Dear Fellow Practitioners in Mental Health,
Although the therapeutic relationship is the main factor in our clients’ progress, you may be contacted by clients who are presenting with the impact of trauma for whom EMDR could be a powerful option; If you have a client whom you would like to talk through,  please contact me. I also offer consultant supervision for practitioners working towards accreditation

You will know that the impact of childhood adversity is often at the root of the mental health problems that our clients present with ^1. Repeated and chronic traumatic events in childhood can manifest in adulthood as Complex Post-traumatic Stress Disorder .

This has been increasingly recognised in the validation and publication of Complex Post-traumatic Stress Disorder [ CPTSD] as a diagnostic category in ICD 11 [2018]. In addition to symptoms of PTSD, clients with CPTSD will have experienced chronic, repeated & prolonged trauma and will have difficulties with emotional regulation, self-identity and relational capacity.²

Therefore, it can be challenging to distinguish borderline personality disorder from CPTSD, although there is an overlap, there are identifiable differences. Some clients who have had chronic, repeated and prolonged trauma will rather develop PTSD than CPTSD. It is possible for single incident trauma to result in CPTSD. CPTSD as might be expected, has a greater impact on functioning. High levels of comorbidity are expected in these clients, especially anxiety, agoraphobia , panic disorder ,  disordered eating , substance misuse and depression .

Women, because they are more likely to be subject to interpersonal violence are more likely to suffer from PTSD and CPTSD, and to experience the symptoms for longer than men. These diagnoses are associated with an increased risk of suicide. PTSD causes poor social and family relationships, absenteeism from work, lower income, education and occupational success.

CPTSD is a new diagnosis, and for this reason, treatment efficacy of E.M.D.R. for this diagnosis as opposed to PTSD has not been subject to randomised controlled trials.

The Assessment of PTSD and CPTSD.

It can be easy to miss or underestimate the impact of trauma in a client for the following reasons.

• The comorbidity associated with the trauma may be the main presentation, so therapy may help with state change, rather than trait change.
• The avoidance of retraumatisation and associated shame and guilt by talking about it in therapy.
• The avoidance is very longstanding, and the client’s behaviour and relationships have adapted.
• Dissociation is not always recognised. Dissociation can present in varied and subtle ways, for example, intermittent emotional shut down in relationships , feeling cut off from those people and places around you , subjective forgetfulness and poor concentration.
• The trauma is embodied rather than in conscious awareness, so without considering physical sensations, will be missed.
• Aspects of the therapeutic relationships trigger traumatic memories and /or the client does not feel safe enough to work on the trauma. ³

The following validated and widely used tools may help to fill gaps in the process of assessment and assess response to treatment ;

PCL- 5 is based on DSM- V [2013], completed by the client assesses the impact of a single event over the last one month.[U.S. Department Veterans Affairs .PTSD : National Center for PTSD. ] This questionnaire assesses symptoms of PTSD .

International Trauma Questionnaire based on ICD-11 2018 criteria ; completed by the client and assesses symptoms of PTSD before asking about the additional areas of emotional regulation , negative self concept , relational capacity and functioning which make up CPTSD ^{4, 5} . The clinician completed International Trauma Interview is in development.

References;

www.psychiatry.org Diagnostic and Statistical Manual of Mental Disorders Fifth Edition pg.272-273.

www.who.org International Classification of Diseases .

1. Moller L.Augsburger M Traumatic experiences , ICD-11 PTSD , ICD-11 Complex PTSD , and the overlap with ICD-10 diagnoses . Acta Psychiatrica Scandinavia 2020 : 141 :421-431
2. Cloitre M. 2020 ; ICD-11 Complex post-traumatic stress disorder ; simplifying diagnosis in trauma populations . British Journal of Psychiatry. Volume 216 Issue
3. The Body keeps the Score ; Mind , brain and body in the transformation of trauma .Bessel Van Der Kolk .Penguin September 2015 . ISBN 9780141978611.
4. Cloitre et al 2018 ; International Trauma Questionnaire . Acta Psychiatrica Scandinavia
   DOI : 10.111/acps.12956
5. Murphy D., Shevlin M., A validation study of the ITQ to assess PTSD in treatment -seeking veterans . British Journal of Psychiatry 2020 .216 , 132-137.

How does Sharon meet criteria for Post-traumatic Stress Disorder ?

DSM - V . 309.81
Criterion A ;
Exposure ;
Traumatic bereavement , Age 16 years.
Sudden , repeated direct exposure to dying patients in circumstances that were outside of her professional experience.

