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Cognitive Behavioral Therapy for PTSD:

The Role of Complex PTSD on Treatment
Outcome
ab
Michelle Lonergan
a
Department of Psychiatry, McGill University, Montreal, Quebec,
Canada
b
Douglas Mental Health University Institute, Montreal, Quebec,
Canada
Click for updates Accepted author version posted online: 24 Mar 2014.Published
online: 16 May 2014.

To cite this article: Michelle Lonergan (2014) Cognitive Behavioral Therapy for PTSD: The Role of
Complex PTSD on Treatment Outcome, Journal of Aggression, Maltreatment & Trauma, 23:5, 494-512,
DOI: 10.1080/10926771.2014.904467

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 Journal of Aggression, Maltreatment & Trauma, 23:494–512, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 1092-6771 print/1545-083X online
DOI: 10.1080/10926771.2014.904467

Cognitive Behavioral Therapy for PTSD: The

Role of Complex PTSD on Treatment Outcome

MICHELLE LONERGAN
Department of Psychiatry, McGill University, Montreal, Quebec, Canada; and
Douglas Mental Health University Institute, Montreal, Quebec, Canada
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Posttraumatic stress disorder (PTSD) represents an often chronic

and debilitating mental illness resulting from exposure to trauma.
Although the most compelling evidence for the treatment of PTSD
is cognitive behavioral therapy (CBT), many patients experience
residual functional impairment, or relapse, suggesting that this
approach does not work for all cases of PTSD. Repeated severe
trauma, particularly during development, might increase the risk
for a more intricate clinical profile, called complex PTSD (CPTSD),
which might contribute to poorer treatment response. The follow-
ing provides a comprehensive summary of the evidence examining
whether CPTSD symptomatology is related to poorer treatment out-
come of CBT, reviews the literature on the treatment of CPTSD,
and offers insights into current issues and future directions of the
construct.

KEYWORDS affective behavioral impairment, childhood abuse,

posttraumatic stress disorder, predictors of outcome, refractory
symptoms, refugee, residual symptoms, trauma

Posttraumatic stress disorder (PTSD) is a severe, often chronic anxiety dis-

order that can develop following exposure to a traumatic, life-threatening
event. The Diagnostic and Statistical Manual of Mental Disorders (4th ed.,
text revision [DSM–IV–TR]; American Psychiatric Association [APA], 2000) cri-
teria for PTSD include three symptom clusters: reexperiencing and intrusive
recollection, avoidance behavior and emotional numbing, and hyperarousal.

Received 12 December 2012; revised 9 April 2013; accepted 10 May 2013.

Address correspondence to Michelle Lonergan, Douglas Mental Health University
Institute, 6875 Boulevard Lasalle, Montreal, Quebec H4H 1R3, Canada. E-mail: m_lonerg@
live.concordia.ca

494
 CBT, PTSD, and Complex PTSD 495

The strongest empirical evidence for the treatment of chronic PTSD comes
from cognitive behavioral therapies (CBT), such as cognitive therapy (CT),
prolonged exposure (PE), and cognitive processing therapy (CPT; Foa,
Keane, Friedman, & Cohen, 2009).
According to practice guidelines from the International Society for
Traumatic Stress Studies (ISTSS; Foa et al., 2009), trauma-focused cognitive
behavioral therapy (TF–CBT), which emphasizes exposure and cognitive
restructuring, has been well established as a first-line intervention for the
treatment of PTSD (Bisson & Andrew, 2007; Bisson et al., 2007; Cahill,
Rothbaum, Resick, & Follette, 2009; Powers, Halpern, Ferenschak, Gillihan,
& Foa, 2010). However, several meta-analyses and systematic reviews have
revealed that as many as half of patients experience substantial residual
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symptoms and functional impairments at posttreatment, still meet diagnostic

criteria at follow-up, or relapse, suggesting that CBT is not always effective
in treating all patients (Bradley, Greene, Russ, Dutra, & Westen, 2005; Kar,
2011; Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008).
Some experts have argued that the current conceptualization of PTSD
within the DSM–IV framework fails to capture its heterogeneous clinical
presentation, perhaps contributing to the variability in treatment response
(Bradley et al., 2005). Epidemiological data and DSM–IV field trials have
found that younger age of onset and repeated interpersonal trauma are
associated with a more complicated symptom profile, sometimes referred
to as complex PTSD (CPTSD; Herman, 1992; van der Kolk, Roth, Pelcovitz,
Sunday, & Spinazzola, 2005). Although not an official DSM–IV–TR (APA,
2000) diagnosis, CPTSD refers to alterations in personality and impairments
in self-regulating capacities, which can result from prolonged trauma expo-
sure, particularly in childhood (Cloitre et al., 2011; Herman, 1992). For the
purposes of clarity, CPTSD is defined in this document following the criteria
put forth by the ISTSS in a recent expert consensus treatment survey (see
below; Cloitre et al., 2011).
CPTSD includes the diagnostic criteria for PTSD with an additional eight
symptom cluster: (a) affective destabilization (e.g., repressed or volatile reac-
tivity) and (b) behavioral dysregulation (e.g., self-harm, violence toward
others, impulsive or risky behavior); (c) dysfunctional or avoidance of rela-
tionships (e.g., chaotic or preoccupation with relationships, dysfunctional
views of or relations with perpetrator); (d) difficulties with attention (e.g.,
profound concentration or attentional difficulties); (e) prominent dissociation
(e.g., feeling estranged from self, others, surroundings); (f) somatic distress
(e.g., chronic pain); (g) dissociative identity symptoms (e.g., impaired self-
concept); and (h) altered systems of meaning (e.g., damaged belief system,
feelings of being permanently negatively changed by the event, despairing;
Cloitre et al., 2011).
This constellation of symptoms has led some experts to argue for
CPTSD as a distinct construct from simple PTSD, entailing its own set of
 496 M. Lonergan

