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Understanding the psychodynamic functioning of patients with PTSD and CPTSD: qualitative analysis from the OPD 2 interview

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Abstract

The traumatic event produces intolerable excitations to the psychic apparatus that searches to relief them through the production of symptoms. When established, patients with post-traumatic stress disorders (PTSD) and complex post-traumatic stress disorder (CPTSD) may experience flashbacks, somatizations, negative emotions about themselves, and difficulty in social contact. This work seeks to understand how the psychodynamic functioning of women victims of interpersonal and urban violence, diagnosed with these disorders, is organized, identifying traumatic experiences, ways of interpersonal relationships, conflicts and psychic structures and use of defense mechanisms, and for peculiarities that may differentiate these disorders. The qualitative transversal method was used through the content analysis of clinical interviews based on the Operationalized Psychodynamic Diagnosis (OPD-2). The sample of this study consisted of five women with PTSD and five with CPTSD. The following categories were created: reasons for seeking care, symptoms and desire for treatment, traumatic developmental events, and characteristics of the psychic functioning. Early trauma generates psychic organizations with greater disintegration. A new traumatic event destabilizes the psychic organization and intensifies symptoms. Relationships were marked by dependence and isolation. Participants with CPTSD presented tendency to disintegration related to the object relation regulation and the psychic conflict was of Individuation versus Dependence, with more primitive flaws in object representations, existential need for the other and direct discharge of impulses. Participants with PTSD had moderate to low level of object relation integration and the conflict was need to be care of versus self-sufficiency, with self-representations being fragile and with reduced capacity to manage impulses. Thus, it could be observed that OPD-2 is capable of assessing in a broad and deep way patients with traumatic disorders, in addition to identifying essential peculiarities to guide health professionals towards treatment in the search for better quality of life for patients.
Favarettoetal. Psicologia: Reexão e Crítica (2022) 35:9
https://doi.org/10.1186/s41155-022-00211-5
RESEARCH
Understanding thepsychodynamic
functioning ofpatients withPTSD andCPTSD:
qualitative analysis fromtheOPD 2 interview
Taís Cristina Favaretto1,2* , Luciane Maria Both1, Sílvia Pereira da Cruz Benetti3 and
Lúcia Helena Machado Freitas1
Abstract
The traumatic event produces intolerable excitations to the psychic apparatus that searches to relief them through
the production of symptoms. When established, patients with post-traumatic stress disorders (PTSD) and complex
post-traumatic stress disorder (CPTSD) may experience flashbacks, somatizations, negative emotions about them-
selves, and difficulty in social contact. This work seeks to understand how the psychodynamic functioning of women
victims of interpersonal and urban violence, diagnosed with these disorders, is organized, identifying traumatic
experiences, ways of interpersonal relationships, conflicts and psychic structures and use of defense mechanisms,
and for peculiarities that may differentiate these disorders. The qualitative transversal method was used through the
content analysis of clinical interviews based on the Operationalized Psychodynamic Diagnosis (OPD-2). The sample of
this study consisted of five women with PTSD and five with CPTSD. The following categories were created: reasons for
seeking care, symptoms and desire for treatment, traumatic developmental events, and characteristics of the psychic
functioning. Early trauma generates psychic organizations with greater disintegration. A new traumatic event desta-
bilizes the psychic organization and intensifies symptoms. Relationships were marked by dependence and isolation.
Participants with CPTSD presented tendency to disintegration related to the object relation regulation and the psy-
chic conflict was of Individuation versus Dependence, with more primitive flaws in object representations, existential
need for the other and direct discharge of impulses. Participants with PTSD had moderate to low level of object rela-
tion integration and the conflict was need to be care of versus self-sufficiency, with self-representations being fragile
and with reduced capacity to manage impulses. Thus, it could be observed that OPD-2 is capable of assessing in a
broad and deep way patients with traumatic disorders, in addition to identifying essential peculiarities to guide health
professionals towards treatment in the search for better quality of life for patients.
Keywords: Psychological trauma, Post-traumatic stress disorder, Chronic post-traumatic stress disorder, Violence,
Psychoanalytic theory, Qualitative research
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Introduction
Post-traumatic stress disorder (PTSD; F43.10) can
develop from exposure to or witnessing one or more
threatening events or episodes of violence. e presence
of intrusive symptoms, overwhelming feelings and avoid-
ance of trauma-related memories (World Health Organi-
zation, 2018) are an adaptive response of the psychic
apparatus to excessive stress disorders producing consid-
erable subjective suffering (Blanco, 2016).
In 2018, based on clinical observations of individuals
who have suffered multiple and/or prolonged traumas
of interpersonal nature throughout their lives, a new
category for stress-associated disorders was included,
Open Access
Psicologia: Reflexão e Crítica
*Correspondence: taisfavaretto@gmail.com
2 Rua Independência 99a, 401, Centro, Passo Fundo, Rio Grande do Sul
99010041, Brazil
Full list of author information is available at the end of the article
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Favarettoetal. Psicologia: Reexão e Crítica (2022) 35:9
namely complex post-traumatic stress disorder
(CPTSD; 6B41). CPTSD is characterized by severe and
persistent problems with affect regulation, diminished
self-beliefs, shame, guilt, or failure related to the trau-
matic event. Such reactions cause significant damage
in different spheres of the subject, including personal,
social, and occupational relationships (World Health
Organization, 2018).
