Last updated: April 25, 2019 at 14:27 pm
In this podcast episode, we explore the world of complex PTSD with Dr. Martin Bohus. Dr. Bohus is the Chair of the Psychosomatic Medicine and Psychotherapy department in Heidelberg University and the scientific director of the Psychiatric and Psychosomatic Psychotherapy Institute in Mannheim, Germany.
Your host is Dr. Wegdan Rashad.
- Complex PTSD is a term used to describe patients with borderline personality disorder comorbid with PTSD.
- DBT-PTSD addresses traumatic memory processing, self-concept, and social interactions. It also has a strong motivational component.
- DBT-PTSD takes 40 to 45 sessions. It can be administered over a year, 6 months or 3 months.
Below we provide a text version of the audio. This transcript has been edited for clarity.
A borderline patient is gifted by a hypersensitive emotional system. And if you treat them adequately and have success, you will help them to create a very rich life. So, change your attitude towards borderline patients and see the rich part in them.
That was Dr. Martin Bohus. I am Dr. Wegdan Rashad and you are listening to the Psychotherapy Academy podcast!
This is the first episode of Psychotherapy Academy. We are very excited to launch this podcast because we believe that therapists do an incredibly important job and we would like to help you practice psychotherapy even better. So, if your work involves providing psychotherapy or counseling to clients, this is the podcast for you. We will be covering psychotherapy issues that matter to you and sometimes even new therapeutic techniques.
Today, we will be exploring the world of complex PTSD; what it is and how to treat it. We will be using snippets from an interview at the ABCT Annual Convention with Dr. Martin Bohus. Dr. Bohus is the Chair of the Psychosomatic Medicine and Psychotherapy department in Heidelberg University and the scientific director of the Psychiatric and Psychosomatic Psychotherapy Institute in Mannheim, Germany.
Defining Complex PTSD
So, first things first. What IS complex PTSD?
So, since 2018, ICD-11 came up with a new diagnosis called complex PTSD which shows a great overlap in patients with borderline personality plus co-occurring PTSD. What they have in common is those patients mostly suffer from the experience of continuous perpetuating childhood abuse or sexual and/or physical abuse. And they mostly grow up in an environment which is simply non-protective and unpredictable.
Aha! So, complex PTSD means a person with borderline personality disorder plus PTSD. And they seek help from you, the therapist. But how different is it from the PTSD that we know?
At the subjective level, they experience this as intermittent, explosive high levels of tension which seem to be unbearable. And the second thing they suffer from is a very negative self-concept. They see themselves as unworthy, ugly, bad, as not having a life worth living. The third component is interpersonal problems. Most of them have difficulties with intimacy and trusting others; they often misinterpret neutral situations, and have trouble perceiving and processing positive social signals.
So, in addition to the symptoms of PTSD, the experience is darkened by intermittent tension, negative self-concept, and problems with trust and intimacy. I would think that this makes therapy for a patient with complex PTSD a tricky business indeed.
Understanding the Trauma Network
Now Dr. Bohus mentioned that some emotions trigger a so-called “Trauma Network”. Do tell us more.
The trauma network is an association between emotions, cognitions, pictures, sensory inputs and physical inputs which are closely related to traumatic experience. This is a model; nobody has seen the trauma network. If you activate one node of this network, all the other nodes will become activated. For instance, if you smell the odor of a perfume which reminds you of your perpetrator, all of a sudden, the fear system is activated and your self-system is activated and you have pictures and you even have the physical appearance. This is what we call the network. Patients often don’t know that this network is activated. They simply think they are stupid or that something is completely out of control.
One very helpful thing we can do is to educate the patient about this trauma network. Sometimes just knowing what’s going on can help.
The Core Idea Behind Complex PTSD Therapy
Now practically speaking, what is the core idea behind complex PTSD therapy?
We train the brain so the patient understands that these experiences belong in the past, that these emotions are currently different than in the past and that you can survive the current experience of powerlessness and you don’t have to avoid these things. And the only way to disentangle this response/reaction pattern — this means that every cue is like a flash activated in the trauma network which then gets out of control — is by re-experiencing in the here and now and having the brain learn the difference between the present and the past.
Working on Domains
What specific domains do we need to work on?
The one mechanism is memory processing. The second mechanism is self-concept. The third mechanism is social interaction and developing of trust. And these are different techniques to help people to improve these three or four domains. And the treatment we developed is a package, a blending of four different techniques which are closely interwoven with a nice algorithm so that therapists really know what to tackle when. There is a very strong motivational part since patients are afraid of this kind of psychotherapy. They need to be motivated, encouraged, cheered on, and supported.
Steps and Duration of DBT-PTSD
This treatment package that Dr. Bohus is talking about is called DBT-PTSD. Like regular dialectical behavioral therapy, it helps patients’ emotional regulation and interpersonal effectiveness. But it is also quite different from DBT, as it has a clear focus on trauma. Let’s follow along with the steps of DBT-PTSD.