treatment concerns (van der Kolk et al., 2005). Although empirically based
treatments might alleviate several PTSD-specific symptoms, many patients
could continue to experience significant impairments in affective and inter-
personal functioning precluding long-term improvement in overall quality of
life (Cloitre, Miranda, Stovall-McClough, & Han, 2005). Thus, one likely can-
didate contributing to variability in treatment outcome in the literature could
be the proportion of participants with CPTSD.
This article reviews the rationale of CBT for the treatment of PTSD based
on etiological theories of the disorder, including a brief overview of the
degree of treatment efficacy. To examine whether CPTSD is predictive of
reduced treatment response, an extensive search was conducted for stud-
ies investigating clinical predictors of outcome, with a focus on symptoms
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and trauma-related characteristics consistent with the conceptualization of

CPTSD. Differences in the underlying physiological mechanisms between
PTSD and CPTSD could also shed light on differential treatment effects (see
Lang & McTeague, 2011; McTeague et al., 2010). Finally, approaches to the
treatment of CPTSD, including adaptations of CBT techniques, are presented.

THEORIES OF PTSD: DEVELOPMENT, MAINTENANCE,

AND RECOVERY

The most prominent theories of the development and maintenance of PTSD

are rooted in traditional learning theory, which views PTSD as condi-
tioned fear (Bisson, 2009; Cloitre, 2009). During trauma exposure, activation
of endogenous stress hormones (i.e., noradrenaline) prolongs the stress
response and facilitates consolidation of the memory (Heim & Nemeroff,
2009). Pathologically, overconsolidation of a trauma memory creates a vast
fear network that is too easily triggered by trauma-related environmental
stimuli, eliciting conditioned fear responses and classic symptoms of PTSD
such as hyperarousal and hypervigilance (Heim & Nemeroff, 2009; Pitman,
1989). Avoidance behavior and emotional numbing are suggested to serve as
negative reinforcers of intense distress when confronted with traumatic con-
textual cues (Bisson, 2009). Under this model, PTSD is seen as a malfunction
of extinction mechanisms (Cahill et al., 2009).
In an attempt to account for the full array of PTSD symptomatology and
individual differences, cognitive theories of PTSD postulate that some indi-
viduals respond to trauma with maladaptive interpretations about the cause
and consequences of the event. Cognitive distortions give rise to automatic
and irrational thoughts such as overgeneralization of danger (i.e., feeling
a constant threat of imminent danger), negative views of the self (i.e., self-
blame, perceived weakness or inability to cope) and others (i.e., trust issues),
and pessimism about the future (Ehlers & Clark, 2000). Thus, PTSD is pro-
posed to be maintained by a strong fear response conditioned at the time
 CBT, PTSD, and Complex PTSD 497

of the event accompanied by secondary negative emotional reactions (e.g.,

anger and guilt) stemming from the subjective meaning of the trauma (Foa
et al., 2009).
Therefore, successful treatment should involve two components: (a)
exposure to the traumatic memory or cues (imaginal or in vivo), and (b) cog-
nitive restructuring (Cahill et al., 2009). Confronting traumatic stimuli within
a therapeutic setting encourages extinction of conditioned fear responses,
assimilates safety information into the fear memory, and breaks the cycle of
negative reinforcement, effectively reducing anxiety and avoidance of trauma
reminders (Cahill et al., 2009). Emotional engagement during exposure ther-
apy is a prerequisite for effective treatment; failure to engage emotionally
has been related to a negative treatment response (Difede et al., 2007; Foa
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et al., 2009). Cognitive restructuring refers to the identification of maladaptive

thought patterns and the integration of more plausible and reasonable inter-
pretations of the trauma into autobiographical memory (Cahill et al., 2009).
This allows the patient to correct distorted schemas about the self, world,
and trauma, resulting in a more adaptive and realistic interpretation of the
event, and subsequently, a reduction in overall distress.