Such classifications, related to trauma disorders and
stressors, defined by the nosological psychiatric diag-
nosis, seek an objective assessment of symptoms, with
concise and clear criteria aimed at adequate treatment
(American Psychiatric Association, 2014). On the other
hand, psychoanalytic theory seeks to understand human
behavior and suffering through the patient’s developmen-
tal history, his/her structural constitution of personality
and how the dynamics between the mental instances,
Id, Ego, and Superego are established. rough psycho-
therapeutic work, by talking and associating, it seeks to
reduce symptoms, change poorly adapted relational pat-
terns, dysfunctional conflicts, and structural limitations,
improving quality of life (Campos, 2017).
eir contributions mention psychic trauma as an
excessive influx or accumulation of excitations that
penetrate the psychic apparatus, exceeding the capac-
ity to face or integrate feelings, in the face of the large
amount of stress (violent traumatic event), needing to
be relieved (Laplanche & Pontalis, 1991). By breaking
through the ego defense mechanisms, this energy puts
the developed psychic structure at risk, leading the sub-
ject to the position of original helplessness, that is, con-
stantly reliving the newborn’s instinctual anguish in the
face of its biological and psychic immaturity (Favero,
2009; Laplanche & Pontalis, 1991; Pereira, 2008). Symp-
toms appear as a discharge or a substitute for the con-
tents that cause the anguish, unconsciously, the psychic
expression of instincts and, consciously, the traumatic
event (Costa, 2019).
Pre- and post-traumatic characteristics enable the
emergence of potentialities and vulnerabilities in cop-
ing with the traumatic event. Protection from trauma
arises mainly in the first moments of development with
the internalization of representations of good rela-
tionships and the constitution of stable self, capable of
regulating emotions and behaviors and making use of
defense mechanisms in the face of anxiety, with greater
flexibility (Eizirik etal., 2015). Traumatic situations such
as violence, especially in childhood, can form disorgan-
ized psychic structures with failures in the repression of
instincts, use of rigid defense mechanisms and low abil-
ity to reflect, which makes psychic reorganization diffi-
cult in the face of a traumatic event (Bateman & Fonagy,
2016). Furthermore, factors such as intensity, duration,
and frequency of trauma (Wilson & Reagan, 2016), social
support, physical and mental comorbidities, and socio-
economic issues should also be considered in coping with
the traumatic event (Steinert etal., 2015).
us, observing the complexity of the human mind
and the need to seek an alignment between assess-
ment of patients based on fundamental psychodynamic
assumptions and the phenomenological orientation of
psychiatric diagnostic glossaries, the Operationalized
Psychodynamic Diagnosis instrument (OPD-2) emerges
as a means of multiaxial assessment that formulates the
way in which patients organize their psychodynamic
functioning based on their clinical situation, areas of
functioning with symptoms or difficulties, subjective suf-
fering, patterns of interpersonal relationships resulting
from intrapsychic conflicts, their resources and compe-
tences, deficits in psychological structure and nosologi-
cal diagnosis. From the integration of axes, it is possible
to indicate the focus of the psychotherapeutic treatment
focused on the dysfunctional relationship pattern and
problems based on conflict and/or structure. For these
purposes, the instrument uses as theoretical basis
assumptions of the attachment theory and object relation
(Task Force, 2016).
us, in view of the traumatic disorders that present
intense severity of symptoms and extensive damages in
the lives of individuals, through OPD-2, this study seeks
to understand how the psychodynamic functioning of
women victims of interpersonal and urban violence,
diagnosed with PTSD and C–PTDS is organized, identi-
fying traumatic experiences, interpersonal relationships,
conflicts and psychic structures, and the use of defense
mechanisms, in addition to looking for peculiarities that
can differentiate these disorders.
Method
is is a qualitative cross-sectional study whose focus
was the content analysis of clinical interviews based
on OPD-2. e construction of the study was organ-
ized through the Consolidated Criteria for Qualitative
Research Reports (Tong etal., 2007). is research is part
of a broader study project with subjects who have gone
through traumatic events.
Participants
Participants are ten women from a public health service
in a large city in Rio Grande do Sul, Brazil, evaluated in
2019. e place is reference in the evaluation and treat-
ment of trauma victims. Selection was carried out by
convenience, among those who were on site at the time
of data collection, which took place on alternate days and
at different times to achieve greater sample heterogene-
ity. Five women with PTSD and five with CPTSD were
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Favarettoetal. Psicologia: Reexão e Crítica (2022) 35:9
included. Diagnosis was performed through a psychiatric
clinical interview present in DSM-5 (American Psychi-
atric Association, 2014) and ICD-11 diagnostic criteria
(World Health Organization, 2018), respectively. e def-
inition of the number of participants was performed by
data saturation.
Instruments
Sociodemographic andclinical form
Sociodemographic and clinical form is used to char-
acterize participants, containing data on age, school-
ing, relationships, and use of psychoactive substances,
among others.
