brain

sciences
Article
Enhanced Skills Training in Affective and Interpersonal
Regulation (ESTAIR): A New Modular Treatment for ICD-11
Complex Posttraumatic Stress Disorder (CPTSD)
Thanos Karatzias 1,2, *, Edel Mc Glanaghy 3 and Marylene Cloitre 4,5

1 School of Health & Social Care, Edinburgh Napier University, Edinburgh EH11 4BN, UK
2 NHS Lothian Rivers Centre, EH11 1BG, Stanford University, 450 Jane Stanford Way, Stanford, CA 94305, USA
3 NHS Forth Valley, Mayfield Building, Falkirk Community Hospital, Scotland FK1 5QE, UK;
[email protected]
4 National Centre for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System,
795 Willow Road, Menlo Park, CA 94025, USA; [email protected]
5 Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
* Correspondence: [email protected]

Abstract: ICD-11 Complex Posttraumatic Stress Disorder (CPTSD) is a relatively new condition;
therefore, there is limited available evidence for its treatment. Prior to the recognition of CPTSD as a
separate trauma condition, people who met criteria were often diagnosed with multiple co-morbid
conditions such as PTSD, anxiety, depression, and emotional dysregulation difficulties. In the absence
of a coherent evidence base, treatment tended to involve multiple treatments for these multiple
conditions or lengthy phase-based interventions, often delivered in an integrative fashion, which was
not standardized. In this paper, we present Enhanced Skills Training in Affective and Interpersonal
Regulation (ESTAIR), a new flexible multi-modular approach for the treatment of CPTSD and its
transdiagnostic symptoms. ESTAIR is consistent with trauma-informed and patient-centered care,
which highlights the importance of patient choice in identification and sequencing in targeting CPTSD
symptoms. Directions for future research are discussed.

Citation: Karatzias, T.; Mc Glanaghy,

Keywords: complex PTSD; CPTSD; modular treatment; ESTAIR
E.; Cloitre, M. Enhanced Skills
Training in Affective and
Interpersonal Regulation (ESTAIR): A
New Modular Treatment for ICD-11
Complex Posttraumatic Stress 1. ICD-11 PTSD and CPTSD
Disorder (CPTSD). Brain Sci. 2023, 13, CPTSD has been formally introduced into the diagnostic nomenclature in the eleventh
1300. https://doi.org/10.3390/ edition of the International Classification of Diseases and Related Health Problems [1]. Given that
brainsci13091300 CPTSD is a new disorder, there is little evidence of effective treatments. There is substantial
Academic Editor: Jeffrey L. Kibler evidence on the effectiveness of interventions for DSM-IV PTSD, but there is little evidence
whether these interventions are equally effective for ICD-11 CPTSD, or which interventions
Received: 22 August 2023 may be optimal for the treatment of this debilitating condition. The purpose of this paper
Revised: 31 August 2023
is to present the rationale for offering a flexible, multi-modular patient-centred approach to
Accepted: 7 September 2023
the treatment of CPTSD, namely Enhanced Skills Training in Affective and Interpersonal
Published: 9 September 2023
Regulation (ESTAIR), as well as its feasibility and potential benefits. The paper concludes
with recommendations for further research on the effectiveness of ESTAIR for CPTSD.

2. Definition of PTSD and CPTSD

Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland. Exposure to a traumatic event is a prerequisite for consideration of either ICD-11
This article is an open access article PTSD or CPTSD. The diagnostic criteria for PTSD consist of three symptom clusters that
distributed under the terms and relate specifically to the traumatic event, including re-experiencing in the here and now,
conditions of the Creative Commons avoidance of traumatic reminders, and heightened sense of threat. Functional impairment
Attribution (CC BY) license (https:// must also be present to meet diagnostic criteria. The diagnosis of CPTSD comprises
creativecommons.org/licenses/by/ six symptom clusters, the three PTSD clusters listed above and three symptom clusters
4.0/). representing pervasive and chronic disturbances in self-organization (DSO), including

Brain Sci. 2023, 13, 1300. https://doi.org/10.3390/brainsci13091300 https://www.mdpi.com/journal/brainsci

