical traces of torture & Deutsch, 2007; Gurris & Wenk-Ansohn,
55 Psychological test diagnostics 2013). If the patient succeeds in overcom-
55 Social anamnesis ing his or her avoidance, traumatic experi-
55 Start with initial social work interven- ences are often verbalized for the first time
tions during the diagnostic phase and a process
55 If necessary and if there are substan- of integrating traumatic fragments in the
tial findings: Preparation of an exten- overall biography begins. A narrative is
sive medico-legal or psychological created that is recorded in writing (see Tes-
report or a shorter expert statement timonial Therapy; Cienfuegos & Monelli,
for the proceeding regarding the right 1983; Jørgensen et al., 2015). The material
of residence can then be part of the expert statement/
55 Joint decision-making with the patient psychological or medico-legal report in the
on treatment planning asylum procedure and at the same time be
a documentation for the patient.
Continuation of the Case Study Mr. S.
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.
25.4.1.4 Psychological Test requires the use of qualified interpreters

Diagnostics or the use of instruments that are already
The use of questionnaires and/or stan- translated into the patient’s language. It
dardised and structured interviews to assess should be pointed out that ad-hoc transla-
mental health is challenging for victims of tions during the diagnostic process should
torture and traumatised refugees, but is how- be avoided if possible, as this can lead to
ever possible and recommended. It should inaccurate translations and specific concepts
be mentioned here that the collection and may be translated incorrectly, which leads to
acquisition of information regarding mental a loss of validity.
symptoms can have different objectives (e.g.
recording of current symptoms, monitor- zz Culture
ing symptom changes over time, support- The perception and experience of psycho-
ing the decision on the diagnosis). Different logical symptoms are also influenced by
instruments are used to operationalise the the cultural background of the person.
respective objective (self-assessment ques- However, it should be noted that “culture”
tionnaire, external assessment scales, inter- does not produce stereotypical symptom
views, behavioural observations). manifestations, but rather that these symp-
The challenges in test diagnostics for tor- tom manifestations are characterised by
ture victims and traumatised refugees can be individual variances (e.g. gender, age, edu-
divided primarily into 2 categories: cation). The challenge is therefore to under-
stand diagnostics as an open exploration
zz Language process. Following on from the concept of
Adequate recording and exploration of the “culture”, the diagnostic instruments per se
symptoms by psychodiagnostic procedures represent a challenge in a transcultural set-
475 25
ting, since they were developed on the basis zz Test Diagnostics Session
of Western concepts of disorders and also During the diagnostic session, as with other
validated in Western samples. For adequate patients, various problems may arise that
application in non-Western contexts, first require appropriate general psychothera-
of all a linguistic adaptation (i.e. indepen- peutic procedures:
dent back and forth translation) is required, 55 Short-term severe stress until decompen-
and in a second step, validation and, if sation or dissociative states;
necessary, cultural adaptation. Currently, 55 Items are not understood;
however, hardly any sufficiently validated 55 Rumination is classified as intrusive
questionnaires are available in the various experiences;
languages. The development, validation 55 Answers too detailed, containment of
and free provision of such instruments for the patient is necessary;
practitioners are desirable and are currently 55 Answers are only given in extremes
being aimed at. (motivation, cultural linguistic customs,
In the practical implementation of etc.);
psychodiagnostics, there are specifics and 55 Different information for clinical anam-
challenges, which are merely listed in the nesis and test diagnosis.
following (for a more detailed overview,
see Stammel & Böttche, 2017; Böttche & 25.4.1.5 Stabilisation
Stammel, 2018). and Resource Work
In the initial phase of therapy (and repeat-
zz Preparation edly in the course of therapy), it has
The diagnostic session should be announced proven to be effective to focus on emotion-
in a timely manner. This includes, on the one regulating, control-restructuring, desensitiz-
hand, the provision of information about ing and resource-activating interventions.
the course of the session, i.e. the duration
(usually 50–100 min) and the content. Since
obtaining information may remind of inter- Proven Stabilizing Treatment Steps
rogations during torture or hearings during 55 Structuring everyday life and promot-
or after flight (e.g. at borders, asylum hearing activity, encouraging self-care
ings), it is also important to explain the pur- 55 Psychoeducation in individual or
pose of the diagnostic session clearly and group settings (Knaevelsrud & Liedl,
comprehensibly beforehand. 2007)
The literacy level should also be assessed. 55 Identification of symptom triggering
Especially when answering questions using conditions in everyday situations,
rating scales (i.e. multi-point rating scales dealing with triggers
such as “never”, “often”, “sometimes”, 55 Skills training (Koch et al., 2017; Sen-
“mostly”, “always”), non-literate persons dera & Sendera, 2007), mindfulness
often find it difficult to classify their symp- training
toms. Visualised rating scales in the form of 55 Practice of self-soothing procedures
differently sized circles or other geometric (e.g. various forms of relaxation, sta-
shapes often help here. bilizing body work [Karcher, 2004]),
Depending on the literacy level (and the physical activation
presence of translated instruments), the 55 Sleep hygiene and possibly sleep-
presence and involvement of the interpreter promoting antidepressant medication
is also necessary.
55 Symptom-oriented methods of pain biography work, guided imaginative

control and management (Gurris, journeys and imaginative techniques
2003a) (Gurris, 2005; Reddemann, 2004),
55 Strengthening the ego functions in resource work with EMDR (Korn &
dealing with current everyday con- Leeds, 2002; Rost, 2008)
flicts, self-management 55 Acknowledgment and therapeutic use
55 Support of self-determined action in of introduced metaphors, exploration
the social environment, “empower- of traditional rites
ment” 55 Acknowledging feelings of grief, e.g.
55 Reviving and anchoring of pre-
25 traumatic resources, e.g. through
loss of home, family structures, cul-
tural environment, property, etc.
The psychiatrist prescribes Mr. S. a sleep- 55 Dealing with trauma-associated triggers,

promoting antidepressant medication with reorientation exercises;
mirtazapine, which he takes for several 55 Resource work, validation of skills, evok-
months. In addition to individual therapy, ing and anchoring of positive childhood
Mr. S. participates in a psychoeducational memories using the lifeline (manualised
group for 12 sessions, in which progressive in Schauer et al., 2005);
muscle relaxation is also practiced. In the 55 Mourning for the loss of his brother and
group, he gradually overcomes his timidity. for leaving the family.
The social worker motivates Mr. S. to take
part in a German course again. In the indi- News of bombings in his home area repeat-
vidual therapy, the first 10 sessions focus on edly leads to crises, in which he sometimes
the following contents: visits the centre without an appointment to
55 Development of a therapeutic working share his worries, to find someone to whom
relationship; he can communicate and who can give him
55 Structuring of everyday life, sleep hygiene support in all the fear.
(e.g. evening walks, no looking at pictures
from home on the Internet in the evening);
25.4.1.6 Trauma-Focused verbalised in a bearable form and a new posi-

Treatment tion in relation to the experience should be
The necessity of integrating the extreme worked out. The trauma-confronting work
traumatic events into the biographical nar- is only started when patient and therapist
rative of those affected is emphasised across are sure that sufficiently strong resources
all therapy schools. This means that avoid- have been “established”.
ance and dissociation should be resolved,
as far as possible in each case, in favour of >>Trauma exposure in torture victims and
the gradual empowerment to expose one- severely traumatised war victims should
self to the traumatic images and memories only take place if there is sufficient sta-
in a conscious and controlled manner. The bility of the external and internal situa-
associated feelings should be admitted and tion and with the patient’s consent and if
477 25
the therapist–patient relationship is sus- mation and distancing, which is carried out
tainable. It should not be carried out in imaginatively and at the same time narrative-
psychosis-near conditions or in cases of meaning-making on changing levels of expe-
suicidal tendencies. rience and behaviour. While the patients are
encouraged to approach the trauma scenes
Depending on the therapeutic background, imaginatively (projected onto an imaginary
different forms of trauma-focused work are screen) in a detailed and continuing man-
used. If, in the diagnostic phase, a rope sym- ner, they can use various previously learned
bolizing the life line was used in the recon- distancing techniques that enable controlled
struction of the biography, this work can be relief and prevent flooding at the same time –
taken up again in the later course of therapy e.g. reducing the size of the screen, switching
for trauma exposure within the framework to a dynamic resource image.
of a therapeutic procedure based on NET Imaginative-narrative trauma-focused
(Schauer et al., 2005; 7 Chap. 16).
techniques, which make proximity and
In addition to narrative process- distance to the painful events and images
ing, “screen work” or “screen technique” controllable for the affected person, enable
(Sachsse, 2008; Putnam, 1989) is a proven a careful reconstruction of memories, sup-
possibility for trauma-focused work. Using ported and deepened by the therapist,
this technique, traumatic events are viewed involving various channels of perception
as in a film and a narrative is created at the and gradual elimination of dissociation,
same time. The screen technique is based on as well as the processing of trauma-related
Putnam (1989) and was further developed emotional and cognitive schemata. This
by Gurris (2003b) as a multidimensional results in a composition of traumatic frag-
imaginative-narrative exposure. At its core, ments and the expression of connected feel-
it is a flexible imaginative form of approxi- ings through verbalisation.
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.
With torture survivors, trauma-focused work situation, attribution of meaning, reactions

is often not possible as a sequential working of the environment, social consequences and
through of the entire traumatic memories. other influencing factors, the centrally effec-
Often, however, elements (“hotspots”) and tive symptom-stabilizing schemata are of
different levels of the traumatic sequence and different types (cf. psychodynamic tension
its meaning can be focused on at different points of the course of the traumatic process;
points in the therapeutic process. Trauma- Bering, 2011). In both cognitive and psycho-
focussing work or trauma exposure should dynamic therapy, work on symptom-stabiliz-
not be seen in isolation, but as part of a treating schemata is an effective component that
ment process, which, as a whole, focuses on can also be applied when detailed exposure
25 the functional impairment at the various lev-
els of the complex trauma sequelae and on
to the traumatic experiences themselves is not
possible or not desired or when symptoms
social rehabilitation (Cloitre et al., 2011). persist after confrontation with the traumatic
memories. External symptom-stabilizing fac-
25.4.1.7 Work on Symptom tors elude the influence of therapy, but the
Stabilizing Cognitive patient may be able to develop a new attitude
and Emotional Schemata towards them. Internal symptom-maintain-
The term symptom-stabilizing schemata here ing schemata, such as shame and guilt (see
is used for psychodynamically effective and Boos, 2005; Kröger et al., 2012), can be dealt
cognitive patterns that can impede the process- with in therapy and their symptom-stabilising
ing and coping with the traumatic experience. effect can be reduced (. Fig. 25.3).