Operationalized Psychodynamic Diagnosis (OPD‑2) clinical
interview
Operationalized Psychodynamic Diagnosis (OPD-2) clin-
ical interview is a qualitative analysis of the semi-struc-
tured clinical interview that allows the formulation of a
multiaxial psychodynamic diagnosis through the follow-
ing axes: (axis I) experience of the disease and prerequi-
sites for treatment, (axis II) interpersonal relationships,
(axis III) conflict, (axis IV) structure, and (axis V) mental
and psychosomatic disorders. In axes I, II, and IV, criteria
that induce the coding of the interview as “0—absent, 1—
mild/insignificant, 2—moderate, 3—high/significant, 4—
very severe/very significant, and 9—not evaluable” are
used. Axis II shows 32 patterns of dysfunctional relation-
ships, themes, and resources presented by the patient and
scored by judges (Task Force, 2016). Detailed description
can be found in the Supplementary TableS1.
Ethical procedures, data collection, andanalysis
e study was approved by the ethics committee of
the Federal University of Rio Grande do Sul (CAAE
68271917.7.0000.5347, No. 2.412.749) and authorized
by the Specialized Center where data were collected.
Participants signed the Free and Informed Consent
Form. Data collection was carried out in a clinical care
room with researcher and participant. e psycholo-
gist researcher has thirteen years of experience in psy-
chodynamic psychotherapy and specific training to
apply the OPD-2 clinical interview and had no previ-
ous knowledge of participants. e questionnaire was
answered and later interviews took place, which were
audio recorded, totaling 5 h and 20 min. Interviews
were operated by two independent judges with agree-
ment on all axes above 0.75, proving to be substantial.
Descriptive analysis was performed to characterize
the sample and identify similarities and peculiarities in
reports. According to Bardin (2008), analysis catego-
ries were created a posteriori. Results were compared
with the existing literature relevant to the topic, scien-
tific productions on PTSD and CPTSD, international
psychodynamic studies and local investigations, since
the occurrence of traumatic events has social attributes
that should be considered.
Results
Sociodemographic andclinical characterization
ofparticipants
Participants were ten women. All were white and with
mean age of 40 years (SD = 13.49). Psychiatric diag-
noses were defined based on experienced symptoms,
where participants 1, 2, 3, 4, and 5 met diagnostic crite-
ria for PTSD (American Psychiatric Association, 2014)
and participants 6, 7, 8, 9, and 10 were diagnosed with
CPTSD (World Health Organization, 2018). Detailed
data are found in Table1.
Table 1 Sociodemographic and clinical data
a Minimum monetary payment, dened by law, that a worker must receive for services rendered
Participants Age Schooling Income Psychoactive
substances Relationship
Participant 1 19 Incomplete high school Between 1 and 2 minimum wagesaDo not use Single
Participant 2 41 Incomplete primary education Less than 1 minimum wage Tabaco Married
Participant 3 47 Incomplete primary education Less than 1 minimum wage Do not use Married
Participant 4 51 Incomplete primary education No income Alcohol Girlfriend
Participant 5 21 Complete primary education No income Do not use Single
Participant 6 27 Complete primary education Between 1 and 2 minimum wages Do not use Single
Participant 7 60 Complete high school No income Do not use Widow
Participant 8 48 Technical education Between 1 and 2 minimum wages Do not use Married
Participant 9 45 Incomplete primary education No income Do not use Married
Participant 10 43 Incomplete primary education No income Do not use Married
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Thematic categories
Based on the analysis of interviews, categories reason for
seeking care, symptoms, and desire for treatment, Trau-
matic developmental experiences and characteristics of
psychic functioning were formed (detailed description
can be found in Supplementary TableS2). It was observed
that some aspects analyzed end up by being included in
more than one category, as there is no way to isolate the
dynamics into independent thematic modalities.
Reason forseeking care, symptoms anddesire fortreatment
is category records reasons for seeking specialized
mental health care, symptoms developed after the index
traumatic event and type of expected treatment. It is
noteworthy that the index traumatic event is indicated as
a triggering symptom of trauma.
e reasons for the initial search for care are similar
for most participants, physical and emotional symptoms
triggered after an index traumatic event: sexual violence,
urban violence, accident with family member, and fire.
Participant 10 points out that she sought care due to an
“accumulation” of traumatic experiences in her develop-
ment, emotional, sexual and domestic violence.
However, participants 2 and 5, despite bringing reports
of traumatic experiences in their lives, are unable to
associate them with their symptoms, seizures, and loss
of leg movement, respectively. Such symptoms were
understood in psychiatric diagnoses as somatic mani-
festations and not as neurological conditions. Partici-
pant 5 reported: “No, I do not know, I have never had an
accident”.
It is noteworthy that, in most cases, the experience of
trauma was not associated with the perception of symp-
toms, requiring referrals to professionals from other
clinical specialties or the intervention of family members.
Only participants 1 and 3, with PTSD, sought help on
their own, identifying problems in their functioning.
