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The Devolution of a Diagnosis: PTSD, Part One

Child abuse is the largest single public health issue in America.
Mary Sykes Wylie, PhD

We currently wage war on drugs, poverty, terror, cancer, gangs, women, and Christmas (according to some). Why no war on child abuse if it’s such a big deal? Better still, why not a child “love-in” (a term from my generation where we professed to make love, not war, supposedly)? Wouldn’t that pretty much take care of all those other wars, over time? Wait a minute, you were expecting another installment of my “Evolution of a Diagnosis” series on PTSD (Posttraumatic Stress Disorder)? Now I’m using the word “devolution” and talking about child abuse. What’s all that about?

Well, I’m about to tell the story of a diagnosis that many people like me (clinicians) have clamored for over the last decade or so. I’m talking about the attempted evolution of the PTSD diagnosis, which covers people who have experienced a one-time trauma, like a car accident. It does not, however, cover people who have experienced ongoing trauma, like three tours in Iraq, domestic violence, torture, imprisonment, kidnapping, child abuse, etc. A valiant group of trauma clinicians and researchers have referred to the resulting condition by various names, such as complex PTSD, Developmental Trauma Disorder (DTD), and the curious-sounding Disorders of Extreme Stress – Not Otherwise Specified (DES-NOS).

Before I go further, most of what you’ll read from here on summarizes an article published in the magazine Psychotherapy Networker by senior editor Mary Sykes Wylie, PhD, called “The Puzzle of Trauma: Redefining PTSD in the DSM.” In my opinion, Dr. Wylie does an excellent job of reporting on a story that needed telling and represents some of the best and the worst of what’s happening in the field of mental health care.

OK, our story starts with the discovery of rampant abuse within our society of both women and children (and, although less so, men) by caretakers, parents, spouses, and so on. This was publicized decades ago during the feminist movement. These abused women and children (and the women and men they grew up to be) exhibit many strange symptoms, not easily accountable within any one existing mental health diagnosis, including PTSD. They get shuffled off to diagnoses like anxiety, depression, Borderline Personality Disorder, Dissociative Identity Disorder and others for women. From the article, “numerous studies had shown that the vast majority of BPD patients ‘have histories of severe abuse and/or neglect starting before age 7.’”

For children, we offer Reactive Attachment Disorder, Disinhibited Social Engagement Disorder, Oppositional Defiant Disorder, Intermittent Explosive Disorder, and the ever-popular Conduct Disorder, among many others (no, I’m not making these up). In fact, I would bet good money that virtually every diagnosis in the DSM® (Diagnostic and Statistical Manual of Mental Disorders®) was, at one time or other, used to describe these unfortunate people.

Several other discoveries became known once this was given more attention by researchers such as Bessel van der Kolk, MD (a trauma-informed psychiatrist, founder of the aptly-named Trauma Center, and one of my personal heroes). For one, it turned out that the abusers were quite often abused themselves, so we have a “gift that keeps on giving,” so to speak.

Further, to quote Dr. van der Kolk, “The severity of a particular trauma—assault, accident, whatever—determined PTSD symptoms, but the child’s relationship to the abuser determined everything else—anger, suicidality, self-injury, disturbed relationships, tendency to be re-victimized.”* So, we start to vary away from the standard PTSD diagnosis given for trauma victims. In addition, our story takes a decided turn away from abused women and from women and men abused as children (all of these being my clientele, unfortunately; but I’m not bitter) and toward children and adolescents who suffer from abuse.

Women and children first, but mostly children! Well, I guess I can’t argue with that too much.

Before we go further in the story, let’s take a moment to brighten the spotlight on child abuse, “the largest single public health issue in America.”* This abuse includes physical abuse (like hitting, burning, spanking too hard, shaking, etc.) and sexual abuse (fondling, molesting, oral sex, intercourse, etc.). It also includes neglect (leaving the child by themselves for a long time, not feeding them or caring for them when ill, etc.) and emotional abuse (yelling, shaming, calling names, etc.). Interestingly, researcher Marylene Cloitre, PhD, found that “emotional abuse and neglect—the absence, failure, or distortion of the child’s relationship to a primary caregiver—did as much, if not more, damage than actual physical abuse.”*

Out of all this, Dr. van der Kolk and others proposed a new diagnosis, called Developmental Trauma Disorder, for publication in the next edition of the DSM® (Fifth Edition, published in June, 2013).

At this point in the story, I have reached my self-imposed article word limit. So, I will leave you hanging regarding how this story turned out until my next article, Part Deux in this series. If you don’t like cliff-hangers or you enjoy spoilers, note that I’ve named the series “Devolution” (maybe “Devil-ution?”) and you may wish to take a breeze through the DSM-5® to see if you can find DTD.

DSM, DSM-5, and Diagnostic and Statistical Manual of Mental Disorders are registered trademarks of the American Psychiatric Association.

Copyright 2014 Daniel J. Metevier

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