Depending on the pre-traumatic personality, The symptom-stabilizing inner schemata

cultural ties, constellation of the traumatic are reflected in the behaviour in the therapeu-
Shame Internalized
principle of silence,
Feelings of guilt honor principle
Gain from illness, e.g. in the

Avoidance family system regarding residence
status or compensation
Symptomatology
Accusatory suffering
(Seagull & Seagull Lack of recognition of injustice
1991)
Shattered basic Impunity of perpetrators

assumptions Persistent feelings
(Janoff-Bulman 1992) of revenge
Crises in the home country
Relatives are in bad health

or are missing
Insecure residence status,

lack of prospects
.. Fig. 25.3 Symptom-stabilizing factors. (Rectangular outer factors, oval inner schemata)
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-
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.
>>The farewell process is of particular graphical origin or ethnicity, but is also

importance. The possibility of aftercare influenced by many factors (e.g. educa-
in the sense of further selective supporttional level, gender). Values, social norms,
in the event of renewed stress, e.g. con-the position of the individual in relation to
other members of the group and patterns
flicts in the building up of life in exile,
should be granted. of thought and action are handed down in
the interaction of the group, change in the
historical and social context over the gen-
erations and form internalized “maps of
25.5 Therapeutic Work
meaning” (Clarke et al., 1979).
in a Transcultural Setting In a traumatic situation, culture-specific
systems of meaning influence the evalu-
25.5.1 Transcultural Encounter ation of the event and interpretations of
in Psychotherapy the trauma and its consequences (Afana
et al., 2010). The culturally shaped actual or
Perception, feeling, thinking and forms anticipated reaction of the social environ-
of expression are culture- and context- ment has a significant impact on the course
dependent. The cultural background of of trauma reactions and coping options. In
individuals is not only determined by geo- women from traditional societies, in which
481 25
honour and shame play a central role in reg-
ulating social status and references, complex Helpful Tools in Transcultural Commu-
trauma-reactive disorders are particularly nication
common after rape or other forms of sexu- 55 Openness and respect
alised violence (Wenk-Ansohn, 2002) with 55 Observing rules of courtesy
chronification processes maintained by col- 55 Mindful handling of shame and
lective dysfunctional cognitions (Kizilhan taboo subjects
& Utz, 2013). The tendency to conceal the 55 Pay attention to potentially culturally
experiences has the effect that treatment is divergent communication styles/lan-
often sought out late and under great pres- guage cultures and indirect expres-
sure, e.g. when deportation is imminent. sions
In diagnostic and therapeutic interven- 55 Inquire meanings of words, phrases,
tions, the systems of meaning as well as metaphors
thought and behavioural patterns underlying 55 Circular questioning, approaching
interpretations must be explored and taken from different perspectives
into account to allow cultural a daptations 55 Clarify misunderstandings and encour-
(Heim & Maercker, 2017; Kizilhan & Utz, age further inquiries
2013). Symptoms and accompanying behav- 55 Reflect and make transparent your
ioural patterns may also vary. Even though own culture/culture-bound behaviour
symptom clusters of PTSD occur across 55 Dialogue on potential differences in
cultures, their form of expression, the inter- culture of origin and exile
pretation of symptoms, their classification, 55 Make the professional role and the
and the understanding of disease may vary therapeutic approach transparent
across cultures (7 Chap. 18).
55 Repeatedly emphasize the own com-
Psychotherapy with refugees means an mitment to confidentiality (and that
encounter with people that demands open- of the interpreter) (also towards rela-
ness to reflect on one’s own reference sys- tives and friends of the patient)
tems, awareness of one’s own cultural and 55 Resourcefulness and courage to
contextual ties and flexibility for changes of improvise (e.g. letting patients draw,
perspective. On the one hand, psychological use of symbolising objects)
models from Western contexts should not 55 Pay attention to non-verbal commu-
take place without verification and adapta- nication
tion (Gurris, 2012; Schnyder et al., 2016). In a
systemic perspective, the societal, historical-
political and current social context should
also be included. On the other hand, the 25.5.2 Communication
therapist should not lose sight of the indi- with Interpreters
vidual patient. Here, an attitude of respect-
ful curiosity and committed neutrality with >>In addition to facilitating linguistic com-
the help of circular questions has proven to munication between patient and thera-
be successful (Oesterreich, 2004). Attention pist, interpreters play an essential role in
to non-verbal communication makes it pos- clarifying culture- and communication-
sible to reduce misunderstandings and to specific questions – a resource that can
enter into a direct, lively contact with each be used in the short follow-up discussion
other (von Lersner & Kizilhan, 2017). after the sessions.
The necessary training of interpreters for

use in a therapeutic context includes the –– No private contacts, no disclosure
teaching of the basics of of the telephone number of the
55 psychopathological symptoms and prob- interpreter to the patients
lems of traumatized persons, –– Presentation of the interpreter and
55 basics of therapeutic work and therapeu- informating the patients about
tic relationship, regulations for language mediation
55 contents of special medical/psychologi- 55 Rules applicable for the interpreter
cal terminologies –– Translating in first person form/
55 concepts related to the everyday reality direct speech
–– Translation as literal as possible
25 of asylum seekers
55 exercises in literal translation in a thera- –– Everything spoken in the room
peutic setting will be translated (also the patient
is informed that every communi-
Training should also include methods of cation between interpreter and
preventing vicarious trauma and burnout. patient outside the therapy will be
Psychotherapy involving interpreters communicated to the therapists)
generally requires clearly structured cooper- –– Generally consecutive translation
ation with clearly defined activities and roles –– Use of regular supervision and
(Abdallah-Steinkopf, 2017). The therapist is further training
responsible for the structuring of communi- 55 Rules for therapists:
cation, the course of the conversation and –– Paying attention to the flow of
the therapeutic process and has the protec- speech of the patients
tion of the interpreter in mind. Transference –– Adapt the language to the level of
and counter-transference reactions take education and ability of abstrac-
place in a triad (patient-interpreter-thera- tion of the patients
pist; Haenel, 2001). The therapist’s constant –– Short sentences and avoidance of
attention to these events and joint reflection abstract or technical terms;
on them with the interpreter is necessary. In –– Polite stopping when the spoken
order to have an overview of all what is hap- gets too long
pening in the triad, a seating arrangement in –– Offer the interpreter to interrupt
a triangle has proven to be effective, which and ask back
also illustrates the aspect of partnership for –– Striving for direct address and eye
successful communication. contact with patients and paying
attention to non-verbal commu-
nication
Rules for Communication –– Follow-up conversation with the
55 General rules aim of relieving the interpreter
–– Preliminary talk before the first by clarifying misunderstand-
assignment ings, peculiarities, methodical
–– Professional and specially trained approaches, triadic aspects of the
interpreters relationship
–– No relatives/acquaintances as
interpreters
–– Confidentiality (set out in writ- If the rules of communication are followed,
ing) therapy in a transcultural setting with the
support of interpreters is not less effective
483 25
than in a native speaker setting. In a meta- In the end, they are thus further inca-
analysis, in which 13 studies with refugees pacitated and fixed in their role as vic-
were evaluated, no treatment-related differ- tims.
ences were found between studies in which
interpreters were used to facilitate sessions In the therapeutic setting, an interaction is
and those in which this was not the case created in which the patient can recognize
(Lambert & Alhassoon, 2015). himself as an equal human being in his
basic human dignity. Fischer and Riedesser
(1998) describe the transference relationship
25.5.3 Therapist–Patient in trauma therapy as a process of re-bond-
Relationship ing. In the case of trauma caused by human
hands, the overcoming of mistrust and the
>>Central to the therapeutic relationship is rediscovery of the foundations of the com-
that it is based on sincere and recognisa- municative reality principle are particularly
ble respect, because regaining a sense of necessary.
dignity is central for victims of torture Torture survivors tend to transfer per-
and other forms of humiliating violence. petrator aspects to the social environment
(Comas-Diaz & Padilla, 1991; Wilson &
In therapy with torture victims and war Lindy, 1994). The setting in diagnostics
traumatised people, extremely contradic- and therapy alone can trigger violent re-
tory attitudes are noticeable frequently. actualizations of the traumas with flash-
On the one hand, too great distance of the backs or dissociative states. On the part of
therapist with a lack of empathy can lead the traumatised person, an associative link
to the patient closing his or her mind and with experienced interrogation situations
even to the termination of therapy. On or psychological tortures develops. If these
the other hand, a lack of distance and too processes cannot be adequately processed
much empathy with over-identification and and resolved, not only is further treatment
even personal involvement are frequently blocked, but retraumatisation can also
observed (Haenel, 1998; Wilson & Lindy, occur. On the other hand, the fear of per-
1994). Experience shows that in therapy with petrator transference can lead the therapist
traumatised people, a controlled distancing to avoid clarification and confrontation, so
from the usual therapeutic abstinence is rec- that therapeutic opportunities are not used.
ommended (Maier & Schnyder, 2007; Wenk- The repeated reflection of the therapeutic
Ansohn, 2002). Of central importance is a relationship in supervision during the course
high degree of transparency in therapeutic of treatment is therefore a basic requirement
work. In additionx, however, the therapeutic (Lansen, 2002).
attitude towards torture victims and refu-
gees also requires partiality with regard to
respect for human rights and condemnation 25.5.4 Vicarious Traumatisation
of human rights violations.
The possible psychological consequences
>>In the case of people traumatised by tor- for care givers in their work with trauma-
ture, an attitude of overprotection can tised persons have been described repeat-
lead to those affected being perceived edly (7 Chap. 27). The particular pressures