Brain Sci. 2023, 13, 1300 2 of 8

affect dysregulation, negative self-concept, and difficulties in forming and maintaining

relationships. Functional impairment resulting from the PTSD symptom cluster and the
DSO are also necessary to meet diagnostic criteria for CPTSD [1].
ICD-11 introduced CPTSD as a diagnosis distinct from PTSD acknowledging the effect
that chronic, repeated, or severe interpersonal trauma can have on self-organization-related
mechanisms. Exposure to traumatic events, which are prolonged and from which escape is
difficult or impossible, is more likely to lead to CPTSD than PTSD. Such traumatic events
include experiences such as repeated childhood sexual or physical abuse, domestic violence,
prolonged combat exposure, torture, and genocide campaigns [1].
Distinct from earlier conceptualizations of complex PTSD [2], the presence of pro-
longed trauma or early life traumas is a risk factor, not a prerequisite for CPTSD and any
traumatic stressor can lead to either PTSD or CPTSD. This recognizes the role of personal
(e.g., genetic or dispositional) and environmental (e.g., social stressors and support) risk
and protective factors for vulnerability to the disorder. Diagnosis is therefore based on the
presence of CPTSD symptoms in the context of the individual’s personal history.

3. Evidence Supporting the Distinction between CPTSD versus PTSD

The selection of symptoms in the PTSD cluster (i.e., re-experiencing, avoidance, and
sense of threat) is supported by decades of research [3]. The identification of the DSO
symptoms of affect dysregulation (e.g., having problems calming down, feeling emotionally
numb), negative self-concept (e.g., feeling worthless or like a failure), and relationship
disturbances (e.g., having difficulty feeling close to others or maintaining relationship) was
based on results from DSM-IV field trials, which investigated the most frequently reported
CPTSD symptoms [4] and results from an expert opinion survey where clinicians were
asked to identify the most common and impairing CPTSD symptoms [5].
This two-factor formulation of CPTSD has been confirmed in several studies all over
the world and across general population and clinical samples [6] and it appears to be easy
for clinicians to correctly identify as indicated by high rates of accurate differential diagnosis
between CPTSD and PTSD and as compared to normality among over 1700 clinicians in
73 countries [7].
Traumatic stressors, especially in childhood, can increase vulnerability for several
conditions later in life [8]. Thus, it is not surprising that CPTSD symptoms can be present in
a number of other conditions (e.g., psychosis; [9,10]) and indeed, prior to the introduction of
CPTSD people often attracted a wide range of diagnoses to account for their wide-ranging
symptoms. Therefore, it is of significant interest to explore whether targeting and treating
CPTSD symptoms in other conditions can result in symptom reduction overall and perhaps
increase our understanding of the mechanisms of distress in other co-morbid conditions
associated with a trauma history.

4. Treating CPTSD Using Effective Treatments for PTSD

The ICD-11 separation of post-traumatic reactions into two rather than one disorder is
consistent with a personalized medicine approach to care and treatment. ICD-11 CPTSD
has a greater number of symptoms typically resulting from multiple, interpersonal, chronic,
and/or childhood problems [11]. Several studies comparing ICD-11 PTSD to ICD-11
CPTSD have indicated that CPTSD is associated with significantly poorer functioning,
greater comorbidity and poorer quality of life compared to ICD-11 PTSD (e.g., [12,13]).
CPTSD is a more common condition than PTSD in trauma-exposed population-based
studies (e.g., 5.3% vs. 12.9% in the UK, [12]), general population-based samples (e.g., 3.4%
vs. 3.8 in the USA, [13]) and clinical trauma samples (e.g., 75.6% vs. 24.4 in the UK, [11]).
Considering that CPTSD comprises a greater number of different types of symptoms and
is more severe than PTSD in clinically meaningful ways (i.e., number of symptoms and
impaired functioning), it may be the case that optimal treatment of CPTSD may require a
greater number of different kinds of interventions or a longer course of treatment compared
to PTSD. Although the development of different treatments may result in better outcomes
Brain Sci. 2023, 13, 1300 3 of 8