In all cases, there is predominance of PTSD-related
symptoms, flashbacks, hypervigilance, persistent feel-
ings of threat, causing sleep difficulties, and distressing
dreams. Fear, anxiety, anguish, and even panic seem to
arise for no apparent reason or when related to activities
and memories of the trauma. Somatic symptoms such as
headache, abdominal pain and fatigue are reported. In
addition, participants with CPTSD pointed to negative
self-images, difficulties in interpersonal relationships,
and persistent affect regulation problems. In addition,
sense of loss of value and feelings of shame in the face of
traumatic experiences are also observed.
In this sense, despite the severity of traumatic events
and triggered symptoms, participants with PTSD were
able to maintain, despite some difficulties, activities in
the personal, social and occupational spheres. However,
participants with CPTSD, who already showed global
functioning with moderate to severe difficulties before
the index traumatic event, had their symptoms intensi-
fied, abandoning most of their activities.
It is pointed out that suicidal ideation was present in
half of participants, regardless of diagnosis. Even more
serious, participants 2 and 10 had made suicide attempts,
and according to participant 2: “I was sick, I took so many
medications and cut myself in my arms”.
Her wish regarding treatment is the reduction of symp-
toms through medication. Participants 7 and 10 perceive
benefits in being able to speak and think through psycho-
therapeutic treatment. “It is hard to speak out, but I leave
here lighter” (participant 7).
Traumatic developmental experiences
is category brings traumatic experiences lived by par-
ticipants throughout their lives, in their development.
Experiences related to family and social contact were
included.
In the life history of all participants, there are traumatic
situations during childhood such as intra-family vio-
lence, fights and arguments between parents, as well as
verbal and physical aggression. Such behaviors triggered
feelings of rejection and affective withdrawal from their
caregivers.
In addition, six participants reported episodes of
childhood sexual violence caused by a family member.
Participants 2 and 6 by their fathers and the others by
brothers-in-law, cousins, or uncles. All of them reported
that their caregivers, especially mothers, knew about the
violence suffered; however, as they had a link with the
aggressor, they neglected the violent episode and did
not file any legal complaints. Consequently, some par-
ticipants felt unassisted and were even abandoned by
caregivers, starting to live with people outside the fam-
ily nucleus. Participant 9 reported: “When I was abused,
my mother sent me to a friend’s house. I had to clean and
cook. It was difficult, I did not understand why she gave
me away.
Among participants, only participants 1 and 3 reported
to have had caregivers with stable affective behavior,
capable of helping in their anxieties and to build an inde-
pendent self. Participant 1 highlighted: “My father always
supported me, he was always by my side, he gave me
affection and explained things.
It was also evident the recurrence of traumatic events
throughout their lives, sexual and urban violence and also
intimate partner violence. In addition, they witnessed
violence against other people, sexual violence against
family members, violent death of close person and house
fire, which were reported as traumas.
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Favarettoetal. Psicologia: Reexão e Crítica (2022) 35:9
Faced with the violation of their rights, none of par-
ticipants who suffered sexual violence or intimate partner
violence made a judicial referral. In contrast, those who
experienced urban violence registered a police report.
Participant 10 reported: “I was very scared, but I went to
the police station and told them what I had experienced”.
Characteristics ofpsychic functioning
e general characteristics of the levels of structural inte-
gration of personality, the main conflicts and their modes
of organization, the defense mechanisms used and also
the way in which interpersonal relationships are estab-
lished, are described.
e personality structure refers to the self and its avail-
ability in the regulation of relationships with internal
objects (autonomous self, internalization of good objects,
self-regulation, self-reflection) or external-perception of
the other and the realized, empathy (Task Force, 2016).
In participants with PTSD and CPTSD, an important dif-
ference was observed in terms of structural personality
functions. In most participants with CPTSD, the regula-
tory capacity dimension (self-regulation and regulation
of the object relation) had low level and tendency to dis-
integration in relation to the object relation regulation.
us, for the Task Force (2016), aggressive impulses com-
ing from the Id cannot be integrated or blocked in the
total aspect of the behavior, given the absence of norma-
tive instances, and the destructive hatred is justified by
the actions of the others, without differentiation between
their experiences, feelings, and interests. Participant 9
revealed: “e swing bothers me. en she was there (my
daughter) swinging, then I started screaming, slapped her
in the face and took her home”.
However, in participants with PTSD, object percep-
tion ranged from moderate to low, where differentiation
between their impulses and interests and those of others
is not absent but reduced, with limited capacity to antici-
pate others’ reactions. It could be perceived in the speech
of participant 5: “For God’s sake, they tell me, why are
you so rude, she told me, but I do not understand why.
In fact, I would rather be alone.” Furthermore, self-reg-
ulation did not vary in both diagnoses, being expressed
at moderate to low level, in which instinctual desires are
poorly tolerated, with low possibility of postponing or
displacing satisfaction.
e other structural, cognitive (self-perception and
object perception), emotional (internal communication
and communication with the external world), and attach-
ment capacity (internal objects and external objects)
functions varied from moderate to low levels in all par-
ticipants with reduced capacities and functions, marking
the permanent tension in relation to their interior with
difficulties to experience their own affections and fear
of losing the object (Task Force, 2016). us, in general,
the total personality structure of participants with PTSD
and CPTSD is at moderate to low level; however, there is
tendency of disintegration in the regulation of the object
relation in participants diagnosed with CPTSD.
