Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11.
University of Zurich1, University College London2, University of New South Wales3, World Health Organization4, Harvard University5, Stellenbosch University6, McGill University7, Mental Health Services8, University of Jaffna9, International Committee of the Red Cross10, International Medical Corps11, Columbia University Medical Center12
TL;DR: Proposals include a narrower concept for PTSD that does not allow the diagnosis to be made based entirely on non‐specific symptoms, a new complex PTSD category that comprises three clusters of intra‐ and interpersonal symptoms in addition to core PTSD symptoms, and a new diagnosis of prolonged grief disorder.
About: This article is published in World Psychiatry.The article was published on 2013-10-01 and is currently open access. It has received 565 citations till now. The article focuses on the topics: Adjustment disorders & Complex post-traumatic stress disorder.
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01 Jan 2013
TL;DR: Wamser et al. as mentioned in this paper found that children exposed to a complex trauma event had significantly higher levels of trauma-related and generalized difficulties as compared to those exposed to other, less severe traumatic events.
Abstract: Complex trauma events, or chronic interpersonal traumas that begin early in life, are thought to result in profound disruptions, well beyond the symptoms of PTSD. Complex trauma events may be especially toxic for children and adolescents, whose regulatory systems are more vulnerable. This study provides empirical support for the previously unexamined hypothesis that complex trauma events result in broad systemic difficulties, not simply higher levels of PTSD symptoms. This study also offers evidence for a dimensional conceptualization of traumatic events, with acute noninterpersonal trauma residing on one end of the spectrum and complex trauma on the other. 346 treatmentseeking children and adolescents who had experienced a traumatic event were included in this study. Results indicated that children exposed to a complex trauma event had significantly higher levels of trauma-related and generalized difficulties as compared to those exposed to other, less severe traumatic events. Children exposed to successively more severe traumatic events were also reported to have increasingly higher levels of difficulties. The evidence of including an impaired caregiving system, operationalized as the child being removed from the home following the onset of the traumatic event, into the definition of complex trauma was examined, but not supported. The results demonstrate the validity of the concept of complex trauma and point to the need for a diagnostic construct related to complex trauma for children and adolescents. Wamser, Rachel, UMSL, 2012 8 Complex Trauma in Children and Adolescents A substantial number of children and adolescents experience traumatic events such as sexual, physical, or emotional abuse, neglect, domestic violence, natural disasters, school or community violence and serious car accidents and other accidents. It is the unfortunate reality that some of these youth receive more than their fair share, experiencing severe, multiple, prolonged traumas. In fact, one nationally representative sample of over two thousand children found that 22% of surveyed children had experienced four or more different kinds of victimization within a single year (Finkelhor, Ormrod, & Turner, 2007). This suggests that the experience of extensive and repeated trauma is not all uncommon, yet this subset of survivors have not received little attention to their unique needs. Decades of research, however, have been devoted to examining the impact of single types of maltreatment (i.e., sexual or physical abuse) and consistently demonstrate the toxicity of various traumatic events. Childhood traumatic experiences have been linked to a variety of physical and mental health problems, risky and selfinjurious behaviors, negative parenting outcomes, revictimization, and perpetration of interpersonal violence (Abram, Teplin, Longworth, McClelland, & Dulcan, 2004; Anda, 2006; Banyard, Williams, & Siegel, 2003; Felitti et al., 1997; Walsh, Blaustein, Knight, Spinazzola, & van der Kolk, 2007; Whitfield, Dube, Anda, & Felitti, 2003). Clearly, these well-documented symptoms extend far beyond the confines of the diagnostic construct Posttraumatic Stress Disorder (PTSD) even for acute traumatic events. When considering the impact of poly-victimization, then PTSD may be insignificant. A diagnosis of PTSD requires the direct or indirect exposure to a traumatic event that involves an actual or perceived threat to the physical integrity of an individual or others (criterion A1; APA, 2000). Traumatic events commonly observed in childhood Wamser, Rachel, UMSL, 2012 9 include, but