A Preview of the DSM-V Anticipated Changes
in Trauma Diagnoses:
Complex Posttraumatic Stress Disorder Rejected
Posttraumatic Stress Disorder
in Preschool Children Added
Complex PTSD is a term used by mental health professionals to describe the sequelae of changes that occur in an individual as a result of severe and often prolonged psychological and/or physical trauma. To date, the American Psychiatric Association has yet to recognize complex PTSD as a diagnosable disorder. It is not included in the DSM-IV-TR and has recently been rejected for inclusion in the DSM-V. Unfortunately, the clinical picture of complex trauma is not adequately captured by the diagnosis of PTSD, which more aptly describes traumatic reactions to combat, a single assault, an accident, or natural disaster. While these types of trauma certainly impact individuals psychologically, the reactions are significantly different than those to complex trauma. Historically, PTSD was introduced into the third edition of the DSM as a result of the increasing numbers of Vietnam War veterans struggling with the effects of combat stress. The current diagnostic criteria are as follows:
A. Exposure to a traumatic event in which both of the following were present:
(1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
(2) The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
B The traumatic event is persistently re-experienced (e.g., recurrent dreams of the event)
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (e.g., efforts to avoid activities, people, or places that arouse recollections of the trauma)
D. Persistent symptoms of arousal (e.g., difficulty falling asleep, exaggerated startle response)
The diagnosis of PTSD does not include symptoms such as emotional dysregulation and somatic distress, which are often seen in reaction to complex trauma. As such, victims of complex trauma are often misdiagnosed with personality disorders and/or dissociative disorders. The implications of this practice can often be further damaging to the already victimized individual and significantly limit diagnostic clarity.
Examples of trauma which result in a complex PTSD presentation are repetitive or chronic and include ongoing physical and sexual abuse (usually at the hands of a caregiver or intimate partner), imprisonment, community violence, and genocide. Unfortunately this type of trauma is more prevalent than single incident trauma and affects as many as one in seven children (Ford & Courtois, 2009). Additionally, there is a significantly higher risk of developing post-traumatic symptoms as a result of complex trauma than after single incident trauma. To further complicate matters, children are often victims of this type of ongoing trauma as they often lack the resources and ability needed to escape abusive situations. Children are negatively affected on a developmental level when trauma occurs during and throughout critical/sensitive periods. This interruption to healthy development results not only in symptoms of anxiety disorders (e.g., PTSD), but can have lasting psychobiological effects. It can leave a child unable to establish a healthy identity and personality and with difficulty establishing and maintaining reciprocal relationships. These latter reactions are more chronic and stable for the individual than the anxiety reaction. Bessel van der Kolk, MD, a leader in the research on complex trauma, states "Because children's brains are still developing, trauma has a much more pervasive and long-range influence on their self-concept, on their sense of the world and on their ability to regulate themselves (DeAngelis, 2007, p. 32).
While victims of complex trauma often meet the criteria for PTSD, they also exhibit a unique array of symptoms that has led some mental health professionals to push for a separate diagnosis (i.e., complex PTSD). Researchers have identified the following:
- Emotional dysregulation. This often includes chronic depression, thoughts of suicide, explosiveness, impulsivity, agitation, and/or inhibited anger.
- Alterations in consciousness. This manifests as a lack of memory for the trauma, hallucinatory re-experiencing of the traumatic events, and/or dissociation (feeling detached from oneself mentally and physically).
- Changes in cognitive processing and beliefs. These changes typically include helplessness, disempowerment, shame, guilt, stigma, and a sense of being alone or different.
- Changes in how one views the perpetrator. Examples include preoccupation with the relationship to the perpetrator, identifying with or idealizing the perpetrator, or repeated thoughts of gaining revenge.
- Interpersonal dysfunction. Typical behaviors include isolation, distrust, intense relationships, idealization of others, revictimization through unhealthy relationships, or search for a rescuer.
- Changes in meaning-making. This can include a loss of faith, spirituality, or a sense of despair and hopelessness.
Trauma and Young Children
The diagnosis of children with PTSD is an additional area of concern for mental health professionals. The Child and Adolescent Disorders Work Group on the DSM-V have identified several problems with the current criteria for PTSD for adequately describing traumatic reactions in preschool and school-aged children beyond the simple vs. complex distinction. They point out the current DSM-IV criteria was developed for adults and adolescents 15 years and older. As a result, despite ample exposure to trauma, rates of PTSD diagnoses in children are unexpectedly low. The Work Group suggests this is likely due to the criteria being developmentally inappropriate for young children. For example, they propose dropping the criterion which requires "fear, helplessness, or horror," arguing that it is unlikely a young child would be able to subjectively describe their experience in this way. They go on to say that the caveat of this being expressed as "disorganized or agitated behavior" in children is unclear and lacking in empirical support. Scheeringa and colleagues (1995, 2001) provide evidence indicating removal of this criterion alone would significantly reduce the number of missed cases in children. The Work Group also suggests adding the caveat that children do not necessarily evidence distress, as required by criterion B nor do they necessarily show a "diminished interest of participation in significant activities" (Criterion C4). They advise modifying the latter with "constriction of play" in young children. Lastly, they argue for adding "extreme temper tantrums" as an example of arousal (Criterion D). Currently, there is no consensus of changes to the PTSD diagnosis in DSM-V though it seems adding a diagnosis of Posttraumatic Stress Disorder in Preschool Children is likely.
Despite diagnostic difficulties in the field, it is important to note treatment for adults and children who have been victims of trauma (single-incident or complex) is critical. Given the complexity of these cases, treatment is often multi-modal, including medication in addition to therapy. The treatment of choice for complex PTSD is typically Cognitive-Behavioral Therapy (CBT), and often Dialectical Behavior Therapy (DBT), which is a specific CBT-based approach that includes the practice of mindfulness. Approaches also typically include a family systems and existential component. The initial focus of treatment is the establishment of safety and reduction and elimination of any self-harm behavior. Treatment includes cognitive restructuring and the teaching and practicing of emotional regulation strategies. A goal is reconnection with society in a healthier and more adaptive way.
Since complex PTSD in children is often the result of chronic abuse, maltreatment, or neglect by the primary caregiver, treatment of children will often involve child protective services. A first priority is to identify and attend to threats to safety of the child or family. Talk and/or play therapy can be highly beneficial for children who have experienced complex trauma and can often help to mitigate its effects. In these cases, it is critical to establish a therapeutic relationship with the child based on safety and trust. In this way, therapy can provide a corrective experience for a child who may not have any healthy relationships with adults. Treatment should also focus on teaching and practicing emotional regulation skills and appropriate social skills.
Clinicians at Lepage Associates are adept at working with children, teens, and adults who have experienced complex trauma. We have several therapists and child psychologists who specialize in trauma therapy and trauma evaluations. View our website to learn more about our team of psychologists: www.lepageassociates.com
DeAngelis, T. (2007). A new diagnosis for childhood trauma? Some push for a new DSM category for children who undergo multiple, complex traumas. Monitor on Psychology, 38 (3)
Ford, J. & Courtois (2009). Defining and understanding complex trauma and complex traumatic stress disorders. In Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (Eds. Julian Ford and Christine Courtois). Guilford Press, New York, NY.
Scheeringa, M.S., Peebles, C.D., Cook, C.A., Zeanah, C.H. (2001). Toward establishing procedural, criterion, and discriminant validity for PTSD in early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 52-60.
Scheeringa, M.S., Zeanah, C.H., Drell, M.J. Larrieu, J.A. (1995). Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 191-200.