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-
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.
485 25
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25
491 26
Gerontopsychotraumatology
Contents

26.1.1 hronic PTSD – 494
C
26.1.2 Delayed PTSD – 494
26.1.3 Current Trauma and PTSD – 495
26.1.4 Comorbidity – 495
26.2 Diagnostic Specifics – 495
26.3 Treatment of Trauma in Older Adults – 496

26.3.1 ccessibility and Utilization of Psychotherapy – 496
A
26.3.2 Gerontopsychotherapeutic Basics – 497
26.3.3 Gerontopsychotherapeutic Approaches
of PTSD Therapy – 497
26.3.4 Indications – 501
Literature – 502
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
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 subsyndromal 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).
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).
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-
tion of a diagnosis or the classification of

severity levels are reliable and valid for older 55 The longer lifespan of older people
people as well. So far, it has been shown leads to a higher prevalence of multi-
that there is a comparable classification of ple, temporally distinct traumatiza-
PTSD severity into “low”, “moderate” and tions. For this reason, the anamnesis
“high” across all age groups (Böttche & must go beyond current traumas to
Knaevelsrud, 2017). It should also be noted include past traumas.
that, depending on age, measuring instru-
ments sometimes include several questions
about physical symptoms, making it difficult 26.3 Treatment of Trauma in Older
to distinguish between psychological and
physical causes of the symptoms. Reference
Adults
is made here to the changes in the ICD-11,
26 where non-specific physical symptoms have 26.3.1 Accessibility
been removed from the PTSD definition. and Utilization
The following factors should be spe- of Psychotherapy
cifically considered in the differentiated
evaluation of diagnostic results (Cook & Despite the significant prevalence rates
O’Donnell, 2005). of trauma sequelae in older people, they
are clearly underrepresented in outpatient
psychotherapeutic care (Byers et al., 2012;
Evaluation of Diagnostic Results of Kruse & Herzog, 2012; Troller et al., 2007).
Older People The low rate of utilization of psychothera-
55 Older people more often conceal or peutic support by older people can be traced
dissimulate post-traumatic symp- back to various aspects, both on the side of
toms, as they are more ashamed of the therapist and on the side of the patient.
suffering from psychological impair- Only in recent years has there been cor-
ments due to their socialisation. In responding gerontological psychiatric/psy-
general, a cohort effect can be chotherapeutic specialist literature as well
observed in that self-opening is rated as few age-specific trainings for specialized
less positively than in younger people. staff. There is still a lack of evidence-based,
55 Gender studies have shown that older widespread concepts for the psychothera-
men in particular have learned a role peutic treatment of older people. Existing
model that equates psychological social images of age contribute to the fact
stress with weakness. (“... tough as that older patients are relatively rarely
leather, hard as Krupp steel ...”). admitted to outpatient psychotherapy, e.g.:
55 It must also be taken into account 55 the assumption that older people benefit
that the “psychotraumatological per- less from psychotherapy (Remmers &
spective” on socio-historical events Walter, 2012),
was not yet developed in the forma- 55 the assumption of resistance to change,
tive years of today’s elderly people: 55 the assumption of age-specific behaviour
the term “post-traumatic stress disor- (e.g. social withdrawal, sleep disorders),
der” (PTSD) was not introduced into 55 the comparison of age with senility,
the diagnostic nomenclature until 55 psychotherapist’s attitude towards older
1980. This can lead to a trivialisation patients (Peters et al., 2013).
of one’s own traumatic experiences
due to lack of awareness. On the other hand, not only therapists, but
also older people themselves often have cer-
497 26
tain prejudices or have their own images of als). However, it should be noted that most
age that prevent them from attending psy- age-related cognitive changes (including lon-
chotherapy (for an overview, see Kammerer ger reaction times, slowing down of infor-
et al., 2015). For example, older people with mation processing) are moderate and do not
a positive image of old age make more use cause significant impairment in everyday life
of psychotherapeutic/psychosocial care ser- (APA, 2004).
vices than people with a negative image of The exploration of existing social con-
old age (Kessler et al., 2015). Beyond that, tacts or, if necessary, the initiation and
older people have a less pronounced ten- strengthening of social support options
dency to perceive the need for psychologi- helps to deepen treatment effects. Relatives
cal help (Mackenzie et al., 2010) and are less should be involved in the therapeutic pro-
likely to admit the need for psychological cess as early as possible. Social reintegration
help (Maercker et al., 2005). These are sig- is an important component, especially given
nificant barriers to their utilization, on top the perceived isolation and loneliness and
of more obvious obstacles such as limited the lack of understanding. Reactions of the
mobility or the aforementioned fear of stig- social environment (trivialisation: “It was
matisation (Arean et al., 2012). so long ago”; accusations: “Why didn’t you/
Stereotypes of this kind can lead not only your parents react earlier”; embarrassment)
to self-fulfilling prophecies, but also to mis- have a decisive influence on coping with the
diagnosis and inappropriately negative prog- traumatic experience.
noses of healing (American Psychological
Association, APA, 2004).
Special Features of Gerontopsycho-
therapy
26.3.2 Gerontopsychotherapeutic 55 Consideration of comorbid psycho-
Basics logical and somatic symptoms
55 Knowledge about life-historical con-
The specificity of geriatric psychotherapy texts, norms and values of different
includes a sound knowledge of physi- age groups
cal illnesses in old age and their treatment 55 Adaptation to slower learning pro-
standards. Due to simultaneous physical cesses and sensory impairments
and potentially also social problems men- 55 Close cooperation of the support net-
tioned above, close networking of the sup- work
port system (family doctor, specialists etc.) 55 Social (re)integration
is helpful (APA, 2004). Knowledge about 55 Confrontation with one’s own fears,
life-historical contexts, norms and values of one’s own ideas about old age, death
different age groups can help to overcome and dying and how to deal with the
obstacles. Dealing with one’s own fears and limited lifetime of this patient group
ideas about old age, death and dying, as well
as dealing with the limited time of life of
this patient group helps to reduce potential 26.3.3 Gerontopsychotherapeutic
insecurities on the therapeutic side. Approaches of PTSD
An age-related decrease in fluid intelli- Therapy
gence, slower learning processes and sensory
impairments necessarily involve a reduced In principle, the evidence-based treat-
work pace, more frequent repetition and the ment like exposure therapy (7 Chap. 13),

use of different media (e.g. written materi- cognitive therapy (7 Chap. 13), EMDR

(7 Chap. 14) and narrative approaches

To the authors’ knowledge, there are no
(7 Chap. 16) are also used in PTSD ther-
randomized controlled pharmaco-studies
apy for older people. For the therapy of specifically targeting older patients with
PTSD in adult populations, there are now PTSD. Clinically, the usual recommenda-
a number of empirically well-evaluated tions of gerontopharmacology apply, i.e.
and effective cognitive- behavioural treat- a lower initial dose and slower increase of
ment approaches. Watts et al. (2013) found substance dosage, which are described in
in their meta-analysis an average effect size detail in 7 Chap. 19.

of d = 1.26 for cognitive-behavioural inter-

ventions. It should be noted here that most 26.3.3.1 Life Review Therapy
of the studies included in this meta-analysis Life review therapy (LRT) offers an exten-
did not address age effects, because the sam- sion of therapeutic approaches, especially
ple of people above 65 years was previously for older people. In LRT, the life story is
26 excluded or too small to derive conclusions chronologically remembered, structured
about the evidence. and evaluated in a therapeutically guided
There are hardly any adequate psycho- process. LRT, which also belongs to the nar-
therapeutic or psychopharmacological inter- rative therapies (for a detailed description
vention studies on treatment approaches for of narrative therapy, please refer to 7 Chap.