are not limited to: child sexual or physical abuse, neglect, domestic violence, life-threatening illness, school or community violence, unexpected death of a family member or close friend, natural disaster, motor vehicle accident or other serious accident. Thus, a wide range of events are captured under the heading of a traumatic event. But would the experience of learning of a friend's non-fatal car accident be expected to result in an identical symptom presentation as chronic sexual abuse perpetrated by one's biological father? According to the PTSD framework, yes. Despite qualitative differences in terms of the degree of involvement, severity, and chronicity of the traumatic event, with the diagnostic construct of PTSD, all traumatic events are assumed to potentially result in the same sequelae. Yet, common sense and clinical lore suggests that survivors of severe traumatic events will have a more complicated symptom presentation. This is affirmed by research. Researchers consistently find that characteristics of the traumatic event are related to a more complicated symptom presentationtypically with non-PTSD symptoms. For example, interpersonal traumas, such as abuse and domestic violence, appear to be particularly harmful, resulting in long-lasting, severe, and more generalized symptoms than non-interpersonal traumas such as motor vehicle accidenets (Briere & Jordan, 2004; Briere, Kaltman, & Green, 2008; Ford, Stockton, Kaltman, & Green, 2006; van der Kolk, 2005). Interpersonal traumas are partly so toxic as they are intentionally perpetrated by another person, thus, the victim’s views regarding safety, intimacy, and trustworthiness are vulnerable to unhelpful or inaccurate alterations (Janoff-Bullman, 1992). The duration and the number of instances of the traumatic event are also related to outcome. Duration and number of incidents are linked together as traumatic events that are chronic, by their nature, have occurred more than once and conversely, multiple incidents of a Wamser, Rachel, UMSL, 2012 10 traumatic event often occur over an extended period of time. Unsurprisingly, the longer and more frequently the trauma occurs, the more severe and varied the post-traumatic sequelae (Blaauw, Winkel, Arensman, Sheridan, & Freeve, 2002; Mechanic, Uhlmansiek, Weaver, & Resick, 2000). Both of these characteristics may contribute to the survivor feeling overwhelmed, helpless, or that the trauma is inescapable. The age of the victim when the trauma begins is important. Traumatic events that begin in childhood result in a more severe symptom presentation compared to those which begin in adulthood (Cloitre, Scarvalone, & Difede, 1997; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). In sum, all traumatic events are not created equal. Taken together, research would suggest that traumatic events which are interpersonal in nature, chronic or multiple, or begin at an early age are related to a more complex symptom presentation (Herman, 1992; Terr, 1991). Within the current PTSD construct, these differences are not acknowledged and instead are subsumed under a single diagnostic category. PTSD also takes a one-size-fits-all approach to trauma-related symptoms, which is tragic as PTSD is fails to capture the full span of trauma-related sequelae. PTSD is classified as an anxiety disorder and consequently, PTSD describes symptoms of anxiety. Trauma survivors unfortunately have problems beyond that of anxiety. Survivors of childhood sexual abuse, for example, have difficulties in a broad range of domains including serious impairments in affect regulation, self-concept, and interpersonal problems, sexualized behavior, and somatic complaints (Cloitre, Stovall-McClough, Zorbas, & Charuvastra, 2003; Spinazzola, 2005; Stovall-McClough & Cloitre, 2006; Zucker, Spinazzola, Blaustein, & van der Kolk, 2006). These symptoms are notably absent from the list of acceptable symptoms of PTSD. As an anxiety disorder, the construct PTSD is unable to capture these difficulties without violating the organization Wamser, Rachel, UMSL, 2012 11 of the DSM. The non-anxiety symptoms which do not fit are relegated to a variety of “comorbid” conditions, which ostensibly are thought to be unrelated to the trauma. This would be acceptable if few traumatized individuals presented with non-PTSD diagnoses. Unfortunately, non-PTSD symptoms are ubiquitous, with more than 80% of individuals diagnosed with PTSD also receiving a comorbid diagnosis (Foa, Freidman & Keane, 2000). PTSD has one of the highest rates of comorbidity of any DSM diagnostic category (Kessler, Chiu, Demier, Merikangas, & Walters, 2005). This may be problematic, it is implied that some, but not all, of the patient's symptoms may be ascribed to the traumatic experience. Conceptualizing other potential effects of trauma as merely “co-morbid,” as opposed to the “real” trauma disorder