Likewise, the characteristics referring to psychic con-
flicts also differed among participants. In psychoanalysis,
psychic conflict is manifested when there are opposing
internal demands, which can be manifest (desire and
moral demand) or latent. Such conflicts can manifest
in the formation of symptoms and behavioral disorders
(Laplanche & Pontalis, 1991). Participants with PTSD
exhibited as main conflict the need to be taken care of
versus Self-sufficiency, where they need the certainty of
attention and care for the other. Participant 6 reported:
“It is difficult, what I do is never good, they always leave
me aside”. In participants with CPTSD; however, Indi-
viduation versus Dependence was identified as the major
conflict, with more primitive developmental issues
related to existential need. Participant 2 reported: “I need
him, I cannot do it alone, I do not know what to do, I am
nobody without him”.
In view of their psychic structures and conflicts, mani-
festations of protection of the self seek to control the
anguish arising from internal aggressions (of instinctual
order) and external sources of contempt, such as trauma,
which can generate excitement (Laplanche & Ponta-
lis, 1991). us, the most used defense mechanisms are
linked to mental inhibition such as Affective Isolation
and Dissociation (Clarkin etal., 2013; Task Force, 2016).
Participant 2 reported “Sometimes I even lose my mem-
ory, I am in that place and I stay like that for half an hour,
and I do not know where I am”. ere was also the occur-
rence of denial of unpleasant facts through rationaliza-
tion: “My mother was pregnant when my father died. So
she forced herself to give it to me. I was one of the oldest”
(participant 5) and defense actions that deal with inter-
nal or external stressors by action or withdrawal, such as
Acting out: “I had so much anger, anger inside me. I once
threw myself in front of a car” (participant 6). In addi-
tion, Somatization: “It was good, but when I got up in the
morning I did not feel anything in my legs anymore (...).
Both feet were bent (participant 2).
is set of characteristics of the participants’ psychic
functioning acts on the way in which interpersonal rela-
tionships developed. Dysfunctional relationships with
little proximity were evidenced, where participants do
not feel understood, the others are felt as imposing them-
selves in a rude way, censoring or neglecting. In addition,
sudden mood changes and avoidance of physical prox-
imity increase interpersonal difficulties. Participant 10
reported: “It is getting more difficult every day, for me it
is a sacrifice to be with someone. Nobody helps me”. e
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Favarettoetal. Psicologia: Reexão e Crítica (2022) 35:9
loss of interest also extends to daily activities like study,
household chores, television programs, and they stop
doing them, starting not feeling or experiencing positive
emotions. Participant 7: “I do not have any joy, I do not
want anything, I do not take care of my pets anymore”.
Discussion
e study was carried out with ten women who sought
a public service specialized in trauma assessment and
treatment. At initial consultation, diagnosis of PTSD and
CPTSD was evidenced. e sociodemographic findings
confirm data provided by DSM-5 that describe patients
with traumatic disorders as having tendency towards
lower schooling, lower socioeconomic status, and less
prevalent behaviors related to the use of psychoactive
substances (American Psychiatric Association, 2014).
rough the OPD-2 clinical interview, experiences
with care ambivalence, emotional, physical, and sexual
violence were identified in their life histories, generat-
ing feelings of anger, fear, and abandonment. In such a
way, the formation of insecure attachment seems to hin-
der the self-object differentiation, the regulation of the
instinctual discharge and, consequently, the capacity for
reflection and reorganization in the face of stress (Cryan
& Quiroga, 2016). In view of this, the psychic struc-
tures of participants when experiencing the index trau-
matic event cannot manage the intensity of energy that
is released, producing symptoms and disorders. Despite
causing dysfunctions in different areas, such symptoms
maintain some control over the mobilized anguish.
Regarding specific sexual violence in childhood, Turner
etal. (2017) point out that trauma becomes an uninter-
rupted horror when perpetrators have close relationship
with victims, when they are not removed from convivi-
ality. Blaming victims, denying, or minimizing the event
and the effects of violence still tend to cause a poly-vic-
timization potential.
Differently, participants 1 and 3 mentioned parents
with the ability to welcome and translate childhood
anxieties, the development of secure attachment and the
internalization of stable representations, helped in the
structuring of a representational model of the self with
greater integration (Eizirik etal., 2015; Task Force, 2016).
In this way, they seem to be able to better regulate the
stress produced by the index traumatic event, enabling
them to actively face their difficulties. Winnicott (1993)
understands that the primary caregivers are a reference
for the establishment of protection from trauma. In addi-
tion, these participants were the only ones to seek care,
perceiving their emotional and behavioral difficulties
after experiencing the trauma.
In general, psychic disorganization was identified
in the vast majority of participants, with personality
structures at moderate to low level of integration,
indicating impaired perception of themselves and oth-
ers, where instinctual impulses end up discharged in
a poorly elaborated way. us, the intense fear of loss
or separation from objects prevails, causing them to
practice unconscious efforts of power and submission,
with predominance of rigid and automatic assumptions
(Sharp etal., 2016). In stressful situations, these rep-
resentations become even more fragile, hindering the
ability to self-regulate and making the presence of the
other in a real way necessary (Task Force, 2016).
