Interpersonal psychotherapy for complex posttraumatic stress disorder related to childhood physical and emotional abuse with great severity of depression: A case report

Abstract

Patients may develop posttraumatic stress disorder (PTSD)—a chronic and incapacitating disorder—following exposure to a traumatic events such as natural disaster, threat of death, serious injury, or sexual violence. In particular, PTSD associated with abuse during childhood is harmful owing to its association with multiple forms of trauma during childhood and adulthood; the traumas include emotional abuse, physical assault, sexual assault, and domestic violence (Coid et al., 2001). The International Classification of Diseases 11th Revision (ICD11) recently defined the diagnosis of complex PTSD (cPTSD) by disturbances in self-organization (DSO) through affective dysregulation, negative self-concept, and disturbed relationship in addition to the classical PTSD symptom cluster (Karatzias et al., 2017). Considering this, particularly overwhelming, long-lasting, repeated childhood traumas are considered a risk factor for the development of cPTSD (de Aquino Ferreira et al., 2018). Childhood abuse is also related to depression. Reportedly, recurrent and persistent depressive episodes were twice as likely to occur in patients who had experienced childhood abuse or neglect (Nanni et al., 2012). Furthermore, data from outpatient samples revealed that adults who have experienced childhood abuse and neglect present with depression that has a relatively higher severity, earlier age of onset, and longer illness duration (Miniati et al., 2010). In patients diagnosed with cPTSD, Powers et al. reported that the likelihood of having a secure attachment was reduced and susceptibility of comorbidity with other psychiatric conditions was increased, compared with those diagnosed with PTSD alone (Powers et al., 2017). Moreover, individuals with comorbid PTSD and major depression have higher suicide attempt rates than those with either disorder alone (Oquendo et al., 2005). Numerous expert bodies and pertinent treatment guidelines recommend cognitive behavioral therapy (CBT), in particular exposurebased treatment, as the first-line treatment for PTSD. However, not all PTSD patients benefit from exposure-based treatment, and the effectiveness of treatments for cPTSD has been less widely studied. For example, a meta-analysis found that PTSD remission was not observed in 17%–42% of patients who underwent an exposure-based treatment course, and PTSD continued to persist in 13%–50% of the patients who completed CBT with some variation of exposure-based treatment (Bradley et al., 2005). Despite recommendation and encouragement from experienced and persuasive clinicians, some patients do not wish to undergo exposure therapy (Markowitz et al., 2016). Moreover, the complex picture of PTSD includes strong interpersonal themes. Patients with PTSD have interpersonal difficulties, such as emotional withdrawal from relationships, because they mistrust not only their interpersonal environments but also their own selves (Bleiberg & Markowitz, 2005). Patients with cPTSD, which may be triggered by interpersonal traumas of childhood abuse or neglect, may have even greater interpersonal difficulties because they also have DSO symptoms. Interpersonal psychotherapy (IPT) (Weissman et al., 2000) is a time limited, affect focused, and diagnosis targeted psychotherapy modality that was originally developed for depression, may be fruitful for treatment of PTSD. IPT for PTSD focuses on current interpersonal encounters rather than past trauma, which exposure-based treatment focuses on. Whereas exposure-based treatment focuses on reducing conditioned fear associated with past trauma, IPT targets insecurity, and discomfort in relationships. IPT may address interpersonal sequelae of trauma that exposure-based treatments may not. In fact, Markowitz et al. reported that IPT was no statistically inferior to prolonged exposure therapy (Markowitz et al., 2015). In this study, the Received: 4 October 2021 Accepted: 1 December 2021