may also limit the validity of trauma research; as such co-morbid conditions are often excluded from traumafocused research. In fact, a review of the treatment outcome studies demonstrated that the typical presenting client would be screened out of PTSD studies because of comorbid conditions (Spinazzola, Blaustein, & van der Kolk, 2005). Thus, much of PTSD research may not be even applicable to the typical client. PTSD is, instead, more useful in capturing the effects of single-episode, acute traumas occurring in adulthood (Cloitre, Scarvalone, & Difede, 1997; van der Kolk, 2005). In fact, PTSD is diagnosed more frequently following single instances of trauma than after multiple or chronic traumatic events (Green et al., 2000). Clearly, this does not indicate that individuals who have experienced repeated and severe traumatic events do not present with trauma-related difficulties, but rather, that the PTSD criteria may be insufficient in describing reactions to more severe traumatic events. Since its inception into the DSM in 1980, leaders in the field of traumatic stress have argued that PTSD does not accurately capture the presentation of victims of child abuse, concentration camps, Wamser, Rachel, UMSL, 2012 12 refugee camps, domestic violence, or those that have experienced other repeated and extensive trauma (Herman, 1992; Cook et al., 2005; Courtois, 2004). The shortcomings of PTSD are too great for the most serious of traumas. Diagnostic issues tend to be magnifie
618 citations
TL;DR: Preliminary data support the proposed ICD-11 distinction between PTSD and complex PTSD and support the value of testing the clinical utility of this distinction in field trials.
Abstract: Background: The WHO International Classification of Diseases, 11th version (ICD-11), has proposed two related diagnoses, posttraumatic stress disorder (PTSD) and complex PTSD within the spectrum of trauma and stress-related disorders. Objective: To use latent profile analysis (LPA) to determine whether there are classes of individuals that are distinguishable according to the PTSD and complex PTSD symptom profiles and to identify potential differences in the type of stressor and severity of impairment associated with each profile. Method: An LPA and related analyses were conducted on 302 individuals who had sought treatment for interpersonal traumas ranging from chronic trauma (e.g., childhood abuse) to single-incident events (e.g., exposure to 9/11 attacks). Results: The LPA revealed three classes of individuals: (1) a complex PTSD class defined by elevated PTSD symptoms as well as disturbances in three domains of self-organization: affective dysregulation, negative selfconcept, and interpersonal problems; (2) a PTSD class defined by elevated PTSD symptoms but low scores on the three self-organization symptom domains; and (3) a low symptom class defined by low scores on all symptoms and problems. Chronic trauma was more strongly predictive of complex PTSD than PTSD and, conversely, single-event trauma was more strongly predictive of PTSD. In addition, complex PTSD was associated with greater impairment than PTSD. The LPA analysis was completed both with and without individuals with borderline personality disorder (BPD) yielding identical results, suggesting the stability of these classes regardless of BPD comorbidity. Conclusion: Preliminary data support the proposed ICD-11 distinction between PTSD and complex PTSD and support the value of testing the clinical utility of this distinction in field trials. Replication of results is necessary. Keywords: Complex PTSD; posttraumatic stress disorder; WHO; ICD-11 (Published: 15 May 2013) For the abstract or full text in other languages, please see Supplementary files in the column to the right (under Article Tools). Citation: European Journal of Psychotraumatology 2013, 4 : 20706 - http://dx.doi.org/10.3402/ejpt.v4i0.20706
486 citations
Cites background from "Diagnosis and classification of dis..."
...Within the spectrum of stress and trauma disorders, the WHO ICD-11 has proposed two related diagnoses, posttraumatic stress disorder (PTSD) and complex PTSD (Maercker et al., 2013)....
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TL;DR: The purpose of this study was to finalize the development of the International Trauma Questionnaire (ITQ), a self‐report diagnostic measure of post‐traumatic stress disorder (PTSD) and complex PTSD (CPTSD), as defined in the 11th version of theInternational Classification of Diseases (ICD‐11).
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Abstract
Objective
The purpose of this study was to finalize the development of the International Trauma Questionnaire (ITQ), a self‐report diagnostic measure of post‐traumatic stress disorder (PTSD) and complex PTSD (CPTSD), as defined in the 11th version of the International Classification of Diseases (ICD‐11).