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
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
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
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.
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505 26
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507 27
Special Features
of Treatment and Self-Care
for Trauma Therapists
A. Maercker
Contents
27.1 Different Causes for Treatment – 508
27.2 articularities and Difficulties on the Patient

P
Side – 509
27.2.1 ealth Care Utilisation Patterns – 509
H
27.2.2 Dropout Rates for PTSD Therapies – 511
27.3 Difficulties on the Therapist’s Side – 512

27.3.1 S tressful Trauma Narratives – 512
27.3.2 Forms of Reaction of Therapists to Trauma Patients – 513
27.3.3 Partisanship for the Patient – 514
27.3.4 Negative Basic Social Mood Towards Traumatised
People – 515
27.4 herapeutic Relationship and Therapeutic

T
Approach – 515
27.4.1 uilding a Trusting Relationship – 516
B
27.4.2 Therapy Goals and Planning – 517
27.5 Self-Care for Therapists – 521

27.5.1 S econdary Traumatisation – 521
27.5.2 What Is to Be Done? – 521
Literature – 522
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.
27.2.1.2 Reactions of the Social

27.2 Particularities Environment and Social
and Difficulties Support
on the Patient Side The symptoms of PTSD have direct conse-
quences for the interpersonal relationships
The fact that patients with trauma sequelae of those affected. Thus, partnership conflicts
start therapy late, not at all or with great and problems in the social environment are
reservations has to do with various factors. explicitly mentioned as symptoms of PTSD
These include particularities of the symp- in DSM-5 and of complex PTSD in ICD-11.
toms, the associated interpersonal prob- Conversely - in the direction from the
lems and - similar to other psychological or environment to the affected person - the
medical problems - individual motivation traumatised person often experience a
problems (Leiner et al. 2012) or structural request from their caregivers to finally put
preconditions of the health care system. an end to the thought of what happened.
Here, statements such as “Life goes on after
all” and “You should simply stop thinking
27.2.1 ealth Care Utilisation
H about it” are common (7 Sect. 2.5.4.2).

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
Basic model Influencing variables

Traumatisation
Knowledge about traumatisation
and symptomatology
Reaction of the social environment
Problem awareness
Social support
Self-esteem problems
Settings for searching help
Posttraumatic avoidance
Shaken confidence
27 Readiness for treatment

Practical feasibility
Expected therapeutic success
Shame and guilt
Victim-perpetrator relationship
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
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-
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-
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
►►Example: Political Imprisonment

55 Adjusted style of conversation: A 32-year-old patient, who was imprisoned
Encouraging the patient to open up for about 2 years for political reasons, briefly
about traumatic experiences or sig- hints that criminal fellow prisoners harassed
naling that he/she only needs to open him. Several follow-up questions are asked
up later by the therapist. Only in a later conversation
55 Clarification of the interpersonal sup- does the patient tell us that he has experi-
port resources of the patient enced various forms of sexual abuse. 9
55 If necessary, support for removal
from persistent dangerous situations In other cases, the test behaviour can also be
(e.g. domestic violence) triggered by the fact that patients expect that
55 Creating safe environmental condi- no counterpart, not even a therapist, can
tions for patients (e.g. leaving doors bear the horrors of the stories. They then
open) adopt a paradoxical, anticipatory, protective
55 Adequate response to rituals in order attitude towards the therapist, whom they
27 to respect the safety needs of patients do not want to overwhelm with their story.
55 Giving psychological complaints a
name and explaining them (psycho- 27.4.1.1 Building Trust Gently
education) Building trust between patient and thera-
55 Joint discussion of concrete therapy pist is a process that takes time. Attempts
goals, the sequence of the therapeutic by the therapist to justify or prove their own
procedure and explanation of the trustworthiness prove to be useless. Rather,
important therapy components (e.g. expressions that show respect for the dif-
self-observation and protocols, trauma ficulty of trusting in the face of what has
exposure or procedure for EMDR) been suffered are perceived by the patient as
55 If necessary, discontinue or reducing a sensitive response.
medication before the start of psycho- The therapist can explain that he does
therapy so that patients can attribute not expect boundless trust from the patient
possible therapeutic success to the and that he is aware that the patient does
psychotherapeutic intervention. not feel safe at first. There is also no reason
to see the therapist as trustworthy from the
beginning. The therapist will try to earn the
trust first, even if this will take some time.
27.4.1 Building a Trusting
Relationship >>To create a trusting patient-therapist
relationship, it is important to consider
Due to the generally shattered confidence of potential issues of sequencing.
many trauma victims (see above), it is not pos-
sible to assume a lasting relationship of trust The formalised initial diagnostics (e.g. with
in the initial period of therapy with trauma- a questionnaire) should not take place
tised persons; the therapeutic relationship is before the interview in which the trauma is
rather “on the test bench”. Patients can show first discussed. Patients may feel repulsed
testing behaviour, e.g. by “throwing” individ- by revealing their traumatic experiences in
ual traumatic experiences into the conversa- written questionnaires or tests before talk-
tion and evaluating the therapist’s reaction to ing about them. Therefore, the time of the
whether or not the therapist reacts appropri- initial diagnostics should be postponed to a
ately to the narrative. later date if necessary.
517 27
Building trust involves anticipating pos- also not without threat to the therapist - as
sible difficulties with the potential financial many trauma victims are impaired in their
reimbursement of health insurance provid- ability to regulate their affects (7 Chap. 3).

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
27.4.2.1 Naming Complaints ous knowledge. Embedded in an implicit or

(Psychoeducation) explicit biopsychosocial model of the disor-
Traumatised patients often have a vague der in question, variable priorities can be set.
impression of the changes that the trauma For psychoeducation on PTSD, meta-
may have caused in them. In the context of phorical terms such as “mental wound” or
psychoeducation, the various changes and “burned wound” are appropriate. These met-
strains perceived by the patient should be aphors can be related to psychological and
summarised and named in a coherent con- physical changes, as shown in . Fig. 27.2.

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
Mental consequences Biological consequences
“The images come back again” Fright and stress hormones change
the resting state of the body
Æ “I have become easily excitable”
Unsuccessful attempts at coping

“Think no more about it”
.. Fig. 27.2 Explanatory model for post-traumatic stress disorders. (Work through example sentences together
with the patient)
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,

a certain “wisdom of the body”, trauma synthesis or trauma exposure and

which wants to be better protected for reorientation. The respective therapy com-
future dangers and wants to make ponents can be explained to the extent that
escape or fighting reactions possible the patient can integrate them based on his
by overexcitation. or her previous knowledge.
55 Information about ubiquitous trigger Since effective therapeutic procedures
stimuli: All possible locations, situa- explicitly address the trauma - in one form
tions, activities and other stimuli serve or another (7 Chap. 11), even particu-

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”
Talk about it,

work through it
.. Fig. 27.3 Working together on a vicious circle of trauma memories and therapy as a way out
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
manent secondary traumatisation (Stamm rienced therapists. Herman (2015) stated

1995): that nobody can work with trauma victims
55 in professional settings, on their own. Only through collegial sup-
55 in the organization of work, port is it possible to retain the necessary
55 in everyday life and leisure activities, strength to treat traumatised patients. To
55 in basic (philosophical) attitudes to life. this end, the establishment of professional
networks of therapists who provide trauma
therapy can be helpful.
27.5.2.1 Professional Settings
The spontaneous occurrence of (parts of) 27.5.2.3 Everyday and Leisure
PTSD symptoms after working with one or Activities
more trauma patients can initially be considered The existential pressure to deal with the
as “a normal reaction to an extremely abnor- subject of trauma, because it is a matter
mal situation” (7 Sect. 27.4.2.1). In addition,
of life and death, violence and crime, can
various techniques of self-observation and self- lead to a preoccupation ad infinitum with
27 protection help in the sense of self-care: this topic. Everyday examples of this are to
repeatedly look at reports in the media on
a trauma topic (e.g. on sexual child abuse).
Techniques of Self-Observation and Trauma experts and therapists should claim
Self-Protection the right to separate work and leisure. In this
55 Recognizing your own reactions sense, advanced training seminars cannot be
–– Develop self-awareness for physi- part of leisure time, but of the profession.
cal signals, e.g. for insomnia, One’s own resilience is best served by using
headaches and sweating and developing one’s own relaxation and lei-
–– Try to find words for your own sure opportunities (Brockhouse et al. 2011;
experiences and feelings Reddemann and Maercker 2008).
55 Learn to cope with your own reac-
tions 27.5.2.4 Basic (Philosophical)
–– Find your own level of comfort to Attitude to Life
allow openness, tolerance and the The confrontation with traumatic events can
willingness to listen to everything also lead to changes in therapists’ attitudes
–– Know that every feeling has a to life. This includes acknowledging the “evil
beginning, a middle and an end in the world” and its many forms of expres-
–– Learning to reduce overwhelming sion as well as accepting the irretrievable. A
feelings without slipping into consciously designed post-traumatic growth
repression process (7 Chap. 2) with its areas: new pri-

–– 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.
27.5.2.2 Organising One’s Work

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525
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
A –– psychotropic drugs 384