for PTSD and CPTSD, it is also possible that the same treatments can be used for these
two conditions with equally good outcomes.
Existing treatment guidelines for PTSD recommend trauma-focused psychological
therapies, such as cognitive-behavioral therapy (CBT), and Eye Movement Desensitiza-
tion and Reprocessing (EMDR) for PTSD (e.g., National Institute for Clinical Excellence
[NICE], [14]; Australian Centre for Posttraumatic Mental Health [ACPMH], [15]). Trauma-
focused treatments typically include repeated in vivo and/or imaginal exposure to the
trauma and/or reappraisal of the meaning of the trauma and its consequences. However,
two recent meta-analyses have suggested that these interventions might be less effective
for patients with CPTSD.
In a meta-analysis by Karatzias and colleagues [16], randomized controlled studies
of PTSD, which included measures of the three symptom clusters of PTSD, as well as
symptoms specific to CPTSD, namely affect dysregulation, negative self-concept, and
disturbances in relationships, were reviewed using proxy measures. Analyses assessing
outcomes for each of the six specific symptom clusters revealed that, compared to waitlist or
treatment as usual, cognitive-behavioral therapies, exposure therapy and EMDR yielded su-
perior outcomes. However, this effect was negatively moderated by a history of childhood
abuse, where outcomes for each of the six CPTSD symptom clusters were consistently less
positive for the subgroup of participants with childhood trauma. A second meta-analysis
by Coventry and colleagues [17] also found that both trauma and non-trauma focused
therapies provided substantial benefits for PTSD symptoms, while the positive effects for
the DSO symptom clusters were modest. It was also suggested that multi-component
therapies led to better outcomes, particularly among survivors of childhood sexual abuse.
This meta-analysis also reported that a likely CPTSD diagnosis was associated with higher
attrition rates compared with PTSD. Overall, these two meta-analyses suggest that existing
therapies routinely used for PTSD may be less optimal for those likely to have CPTSD and
that multicomponent modular therapies can be useful for those with CPTSD.

5. Patient-Centred Care and CPTSD

Patient-centred care advocates that symptoms or difficulties that are important to
one individual might not necessarily be important for another individual with the same
condition. The principles of patient-centred care also highlight that the needs of people
with mental health problems may change over time while they receive treatment and care
from services [18]. The Health Foundation [18] has identified a framework that comprises
four principles of person-centred care, including offering dignity, compassion and respect,
coordinated care, personalised care and empowerment, resilience, and agency.
In this framework, the role of the health care professional is to enable the individual to
make decisions about their own care and treatment based on their needs at the time they
access help and support. This approach is also aligned with the trauma-informed principles
of empowerment and collaboration [19]. Several health and economic outcomes have been
associated with person-centred care including less use of emergency services [20], greater
treatment adherence [21], greater patient satisfaction [22], and increased staff performance
and morale [21].
The use of flexible modular and sequential treatments, where therapeutic targets and
interventions are offered in line with patient recovery stage, needs, and preferences are
consistent with the principles of person-centred care. Using person-centred care might also
result in reduced attrition rates, which can be a particular issue in those with CPTSD [17],
although this is still an empirical question. In conclusion, person-centred treatment ap-
proaches implemented through the use of flexible modular therapies hold the promise of
being an efficient and effective strategy for optimizing outcomes for those with CPTSD [23].
Brain Sci. 2023, 13, 1300 4 of 8

6. The Development of STAIR Narrative Therapy for PTSD and Other Complex Forms
of Traumatization
Skills Training in Affective and Interpersonal Regulation (STAIR) followed by narrative
therapy (NT) is a two-module treatment that was developed, prior to the introduction of
CPTSD to address the multiple problems that individuals with histories of childhood abuse
may develop. This was based on a substantial literature base indicating that in addition to
PTSD, these individuals presented with significant problems in emotion regulation and
relational capacities (see [24]).
The rationale for the treatment was to directly target and address these difficulties
as well as the PTSD symptoms. STAIR included interventions that helped individuals
become more skilled in experiencing, managing and modulating the expression of feelings
(e.g., using feelings wheel, written descriptions of feelings, focused breathing) and to
become more flexible in interpersonal expectations (e.g., cognitive re-appraisal), more
skilled in communication (e.g., effective assertiveness) and more comfortable and trusting
in relationships (e.g., practicing positive activities and engaging in social support). The
Narrative Therapy module was an adapted version of exposure therapy (i.e., prolonged
exposure), in which the participant recounted memories of their traumatic experiences
with the goal of reducing fear reactions to these events and re-appraising the meaning of
the experience(s) in a more adaptive manner.
The treatment was sequenced so that STAIR preceded NT. The primary goal of the
STAIR modules was to improve overall functioning in day-to-day life. A secondary goal
was to use the time during STAIR to establish a stable therapeutic alliance and emotion
regulation skills both of which were expected and indeed demonstrated to facilitate the
narrative work [25]. Three randomized controlled trials [26–28] indicated that STAIR
Narrative Therapy provided significant improvements and large effect sizes in regard to
PTSD, emotion regulation, and interpersonal difficulties.
Over time, and particularly with the introduction of the CPTSD diagnosis, it became
evident that the symptom profile, which was first observed among individuals with early
life trauma was also applicable to individuals with adult-onset traumas of a sustained
nature including child soldiers [29], prisoners of war [30], refugees [31] and individuals
experiencing sustained community violence [32]. The STAIR-NT protocol has therefore
been adapted and revised to address the full range of symptom clusters comprising the
diagnosis of CPTSD, to be appropriate to the wide range of trauma-exposed populations
experiencing CPTSD, and to attend to the principles of personalized care.
The revised protocol, now called Enhanced STAIR (ESTAIR), comprises four modules:
Emotion Regulation, Relationship Patterns, Self-Concept, and Narrative Therapy. The
treatment is proposed to be applicable to a wide range of trauma-exposed populations with
CPTSD such as veterans, refugees, individuals who have experienced domestic violence, or
those with childhood trauma. Lastly, and most importantly, the four modules are expected
to be used in a flexible order and a flexible duration to be responsive to the needs and
preferences of the patients.