Method
The optimal symptom indicators of PTSD and CPTSD were identified by applying item response theory (IRT) analysis to data from a trauma‐exposed community sample (n = 1051) and a trauma‐exposed clinical sample (n = 247) from the United Kingdom. The validity of the optimized 12‐item ITQ was assessed with confirmatory factor analyses. Diagnostic rates were estimated and compared to previous validation studies.
Results
The latent structure of the 12‐item, optimized ITQ was consistent with prior findings, and diagnostic rates of PTSD and CPTSD were in line with previous estimates.
Conclusion
The ITQ is a brief, simply worded measure of the core features of PTSD and CPTSD. It is consistent with the organizing principles of the ICD‐11 to maximize clinical utility and international applicability through a focus on a limited but central set of symptoms. The measure is freely available and can be found in the body of this paper.
465 citations
TL;DR: This first systematic review and meta-analysis of the prevalence of PGD suggests that one out of ten bereaved adults is at risk for PGD, and underscores the importance of identifying and offer treatment to those bereaved individuals in greatest need.
456 citations
Cites background from "Diagnosis and classification of dis..."
...…with impairment of the bereaved person's familial, social, and occupational functioning to a similar extent as found for other mental disorders, e.g., depression and post-traumatic stress disorder (Jordan and Litz, 2014; Maercker et al., 2013; Prigerson et al., 2009; Shah and Meeks, 2012)....
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...Instead of a decreasing intensity of griefrelated distress, these individuals experience severe grief reactions that become abnormally persistent and increasingly debilitating across time (Jordan and Litz, 2014; Maercker et al., 2013; Prigerson et al., 2009)....
[...]
...From a nosological perspective, expansions and alignment of this research seems crucial as PGD is included in the Appendix of DSM-5 and is expected to be included as a mental disorder in ICD-11 (Bryant, 2014; Maciejewski et al., 2016; Maercker et al., 2013; Rosner, 2015)....
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TL;DR: Major changes to the structure of the I CD‐11 classification of mental disorders as compared to the ICD‐10 are described, and the development of two new ICD-11 chapters relevant to mental health practice are described.
416 citations
References
More filters
Brigham and Women's Hospital1, Harvard University2, University of California, San Francisco3, Yale University4, St Christopher's Hospice5, University of California, Los Angeles6, Cedars-Sinai Medical Center7, University of Western Sydney8, University of Missouri–St. Louis9, Stony Brook University10, University of Memphis11, Columbia University12, Memorial Sloan Kettering Cancer Center13, Utrecht University14, University of Zurich15, Veterans Health Administration16, Boston University17
TL;DR: The psychometric validity of criteria for prolonged grief disorder (PGD) is tested to enhance the detection and care of bereaved individuals at heightened risk of persistent distress and dysfunction.
Abstract: Background: Bereavement is a universal experience, and its association with excess morbidity and mortality is well established. Nevertheless, grief becomes a serious health concern for a relative few. For such individuals, intense grief persists, is distressing and disabling, and may meet criteria as a distinct mental disorder. At present, grief is not recognized as a mental disorder in the DSM-IV or ICD-10. The goal of this study was to determine the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and potential treatment of bereaved individuals at heightened risk of persistent distress and dysfunction. Methods and Findings: A total of 291 bereaved respondents were interviewed three times, grouped as 0–6, 6–12, and 12– 24 mo post-loss. Item response theory (IRT) analyses derived the most informative, unbiased PGD symptoms. Combinatoric analyses identified the most sensitive and specific PGD algorithm that was then tested to evaluate its psychometric validity. Criteria require reactions to a significant loss that involve the experience of yearning (e.g., physical or emotional suffering as a result of the desired, but unfulfilled, reunion with the deceased) and at least five of the following nine symptoms experienced at least daily or to a disabling degree: feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitterness over the loss; difficulty accepting the loss; identity confusion; avoidance of the reality of the loss; or difficulty moving on with life. Symptoms must be present at sufficiently high levels at least six mo from the death and be associated with functional impairment. Conclusions: The criteria set for PGD appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction. The results support the psychometric validity of the criteria for PGD that we propose for inclusion in DSM-V and ICD-11. Please see later in the article for the Editors’ Summary.