EFFICACY OF CBT FOR CHRONIC PTSD

To objectively examine the degree of efficacy for CBT, an extensive lit-

erature review was conducted for meta-analyses published since the year
2000 examining the efficacy of psychological treatments for chronic PTSD
resulting from various traumas. Seven meta-analyses were retrieved (Benish,
Imel, & Wampold, 2008; Bisson & Andrew, 2007; Bisson et al., 2007; Bradley
et al., 2005; Goodson et al., 2011; Mendes, Mello, Ventura, Passarela Cde, &
Mari Jde, 2008; Powers et al., 2010). Compelling support for TF–CBT relative
to non-trauma-focused therapies (i.e., supportive counseling, hypnotherapy,
psychodynamic therapy) has been established in all but one meta-analysis
(see Benish et al., 2008). However, positive outcomes have been observed
with non-trauma-focused therapies, such as stress management and psy-
chodynamic therapy (see Benish et al., 2008, and Ehlers et al., 2010, for
a discussion on this topic). Nevertheless, international guidelines suggest tar-
geting the traumatic memory and subjective meaning is central to effective
treatment (Foa et al., 2009).

Nonresponse and Dropout Rates

Findings from Bradley et al. (2005) indicated that roughly half of intent-to-
treat participants no longer met diagnostic criteria for PTSD at posttreatment,
and 44% demonstrated clinical improvement (using investigator-defined cri-
teria such as a decrease of at least 2 SD on PTSD symptom scores). Treatment
 498 M. Lonergan

gains tended to be maintained at follow-up. Nevertheless, the average post-

treatment PTSD symptom scores remained relatively high, albeit below
diagnostic threshold, suggesting the presence of important residual impair-
ments in many patients. Of the seven meta-analyses included, only four
reported completion and dropout rates (Bisson & Andrew, 2007; Bisson
et al., 2007; Bradley et al., 2005; Mendes et al., 2008). In general, non-
significant trends emerged where participants were more likely to drop out
of trauma-focused treatments than non-trauma-focused therapies. However,
despite wide variability in dropout rates between individual studies (0–50%;
Shottenbauer et al., 2008), TF-CBT may not be tolerated by some patients.

Limitations of Treatment Outcome Literature

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A major criticism concerning PTSD treatment literature pertains to difficulties

in generalizing efficacy results to patients commonly found in clinical prac-
tice (i.e., effectiveness). Many, but not all, treatment studies have excluded
patients with complex clinical profiles including childhood abuse histories,
concurrent substance disorders, personality disorders, suicidality or self-
injurious behavior, and significant dissociative symptoms, among others (van
der Kolk et al., 2005). For instance, Bradley et al. (2005) found a positive
association between the number of exclusion criteria and the strength of
effect sizes, such that studies with stricter inclusion criteria tended to report
larger treatment effects.
Additionally, numerous studies fail to report whether patients experi-
ence any adverse effects from psychological treatments (Bisson & Andrew,
2007), rendering it difficult to ascertain who CBT works best for, or whether
dropout rates directly result from treatment demands. Notably, DSM–IV field
trials for PTSD uncovered that complex psychological sequelae derived from
repeated victimization (i.e., affective instability, dysphoria, and interpersonal
dysfunction) tend to differentiate treatment-seeking PTSD patients from those
who do not seek treatment (van der Kolk et al., 2005). Thus, traditional CBT
therapies designed to target distorted fear memories surrounding a discrete
traumatic event might not always be enough for those presenting with more
complex pathologies.

CPTSD: OVERVIEW, PREDICTORS OF OUTCOME, AND

PSYCHOPHYSIOLOGY

CPTSD, often used interchangeably with the term disorders of extreme

stress not otherwise specified (DESNOS), has most often been applied to
adult victims of prolonged interpersonal trauma stemming from childhood.
However, the syndrome has also been suggested to occur in other chronically
traumatized populations, such as refugees, victims of genocidal campaigns,
 CBT, PTSD, and Complex PTSD 499

war or political prisoners, child soldiers, domestic violence survivors, and

victims of international prostitution rings (Cloitre et al., 2011; Herman, 1992).
Prolonged interpersonal trauma occurs when an aggressor maintains com-
plete control over his or her victim; any opportunity to escape the abuse,
either physically, psychologically, or emotionally, is absent (Herman, 1992).
From a developmental perspective, this type of sustained captivity might
impede the growth of healthy attachment, self-regulation capacities, adap-
tation and coping abilities, and emotional maturity, leading to impairments
in personality integration, emotional instability, and difficulties in managing
personal relationships in adulthood (Cloitre et al., 2009).
Repeated trauma in childhood has been associated with the develop-
ment of CPTSD. Several studies have examined this hypothesis empirically.
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For example, McLean and Gallop (2003) investigated the influence of early
life trauma (≤12 years) compared to later life trauma (≥13 years) on preva-
lence of CPTSD in a convenience sample of adult women. Results revealed
significantly higher rates of CPTSD diagnosis, as assessed by the Structured
Interview for Disorders of Extreme Stress (SIDES; Pelcovitz et al., 1997), in
women reporting early-onset childhood sexual abuse. The SIDES is a vali-
dated clinician-administered structured interview that assesses trauma-related
symptoms conceptually relevant to CPTSD: affective and behavioral dys-
regulation, alterations in perception of self and perpetrator, attentional and
dissociative disturbances, interpersonal dysfunction, damaged belief system,
and somatization (Pelcovitz et al., 1997). In a recent investigation, Cloitre
et al. (2009) examined the effects of cumulative trauma in either childhood
or adulthood on symptom complexity in a sample of adult women with
histories of repeated trauma. Only cumulative trauma experienced in child-
hood predicted complex symptoms in adults, suggesting that PTSD patients
with a history of childhood abuse might represent a distinct population with
unique treatment needs (see Cloitre et al., 2009, for a complete description
of measures and methods).

