Healing wounded trees: clinicians' perspectives on treatment of complex posttraumatic stress disorder.

While treatment guidelines agree on the first-line interventions for the treatment of posttraumatic stress disorder (PTSD), there is an ongoing debate between experts regarding the treatment of complex posttraumatic stress disorder (C-PTSD). As scientific research is slowly emerging, different treatment approaches are used in clinical practice This article aims to provide a set of treatment options for C-PTSD in adult survivors of repeated exposure to severe violence and abuse, both in childhood and later on in life. The developmental-contextual perspective on mental health forms the basis of this approach. This perspective is elaborated using the tree metaphor. Then, several treatment strategies are suggested. The presented strategies are a combination of the existing evidence-based approaches for the treatment of PTSD and personality disorders. They target psychological damage in survivors while taking their developmental trajectories and ecological environments into consideration. The treatment model presented is based on longstanding clinical practice and it may be a promising framework for treating C-PTSD. However, it still needs to be scientifically examined for acceptability and effectiveness.

A randomized controlled trial to pilot the efficacy of a computer-based intervention with elements of virtual reality and limited therapist assistance for the treatment of post-traumatic stress disorder.

Although well-established therapies exist for post-traumatic stress disorder (PTSD), barriers to seek mental health care are high. Technology-based interventions may play a role in improving the reach of efforts to treat, especially when therapist availability is low. The goal of the current randomized controlled trial was to pilot the efficacy of a computer-based trauma intervention with elements of virtual reality (VR; 3MR system) and limited therapist involvement for the treatment of PTSD in a childhood sexual abuse (CSA) and war veteran sample and to compare this to "treatment as usual" (TAU). TAU consisted of evidence-based approaches such as imaginal exposure, EMDR, or narrative exposure therapy. A total of 44 patients with PTSD were included and randomly assigned to 12 sessions of 3MR intervention or TAU (completer n 3MR = 12, TAU = 18). Several measures (PCL-5, BDI-II, OQ-45-2, and the M.I.N.I. 5.0.0.) were administered to measure symptoms of PTSD and depression and scores of overall well-being at pre, post, and a three-month follow-up measurement. Analyses suggest that symptoms of PTSD and depression in the 3MR condition decreased, and overall well-being increased between pre and post measurements. Results did not indicate any clear differences between the treatment conditions over time which suggests that treatment gains of the 3MR intervention seem no less than those of TAU. Finally, both treatment conditions produced similar remission rates of PTSD and depression. Therefore, the 3MR intervention could possibly constitute an appropriate treatment alternative. The small sample size as well as evident drop-out rates in the 3MR condition (45%) do warrant further research. The procedures of this study were approved by the Medical Ethical Research Committee (MERC) of the Erasmus Medical Center in Rotterdam (MEC-NL46279.078.13) and pre-registered via ClinicalTrials.gov (Protocol Record CI1-12-S028-1).

"Hidden" and Diverse Long-Term Impacts of Exposure to War and Violence.

Nowadays, the PTSD diagnosis is often a prerequisite for the survivor's access to specialized treatment services and for obtaining legal recognition or financial compensation when exposed to violence. However, some survivors do not meet all necessary criteria for the PTSD diagnosis, particularly not in the long term. Therefore, they run the risk of being misdiagnosed, inadequately helped or undertreated, and may remain legally unrecognized and unprotected. In this article the "hidden" long-term impacts of exposure to war and violence, beyond the PTSD diagnosis, are presented, discussed, and illustrated with case presentations. They include dissociative states, attachment problems, personality changes, guilt, shame, rage, identity issues, moral injury, substances abuse, damaged core beliefs, and bodily sensations linked to stress activation. These phenomena are not persistent, but fluctuate over the survivor's life trajectories. Moreover, the "hidden" impacts are framed within theoretical models for understanding long-term impacts of exposure to violence. The models help us grasp the dynamics of interactions between resilience, psychological damage, context and time. These interactions are non linear, and contingently result in development of psychopathological phenomena when reaching a threshold during a process of accumulating potentially traumatic experiences over a survivors' lifetime. Understanding psychological impacts of exposure to violence as a spectrum of interchangeable phenomena over a lifetime, and learning to recognize the "hidden" manifestations of psychological trauma will help to improve mental and legal assistance to the survivors both on a short and long term.