It is noteworthy that participants with CPTSD were
identified as having severe commitment, with ten-
dency to disintegration related to the object rela-
tion regulation. is marks an undifferentiated self, in
which behaviors have no sense of authorship or nor-
mative instances, that is, they simply occur. Aggres-
sive impulses are not recognized, but experienced as a
justified reaction to the behavior of the other. us, the
other, his/her interests and desires are not considered
(Task Force, 2016).
Some authors already identified that emotional regu-
lation difficulties were related to the development of
PTSD symptoms (Bardeen et al., 2013) and that per-
sonality traits could be predictive for the development
of the disease (DiGangi et al., 2013). Baie et al. (2020),
in an investigation specifically on the personality struc-
ture of patients with PTSD, reported that the lower the
structural level of integration of the subject’s personal-
ity, the more pronounced the symptoms of the disease.
His study, however, did not evaluate CPTSD patients, in
which according to ICD 11 (2018), symptoms are more
severe and generalized and focused on the organization
of the self-differentiation and regulation, as pointed out
in this study.
Corroborating the structural level findings, there were
differences regarding the main psychic conflicts between
PTSD and CPTSD participants. Women with PTSD pre-
sented the conflict of need to be taken care of versus self-
sufficiency, in which the image of the other is present in
a fragile way, with fear of its loss. us, they constantly
seek to have the attention of the other and his/her care,
obtaining benefits and understanding them as security.
Physical symptoms or diseases offer a legitimation of
their dependence (Task Force, 2016). However, partici-
pants with CPTSD presented the conflict of individu-
ation versus dependence, in which the self is confused
with the other, being undifferentiated. In such a way, the
annihilation anguish is constant, with a feeling of not
existing on its own. us, it was observed that partici-
pants with CPTSD present greater impairments in their
levels of functioning, greater severity of symptoms and
worse quality of life.
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Favarettoetal. Psicologia: Reexão e Crítica (2022) 35:9
Regarding the personality structure and psychic con-
flicts presented, all participants, regardless of diagno-
sis, used low qualitative and effectiveness variations in
relation to the ego defenses with predominant imma-
ture development factor involving mental inhibition
and denial of reality. For Gabbard (2016), this inflexible
defense pattern would imply worse capacity to adapt
to stressful events. us, according to other studies
with PTSD patients, through affective isolation, they
seek to separate the image of the traumatic event and
the distressing affects produced in an attempt to avoid
unbearable stress (Paulo & Pires, 2013; Teche etal.,
2017). Or, through the defense mechanisms of dis-
sociation, they try to separate potentially threatening
thoughts and desires from consciousness, reducing
anguish and the feeling of helplessness (Gabbard, 2016;
Task Force, 2016).
Unlike MØller etal. (2021), who identified associations
between dissociative phenomena only in patients with
CPTSD, this study identified its use in all participants.
Also, the use of Somatization and Rationalization has
been registered as a way of converting emotional pain
into physical symptoms, changing the focus of concerns
(Laplanche & Pontalis, 1991) such as headaches, chest,
and abdomen pains, trying to justify their dependence,
impulsive behaviors faced with the attitudes of others,
sudden mood changes, sometimes hypervigilant, irritable
or aggressive, sometimes disinterested, alien, or unable to
feel satisfaction.
Faced with this psychic organization with primitive
constitution issues, participants demonstrate in their
current interpersonal relationships a repetitive model of
approximation, fear of fusion, distancing, and constant
rupture. In view of this, tendency of dyadic relational
patterns of dependence and need is observed, where the
other is a significant object of support and regulation,
remaining in relationships for a long period even if they
are submitted or neglected. However, they seek to iden-
tify a tolerable distance, given the fear of merging with
the object, their own destruction or the destruction of
the other. However, in the anguish intensification, they
end up by breaking relationships. is distancing, how-
ever, is also intolerable, given the reactivation of feelings
of helplessness and instinctual anguish from the first
moments of childhood (Task Force, 2016).
With inadequate coping strategies, the use of acting
out manifests itself with self-destructive behaviors, such
as suicide attempts. It is known that people with PTSD
are more likely to develop a suicidal plan than people
without the disease and that women are at higher risk
(4.3%) when compared to men (2.3%) (O’Neill et al.,
2014). In this sense, the severity of the disorder, its symp-
toms, and subjective suffering were evident where half of
participants alluded to suicidal ideation and two tried to
commit suicide on more than one occasion.
e reasons for seeking treatment or referrals were
complaints related to symptoms and the desire to reduce
them through medication, with low availability to talk
about themselves and little capacity to relate them to
traumatic situations. However, with the psychodynamic
assessment through the OPD-2 clinical interview, it was
possible to understand traumatic events in their life his-
tories, constitution of psychological and social resources,
in addition to the identification of the different modes of
functioning in each of the traumatic disorders.
e possibility of building a safe space to tell their his-
tories, their suffering and to be heard are the basis for
the establishment of trust and therapeutic alliance, fun-
damental for treatment. However, one should be aware
of movements of premature interruptions and abandon-
ment, given characteristics related to feelings of danger
and instabilities in relationships (Outcalt etal., 2016).