1,437 citations
"Diagnosis and classification of dis..." refers background in this paper
...Although most people report at least partial remission from the acute pain of grief by around 6 months following bereavement, those who continue experiencing severe grief reactions beyond this time frame are likely to have a significant impairment in their general functioning (25)....
[...]
TL;DR: In this article, the authors highlight seven primary domains of impairment observed in children exposed to complex trauma and identify phenomenologically based domains based on the extant child clinical and research literatures.
Abstract: The present paper highlights seven primary domains of impairment observed in children exposed to complex trauma. These phenomenologically based domains have been identified based on the extant child clinical and research literatures, the adult research on Disorders of Extreme Stress Not Otherwise Specified (Pelcovitz et al, 1997; van der Kolk, Pelcovitz, Roth, Mandel, McFarlane, & Herman, 1996; van der Kolk, Roth, et al., in press), and the combined expertise of the NCTSN Complex Trauma Taskforce.
1,216 citations
TL;DR: Complicated grief treatment is an improved treatment over interpersonal psychotherapy, showing higher response rates and faster time to response.
Abstract: ContextComplicated grief is a debilitating disorder associated with important
negative health consequences, but the results of existing treatments for it
have been disappointing.ObjectiveTo compare the efficacy of a novel approach, complicated grief treatment,
with a standard psychotherapy (interpersonal psychotherapy).DesignTwo-cell, prospective, randomized controlled clinical trial, stratified
by manner of death of loved one and treatment site.SettingA university-based psychiatric research clinic as well as a satellite
clinic in a low-income African American community between April 2001 and April
2004.ParticipantsA total of 83 women and 12 men aged 18 to 85 years recruited through
professional referral, self-referral, and media announcements who met criteria
for complicated grief.InterventionsParticipants were randomly assigned to receive interpersonal psychotherapy
(n = 46) or complicated grief treatment (n = 49); both
were administered in 16 sessions during an average interval of 19 weeks per
participant.Main Outcome MeasureTreatment response, defined either as independent evaluator-rated Clinical
Global Improvement score of 1 or 2 or as time to a 20-point or better improvement
in the self-reported Inventory of Complicated Grief.ResultsBoth treatments produced improvement in complicated grief symptoms.
The response rate was greater for complicated grief treatment (51%) than for
interpersonal psychotherapy (28%; P = .02)
and time to response was faster for complicated grief treatment (P = .02). The number needed to treat was 4.3.ConclusionComplicated grief treatment is an improved treatment over interpersonal
psychotherapy, showing higher response rates and faster time to response.
972 citations
"Diagnosis and classification of dis..." refers background in this paper
...Importantly, psychological therapy that strategically targets the symptoms of prolonged grief disorder has been shown to alleviate their occurrence more effectively than treatments that target depression (30)....
[...]
Columbia University1, University of California, San Diego2, University of Memphis3, University of Pittsburgh4, Harvard University5, American Foundation for Suicide Prevention6, Musashino University7, Wayne State University8, Hebrew University of Jerusalem9, University of California, Los Angeles10, University of Manitoba11, Pace University12
TL;DR: Modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders are discussed.
Abstract: Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over-and under-diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over-diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders.
796 citations
"Diagnosis and classification of dis..." refers background in this paper
...Finally, there are distinctive neural dysfunctions and cognitive patterns associated with prolonged grief disorder (26,28)....
[...]
...This entity has been validated across a wide range of cultures, including non-Western settings, as well as across the lifespan (26)....
[...]
...Many studies from around the world, including both Western and Eastern cultures, have identified a small but significant portion of bereaved people who meet this definition (26)....
[...]
01 Jan 2013
TL;DR: Wamser et al. as mentioned in this paper found that children exposed to a complex trauma event had significantly higher levels of trauma-related and generalized difficulties as compared to those exposed to other, less severe traumatic events.