CPTSD as a Predictor of Treatment Outcome

Unfortunately, a dearth of literature exists examining whether CPTSD is a
negative prognostic factor within treatment studies. Only one study con-
ducted by Ford and Kidd (1998) directly assessed the impact of DESNOS
on treatment outcome in a sample of patients with chronic military-related
PTSD. The treatment, which included TF–CBT, was a multimodal 3-month
intensive residential program. Forty-two percent of the sample reported his-
tories of childhood abuse and met criteria for DESNOS as assessed by the
SIDES (see earlier). The authors found that participants who met criteria
for DESNOS were significantly less likely to improve compared to their
non-DESNOS counterparts on PTSD symptoms, generalized anxiety, and
overall quality of life. Additionally, DESNOS was associated with a relative
 500 M. Lonergan

lack of clinically meaningful therapeutic change (Ford & Kidd, 1998). These
results are important, especially given the elaborate multifaceted treatment
approach; however, replication is needed. Given this gap within the lit-
erature, one way to further investigate whether CPTSD relates to poorer
treatment response would be to draw parallels from research on symptom-
specific and trauma-related predictors of outcome consistent with the CPTSD
conceptualization.

PREDICTORS OF OUTCOME : CLINICAL SYMPTOMS CONSISTENT WITH CPTSD

Affective dysregulation is described as considerable emotional volatility that
often encompasses behavioral impulsiveness (e.g., suicidality, self-harming
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behavior) and profound impairments in interpersonal relations (Cloitre,

Koenen, Cohen, & Han, 2002). These core symptoms of CPTSD have been
found to be significant predictors of functional impairments over and above
the effects of PTSD in a sample of treatment-seeking women with chronic
PTSD stemming from childhood abuse (Cloitre et al., 2005). Similarly, Tarrier,
Sommerfield, Pilgrim, and Faragher (2000) found increased suicidality pre-
dictive of reduced response to CBT in a sample of patients with chronic
PTSD.
Notably, an association between CPTSD, avoidant personality character-
istics, and problematic emotional management has been highlighted in the
literature. In one study, self-harming behavior was more frequently related
to PTSD when participants also met criteria for avoidant personality disor-
der (Gratz & Tull, 2012). Furthermore, Tarrier and Sommerfield (2004) found
higher avoidance and numbing symptoms predictive of negative outcome
in a 5-year follow-up investigation of CBT for chronic PTSD. Findings such
as these provide indirect evidence that affective and behavioral dysregu-
lation, symptoms consistent with CPTSD, might play a role in explaining
the presence of substantial residual symptoms and continued difficulties
in psychosocial functioning following treatment. However, the impact of
these characteristics on CBT outcome has not been fully explored, and cau-
tion should be applied in interpreting this conclusion. Of particular note,
both Tarrier and colleagues’ (Tarrier & Sommerfield, 2004; Tarrier et al.,
2000) studies excluded individuals with long-standing PTSD (>10 years) and
childhood abuse histories.
Further complicating the issue, an association between childhood abuse
and borderline personality disorder (BPD) has become consistent within the
trauma literature (Lewis & Grenyer, 2009), and substantial symptom overlap
between CPTSD and BPD has led some to question the validity of the CPTSD
construct. Of particular relevance are the similarities in emotional volatility
(i.e., self-harm, explosive anger), chaotic personal relationships, impairments
in self-concept and identity integration, and dissociative symptoms between
the two disorders (Lewis & Grenyer, 2009).
 CBT, PTSD, and Complex PTSD 501

Although outcome studies have shown that PTSD patients with BPD
can benefit from TF–CBT, they typically experience poorer end-state func-
tioning than those with PTSD only (Feeny, Zoellner, & Foa, 2002; Hembree,
Cahill, & Foa, 2004). Furthermore, McDonagh et al. (2005) found that a
comorbid BPD/PTSD was related to dropout of CBT, suggesting that dif-
ficulties with interpersonal and emotional regulation could contribute to
negative outcome. It should be noted that these findings have not con-
sistently been replicated (Clarke, Rizvi, & Resick, 2008; Poundja, Sanche,
Tremblay, & Brunet, 2012). However, BPD patients tend to be excluded
from PTSD treatment trials (Bradley et al., 2005), especially those with more
severe symptomatology (e.g., acute self-harming behavior). Thus, it is not
yet possible to directly confirm which, if any, symptom patterns common
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to both BPD and CPTSD might lead to negative response in trauma-focused