–– with somatic diseases 379
Absorption technique 280 –– spontaneous remission 84
Abuse, sexual 50, 55, 109, 118 –– as stress-related syndrome 434
–– hippocampal volume 90, 94, 95, 100 –– and substance abuse 84
–– neurobiology 90–94, 96–100 –– and suicidal tendencies 85
–– prevalence 109 –– torture victims and refugees 23
–– sex differences 90 –– in the total population 83
Acceleration trauma of the cervical spine 164, 434 –– vulnerability-stress model 81
Acceptance 334, 336, 338, 364, 365, 383 ADNM-20, see Adjustment Disorder-New Modules
–– and acceptance exercises 321 Adolescents
–– at mourning 11 –– communication strategies 310
Acceptance and commitment therapy 454 –– modification of control beliefs 311
Accommodation 11, 227, 239, 252, 276 –– promotion of resilience 178
Acknowledgement 111 –– psychoeducation 185
–– social 111 –– STAIR/narrative therapy 313
A-criterion 15, 128, 135, 169 Adverse Childhood Experiences (ACE) 136, 432
Acute care, psychosocial 183, 191 Affect regulation 49, 56, 116, 119, 206, 357, 414, 415
Acute respiratory distress syndrome (ARDS) 428 –– children and young people 416
Acute stress disorder (ASD) 126, 127, 137, 176, –– dysregulation 415
178–181 Afghanistan war 445
–– Interview (ASDI) 181 Aggravation 154, 163, 164, 334
–– Scale (ASDS) 137 Agoraphobia 139, 278, 447
Acute stress reaction 181, 427 AIP model 262, 276
Adequacy theory 159 Alcohol addiction in young people 109, 269
ADHD, See Attention Deficit/Hyperactivity Algorithm, diagnostic 21, 22
Disorder Alienation, feeling of 21
Adjustment disorder 465 Alprazolam 351, 353, 384
–– biological factors 81, 82 Amitriptyline 351, 352
–– cancer diseases 379, 382 –– for veterans 352, 353
–– client-centric short-term therapy 382 Amnesia 21, 23, 161, 181, 349
–– cognitive behavioral therapy, – 381, 382 Amygdala 90, 91, 93, 94, 96–98, 117
–– crisis model 80 –– for abused children 117
–– definition 76 –– volume data 90
–– and depression 79 Anterior cingulate cortex (ACC) 91
–– in developing countries 379 Anticonvulsants 351, 354–355, 357
–– diagnostics 77, 78 –– carbamazepine 354
–– DSM-5 78 –– lamotrigine 354
–– EMDR 383 –– valproate 354
–– with fear 92 Antidepressants 188, 348–354, 356, 357, 371,
–– frequency 84 384–385
–– generic therapeutic strategies 381 –– for adjustment disorder 384
–– ICD-11 83 –– children 356
–– in medical facilities 83 –– MAO inhibitors (monoamine oxidase
–– New Module (ADNM) 83 inhibitors) 352, 353
–– New Module (ADNM-6) 138 –– selective serotonin- reuptake inhibitor (SSRI)
–– and personality disorders 84 350, 351
–– phase model 97 –– tricyclic 352
–– problem solving therapy 383 Antipsychotics, atypical 351, 355, 356
–– in psychiatric setting 84 Anxiety activation 97
–– psychodynamic psychotherapy 287 Anxiety disorder 61, 76, 97, 278, 333, 341, 354,
–– psychotherapeutic procedure 381 402, 434
528 Index
Anxiolytics 351, 353–354, 384 Bullying 82

–– for adjustment failure 429 –– in children 108, 113
–– buspiron 354 Burnout 484, 513
–– benzodiazepines 384 Buspiron 351, 354
ARDS, see Acute respiratory distress syndrome
Armed forces 292, 442, 444, 446–449, 456, 494
–– concepts of stress management 79 C
–– foreign deployments 446, 448
–– psychological screening 448 Cambridge Depersonalization Scale (CDS) 140, 267
–– treatment settings 450 Cancer
–– use of digital media 290 –– adjustment disorder 379
Arteriosclerosis 427 –– depersonalization 221
ASD, see Acute stress disorder Carbamazepine 351, 354
ASR, see Acute stress reaction Cardiac arrhythmia 433
Association 90, 96, 97, 125, 164, 181, 185, 192, 211, Cardiac disease-induced-PTSD 433
250, 262, 279, 334, 399, 401, 402, 413, 427 Cardioverter defibrillator (AICD) 432
–– learned 239 Causal chain 156
Asylum initial proceedings Causality, liability 156
Asylum laws 464 CBT, see Cognitive behavioral therapy
Asylum procedure 467, 472, 474, 479 Cervical spine acceleration trauma 434
Asylum seekers 154, 162, 169, 170, 462, 482 Cervical spine distortion 164
–– traumatization 161, 177, 207 Change of perspective 183
Attachment theory 56, 363 Child
Attention deficit/hyperactivity disorder 397 –– and adolescent trauma screening (CATS) 404
Attitude –– post-traumatic Stress Disorder Reaction Index
–– culturally sensitive 207 (CPTSD-RI) 404
–– therapeutic 207, 225, 323, 483 Child abuse 109, 115, 414
–– therapeutic for victims of torture and –– brain alterations 82
refugees 483 –– causes 115
Attitude to life, philosophical 522 –– definition 115
Awareness raising 293 –– expert opinion 50, 126
–– fatalities 432
–– prevalences 67
B Childhood trauma 55, 135, 136
–– Questionnaire (CTQ) 135
Beliefs, negative 21, 271, 307 –– screener (CTS) 136
Benzodiazepines 188, 350, 351, 353–354, 356, 384, Children
430 –– autobiographical memory 402
–– for adjustment disorder 384 –– cognitive development level 400
Bibliotherapy 377, 379, 386 –– narrations 399
Biofeedback 434 –– pre-traumatic psychopathology 397
Biography work 476, 500 –– as witnesses 114
Blended therapy 380 Children and adolescents
Body-mind-spirit (BMS) therapy 383 –– developmental psychopathology model 298
Body test 188 –– drug abuse 417
Booster session 258 –– incidence of somatic 398
Borderline personality disorder (BPD) 50–52, 54, 90, –– prevalence rate for PTSD 397
94, 125, 140, 395, 396, 417 Children’s Impact of Event Scale 405
–– neurobiology 51 Child soldiers 112
–– children and young people 50 Citalopram 351, 365, 371
Brain spotting 279, 280 –– for PGD 371
Breast cancer 430, 433, 435 Clinician-Administered PTSD Scale (CAPS) 53, 129,
Breathing, controlled 415 168, 192, 329, 356
Bricolage 336 Clinician Administered PTSD Scale for Children and
Brief eclectic psychotherapy 229 Adolescents (CAPS-CA) 404, 406
Brofaromine 353 Clomipramine 351
Bronchial carcinoma 426, 432 Clonidine 355
529 A–D
Index
CoachPTSD App 449 Conspiracy of silence 513

Cognition, distorted 21 Contextual memory (C-reps) 32
Cognition, dysfunctional Control process, cognitive 35
–– children and adolescents 116 Coping 30, 38, 65, 80, 81, 128, 142, 144, 157, 178,
–– of parents 116 179, 183, 217, 218, 236, 240, 255, 265, 288, 289,
Cognitive behavioral therapy (CBT) 93, 186, 290, 291, 293, 301, 302, 304, 310, 311, 313, 314,
378, 381–382 318–321, 341, 363, 376, 377, 379, 380, 400, 402,
–– with confrontation 366 433, 448, 452, 480, 493, 498
–– culturally sensitive 207 –– avoiding 27
–– integrative 366–369 –– improvement 377
–– internet-based 369–370 Coping strategy 313
–– trauma-focused 186 –– age-specific 319
Combat fatigue 444 –– dysfunctional 289
Combat stress reaction 445 –– secondary 321
Communication 177, 183, 191, 250, 481 –– STAIR/narrative therapy 298–301, 303–313, 315
–– intercultural 412 Coronary heart disease 432
Communication style Coronary syndrome, acute 436
–– culturally divergent 21 Corpus callosum in maltreated children 117
–– of parents 21, 402 Cortex
Community-based program 286, 292–293 –– anterior cingulate 91
Comorbidity 23, 68, 84, 139, 205–206, 349, 352, 355, –– dorsal medial 96
366, 431, 495 Cortex prefrontal
Compassion 307, 319, 324, 325, 335, 336, 338, 368, 484 –– abused children 117
–– fatigue in torture victims and refugees 521 –– medial frontal 93, 96
–– Focused Therapy (CFT) 291 –– medial prefrontal 96
–– with others 307, 313, 320 –– prefrontal 91, 117
–– with yourself 307 –– ventromedial prefrontal 98
Compassionate 324, 328 Corticotropin-releasing hormone (CRH) 92
–– mindfulness 319 Cortisol level 82, 92, 383
–– self 307 Counter transfer 165–166, 170, 218, 224, 482
Compassion fatigue 24, 38, 39, 521 Crisis intervention 177, 183, 190, 192, 193, 287, 325,
Compensation claims 4, 163 452, 468, 471
Compensation, financial 515 Crisis model 80, 81
Compensation law, social 167, 169 Critical Incident Stress Debriefing for children and
Compensation scheme 155 young people 414
Completion tendency 30 Cultural group
Complicated grief 61, 62, 67, 69, 80, 138 –– African-American 342
–– dropout rates of treatment 511 –– Buddhist 339
–– group setting 287 –– Cambodian 344
–– treatment 363 –– Caribbean 339
Composite International Diagnostic Interview –– Islamic 339
(CIDI) 82, 128 –– Latin American 332, 338, 340, 341, 344
Comprehensive soldier fitness 178, 288 –– Southeast Asian 336, 338, 339, 341
Computerized cognitive behavioral therapy 290 Cultural sensitivity 210
Concentration difficulties 20, 349, 381 Cybervictimization
Conditioning 97–100 Cycle of abuse 115
–– classic 97
–– operante 30
Confrontation 94, 228, 249, 263, 265, 268, 271, 288, D
293, 314, 333, 335, 336, 362, 364, 366, 383
–– self-confrontation 291 Da-Costa syndrome 443
–– See also Exposure Data protection for internet-based
Confrontation in sensu interventions 290
–– children and young people 416 DBT-PTSD 252, 318, 319, 322–325, 328, 329
–– for heart diseases 432 –– effectiveness 370–371
Confrontation in vivo 263 –– proof of effectiveness 328–329
–– for PGD 367, 368 –– treatment phases 324, 325
530 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
Emergency care, psychosocial 177, 190 –– for PGD 362–366, 368–371