First, we will get a short overview of your life history. Second, we will work with you and explain to you how your PTSD functions. We explain to you how your brain works. Third, we work with you so that you discover your own escape and avoidance strategies. Then we teach you skills on how to cope with dissociation, strong emotions, and strong aversive tension.
Quick recap. 1. We take a full history, 2. educate the patient about PTSD and the trauma network, 3. teach coping skills.
Then we define an index trauma which we first tackle. Then we will go through a guided exposure. Then we work on radical acceptance of the past. And then we have about 10 sessions to help you develop and regain a new life, since this treatment will be so effective that you’ll need to design a new life.
- define a specific trauma to tackle 5. guided exposure 6. Work on acceptance of the past and finally sessions on planning for a new life. Hopefully, PTSD-free!
I can’t help but think that this is going to take some time. I wonder how long this therapy lasts for?
All in all, it takes about 40, 45 sessions. You can provide one session weekly for a year. You can condense it and provide two sessions a week for six months. You can also do it in three months, which is four sessions a week.
Effectiveness of DBT-PTSD
Now, this is all very good. But just how effective is this therapy?
Well, in 2013, Dr. Bohus and his team conducted a randomized controlled study on women with PTSD secondary to childhood sexual abuse. Women who underwent DBT-PTSD showed a response rate of 40% compared to the control group at 3%. I think it’s important to note that these ladies had treatment-resistant PTSD.
A more recent trial published in 2018 by Dr. Steil et al showed some impressive results. By the end of the study, in the post-assessment, nearly 80% of patients no longer fulfilled the criteria for PTSD AND 100% of them no longer met criteria for borderline personality disorder! Wow! These findings were found only in those who completed the intervention to the end. Keep in mind, however, that this study was conducted on only 14 patients in an outpatient setting.
We’ve covered a lot! We spoke about the guiding principles for the treatment of complex-PTSD. We also went through the steps of DBT-PTSD and found out just how effective it is.
I asked Dr. Bohus about some important messages we can take home with us.
First, take these patients seriously and make it clear that their behavior makes sense. It may look crazy and weird. However, this is the best thing they can do to cope with unbearable pain. Second thing is to validate this. This means tell patients that their behavior makes sense on the one hand. On the other hand, encourage them by explaining that it’s possible to cope with this problem — this emotion dysregulation — a little bit more adequately. Then third, I think it’s a question of balance. So, you have to find a balance between taking care of these patients and giving them their own responsibility for themselves. And this is a complicated thing. And the moment you don’t take care of them, they will go after you since they really need somebody. On the other hand, if you take it too much, then they give every responsibility to you and they give up their work. You have to provide them tools and this is I think very important. The more severe the patients are, the more tools they need.
Excellent points! Thanks, Dr. Bohus
Now, that’s about it for today’s podcast. And now let’s return to our safe place, the key points.
- Complex PTSD occurs in patients with borderline personality disorder comorbid with PTSD.
- In addition to PTSD symptoms, patients experience intermittent tension, negative self-concept, and problems with trust and intimacy.
- The trauma network is a model that associates emotions, cognitions, pictures, sensory and physical inputs. These are closely related to traumatic experiences.
- DBT-PTSD addresses traumatic memory processing, self-concept, and social interaction. It also has a strong motivational component.
- The steps of DBT-PTSD include taking a full history, education, coping skills, tackling a specific trauma, guided exposure, acceptance, and planning for a new life.
- This therapy takes 40 to 45 sessions. It can be administered over a year, 6 months or 3 months.
- DBT-PTSD has been shown to be effective, in varying degrees for both PTSD and borderline personality disorder symptoms. Bigger RCTs are needed to define more clearly its effectiveness.
Did you enjoy this podcast? Stay tuned for more episodes and be sure to check out our website psychotherapyacademy.org. When you go there, you’ll find that we’ve just released a new module on DBT basics. Covering dialectical behavioral therapy from step one.
The following people participated in this episode: Drs. Jessica Diaz and Flavio Guzman as content advisors, Mark Young as the audio engineer, Pamela Gonzalez as the project manager, and myself Dr. Wegdan Rashad as the host. We’d also like to thank Dr. Martin Bohus for being with us.
Thank you for tuning into Psychotherapy Academy. We hope to see you soon, bye!
- Bohus, M., Dyer, A. S., Priebe, K., Krüger, A., Kleindienst, N., Schmahl, C., … & Steil, R. (2013). Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: a randomised controlled trial. Psychotherapy and psychosomatics, 82(4), 221-233.
- Steil, R., Dittmann, C., Müller-Engelmann, M., Dyer, A., Maasch, A. M., & Priebe, K. (2018). Dialectical behaviour therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study in an outpatient treatment setting. European journal of psychotraumatology, 9(1), 1423832.