Regarding patients with greater psychic disorganiza-
tion, as observed in these participants, it is necessary to
strengthen the ego functions so that they can deal with
reality, where the psychotherapist places himself as a
real person and not just as a transference object (Zimer-
man, 1999). In addition to education about symptoms
and the nature of PTSD, expectations, fears, and resist-
ances must be clarified, with empathy and compassion
(Martínez, 2019).
Especially for patients with CPTSD, the therapeutic
focus should be on the structure, as difficulties are related
to limitation in development, with severe frailties of the
self. us, the therapeutic relationship must seek to build
elements that are absent in the patient’s history, in addi-
tion to containing emotions. Communication should
not be just verbal, but through the therapist’s behaviors,
transmitting security and truth. Representing a new pri-
mary attachment figure, the patient should be directed
towards autonomy, offering new connections capable of
changing poorly adapted relational patterns, starting to
relate to good objects and using resources from external
relationships. e hypotheses must be offered by looking
at their later formulations (Task Force, 2016).
Limitations andfuture researches
Despite the contribution of this study on traumatic dis-
orders in southern Brazil, it has some limitations. Since
its cross-sectional design demonstrates the current situa-
tion of participants, it is not possible to show how symp-
toms and treatments evolved in the different participants
and different disorders. Interviews were analyzed by
audio transcription by two judges in order to minimize
the subjective influence of the researcher. Expressiveness
was kept in report, such as crying and feelings of anger,
Page 8 of 9
Favarettoetal. Psicologia: Reexão e Crítica (2022) 35:9
among others. Data were based on the COREQ guide-
lines (Tong et al., 2007) for greater consistency among
methodologies. Regarding the sample size, the criterion
of data saturation was used, seeking to be consistent with
reality; however, they should not be seen as conclusive.
Future researches on the different disorders may expand
data in the psychodynamic perspective related to trauma.
In addition, longitudinal studies could obtain informa-
tion about post-traumatic growth and trauma perpetua-
tion throughout life.
Conclusions
In general, the results indicate that the use of psychody-
namic assessment in trauma patients, based on OPD-2,
can be essential to understand differences and peculiari-
ties in their psychic organizations and help health pro-
fessionals in the direction of treatment. It was found
that participants with CPTSD presented in their psychic
structures tendency to disintegration related to the regu-
lation of the object relation and the psychic conflict was
individuation versus dependence, which demonstrates
failures in the positive representation of objects and in
the capacity to differentiate the object in face of their
existential need, in addition to the direct discharge of
impulses without sense of authorship. Participants with
PTSD had moderate to low level of integration of their
structures and the conflict of need to be cared for versus
self-sufficiency, with reduced perception of the internal-
ized object, fragile self-representations, and intense need
for attention and care (Task Force, 2016).
It was possible to identify a cycle of adverse events in
the participants’ lives, causing psychic organization with
certain disintegration, difficulties in emotional regulation
and, consequently, in reflection. Later traumas further
disorganize the psychic structure, intensifying anguish,
search for control in relation to the other, isolation, and
somatic symptoms.
Such assimilation makes it possible to consider risk
factors for the development of disorders, patterns of
transgenerational violence, urban violence, and psychic
organization. In addition, diversity of symptoms and
the scope of affected areas in the life of the individual
are observed, which should guide actions for the non-
consolidation of the disease, involving the early identi-
fication of traumas and new ways of offering support to
patients, creating a space for talking, listening, and think-
ing, and identifying psychological and social resources
and obstacles to treatment. e training of public health
services for early identification and action in cases of
traumatic situations and Brief Analytical Orientation
Psychotherapy (Eizirik et al., 2015) or cognitive-behav-
ioral interventions (Cloitre et al., 2002), works focused
on interpersonal skills and compassion (Karatzias etal.,
2019), in addition to psychotropic drugs when necessary,
have shown significant results. Aspects to prevent vio-
lence must be developed, such as actions to guide parents
and caregivers and the deconstruction of cultural and
social aspects related to the naturalization of aggression,
especially in childhood. Likewise, understanding work
as a promoter of quality of life, organizations must have
worker health policies aimed at prevention and recov-
ery in cases of exposure to or witnessing stressful events,
thus avoiding absenteeism, leaves, or work abandon-
ment. Specific works with aggressors must be performed,
reducing the possibilities of reproducing violence.
Abbreviations
PTSD: Post-traumatic stress disorder; CPTSD: Complex post-traumatic stress
disorder; OPD-2: Operationalized Psychodynamic Diagnosis-2; DSM-5:
Diagnostic and Statistical Manual of Mental Disorders; ICD 11: International
Classification of Diseases for Mortality and Morbidity Statistics.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s41155- 022- 00211-5.
Additional le1: TableS1. Axes definition, classification, alignment and
reference description according to OPD-2.
Additional le2: TableS2. Comprehensive description of categories.
Authors’ contributions
All authors read and approved the final manuscript.