therapy.
State-like dissociation, including depersonalization and derealization, is
pronounced in CPTSD and is captured under its alterations in consciousness
symptom cluster (Cloitre et al., 2011). As mentioned previously, successful
CBT treatment is contingent on emotionally engaging in the fear memory
during exposure (Foa et al., 2009). Accordingly, it has been hypothesized
that marked dissociative symptoms (e.g., emotional numbing, dissociative
amnesia) might impede successful activation of the fear network, leading
to reduced treatment response (Hagenaars, van Minnen, & Hoogduin, 2010;
Resick, Suvak, Johnides, Mitchell, & Iverson, 2012). In parallel, depersonal-
ization or derealization might also prevent adaptive cognitive modifications
surrounding the subjective meaning of the trauma event (Cloitre, Petkova,
Wang, & Lu Lassell, 2012). Consequently, patients with elevated dissociative
symptoms are often excluded from clinical trials involving exposure-based
therapies (Bradley et al., 2005; Hagenaars et al., 2010), rendering the
literature on dissociation as a predictor of outcome sparse and intricate.
Hagenaars et al. (2010) examined the influence of dissociative symp-
toms on outcome of a PE protocol with a mixed-trauma sample of 71 chronic
PTSD sufferers. Over half had been repeatedly traumatized, and 70% met cri-
teria for other Axis I or II disorders. Contrary to the hypothesis, participants
classified as highly dissociative improved just as much as low dissociative
patients on symptoms of PTSD and dissociation. Furthermore, higher peri-
traumatic dissociation scores were associated with increased subjective fear
during exposure, yet this result was largely controlled by baseline PTSD
symptom severity. Sixty-nine percent of those with high levels of dissocia-
tion, compared to only 10% of those with low dissociation scores, retained
a PTSD diagnosis at six-month follow-up, suggesting dissociation might be
related to more severe baseline PTSD and continued impairment following
treatment.
Recently, in a sample of female sexual assault survivors with chronic
PTSD engaged in a TF–CBT program, Resick, Suvak, et al. (2012) found
 502 M. Lonergan

that patients with higher levels of dissociation responded significantly bet-

ter to a combination of CT plus imaginal exposure, compared to CT or
imaginal exposure alone. Additionally, dissociation scores improved sig-
nificantly throughout the course of treatment, regardless of the treatment
condition, suggesting that levels of dissociation do not adversely impact
treatment outcome. However, this result has not always been replicated
(McDonagh et al., 2005). These findings highlight an important need for fur-
ther research aimed at clarifying the relationship between dissociation and
CBT treatment outcome, especially as it applies to patients with full CPTSD
symptomatology.
Patients with CPTSD might perceive themselves as being permanently
damaged or sense that they have been forever changed by the trauma events;
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they might feel that a part of them has died or believe that others will
never again see them in a positive way (Ehlers et al., 1998). The term men-
tal defeat has been used to describe the sense of complete powerlessness,
hopelessness, and loss of autonomy that can occur during severe interper-
sonal assault. These symptoms are prominent in CPTSD and are described in
their altered systems of meaning and impaired self-concept symptom clus-
ters (Cloitre et al., 2011). In an examination of the influence of these factors
on outcome of PE, Ehlers et al. (1998) found that female rape victims with
poorer outcome were more likely to experience mental defeat while recalling
the trauma during exposure. The perception of being permanently damaged
since the event was also associated with worse outcome. Although it remains
unknown whether patients in this study met criteria for CPTSD, these results
suggest that some core features of the disorder might lead to a reduced
response to exposure-based treatments.

PREDICTORS OF OUTCOME : CPTSD TRAUMA - RELATED CHARACTERISTICS

As mentioned previously, empirical evidence surrounding CPTSD sug-

gests this disorder is particularly associated with prolonged and repeated
childhood interpersonal trauma (van der Kolk et al., 2005). However, incon-
sistencies have been reported within the treatment literature regarding the
influence of these characteristics on outcome. For instance, Hembree, Street,
Riggs, and Foa (2004) examined trauma-related predictors of outcome of a PE
and stress management program in a sample of women with chronic PTSD.
Results revealed that a history of childhood trauma predicted increased
residual symptoms at posttreatment. Additionally, a marginally significant
trend emerged indicating that assault by a known perpetrator, compared
to assault by an unknown assailant, was indicative of more posttreatment
PTSD symptoms. Conversely, van Minnen, Arntz, and Keijsers (2002) exam-
ined predictors of outcome of a PE protocol in two samples of chronic
PTSD patients. Two samples were used to replicate findings. History of
childhood abuse, prolonged or repeated trauma, and interpersonal trauma
 CBT, PTSD, and Complex PTSD 503

were predictive of residual PTSD symptoms in only one of the two samples,
reflecting observed discrepancies within the literature.
The appropriateness of exposure-based CBT for individuals experienc-
ing complex symptoms has been debated throughout the treatment literature
(Palic & Elklit, 2011; Spinazzola, Blaustein, & van der Kolk, 2005; van der
Kolk et al., 2005). Some experts argue that neglecting to target dissociative
symptoms, impairments in interpersonal function, and emotional instabil-
ity prior to trauma exposure could hinder positive outcomes (Bisson et al.,
2007). Furthermore, this approach has been criticized as contributing to
a lack of improvement in overall quality of life, worsening of symptoms,
or even retraumatization in some complex patients (Cloitre et al., 2010;
Courtois, 2004; Foa et al., 2009). However, as reviewed below, standard
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TF–CBT approaches have been successful in treating some individuals with

CPTSD symptoms and trauma histories (see Resick, Nishith, & Griffin, 2003).