Emergency case 267, 291 Exposure in vivo
Emergency medicine 442 –– for PGD 236, 368, 414, 416
Emergency personnel 178, 183, 191 Exposure, prolonged 187, 206, 208, 228, 236, 245,
Emotional exposure 332, 334–336 246, 257, 303, 304, 312, 313
–– techniques 332 Exposure therapy
Emotionality, low 251 –– cycloser 98, 99
Emotional surfing 306, 309 –– narratives in children and teenagers 405
Emotion, secondary 24, 321, 406 –– for older people 497–499
Emotion switch 337 Exposure therapy, narrative
Empathy 38, 56, 166, 256, 415, 514 –– for children and teenagers (KIDNET) 119
Emptiness, feeling 357 –– torture victims and refugees 465, 474
Enduring personality change after extreme stress Expressive writing 293, 294
–– assessment 130 External hazard 432, 452, 454, 508, 510
Escape, mental 326 Externalization 221–225
Escape strategies 321, 326 Extinction 90, 97–100
Escitalopram 188, 356 Eye movement desensitization and reprocessing
Ethnopsychology 338 (EMDR) 187, 209, 262–279, 383, 450, 512
Etifoxine 384 –– for adjustment disorder, – 82, 83
Evaluation 6, 69, 79, 128–130, 134, 136–137, 143, –– for children 269, 277, 279, 407, 412
144, 155, 157, 159, 161, 167–170, 185, 187, 218, –– children and young people 279
231, 237, 247, 253, 278, 288, 289, 291, 294, 313, –– contraindications 268, 269
319, 320, 450, 480, 496 –– effectiveness studies 277–279
–– change 4 –– in early intervention 187, 188
–– dysfunctional 62, 240, 254 –– legal proceedings 269, 270
–– of results 144, 218 –– in military patients 451
Excitation control 453 –– for older people 262, 265
Excitation triad 344 –– phases 262–276
Exhibitionism 112, 118 –– resources EMDR 262, 263, 265–268, 279, 280
Experience of abuse 298–302, 318, 324, 326, 329, 353 –– stabilization phase 262, 266, 280
Expert opinion 24, 130, 154–156, 161, 162, 165, 166, Eysencks Personality Inventory (EPI) 163
168, 169
–– counter-transfer 22
–– exploration 154 F
–– migration background 163
–– social law 154, 156, 160 Family doctor 357, 497
–– test diagnostics 168 Fascia yoga 338
–– torture victims and refugees 462 Fear 5, 8, 9, 15, 18, 19, 21–23, 30–32, 35, 52, 68, 80,
Expert opinion, socio-medical 154, 155 93, 97–100, 108, 139, 158, 179, 182, 186, 224, 247,
Exploitation 300 268, 276, 277, 300, 303, 304, 308, 309, 319, 321,
–– in relationships 7 323, 327, 333–335, 340–343, 354, 363, 367, 395,
–– sexual 10 426, 427, 455, 476, 494, 511
Exploration 130, 134, 136, 154, 162, 163, 165–167, –– neurobiology 92, 95, 97
181, 250 –– psychotropic drugs 278, 348
–– appraisal 246 –– trauma-focused CBT 248
–– older adults 497 Fear conditioning 189
Exposure –– genetic factors 179
–– culturally adapted 332–334, 338 Fear reduction 99
–– interoceptive 333, 334, 340, 343 –– cycloser 99
–– prolonged 187, 206, 208, 228, 236, 245, 246, 257, Fear structure model 30, 276
303, 304, 312, 313 Feeling of danger 20, 36, 51, 517
–– prolonged with young people 412, 463 Fibromyalgia syndrome 434
–– self-controlled 119 Finding a mission 211
–– in sensu 186, 187, 364–366, 368, 407 Fire department 177, 190
–– in vivo 236, 368, 414, 416 First aid, mental 183, 184
Exposure, imaginative 187, 246, 247, 255, 381 First World War 6–8
Exposure in sensu Fitness, mental 288–289
532 Index
Flashback 19, 23, 33 Horse assisted intervention 451

–– torture victims and refugees 483 Hotspot 238, 244–248, 263, 270, 327, 478
Flexibility HPA axis, see Hypothalamus-pituitary-adrenal axis
–– acoustic symbol image 339 Humiliation 108, 319, 463
–– protocol 339 Humor as a resource 274
–– psychological 332, 336–340 Hydrocortisone 92, 93, 188, 356
–– visual 336 Hyperalgesia, pain-induced 434
Fluoxetine 278, 350–352, 511 Hyperarousal 15, 18, 19, 24, 68, 100, 131, 132, 134,
Follow-up contact 185 140, 427, 434
Forms of maltreatment, specific 114, 118 –– preoperative 433
Freezing 93, 100, 115 –– in somatic diseases 427
Frightening 20, 185, 222 Hypercortisolism 92
Frontal brain 56 Hypervigilance 20, 22, 257, 349, 355
Hypnosis 186
Hypnotherapy 208, 225, 262
G Hypocortisolism 92
Hypothalamic-pituitary-adrenal cortex (HPA)
Gamma-aminobutyric acid 179 axis 81, 92, 93, 100, 179
Genetic vulnerability 179 Hysteria 5–7
Genograms 367 –– traumatic 5, 216
Gerontopsychotherapy 497
–– integration of new media 499
Gestalt therapy I
–– for PGD 362, 366, 369
–– grief therapy 70, 362, 369 ICD-10 15, 23, 25, 49, 50, 76, 79, 83, 117, 127, 128,
Gingko bilboa 384 137, 139, 140, 142, 157, 167, 180, 181, 356, 357,
Glutamate 92, 94, 98 396, 427, 493
–– cytotoxic 92 ICD-11 167, 180
Grounding technology 252 –– acute stress reaction 21, 77, 137, 181, 357, 376,
Group therapy 379, 385
–– for cancer survivors 379 –– adjustment disorder 24, 76, 77, 79, 80, 83, 84, 137,
–– for STAIR/narrative therapy 305 138, 376, 379, 385, 428, 466
Group work –– complex PTSD 18, 19, 22, 24, 46–50, 52, 53, 204,
–– torture victims and refugees 471, 472, 484 417, 465
Guanfacine 355 –– diagnostics 21–23, 47, 53, 63, 69, 77, 125,
Gulf War syndrome 445 376, 496
–– physical illness 426
–– prolonged grief disorder 60–64, 66, 67, 69,
H 70, 138
–– PTSD 15, 18–21, 23–26, 49, 132, 135, 396
Habituation 7, 32, 98, 99, 141, 228, 244–246, 257, –– PTSD in children and adolescents 396, 417
288, 304 –– torture victims and refugees 5
Healing ritual 340 –– trauma criterion 15, 46, 49
Heart disease, acute 433, 436 ICG-R(revised) 69
Heart disease, coronary 432, 433 Idealization of the therapist 224
Heart transplantation 431 Identity disorder
Helplessness 15, 179, 182, 221, 222, 248, 255, 293, –– dissociative 52, 53
308, 311, 367, 426, 477, 484, 514 –– partial dissociative 52, 53
Herbal remedies for adjustment disorder 384 Imagery rescripting 237, 241, 248, 249, 251,
Hippocampal volume 90, 91, 94, 95, 179 280, 454
–– in animal model 100 –– and reprocessing 237, 248, 280, 454
Hippocampus 90 Impact of Event Scale-Revised (IES-R) 131, 132,
–– abused children 91, 94 433, 456
Holocaust 9, 23, 433, 494, 514 Implicit Association Test 97
Homework Index trauma 336, 338, 343
–– for PGD 369 Industrial accident 5
–– online-based personalized 380 Information overload 217
533 F–M
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
Method integration 229 Neurosis, traumatic 6