Availability of data and materials
The data analysed in the study are detailed in the Complementary Tables.
Table S1 briefly describes how the psychodynamic diagnosis of the interviews
was performed. Table S2 provides a detailed description of the Categories
based on data from participant interviews. Other data and materials may be
made available upon request to the corresponding author upon reasonable
request.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Federal University of Rio Grande do Sul (UFRGS), Av. Paulo Gama 110, Bairro
Farroupilha, Porto Alegre, Rio Grande do Sul 90040-060, Brazil. 2 Rua I nde-
pendência 99a, 401, Centro, Passo Fundo, Rio Grande do Sul 99010041, Brazil.
3 University of Vale do Rio dos Sinos, São Leopoldo, Brazil.
Received: 6 October 2021 Accepted: 1 April 2022
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Objective The structure of the relationship between ICD-11 Complex Post-traumatic Stress Disorder (C-PTSD) and dissociative symptoms requires more extensive research, especially with respect to the empirical support for a DSM-5 dissociative subtype of PTSD. The present study sought to examine (1) the structural validity of ICD-11 C-PTSD, (2) the association between latent C-PTSD factors and features of dissociation, and (3) whether patients with C-PTSD show elevated levels of dissociation when compared to PTSD and no-disorder. Methods A sample of traumatized psychiatric outpatients (N = 114) were diagnosed with a structured interview and subsequently administered the International Trauma Questionnaire (ITQ), the Dissociative Symptom Scale (DSS), and the Somatoform Dissociation Questionnaire, 5-items (SDQ). We used Confirmatory Factor Analysis (CFA) to replicate the established structure of C-PTSD as operationalized with the ITQ. Subsequently, a structural equation model (SEM) approach was employed to examine associations of ITQ with psychoform and somatoform dissociation as measured with the DSS and SDQ. Results The expected factorial structure of C-PTSD was replicated in the present sample, and the domains PTSD and disturbance in self-organization were found to be related but distinct constructs. All ICD-11 C-PTSD latent factors were associated with dissociative experiences. The strongest effects were found for the symptom clusters Affective Dysregulation, Disturbances in Relationship, and Re-Experiencing. However, dissociative Gaps in Awareness and Memory and Sensory Misperception were not predicted by any ICD-11 C-PTSD latent factors. Cumulative levels of dissociative experiences appeared to differentiate ICD-11 PTSD and C-PTSD with significantly higher levels for C-PTSD. Conclusion ICD-11 C-PTSD is strongly associated with dissociative phenomena in complex ways. Somatoform and psychoform manifestations of dissociation should be routinely assessed in patients with ICD-11 C-PTSD because such expressions may cover intense affects and painful relationship experiences. Future studies are needed to substantiate the causal and predictive relationship between ICD-11 C-PTSD and dissociation.
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Because posttraumatic stress disorder (PTSD) is both prevalent and underrecognized, routine primary care-based screening for PTSD has been implemented across the Veterans Health Administration. PTSD is frequently complicated by the presence of comorbid chronic pain, and patients with both conditions have increased symptom severity and poorer prognosis. Our objective was to determine whether the presence of pain affects diagnosis and treatment of PTSD among Department of Veterans Affairs (VA) patients who have a positive PTSD screening test. This retrospective cohort study used clinical and administrative data from six Midwestern VA medical centers. We identified 4,244 VA primary care patients with a positive PTSD screen and compared outcomes for those with and without a coexisting pain diagnosis. Outcomes were three clinically appropriate responses to positive PTSD screening: (1) mental health visit, (2) PTSD diagnosis, and (3) new selective serotonin reuptake inhibitor (SSRI) prescription. We found that patients with coexisting pain had a lower rate of mental health visits than those without pain (hazard ratio: 0.889, 95% confidence interval: 0.821-0.962). There were no significant differences in the rate of PTSD diagnosis or new SSRI prescription between patients with and without coexisting pain. © 2016, Rehabilitation Research and Development Service. All rights reserved.
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Several developmental models of borderline personality disorder (BPD) emphasize the role of disrupted interpersonal relationships or insecure attachment. As yet, attachment quality and the mechanisms by which insecure attachment relates to borderline features in adolescents have not been investigated. In this study, we used a multiple mediational approach to examine the cross-sectional interplay between attachment, social cognition (in particular hypermentalizing), emotion dysregulation, and borderline features in adolescence, controlling for internalizing and externalizing symptoms. The sample included 259 consecutive admissions to an adolescent inpatient unit (Mage=15.42, SD=1.43; 63.1% female). The Child Attachment Interview (CAI) was used to obtain a dimensional index of overall coherence of the attachment narrative. An experimental task was used to assess hypermentalizing, alongside self-report measures of emotion dyregulation and BPD. Our findings suggested that, in a multiple mediation model, hypermentalizing and emotion dysregulation together mediated the relation between attachment coherence and borderline features, but that this effect was driven by hypermentalizing; that is, emotion dysregulation failed to mediate the link between attachment coherence and borderline features while hypermentalizing demonstrated mediational effects. The study provides the first empirical evidence of well-established theoretical approaches to the development of BPD. Copyright © 2015. Published by Elsevier Inc.