Trauma Diagnosis
101Trauma
There is no greater agony than bearing an untold story inside you.
~Maya Angelou
Treatment is Based on Diagnosis;
We Need Better Options
Differential Diagnosis
Simple PTSD vs.
Complex PTSD vs.
Developmental Trauma Disorder (DTD)
Simple Post-Traumatic Stress Disorder (PTSD)
Simple Post-Traumatic Stress Disorder (PTSD) develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers. PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes. People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used to enjoy, have trouble feeling affectionate, be irritable, become more aggressive, or even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping. Most people with PTSD repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of images, sounds, smells, or feelings, and are often triggered by ordinary occurrences, such as a door slamming or a car backfiring on the street.
Read Seminal paper by Bessel van der Kolk
Complex Post-Traumatic Stress Disorder (C-PTSD)
According to Judith Herman:
Even the diagnosis of 'post-traumatic stress disorder', as it is presently defined, does not fit. The existing diagnostic criteria for this disorder are derived mainly from survivors of circumscribed traumatic events. They are based on the prototypes of combat, disaster, and rape. In survivors of prolonged, repeated trauma, the symptom picture is often far more complex. Survivors of prolonged abuse develop characteristic personality changes, including deformations of relatedness and identity. Survivors of abuse in childhood develop similar problems with relationships and identity; in addition, they are particularly vulnerable to repeated harm, both self-inflicted and at the hands of others. The current formulation of post-traumatic stress disorder fails to capture either the protean symptomatic manifestations of prolonged, repeated trauma or the profound deformations of personality that occur in captivity. The syndrome that follows upon prolonged repeated trauma needs its own name. I propose to call it 'complex post-traumatic stress disorder’. The responses to trauma are best understood as a spectrum of conditions rather than as a single disorder. They range from a brief stress reaction that gets better by itself and never qualifies for a diagnosis, to classic or simple post-traumatic stress disorder, to the complex syndrome of prolonged, repeated trauma. As the concept of a complex traumatic syndrome has gained wider recognition, it has been given several additional names. The working group for the diagnostic manual of the American Psychiatric Association has chosen the designation, Disorder of Extreme Stress not Otherwise Specified.
Proposed Diagnostic Criteria for Complex Post-Traumatic Stress Disorder
A History of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.
1. Alterations in Consciousness, including:
Amnesia or hypermnesia for traumatic events.
Transient dissociative episodes.
Depersonalization/derealization.
Reliving experiences, either in the form of intrusive post-traumatic stress disorder symptoms or in the form of ruminative preoccupation.
2. Alterations in self-perception, including:
Sense of helplessness or paralysis of initiative.
Shame, guilt, and self-blame.
Sense of defilement or stigma.
Sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or non-human identity).
3. Alterations in perception of perpetrator, including:
Preoccupation with relationship with perpetrator (includes preoccupation with revenge).
Unrealistic attribution of total power to perpetrator (victim’s assessment of power realities may be more realistic than clinician’s).
Idealization or paradoxical gratitude.
Sense of special or supernatural relationship.
Acceptance of belief system or rationalizations of perpetrator.
4. Alterations in relations with others, including:
Isolation and withdrawal.
Disruption in intimate relationships.
Repeated search for rescuer (may alternate with isolation and withdrawal).
Persistent distrust.
Repeated failures of self-protection.
5. Alterations in systems of meaning:
Loss of sustaining faith.
Sense of hopelessness and despair.
Naming the syndrome of complex post-traumatic stress disorder represents an essential step toward granting those who have endured prolonged exploitation a measure of the recognition they deserve. It is an attempt to find a language that is at once faithful to the traditions of accurate psychological observation and to the moral demands of traumatized people. It is an attempt to learn from survivors, who understand, more profoundly than any investigator, the effects of captivity.
~Trauma and Recovery, Judith Herman,1992
Developmental Trauma Disorder (DTD)
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For Full Interview
Developmental Trauma Disorder (DTD)
Proposed Criteria for Developmental Trauma Disorder
A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse.
B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following:
1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization.
2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions).
3. Diminished awareness/dissociation of sensations, emotions and bodily states B. 4. Impaired capacity to describe emotions or bodily states.
C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following:
1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues.
2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking.
3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation).
4. Habitual (intentional or automatic) or reactive self-harm.
5. Inability to initiate or sustain goal-directed behavior.
D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following:
1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation.
2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness.
3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers.
4. Reactive physical or verbal aggression toward peers, caregivers, or other adults.
5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance.
6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness.
E. Post traumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, D.
F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months.
G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at two of the following areas of functioning:
1. Scholastic: under-performance, non-attendance, disciplinary problems, drop-out, failure to complete degree/credential(s), conflict with school personnel, learning disabilities or intellectual impairment that cannot be accounted for by neurological or other factors.
2. Familial: conflict, avoidance/passivity, running away, detachment and surrogate replacements, attempts to physically or emotionally hurt family members, non-fulfillment of responsibilities within the family.
3. Peer Group: isolation, deviant affiliations, persistent physical or emotional conflict, avoidance/passivity, involvement in violence or unsafe acts, age- inappropriate affiliations or style of interaction.
4. Legal: arrests/recidivism, detention, convictions, incarceration, violation of probation or other court orders, increasingly severe offenses, crimes against other persons, disregard or contempt for the law or for conventional moral standards.
5. Health: physical illness or problems that cannot be fully accounted for physical injury or degeneration, involving the digestive, neurological (including conversion symptoms and analgesia), sexual, immune, cardiopulmonary, proprioceptive, or sensory systems, or severe headaches (including migraine) or chronic pain or fatigue.