Psychophysiology in Complex Trauma

Because sensitized physiological arousal to trauma-related cues (i.e., startle
reflex, increased heart rate and skin conductance) reflects a diagnostic hall-
mark of PTSD, recent studies have examined whether there are fundamental
differences in these mechanisms in victims of multiple traumas. Using a
script-driven imagery paradigm, McTeague and colleagues (2010) examined
physiological reactivity to traumatic and neutral stimuli in single- versus
multiple-trauma PTSD survivors. At baseline, the recurrently traumatized
group reported earlier trauma onset, higher rates of developmental and
interpersonal trauma, longer standing PTSD, and more severe functional
impairment and subjective distress than all other groups. As expected, PTSD
patients as a whole demonstrated increased physiological reactivity to trau-
matic scripts relative to controls (i.e., trauma-exposed non-PTSD patients).
However, when compared to discrete PTSD victims, the prolonged PTSD
group demonstrated hyporeactivity, or dulled physiological responding.
In fact, the repeated trauma group showed similar reactivity to personal
trauma scripts and neutral imagery, despite having the highest ratings of
subjective arousal and aversiveness to the emotionally negative stimuli.
Subsequently, Lang and McTeague (2011) interpreted their results under
a fear versus anxious or misery paradigm, suggesting that discrete trauma
exposure results in “pure” PTSD where traumatic cues too easily reactivate
the brain’s fear and defense network. Reflexive defenses that serve to escape
potential danger occur in response to any perceived threat associated with
the original traumatic event. Conversely, sustained trauma exposure eventu-
ally overwhelms and incapacitates the neurobiological fear circuit, resulting
in a clinical presentation of chronic anxious despair (Lang & McTeague,
2011). The observation that their sample of multiple-trauma victims reported
greater anxious and depressive comorbidity than all other participants lends
 504 M. Lonergan

support to this hypothesis (McTeague et al., 2010). Thus, the results pro-
vide indirect biological evidence that first-line psychological interventions
that emphasize extinction of the hyperactive fear memory, such as expo-
sure, might not be enough to qualitatively improve overall functioning in
individuals with complex trauma pathologies.

COMPLEX PTSD: TREATMENT OVERVIEW

Over the last decade, several groups have examined whether standard cog-
nitive behavioral approaches have beneficial effects in cases reminiscent of
CPTSD. For instance, Resick et al. (2003) examined outcome of CPT, a form
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of CBT originally developed for female rape victims that includes exposure
techniques, between sexual abuse survivors with childhood trauma histories
and complex symptoms and those without. CPTSD was assessed using the
Trauma Symptom Inventory (TSI; Briere, Elliott, Harris, & Cotman, 1995).
The TSI is a self-report questionnaire designed to assess trauma-related
symptoms consistent with the CPTSD concept, such as enduring dissocia-
tive disturbances, affective or behavioral dysregulation, and interpersonal
dysfunction. At baseline, women with histories of childhood sexual abuse
reported greater severity on the TSI than their counterparts, indicating more
severe overall pathology. Both groups showed significant improvements in
clinician-assessed PTSD symptoms and TSI scores through follow-up, with
no meaningful differences between them. Although women with childhood
abuse histories tended to show marginally elevated TSI symptom scores
through follow-up, the authors demonstrated that standard CBT techniques
can be effective for treating complex posttraumatic pathologies. However,
although the TSI is validated for evaluating the pathological sequelae of
trauma over and above simple PTSD, the study results are limited by the
fact that the TSI does not fully capture the CPTSD symptom profile as it is
currently conceptualized (Resick et al., 2003).

Treating CPTSD: A Multimodal Phase-Based Approach

Therapies that primarily target restabilization of emotional volatility and
resulting deficits in interpersonal skills have been proposed to increase treat-
ment efficacy for CPTSD (Cloitre, 2009; Cloitre et al., 2011; Foa et al., 2009).
Results from the ISTSS expert consensus on best practices survey concluded
that a phase-based approach, which first attends to the patients’ sense of
security and emotional and interpersonal management prior to implementing
CBT techniques, was most appropriate for complex patients (Cloitre et al.,
2011). In line with this, efficacy research over the last decade has examined
whether any additive benefits would be obtained from augmenting standard
exposure-based CBT techniques with emotional and relational skills training.
 CBT, PTSD, and Complex PTSD 505