Abstract: Complex trauma events, or chronic interpersonal traumas that begin early in life, are thought to result in profound disruptions, well beyond the symptoms of PTSD. Complex trauma events may be especially toxic for children and adolescents, whose regulatory systems are more vulnerable. This study provides empirical support for the previously unexamined hypothesis that complex trauma events result in broad systemic difficulties, not simply higher levels of PTSD symptoms. This study also offers evidence for a dimensional conceptualization of traumatic events, with acute noninterpersonal trauma residing on one end of the spectrum and complex trauma on the other. 346 treatmentseeking children and adolescents who had experienced a traumatic event were included in this study. Results indicated that children exposed to a complex trauma event had significantly higher levels of trauma-related and generalized difficulties as compared to those exposed to other, less severe traumatic events. Children exposed to successively more severe traumatic events were also reported to have increasingly higher levels of difficulties. The evidence of including an impaired caregiving system, operationalized as the child being removed from the home following the onset of the traumatic event, into the definition of complex trauma was examined, but not supported. The results demonstrate the validity of the concept of complex trauma and point to the need for a diagnostic construct related to complex trauma for children and adolescents. Wamser, Rachel, UMSL, 2012 8 Complex Trauma in Children and Adolescents A substantial number of children and adolescents experience traumatic events such as sexual, physical, or emotional abuse, neglect, domestic violence, natural disasters, school or community violence and serious car accidents and other accidents. It is the unfortunate reality that some of these youth receive more than their fair share, experiencing severe, multiple, prolonged traumas. In fact, one nationally representative sample of over two thousand children found that 22% of surveyed children had experienced four or more different kinds of victimization within a single year (Finkelhor, Ormrod, & Turner, 2007). This suggests that the experience of extensive and repeated trauma is not all uncommon, yet this subset of survivors have not received little attention to their unique needs. Decades of research, however, have been devoted to examining the impact of single types of maltreatment (i.e., sexual or physical abuse) and consistently demonstrate the toxicity of various traumatic events. Childhood traumatic experiences have been linked to a variety of physical and mental health problems, risky and selfinjurious behaviors, negative parenting outcomes, revictimization, and perpetration of interpersonal violence (Abram, Teplin, Longworth, McClelland, & Dulcan, 2004; Anda, 2006; Banyard, Williams, & Siegel, 2003; Felitti et al., 1997; Walsh, Blaustein, Knight, Spinazzola, & van der Kolk, 2007; Whitfield, Dube, Anda, & Felitti, 2003). Clearly, these well-documented symptoms extend far beyond the confines of the diagnostic construct Posttraumatic Stress Disorder (PTSD) even for acute traumatic events. When considering the impact of poly-victimization, then PTSD may be insignificant. A diagnosis of PTSD requires the direct or indirect exposure to a traumatic event that involves an actual or perceived threat to the physical integrity of an individual or others (criterion A1; APA, 2000). Traumatic events commonly observed in childhood Wamser, Rachel, UMSL, 2012 9 include, but are not limited to: child sexual or physical abuse, neglect, domestic violence, life-threatening illness, school or community violence, unexpected death of a family member or close friend, natural disaster, motor vehicle accident or other serious accident. Thus, a wide range of events are captured under the heading of a traumatic event. But would the experience of learning of a friend's non-fatal car accident be expected to result in an identical symptom presentation as chronic sexual abuse perpetrated by one's biological father? According to the PTSD framework, yes. Despite qualitative differences in terms of the degree of involvement, severity, and chronicity of the traumatic event, with the diagnostic construct of PTSD, all traumatic events are assumed to potentially result in the same sequelae. Yet, common sense and clinical lore suggests that survivors of severe traumatic events will have a more complicated symptom presentation. This is affirmed by research. Researchers consistently find that characteristics of the traumatic event are related to a more complicated symptom presentationtypically with non-PTSD symptoms. For example, interpersonal traumas, such as abuse and domestic violence, appear to be particularly harmful, resulting in long-lasting, severe, and more generalized symptoms than non-interpersonal traumas such as motor vehicle accidenets (Briere & Jordan, 2004; Briere, Kaltman, & Green, 2008; Ford, Stockton, Kaltman, & Green, 2006; van der Kolk, 2005). Interpersonal traumas are partly so toxic as they