Criterion B ;
One or more of the following ;

1. Recurrent involuntary and intrusive memories;
   Images of the faces of patients she had nursed.
2. Recurrent distressing dreams;
   Nightmares of close relatives dying .
3. Dissociative reactions;
   Gaps in recalling what she had done the day before.
4. Intense or prolonged distress to internal or external cues that symbolise or resemble an aspect of the traumatic event;
   Anxiety and panic going to work
   Overwhelmed by feelings of anger if public not following Covid rules.
   Tearful when watching the news.
5. Marked physiological reactions to internal and external cues that symbolise or resemble an aspect of the trauma event;
   Waking unable to breath.
   Panic going to work.

C ; Persistent avoidance of stimuli associated with the traumatic event . One or both of the following ;

1. Avoidance of distressing memories,thoughts,feelings
   Drinking alcohol
2. Avoidance of external reminders ; people , conversations and interpersonal situations .
   Unable to work.

D ; Negative alterations in cognition and mood ;
Low self esteem.
Feelings of guilt and responsibility.

E ; Alterations in reactivity and arousal ;
Panicky if her father did not pick up the phone.
Poor sleep.

F ; B,C,and D have lasted longer than a month .
Yes.

G ; Significant distress and/ or social , occupational or other functional impairment ;
Sharon is significantly distressed and unable to work .

H ; Presentation cannot be attributed to the use of a psychoactive substance , medication or medical condition.
Drinking alcohol is to alleviate her symptoms and not the cause .

Sutton House Consulting Rooms
27 Wilson Patten St, Warrington,
Cheshire WA1 1PG

Tel : 07942 339 365
Email: hello@emdr-help.co.uk

Complaints need to be addressed to the Independent Doctors Federation. Dr Frances Lindon is insured in her practice by the Medical Defence Union.

The following case study is fictitious and serve to illustrate real-life a problem and how E.M.D.R. can help;

Sharon is an experienced nurse redeployed to intensive care at short notice at the out break of Covid-19 . She initially coped with caring for a greater number of patients in PPE , communicating with distressed relatives by telephone and patients dying more often than normal. However , her work schedule and self isolation with her partner contributed to the break up of this relationship .

She noticed that she started to experience anxiety and panic going to work , her sleep deteriorated and she experienced nightmares during which close relatives died and she woke unable to breath . She had intrusive images of the faces of patients she had nursed occurring while awake . She would start to feel panicky if her father did not pick up the phone. She felt overwhelmed by feelings of anger if she saw members of the public breaking the Covid-19 rules. She felt tearful if she watched a sad film or followed the news. Sometimes she would dissociate as she was aware of gaps in recalling what she had done the day before . Sharon found that she was drinking 2-3 units of wine to help her to sleep every night . Eventually , she felt that she had to take a break from work .

At the age of 16 years she had been suddenly bereaved of her mother. As a family , they struggled with the consequences of this ; Sharon herself experienced low self esteem and feelings of guilt and responsibility regarding her loss .

With her EMDR practitioner she identified the beliefs about herself and associated physical feelings triggered by recent events , linking them to their source earlier in her life .

Sharon learnt to temporarily place her feelings of emotional distress and physical sensations into a container.
She learnt grounding techniques to reduce the tendency to dissociate.
She learnt to access a place in her mind where she felt calm [ safe place ] .
These techniques were installed using slow bilateral stimulation [ she chose butterfly taps ]
She was encouraged to attend to self-care ; regular exercise , periods of relaxation , regular diet and sleep hygiene .

Butterfly Taps

Butterfly taps are being used by Sharon in Phase 4  and can also be used to enhance resourcing

This is a self soothing technique originally developed for use in children.
Cross your hands over your chest .
Make  the shape of the butterfly with your hands.
Place the tips of your middle fingers on your collar bones and tap your fingers alternately at the speed suggested by the therapist.
Close your eyes or focus your gaze internally.
Take yourself to the safe place that you have developed and bring this together with the Breath deeply .
Notice your bodily feelings.
Continue tapping for 1-3 minutes .
Come out of your safe place and back in to the room. 

Once Sharon had reprocessed the significant events from the past she found that she felt less distressed by the impact of Covid-19 . At this point she was sleeping better, no longer had nightmares and was no longer depressed or anxious . There were still a couple of incidents which she found overwhelming which she went on to reprocess.She also reprocessed a recent incident when a member of the public not wearing a mask had bumped in to her in a shop.

Future Template ;

• Using Bilateral Stimulation Sharon visualised herself at work , together with the changed belief she now holds about herself in that situation and associated physical feelings .
• This prepared her mentally for a phased return to work which she completed successfully.