Cloitre et al. (2002) devised a sequential phase-based cognitive-

behavioral approach in which Skills Training in Affective and Interpersonal
Regulation (STAIR) was provided prior to exposure treatment. The sample
(n = 58) consisted entirely of women with PTSD secondary to developmen-
tal sexual or physical trauma. Although CPTSD was not directly assessed, all
women experienced high rates of Axis I comorbidity, difficulties in regulat-
ing emotions, and interpersonal distress at baseline. Compared to wait-list
controls, those who received the STAIR exposure treatment demonstrated
significant improvements on PTSD symptoms, affect regulation, and inter-
personal functioning at posttreatment; treatment gains continued through
follow-up. Furthermore, a quarter of STAIR-exposure-treated participants
retained a PTSD diagnosis at follow-up, compared to three quarters of the
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control group. Despite only 46% of the treatment sample achieving good
end-state functioning (compared to 4% of controls), the authors concluded
that augmenting standard TF–CBT with an emotional and interpersonal
stabilization phase is valuable in this complex population.
In a more recent investigation, Cloitre et al. (2010) aimed to extend their
findings by comparing the STAIR exposure approach to standard PE treat-
ment in a sample of women with chronic PTSD stemming from childhood
abuse. The authors broadened their inclusion criteria to increase ecologi-
cal validity; unlike their previous study (Cloitre et al., 2002), patients with
dissociative or personality disorders were not excluded. Compared to par-
ticipants receiving exposure alone, those treated with the STAIR exposure
protocol were significantly more likely to achieve full remission (6% vs.
27%, respectively) and no longer meet PTSD diagnostic criteria (33% vs.
61%, respectively) at posttreatment. Furthermore, participants in the STAIR
exposure condition were significantly less likely to drop out of treatment
(15% STAIR exposure vs. 39% exposure alone). These results strengthen the
suggestion that targeting disruptions in affect regulation and interpersonal
function in patients with complex symptom patterns prior to implementing
exposure-based therapies could lead to substantial increases in treatment
efficacy (see Cloitre et al., 2011, for a complete review).
One of the main drawbacks of Cloitre et al.’s (2002; 2010) studies is
their inclusion of participants based on past history of childhood trauma
rather than a standardized assessment of CPTSD (Bryant, 2010). Although
participants experienced chronic PTSD accompanied by emotional volatility
and interpersonal dysfunction, it remains to be seen if the approach would
demonstrate success in those meeting the full CPTSD diagnosis. Finally, both
samples consisted of female patients with histories of childhood and adult-
hood sexual abuse; whether results would generalize to other chronically
traumatized populations, such as refugees, remains elusive. Research on the
assessment and treatment of CPTSD within this population is still in its early
stages (see Palic & Elklit, 2011, for a recent review on this topic).
 506 M. Lonergan

Beyond investigations into the treatment of CPTSD in childhood abuse

victims, Cloitre (2009) reviewed five studies pertaining to victims of chronic
traumatization due to war (e.g., refugees, political prisoners) and con-
cluded that culturally adapted CBT might be beneficial in these populations.
Additionally, two recent reviews of psychotherapy for CPTSD in adult
refugees found preliminary evidence in favor of trauma-focused approaches
(Nickerson, Bryant, Silove, & Steel, 2011; Palic & Elklit, 2011). Furthermore,
recent advances are exploring the efficacy and feasibility of enhanced
multimodal CBTs for refugee populations (see Palic & Elklit, 2011). However,
the overall conclusion contends that treatment of CPTSD in these populations
remains underresearched (Cloitre, 2009; Palic & Elklit, 2011). With this in
mind, preliminary findings have fostered support for continued examination
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of sequential interventions personalized to promote safety, stabilize affective

volatility, and enhance interpersonal skills prior to the implementation of
exposure-based cognitive therapies in chronically traumatized populations
(see Cloitre et al., 2011).

CONCLUSION: SUMMARY AND FUTURE DIRECTIONS

The observation that prompted this review was the consistent finding that as
many as half of patients with chronic PTSD fail to benefit from first-line
evidence-based psychological treatments. Although TF–CBT has received
substantial empirical support, this approach can suffer from high dropout and
nonresponse rates (Bradley et al., 2005; Schottenbauer et al., 2008). Experts
have cautioned that the diagnostic construct of PTSD within the DSM–IV
framework is limiting itself to one of many posttraumatic pathological out-
comes (Herman, 1992; Palic & Elklit, 2011). Due to the pronounced clinical
heterogeneity within chronic PTSD, variability in response to a standardized
treatment is to be expected. Indeed, it appears as though the presence of a
CPTSD symptomatology in some patients with chronic PTSD might represent
a significant barrier to positive therapeutic outcome.
According to epidemiological data, about 80% of individuals with
chronic PTSD meet criteria for one or more comorbid conditions, such as
depression, other anxiety disorders, personality disorders, somatoform dis-
orders, eating disorders, and dissociative disorders (Foa et al., 2009). Some
experts argue that viewing the various posttraumatic reactions as indepen-
dent comorbid conditions has led to a fragmented view of the disorder and
a relative lack of research in the assessment and intervention of CPTSD
(Herman, 1992; Palic & Elklit, 2011). This observation is reflected in the
limitations of current treatment research, such that a variety of syndromes
consistent with the conceptualization of CPTSD tend to be reasons for
excluding participants from clinical trials (Bradley et al., 2005). Although
efforts are underway to increase the ecological validity of treatment trials,
 CBT, PTSD, and Complex PTSD 507