are intentionally perpetrated by another person, thus, the victim’s views regarding safety, intimacy, and trustworthiness are vulnerable to unhelpful or inaccurate alterations (Janoff-Bullman, 1992). The duration and the number of instances of the traumatic event are also related to outcome. Duration and number of incidents are linked together as traumatic events that are chronic, by their nature, have occurred more than once and conversely, multiple incidents of a Wamser, Rachel, UMSL, 2012 10 traumatic event often occur over an extended period of time. Unsurprisingly, the longer and more frequently the trauma occurs, the more severe and varied the post-traumatic sequelae (Blaauw, Winkel, Arensman, Sheridan, & Freeve, 2002; Mechanic, Uhlmansiek, Weaver, & Resick, 2000). Both of these characteristics may contribute to the survivor feeling overwhelmed, helpless, or that the trauma is inescapable. The age of the victim when the trauma begins is important. Traumatic events that begin in childhood result in a more severe symptom presentation compared to those which begin in adulthood (Cloitre, Scarvalone, & Difede, 1997; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). In sum, all traumatic events are not created equal. Taken together, research would suggest that traumatic events which are interpersonal in nature, chronic or multiple, or begin at an early age are related to a more complex symptom presentation (Herman, 1992; Terr, 1991). Within the current PTSD construct, these differences are not acknowledged and instead are subsumed under a single diagnostic category. PTSD also takes a one-size-fits-all approach to trauma-related symptoms, which is tragic as PTSD is fails to capture the full span of trauma-related sequelae. PTSD is classified as an anxiety disorder and consequently, PTSD describes symptoms of anxiety. Trauma survivors unfortunately have problems beyond that of anxiety. Survivors of childhood sexual abuse, for example, have difficulties in a broad range of domains including serious impairments in affect regulation, self-concept, and interpersonal problems, sexualized behavior, and somatic complaints (Cloitre, Stovall-McClough, Zorbas, & Charuvastra, 2003; Spinazzola, 2005; Stovall-McClough & Cloitre, 2006; Zucker, Spinazzola, Blaustein, & van der Kolk, 2006). These symptoms are notably absent from the list of acceptable symptoms of PTSD. As an anxiety disorder, the construct PTSD is unable to capture these difficulties without violating the organization Wamser, Rachel, UMSL, 2012 11 of the DSM. The non-anxiety symptoms which do not fit are relegated to a variety of “comorbid” conditions, which ostensibly are thought to be unrelated to the trauma. This would be acceptable if few traumatized individuals presented with non-PTSD diagnoses. Unfortunately, non-PTSD symptoms are ubiquitous, with more than 80% of individuals diagnosed with PTSD also receiving a comorbid diagnosis (Foa, Freidman & Keane, 2000). PTSD has one of the highest rates of comorbidity of any DSM diagnostic category (Kessler, Chiu, Demier, Merikangas, & Walters, 2005). This may be problematic, it is implied that some, but not all, of the patient's symptoms may be ascribed to the traumatic experience. Conceptualizing other potential effects of trauma as merely “co-morbid,” as opposed to the “real” trauma disorder may also limit the validity of trauma research; as such co-morbid conditions are often excluded from traumafocused research. In fact, a review of the treatment outcome studies demonstrated that the typical presenting client would be screened out of PTSD studies because of comorbid conditions (Spinazzola, Blaustein, & van der Kolk, 2005). Thus, much of PTSD research may not be even applicable to the typical client. PTSD is, instead, more useful in capturing the effects of single-episode, acute traumas occurring in adulthood (Cloitre, Scarvalone, & Difede, 1997; van der Kolk, 2005). In fact, PTSD is diagnosed more frequently following single instances of trauma than after multiple or chronic traumatic events (Green et al., 2000). Clearly, this does not indicate that individuals who have experienced repeated and severe traumatic events do not present with trauma-related difficulties, but rather, that the PTSD criteria may be insufficient in describing reactions to more severe traumatic events. Since its inception into the DSM in 1980, leaders in the field of traumatic stress have argued that PTSD does not accurately capture the presentation of victims of child abuse, concentration camps, Wamser, Rachel, UMSL, 2012 12 refugee camps, domestic violence, or those that have experienced other repeated and extensive trauma (Herman, 1992; Cook et al., 2005; Courtois, 2004). The shortcomings of PTSD are too great for the most serious of traumas. Diagnostic issues tend to be magnifie
618 citations
"Diagnosis and classification of dis..." refers background in this paper
...In adolescence, substance use, risky behaviours (unsafe sex, unsafe driving) and aggressive behaviours may be particularly evident as expressions of emotion dysregulation and interpersonal difficulties (39)....
[...]