Mifepristone 92 Nightmare 219, 249, 276, 334, 342
Migrant 109, 169 –– cultural context 342
Military 7, 8, 55, 177, 445, 456 –– EMDR 262–279
–– CBT 382, 383 –– therapy 93
–– child soldiers 412 –– torture victims and refugees 2
–– resilience programs 286 Noncompliance 431
–– veterans 311 Non-suicide contract 325
Mindfulness 288, 319, 321, 324, 325, 333–336, 338, Noradrenaline-reuptake inhibitor 278, 350
339, 379, 380, 383, 469 Nucleus accumbens 55
Mindfulness intervention 226 Numbing 21, 35, 216
–– mindfulness-based 226 –– emotional 53
Minnesota Multiphasic Personality Inventory –– psychotropic drugs 348, 349, 351, 353, 384, 385
(MMPI) 163
Mirtazapine 350–352, 357, 476
Misperception 23 O
Moclobemide 351, 353
Model, cognitive 34–36, 70, 237, 240, 252, 365, 399 Olanzapine, 351, 355, 356
–– children 12 Old age psychotherapy 108
Model, interpersonal-socio cognitive 29 Older adults
Model learning 401 –– exploration 92, 134
Mood stabilizers 354, 357 –– use of psychotherapeuticm 108
Moral violations 455 –– violence against, 108
Morphometry, voxel-based 91 On Scene Support Service 191
Mortality Operant conditioning 30
–– after transplantation 431, 432 Operational force
–– cardioverter defibrillator 432 –– awareness-raising programs 293
Multiple traumatization of children 207 –– low-threshold programs 288
Multiplex model of PTSD origin 332, 334, 341, 342 Opioid system
Munchausen by Proxy syndrome 108 –– antagonists 94
Muscle relaxation 334, 337, 338, 343, 453, 476 –– dissociation 94
Myocardial infarction 428, 430
Myth creation 415
MyTraumaRecovery (MTR) 291 P
Panic
N –– disorder 77, 105, 139, 181, 278, 344, 352
–– nocturnal 335
Nalmefene 355 –– psychotropic drugs 348
Naloxone 94 Parent role 400, 403
Naltrexone 94, 101, 355 Parents
Narration –– of children with cancer 436
–– of children 399 –– orphaned 24
–– for PGD 371 –– as therapists 414, 416, 417
Narrative 80, 187, 248, 301, 303–305, 312, 477, 498 Paroxetine 188, 348, 352, 356, 357, 511
Natural disaster 17, 25, 177, 292, 395, 428 Patient, extremely dangerous 15
–– older adults Peer intervention 293
–– traumatized children 396 Peer support 379
Network model, multisystemic 332, 337 Performance 56, 99, 117, 167, 168, 307, 340, 398, 406
Network, professional 522 –– objectification 167, 168
Neurasthenia 6–8 Peritraumatic Emotions Questionnaire 182
–– traumatic 5 Perpetual avoidance model 434
Neurobiology 100 Persistent complex bereavement disorder (PCBD)
–– children and young people 90, 94, 100 62, 69
Neuroleptics 355, 357 Personality 9, 30, 49, 52, 81, 140, 166, 168, 217, 222,
Neuroleptics, atypical 355 230, 357, 400, 479
–– See also Atypical antipsychotics –– children and young people 220, 224
535 M–P
Index
–– narcissistic 220, 224 –– selective 178

–– restructuring 224 –– structural 177
Personality change, enduring –– universal 177
–– after extreme stress 167 Primary prevention 448
Personality style 220–224 –– with the German Armed Forces 447
Personality traits 28, 164, 180, 322, 513 Priming, perceptual 29
PGD, See Persistent grief disorder Prisoner of war 157
Pharmacotherapy –– appraisal 161
–– dropout rate 511 Problems 29, 38, 46–49, 54, 55, 61, 64, 77, 78, 80, 83,
–– guidelines 350 119, 142, 144, 168, 169, 179, 191, 208, 218, 219,
–– in neurobiology 90 225, 227, 236, 240, 243, 257, 263, 264, 269, 290,
–– for PGD 363, 369 291, 294, 298–302, 308, 312, 313, 318, 323, 325,
Phenelzine 352, 353 336, 341, 342, 357, 398, 403, 492, 508, 515, 517
Phenytoin 94, 354 –– trauma prevalence 493
Phobia, social 139 –– vulnerability 179
–– cycloser 99 Problem solving therapy for adjustment
Police 115, 177, 178, 190, 249 disorder 383
–– assessment of work-related accidents 169 Prolonged exposure 187, 207, 208, 245, 257, 282,
Polyvictimization in children 114 284, 303
Post-migration stressors 180, 464, 466 Prolonged Grief-13 (PG-13) 138
Posttraumatic Adjustment Scale (PAS) 182 Prolonged grief disorder (PGD) 60–70, 126, 138,
Posttraumatic cognitions 216, 253 362, 370, 465
Posttraumatic Cognitions Inventory (PTCI) 141, 253 –– citalopram 365
Posttraumatic Diagnostic Scale (PDS) 132 –– cognitive behavioral therapy 378
Posttraumatic growth 30 –– complicated grief treatment 362–365
Post-Traumatic Growth Inventory (PTGI) 142 –– death of a child 70
Posttraumatic stress disorder (PTSD) 82, 348, 357, –– definition 60
383, 465 –– distribution 3, 8
–– after transplants 431 –– DSM-5 62
–– animal models, , – 90, 99, 100 –– event factors 70
–– chronic pain 434 –– gestalt therapy 70
–– classic 46, 50, 56, 167, 204, 465 –– ICD-11 2
–– complex, torture victims and refugees 465 –– internet-based cognitive behavioral
–– delayed 26, 167, 494 therapy 366
–– differential diagnostics 396 –– interpersonal therapy 381
–– dissociative subtype 48 –– and major depression 68
–– epidemiology 25–26 –– person-specific factors 70
–– gender differences 110 –– pharmacotherapy 363
–– history of the term 164 –– and PTSD 68
–– partial 137, 159 –– social sharing 292
–– partnership crises 142 –– supportive therapy 366
–– prevalence among the elderly 494 –– systemic therapy 468
–– resources and competencies 141 –– time reference criterion 6
–– secondary 521 Propanolol 99, 355
–– specific features for children and adolescents 21 Psychiatry, transcultural 341
–– subsyndromal 430 Psychobiology 81, 384
–– torture victims and refugees 2 Psychodynamic imaginative trauma therapy
–– trauma criteria 426 (PITT) 190, 225, 228, 229
–– type of traumatization 319 Psychoeducation 185, 257, 286–287, 291, 293, 302,
–– unemployment 137 363, 365, 368, 370, 379, 415, 448, 516
Prazosin 355 –– for PGD 363, 365, 370
Preoccupation 60–63, 68, 77, 80, 428, 466, 522 –– with the German Armed Forces 292
–– for physical diseases 427 –– specific 270
–– intrusive 381, 383 –– teenagers 405
Present-oriented therapy 207 Psychological debriefing 189
Prevention –– children and young people 189
–– primary 177 Psychological support 190, 191, 218, 466
536 Index
Psychology Relationship building 302, 363, 366, 451, 453

–– ethnopsychology 338 –– in military environment 453
–– humanistic 288 Relationship, therapeutic 119, 263, 264, 302,
–– operative 10 312, 314, 323, 326, 341, 382, 453, 478, 482,
–– positive 288, 290, 380 515–517, 521
Psycho-oncology 433 Relatives
Psychopathology 99, 100, 166, 401, 407 –– gerontopsychiatry 497
–– maternal 402 –– questionnaire 38
–– parental 400, 412 –– somatic patient 83
–– pre-traumatic 402 –– as therapy seekers 508
–– pre-traumatic in children 397 –– work with relatives in Armed Forces
Psychopharmacotherapy Hospitals 450
–– for adjustment disorder 382 Relaxation method 267, 415
–– for children and young people 348 –– children and young people 267
–– indications 348–350 Retirement 26, 154
–– studies 348 Rumination 24, 77, 179, 257, 365, 366, 401, 511
Psychosis 6 –– in PGD 366
–– EMDR, 287
–– organic 430
–– psychotropic drugs 349, 353 S
–– STAIR/narrative therapy 298
Psychotherapy 31, 35, 52, 98, 99, 165, 169, 185, 190, Sacrificial experience 340
204, 208, 209, 220, 229, 263, 264, 268, 277, 278, Save place 227–229, 262, 268, 270, 275
287, 288, 294, 323, 348, 357, 365, 368, 371, Self-management skills
378–382, 384, 385, 396, 413, 468, 471, 481, 482, –– for guilt, shame, anger 162, 182, 207
492, 496–497, 499, 508 –– at post-traumatic adjustment 137, 142
–– for adjustment failure 429 Self-medication 218, 349, 398
–– cognitive 217 Sense of autonomy 28
–– cognitive with older people 432 Sense of coherence 29, 81, 180
–– dropout rates 511–512 Shifts of meaning 221–223
–– integrative psychodynamic-cognitive 216–217 Spiritual orientation 522
–– interpersonal 228 Stress disorder 15, 22, 77, 91, 116–118, 126, 127, 133,
–– interpersonal for PGD 221 134, 137, 154, 176, 181, 183, 184, 192, 216, 225,
–– mindfulness meditation 190 236, 242, 286, 298, 348, 356, 357, 364, 369, 370,
–– proof of effectiveness 328–329 383, 404, 455, 462, 508, 519
–– psychodynamic for adjustment disorder 396 –– acute 21, 24, 80, 180, 181, 402, 427
–– psychodynamic with torture victims and refu- –– children and young people 113
gees 8–9 –– chronic 28, 176
–– supportive 184 –– development 4
–– supportive for PGD 365 –– diagnostics 125
–– torture victims and refugees 2–3 –– trauma-focused CBT 119, 186
–– transcultural 480 Stressful childhood experiences 135, 136
–– trauma-focused 8 Stress reaction
Psychotherapy for children and adolescents 414 –– acute 21, 77
–– effect size 209 –– diagnostics 137
–– prevalence in somatic diseases 379
–– psychotropic drugs 384, 385
R Support 32, 38, 63, 94, 115, 119, 125, 126, 142, 154,
165, 168, 169, 176, 180, 183–185, 189, 192, 193,
Railroad accidents 4, 6, 10 211, 218, 221, 224, 226, 227, 236, 243, 245, 246,
Reduction of interests 21, 349 258, 264, 267, 268, 272, 291, 299, 303, 307, 308,
Regulation of emotions 310–313, 320, 324, 326, 328, 364, 376, 377,
–– culturally adapted techniques 332–334, 338, 340 379–383, 401, 442, 448, 467, 476, 480, 497,
–– deficits 299 515, 522
–– neurobiology 47, 54 –– cognitive changes 497
–– religious techniques 340 –– measuring instruments 496
537 P–Y
Index
–– mortality in PTSD 431 V