there exists a gap in the literature on how CPTSD might impact prognostic
outcome, as well as how it is measured across samples and trauma types,
possibly due to continued debate concerning the validity of the construct.
Difficulties in operationalizing CPTSD lie in the debate concerning
whether or not the syndrome represents a distinct construct from PTSD
and other related disorders, such as BPD (see Resick, Bovin, et al., 2012).
Importantly, many, but not all, patients with BPD report histories of child-
hood abuse. Within their sample, McLean and Gallop (2003) found that
comorbid BPD/CPTSD diagnoses were significantly higher in patients with
early-life childhood trauma. Thus, the authors argued that a CPTSD diag-
nosis might be more appropriate for borderline patients with extensive
childhood abuse histories; however, replication is needed. Nevertheless,
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this would have important therapeutic implications, as an approach that

includes exposure in addition to skills training might confer greater bene-
fit for these patients (Cloitre et al., 2010). Further studies dismantling the
discriminant validity of CPTSD would serve to solidify the operational defini-
tion of the construct and provide valuable insight into appropriate diagnosis
and intervention.
Of relevance to advancements in understanding the CPTSD construct,
one recent study has revealed important differences in underlying physi-
ological mechanisms between discrete- trauma and multiple-trauma PTSD.
Etiological theories of PTSD maintain that memory overconsolidation cre-
ates a strong conditioned fear network leading to pathological and reflexive
escape and avoidance behavior when confronted with traumatic cues.
Indeed, symptoms of hyperarousal and hyperreactivity to trauma-related
cues are a hallmark of PTSD. Thus, traditional exposure-based therapies con-
tend that promoting extinction of conditioned responses is central to effective
treatment. However, as McTeague et al. (2010) revealed, psychophysiologi-
cal reactivity to traumatic cues appears to be blunted in those with repeated
or prolonged trauma histories, reflecting a state of persistent anxious depres-
sion. Results such as these lend further support to the notion that individuals
with complex trauma histories and symptoms might not respond as well
to CBT emphasizing exposure. An interesting extension for future studies
would be to examine this phenomenon in individuals meeting full criteria
for CPTSD. Furthermore, although the neurobiology of PTSD has been exten-
sively explored (see Heim & Nemeroff, 2009), relatively little is known about
the underlying neurobiological mechanisms in adults with CPTSD (Resick,
Bovin, et al., 2012). Future examinations into the pathophysiology of CPTSD
will serve to further establish its construct validity.
Prolonged adversity in childhood could hinder the development of
healthy attachment, which can lead to significant impairments in person-
ality integration and self-regulation capacities in adulthood. These notions
are supported by neurodevelopmental literature investigating the impact of
trauma on the developing brain (see van der Kolk, 2003, for a thorough
 508 M. Lonergan

review). Accordingly, CPTSD has most often been studied from a devel-
opmental perspective. Current advances in treating CPTSD stemming from
developmental trauma have focused on emotional stabilization and interper-
sonal skills training prior to implementing standard TF–CBT with promising
results (Cloitre, 2009). However, refugees can experience a range of severe
psychological trauma in either childhood or adulthood, such as separation
from family, relocation and culture shock, famine, torture, and witnessing
the death of loved ones (Palic & Elklit, 2011), requiring the stabilization of
fundamental needs prior to any psychological intervention (Cloitre et al.,
2011). Further complications arise from cultural barriers where predomi-
nantly Western approaches might not be fully applicable in these populations
(Palic & Elklit, 2011). Investigations into the construct validity of CPTSD, how
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it applies to a range of chronically traumatized populations, and how best to

approach its assessment and treatment will considerably advance the field of
traumatic stress intervention.
Reflecting a possible step in this direction, significant revisions to
the diagnostic criteria of PTSD have been made in the recently released
Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM–5]; APA,
2013) in an attempt to refine the construct. Although CPTSD is not a separate
diagnostic construct, debate continues as to whether it should be considered
as a subtype of PTSD (Friedman, Resick, Bryant, & Brewin, 2011). However,
revisions to certain PTSD diagnostic criteria emphasizing behavioral and
emotional instability and related interpersonal difficulties (i.e., aggressive
behavior to others, self-harm, risk-taking behavior) are now incorporated
(APA, 2013). Thus, it will be interesting to see how the proposed revisions
will impact the treatment outcome literature. With an added emphasis on
certain symptoms consistent with the CPTSD concept, it is possible that the
new diagnosis will more accurately account for some of the heterogeneity
in the clinical presentation of PTSD, leading to a more refined approach to
intervention.

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