7. ESTAIR: A New Modular Person-Centred Therapy for CPTSD

ESTAIR has adopted all the theoretical and clinical principles of STAIR Narrative
Therapy but in line with the ICD-11 formulation of CPTSD, ESTAIR includes modules to
treat all symptom clusters of CPTSD, as detailed in Table 1 below. The essential principle of
STAIR Narrative Therapy is that trauma recovery involves not only attention to memories
of traumatic events from the past, but also covers the impact of trauma on the present as
it impacts current relationships, emotional distress in day-to-day life and quality of life.
Accordingly, the program includes traditional interventions related to processing of the
trauma memories (e.g., reappraisal of their meaning) as well as practical skills training
and related interventions to improve relationships, sense of self, emotion regulation, and
mood management.
Brain Sci. 2023, 13, 1300 5 of 8

Table 1. ESTAIR modules and session content.

Formulation Session
Understanding difficulties and preparing for change.
During session 1, one of the four modules is collaboratively chosen to begin with.
Emotion Regulation Sense of Self
1. Introduction and Emotional Awareness 1. What is the ‘Self’
2. Focus on the Body 2. Me in the Moment
3. Focus on Thoughts 3. Thinking about Self
4. Focus on Behaviours 4. Criticism and Compassion
5. Distress Tolerance 5. Who am I, In Relation to Others
6. Accomplishments and Summary of Work 6. Accomplishments and Summary of Work
Relationship Patterns Narrative Reprocessing
1. Understanding Relationship Patterns 1. Introduction to Narrative Reprocessing
2. Increasing Assertiveness 2. Narrative of the Most Distressing Memory
3. Managing Power with Respect 3. Continuation of Narrative Reprocessing
4. Increasing Respect for Yourself and Others 4. Continuation of Narrative Reprocessing
5. Increasing Closeness 5. Continuation of Narrative Reprocessing
6. Summary of Skills and Accomplishment 6. Relapse Prevention and Summary of Work

ESTAIR is a flexible modular approach for the treatment of CPTSD, where patient and
therapist collaborate on the selection of a set treatment modules intended to resolve specific
problems of concern, based on the stage of recovery the person is at, their preference and
the symptoms associated with most distress at that particular moment when they access
treatment and support.
Each of the four ESTAIR modules is structurally equivalent (6 sessions each). The
Affect Dysregulation module focuses on skills training in relation to identifying and la-
belling feelings, emotion management, distress tolerance, and acceptance of feelings and
experiencing positive emotions. The Negative Self-concept module focuses on the impact
of trauma on one’s self concept, how to stay in the present moment and combat dissociation,
cultivate self—compassion and mindfulness skills, challenge thinking patterns including
tackling negative thoughts rules and assumptions that relate to ones-self, how to be more
nurturing towards oneself, explore personal qualities, and develop a balanced view of self.
The Disturbed Relationships module focuses on exploration and revision of maladaptive
interpersonal schemas, effective assertiveness, awareness of social context, and flexibility
in interpersonal expectations and behaviours that are displayed in social interactions. The
Narrative Therapy module begins with an organization of a memory hierarchy in which
the individual identifies several key traumatic memories. The remaining sessions are
dedicated to telling the story of selected experiences and a re-appraisal of the meaning of
the event. Interventions associated with the trauma-processing work include flexible use of
adjunctive interventions such as systematic journaling about the experience and visiting
and re-evaluating the experience at the site of the trauma. Importantly, both therapist and
patient contrast and compare old trauma-generated beliefs to the newly emerging and
more positive sense of self and perspectives on others [33].

