I wrote yesterday about Marylene Cloitre et al's fine recent research study "Treatment for PTSD Related to Childhood Abuse: A Randomized Controlled Trial." I ended the post with the paragraph: For me, her work is both exciting and also raises a whole series of questions.  These include 1.) Would her skills-based plus trauma processing approach be relevant for others suffering from particularly severe forms of PTSD (e.g. some torture victims & sufferers from prolonged domestic violence) as well as for survivors of child abuse?  2.) How does this research relate to Arnoud Arntz's work treating sufferers from borderline personality disorder?  3.)  Cloitre reports an intervention that only takes 16 sessions for complex, difficult cases.  How much is her treatment very time efficient and how much has she undertreated these patients who might have done better with more prolonged work?  4.)  What is involved in her skills-training module (an adaptation of dialectical behaviour therapy) and are there lessons here for other patients?  5.)  Arntz talks about the "limited re-parenting" involved in his work.  Cloitre discusses attachment issues and the importance of the therapeutic alliance.  Are there lessons here?  6.)  Was Cloitre's trauma processing treatment component as good as it could have been e.g. comparing it with Ehlers & Clark's version of trauma-focused CBT?   

Taking these points in turn - 1.) Would her skills-based plus trauma processing approach be relevant for others suffering from particularly severe forms of PTSD (e.g. some torture victims & sufferers from prolonged domestic violence) as well as for survivors of child abuse?  Richard Bryant, in his excellent linked editorial "The Complexity of Complex PTSD" makes this point, stating "Cloitre et al. admitted patients to their study on the basis of PTSD secondary to childhood abuse. The definition of complex PTSD should instead be based on an operational definition of measurable indices of emotion dysregulation rather than a history of childhood abuse. Survivors of childhood abuse can present with PTSD and not have marked difficulties with emotion regulation. Conversely, PTSD patients who suffer trauma as an adult can present with marked emotion dysregulation deficits. Refugees, torture victims, or survivors of prolonged interpersonal violence may have difficulties managing emotional distress. Any definition of complex PTSD should center on current symptomatology rather than on historical precedent."  It seems quite possible that many or most sufferers from more complex PTSD with marked emotion regulation difficulties - whether the PTSD has its origins in childhood or not - would respond better to Cloitre's adaptation of trauma-focused CBT (with its addition of skills training in affect & interpersonal regulation - "STAIR") than to the more narrowly targeted standard form of trauma-focused CBT.

My second question 2.) How does this research relate to Arnoud Arntz's work treating sufferers from borderline personality disorder? is also addressed in Bryant's editorial with his comment "Complex PTSD is not formally recognized by DSM-IV, or the proposed DSM-5, as a distinct construct. Although DSM-IV lists emotion dysregulation as an associated feature of PTSD, the construct is generally conceptualized as a form of PTSD in which the patient has especially marked impairment in regulating their emotions, which results in maladaptive responses to extreme emotions, including self-harm, risky sexual or spending behavior, and chaotic interpersonal relationships. It shares certain properties with borderline personality disorder, but the latter is distinguished by its emphasis on severe behavioral and emotional dysregulation and fear of abandonment rather than PTSD symptoms. Whereas some studies of borderline personality report increased reactivity to stimuli, as would be expected in patients with PTSD, others have found that patients with borderline personality disorder are characterized by elevated tonic levels of emotional intensity but not increased reactivity."  My personal take on this is that both PTSD and borderline personality disorder are fairly broad diagnoses that scoop in groups of people who differ - often importantly - in their symptoms.  See for example James Chu's recent paper "Posttraumatic stress disorder: beyond DSM-IV" where he states "While the DSM-IV criteria for PTSD are useful in defining the disorder and distinguishing it from other diagnostic categories, there are important characteristics and subtypes commonly seen in clinical practice that affect its clinical course and response to treatment".  So one simple response to this would be to treat standard PTSD with trauma-focused cognitive therapy, precede this approach with Cloitre's STAIR module for those presenting a more emotional/interpersonal chaotic picture, and consider prolonging the therapy with additions from Arntz's treatment of borderline personality disorder or more extended application of dialectical behavior therapy for those whose emotional/interpersonal dysregulatory symptoms/behaviours are not adequately addressed by the limited eight session STAIR approach.

This leads naturally into my third question 3.) Cloitre reports an intervention that only takes 16 sessions for complex, difficult cases.  How much is her treatment very time efficient and how much has she undertreated these patients who might have done better with more prolonged work?  Well maybe - as is so often is the case - the answer is a bit of both!  Cloitre reports "The STAIR/Exposure (full therapy package) group was more likely to achieve sustained and full PTSD remission relative to the exposure comparator, while the skills comparator condition fell in the middle (27% versus 13% versus 0%)."  So the results of combined STAIR and trauma-focused exposure lead to 27% achieving sustained and full PTSD remission.  This is both half full and half empty.  Good, encouraging results and clearly also plenty of room for improvement.  Although longer therapies aren't necessarily more effective than shorter, they seem to be for some - possibly more troubled - clients.  See for example Shapiro et al or Knekt et al.  It would probably be a naive therapist who, by choice, treated a sufferer from borderline personality disorder for only 16 sessions.  And borderline is characterised by "disturbed relatedness, behavioral dysregulation, and affective dysregulation" - very much the symptom territory of Cloitre's child abuse survivors.  It's worth noting that Arnoud Arntz & colleagues's ground-breaking research on the treatment of borderline involved twice weekly sessions for three years - although this has more recently been abbreviated to an 18 month intervention - and despite this treatment's original 300 session, 3 year intensity there are good arguments for its cost-effectiveness.

Tomorrow I'll write a third post covering the last three questions that were raised for me by reading Cloitre's work - see "Improving treatments for complex PTSD ... (third post)" .