–– PTSD prevalence 431
–– stigmatization of psychological 448 Ventilation, artificial 428
Violence, in marriage, screening 93, 474, 500
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

Trauma Sequelae (Libro)

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Trauma Sequelae (Libro)

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Andreas Maercker Editor

ISBN 978-3-662-64059-3 ISBN 978-3-662-64057-9 (eBook)

Preface to the Fifth Edition

2 Post-traumatic Stress Disorder............................................................................................. 13

3 Complex PTSD.................................................................................................................................. 45

4 Prolonged Grief Disorder......................................................................................................... 59

5 Adjustment Disorder................................................................................................................... 75

7 Childhood Violence and Its Consequences................................................................... 107

8 Diagnostics and Differential Diagnostics...................................................................... 123

9 Expert Evidence.............................................................................................................................. 153

11 Systematics and Effectiveness of Therapy Methods............................................... 203

12 Psychodynamic Treatment of People with Trauma Sequelae........................... 215

13 Cognitive Behavioural Therapy............................................................................................ 235

14 Eye Movement Desensitization and Reprocessing (EMDR)............................... 261

15 Low-Threshold and Innovative Interventions............................................................. 285

16 Treatment of Complex PTSD with STAIR/Narrative Therapy............................. 297

17 Dialectical-Behavior Therapy for Complex PTSD...................................................... 317

18 Approaches of Culturally Adapted Cognitive Behavioural Therapy............ 331

19 Psychopharmacotherapy of Trauma Sequelae........................................................... 347

20 Therapy of Prolonged Grief Disorder............................................................................... 361

21 Therapy of the Adjustment Disorder................................................................................ 375

III Specific Aspects

23  ost-traumatic Stress Disorders in Physical

25 Torture Survivors and Traumatised Refugees............................................................ 461

27 Special Features of Treatment and Self-Care for Trauma Therapists........... 507

J. Angenendt Department of Psychiatry and Psychotherapy, Psychotraumatological

M. Augsburger Division of Psychopathology and Clinical Intervention, Department of Psy-

R. Bachem Psychopathology and Clinical Intervention, University of Zurich, Zurich,

K. Barre German Armed Forces Hospital Hamburg, Hamburg, Germany

M. Bauer Department of Psychiatry and Psychotherapy, Dresden University of Technology,

H. Baumeister Department of Clinical Psychology and Psychotherapy, Institute of Psychol-

K. Becker-Nehring Education and Consulting Center, Promotional Focus on Hearing,

J. Bengel Institute for Psychology, Department of Rehabilitation Psychology and

K. -H. Biesold German Armed Forces Hospital Hamburg, Hamburg, Germany

M. Bohus Heidelberg University, Heidelberg, Germany

J. Borowski Department of Psychiatry and Psychotherapy, University Medical Center Ham-

M. Böttche Center ÜBERLEBEN, Berlin, Germany

A. Brink Department of Psychotraumatology, Unfallkrankenhaus Berlin, Berlin, Germany

H. Comtesse Clinical and Biological Psychology, Catholic University Eichstätt-­Ingolstadt,

M. Domhardt Department of Clinical Psychology and Psychotherapy, Institute of Psychol-

T. Ehring Department of Psychology, Clinical Psychology and Psychotherapy, Ludwig-­

U. Frommberger Department of Psychiatry and Psychotherapy, University Medical Center

J. Hillebrecht Institute of Psychology, Department of Rehabilitation Psychology and

C. Killikelly Division of Psychopathology and Clinical Intervention, University of Zurich,

C. Knaevelsrud Clinical-Psychological Intervention, Freie Universität Berlin, Berlin,

V. Köllner Department of Psychosomatic Medicine, Rehabilitation Center Seehof, Federal

P. Kuwert University Medicine Greifswald, Greifswald, Germany

M. A. Landolt Department of Psychology - Division of Child and Adolescent Health Psy-

A. Maercker Division of Psychopathology and Clinical Intervention, Department of

R. Rosner Clinical and Biological Psychology, Catholic University Eichstätt-Ingolstadt,

I. Schäfer Department of Psychiatry and Psychotherapy, University Medical Center

C. Schmahl Department of Psychosomatic Medicine and Psychotherapy, Central Institute

O. Schubbe Institut für Traumatherapie Oliver Schubbe, Berlin, Germany

M. Schützwohl Department of Psychiatry and Psychotherapy, Dresden University of

E. Severus Department of Psychiatry and Psychotherapy, Dresden University of Technology,

N. Stammel Center ÜBERLEBEN, Berlin, Germany

R. Steil Institute of Psychology, Department of Clinical Psychology and Psychotherapy,

S. Trautmann Medical School Hamburg, Am Kaiserkai 1, Hamburg, Germany

M. Wenk-Ansohn Center ÜBERLEBEN, Berlin, Germany

L. Wittmann International Psychoanalytic University, Berlin, Germany

P. Zimmermann Armed Forces Hospital Berlin, Berlin, Germany

Chapter 1  he History of Psychotraumatology – 3

Chapter 2  ost-traumatic Stress Disorder – 13

2 Post-traumatic Stress Disorder............................................................................................. 13

3 Complex PTSD.................................................................................................................................. 45

4 Prolonged Grief Disorder......................................................................................................... 59

5 Adjustment Disorder................................................................................................................... 75

7 Childhood Violence and Its Consequences................................................................... 107

8 Diagnostics and Differential Diagnostics...................................................................... 123

9 Expert Evidence.............................................................................................................................. 153

11 Systematics and Effectiveness of Therapy Methods............................................... 203

12 Psychodynamic Treatment of People with Trauma Sequelae........................... 215

13 Cognitive Behavioural Therapy............................................................................................ 235

14 Eye Movement Desensitization and Reprocessing (EMDR)............................... 261

15 Low-Threshold and Innovative Interventions............................................................. 285

16 Treatment of Complex PTSD with STAIR/Narrative Therapy............................. 297

17 Dialectical-Behavior Therapy for Complex PTSD...................................................... 317

18 Approaches of Culturally Adapted Cognitive Behavioural Therapy............ 331

19 Psychopharmacotherapy of Trauma Sequelae........................................................... 347

20 Therapy of Prolonged Grief Disorder............................................................................... 361

21 Therapy of the Adjustment Disorder................................................................................ 375

23 ost-traumatic Stress Disorders in Physical

25 Torture Survivors and Traumatised Refugees............................................................ 461

27 Special Features of Treatment and Self-Care for Trauma Therapists........... 507

H. Comtesse Clinical and Biological Psychology, Catholic University Eichstätt-Ingolstadt,

T. Ehring Department of Psychology, Clinical Psychology and Psychotherapy, Ludwig-

Chapter 1 he History of Psychotraumatology – 3

Chapter 2 ost-traumatic Stress Disorder – 13

Chapter 3 Complex PTSD – 45

Chapter4 rolonged Grief Disorder – 59

Chapter 5 Adjustment Disorder – 75

Chapter 7 hildhood Violence and Its Consequences – 107

Chapter 8 iagnostics and Differential Diagnostics – 123

Chapter 9 Expert Evidence – 153

1.1 Of the Diversity of Diagnoses – 4

1.2 Nervous Disorders and War – 7

1.3 Discussion After 1945 – 9

Psychological reactions to shocking events 1.1 Of the Diversity of Diagnoses

2.1 Definition of Trauma and Trauma Types – 15

2.2 Clinical Picture of PTSD – 18

2.3 PTSD in the Context of Stress-Related Disorders – 24

2.4 Epidemiology and Course of PTSD – 25

2.5 he Development of PTSD: A Multifactorial Framework

2.6 Memory Models – 30

2.8 The Social-Interpersonal Model – 36

2.1.2 Classification of Traumas by low predictability of further traumatic

2.2 Clinical Picture of PTSD

Case Study: Victim of a Criminal Attack

2.2.1 Symptom Triad of PTSD Symptoms of re-experience can occur in the

Abbreviation Explanations ICD-11- DSM-5-

2.2.1.2 Avoidance (hyperarousal). . Table 2.4 describes indi-

Abbreviation Explanations ICD-11 DSM-5

studies, it appears that it has been possible to 2.2.4.2 Shame and Guilt

the trauma victim or have professional deal- 2.3 PTSD in the Context

2.4 Epidemiology and Course In Germany, for example, a 1-month preva-

2.5.5 Post-traumatic Processes

2.7 Cognitive Models ►►Example 1: Changed the World Scheme

2.7.1 Altered Cognitive Schemata 2.7.1.1 Cognitive-Psychodynamic