8. Limitations of ESTAIR as an Intervention for CPTSD

Although ESTAIR has a number of advantages for the treatment of CPTSD, it also
presents with several limitations, which are common across all flexible multi-modular
approaches. Firstly, there may be greater reliance on clinician’s skill in building a thera-
peutic alliance with the patient in order to enable decisions on the sequencing of modules.
Although ESTAIR modules can be offered in a set order, this would be against the princi-
ples of person-centred care. It would be essential to have a discussion very early in the
treatment about identifying appropriate treatment goals and symptom targets on the basis
of the recovery stage that a person is in, risk of decompensation and current symptom
prominence. Emerging evidence suggests that slightly different CPTSD symptom profiles
might emerge from difference traumatic stressors in terms of symptom prominence [34]
and this information can also guide the sequencing of modules. Secondly, the application
Brain Sci. 2023, 13, 1300 6 of 8

of ESTAIR also requires routine assessment of symptoms for feedback and decision making,
which may be viewed as burdensome by some services and clinicians, but which may
actually reduce the likelihood of dropout [35]. Considering that the application of ESTAIR
requires therapists making judgments about the sequencing of different modules, it is
essential to provide appropriate support at the service level, including the use of clinical
supervision to enable clinician’s decision making.

9. Directions for Future Research Using ESTAIR for the Treatment of CPTSD
This paper has presented ESTAIR, a promising person-centred flexible treatment
approach and provided the rationale for its usefulness for people with CPTSD. However,
there is clearly a need for further research in the field. Firstly, it is essential to assess
whether ESTAIR is a suitable intervention not only for CPTSD but also PTSD. Although this
is still an empirical question, it is expected that fewer sessions or modules may be required
for PTSD. There is also a need to compare ESTAIR with existing interventions routinely
used for PTSD to explore optimal approaches for the treatment of CPTSD. Some recent
evidence suggests that combination of modular therapies, i.e., STAIR plus established PTSD
treatments such as prolonged exposure are not superior to prolonged exposure alone for
the treatment of CPTSD related to childhood abuse [36]. Although this evidence might
raise some concerns about the usefulness of modular therapies for CPTSD, it might also
be useful to conduct further research in these areas using ESTAIR as opposed to STAIR
across different populations with CPTSD. Furthermore, comparing the effectiveness of
ESTAIR vs. existing therapies routinely used for PTSD, such as prolonged exposure or
EMDR in those with CPTSD should include t numerous outcomes addressing not only
symptom reduction, but also drop-out rates and patient satisfaction. Future research
should also explore the effectiveness of adaptation of treatments for other disorders or from
other traditions such as Interpersonal Psychotherapy (IPT) and mindfulness therapy or the
comparative effectiveness of ESTAIR against these interventions.
Furthermore, it would also be useful to explore different kinds of sequencing strategies
for the ESTAIR modules of where, for example, in one condition patient choice drives the
sequencing compared with a fixed sequence. At present, there is mixed evidence for the
impact of patient choice on therapy effectiveness (e.g., for depression [37]). Another design,
namely “sequential, multiple assignment randomized trials” or SMART [38], would involve
open-ended treatment sequences, where the selection of the next module is determined
by the patient’s response to previous module. Furthermore, there is a need to assess
the effectiveness and acceptability of ESTAIR in real life clinics using pragmatic designs
with fewer inclusion and exclusion criteria and across different populations with CPTSD
including community populations, prisoners, refugees, and veterans. Considering that the
DSO symptoms of CPTSD are cross diagnostic and present in a number of conditions that
might also result from traumatic stressors, it would also be essential to explore whether
ESTAIR is a beneficial treatment for comorbid CPTSD symptoms that can be present in
other conditions such as psychosis, and whether actively targeting these symptoms can
have an impact on symptom severity of the primary diagnosis. Finally, considering that
there may be some cultural variations in the DSO symptoms of CPTSD [39], ESTAIR may
require cultural adaptations in its content to enhance its cross-cultural relevance. We now
have an opportunity to target specific and effective therapies to those who need them most
and the CPTSD diagnosis allows us to be more precise about how we can best do this, in a
trauma-informed, person-centred manner.

Author Contributions: Conceptualization, T.K. and M.C.; writing—original draft preparation, T.K.;
writing—review and editing, M.C. and E.M.G. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Brain Sci. 2023, 13, 1300 7 of 8

Informed Consent Statement: Not applicable.

Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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