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Should there be a separate diagnostic category for complex PTSD related to childhood trauma in the DSM-V?
Physicians and researchers such as Bessel van der Kolk, MD, Robert Pynoos, MD, and Marylene Cloitre , PhD think so. Over a year ago, these medical professionals formed a task force advocating that a diagnosis called Developmental Trauma Disorder be in the DSM-V.
The task force notes the diagnostic criteria for the current diagnosis of PTSD was based on symptoms of World War II combat veterans. We know that many people who have have experienced chronic childhood abuse or neglect also exhibit some PTSD symptoms. But, they also display problems with emotional regulation, learning disabilities, and attachment that are given separate diagnoses and treated differently.
At a conference I attended in February 2010, Dr. van der Kolk opined this lack of an adequate diagnostic code resulted in dangerous consequences for kids. He estimates that as many as 8 million children in the U.S.A. have been diagnosed with Bipolar Disorder and/or ADHD and prescribed large doses of medication. Yet, he’s observed the root of the problem for many of these kids lies in disrupted attachment, abuse, or neglect that is often left untreated.
Similarly, as abused kids reach adulthood they are given diagnoses of recurrent depression, anxiety disorders, personality disorders, or somatization disorders because they don’t match the current criteria for PTSD. Not only do these patients have to live with the stigma of other diagnoses, but it also leaves the root cause of the problem untreated.
Fortunately, Cloitre et. al just published an article in the August 2010 addition of the American Journal of Psychiatry that lends more support for this new diagnosis. Their research illustrates that treatment for issues related to chronic childhood traumas is different. See my post titled “Complex PTSD requires emotional skills training + trauma focused therapy” for information about this research.
Similarly research by Pitman, et al. presented at the 2008 ANCP meeting found that diminished volume of the hippocampus and ventro-medial pre-frontal cortex seemed to make a person more vulnerable to developing PTSD. We know that people exposed to chronic stress, especially as a child, tend to have diminished volume in these areas. Having diminished volume in these areas makes it more difficult to regulate emotions and assemble memory.
Diagnosing these issues appropriately has important implications for treatment. For example, Cloitre’s research suggests we have to do a combination of emotional skills training and trauma focused therapy for optimal treatment response. For children, it suggests family counseling with parenting support and coaching is needed for optimal treatment responses.
Even if the new diagnosis is accepted for the upcoming DSM-V, it would only be approved as a diagnosis for children and adolescents at this time, not adults. Still, it would be a step in the right direction in terms of getting these folks appropriate treatment.
What do you think? Do you think there needs to be separate diagnostic category for complex PTSD related to childhood trauma in the upcoming DSM-V?
For more information about this proposal and the suggested diagnostic criteria, visit www.traumacenter.org.
Courtney Armstrong is a Licensed Professional Counselor who specializes in trauma therapy. She has a private practice in Chattanooga, TN and also trains mental health professionals in creative ways to treat trauma. To contact Courtney, visit her website at www.courtneyarmstronglpc.com
Omega Sunrise II by Irargerich via Flickr
**Cassie came to therapy plagued by memories of physical, emotional, and sexual abuse from her childhood. She was in a good marriage now, had a sweet daughter, and many friends. Yet, Cassie continued to feel unworthy of anyone’s love.
When she was younger, Cassie’s step-father was very violent and often threatened her and her brother with a gun. Her mother constantly told her that she was “fat, lazy, and stupid.” The only person that seemed to value Cassie was her grandfather. They’d go fishing every few weeks, and he’d call Cassie “his Sunshine.” She never told her grandfather what was going on at home for fear she’d lose his love and respect too.
As Cassie and I addressed the traumatic memories from her childhood, I shared a beautiful metaphor with her that I learned from Dr. Jon Connelly. Cassie later told me that this metaphor was instrumental in her recovery, and I want to share it with you too.
First, I asked Cassie to close her eyes and imagine being out on the lake with her grandfather, hearing him call her “Sunshine.” I asked her what she felt as she recalled this experience. Cassie said, “I feel warmth, peace, and love.”
I suggested that the experience of being with her grandfather drew her awareness to where she had warmth, peace, and love at her center. In fact, this light of warmth, peace, and love wasn’t just hers. It is her essence, who she really is deep inside, and it is with her all the time.
Cassie opened her eyes and tearfully smiled as she said, “I thought I was full of darkness. But now I realize you are right, I AM the Sunshine! My grandfather saw that in me. I am not those things my mom said about me. I am the Light and can chase old shadows away.” I teared up too as I watched her entire countenance change and she got up to give me a big hug.
Cassie is an avid gardener and now teaches troubled kids how to use gardening to heal and remember that they are the “Sunshine.”
**The name and identifying details have been changed in this story to protect privacy.
Courtney Armstrong is a Licensed Professional Counselor who specializes in trauma therapy. She has a private practice in Chattanooga, TN and also trains mental health professionals in creative ways to treat trauma. To contact Courtney, visit her website at www.courtneyarmstronglpc.com
**Ross was a screenwriter who was referred to me by his doctor to treat a severe needle phobia. Ross had a health condition that required blood to be drawn once a month. But, the nurses had been unsuccessful in drawing blood because Ross would go into a full-blown panic attack at the sight of a needle.
Ross indicated the event that caused his phobia was a scary experience in a hospital as a child. He recalled a nurse holding him down, yelling at him, and attempting to draw blood from his arm. However, he panicked mid-way through telling me the story. He began to sweat, and gasp for air. He cried, “I don’t think I can do this.”
I remained calm and got him talking about a script he was writing until I noticed the anxiety dissipate. Then I suggested we go through the story of the traumatic event again. But this time I suggested we take turns telling different parts of the story and speak in foreign accents.
He raised his eyebrows and said, “What?” I encouraged him to just humor me a bit and think of himself as an actor. After all, Ross was a screenwriter and had a great sense of humor. I knew he could do this.
Ross decided that I could play his role and wanted me to be a Frenchman. He played the nurse and gave her a German accent. I began by saying, “Excusez moi, large-boned lady, but what is zis business of moving a sharp, pointy object toward my arm?”
Ross replied in his best German accent, “You vill allow me to insert dis needle into your arm and you vill like it, tiny Frenchman! When we are done, I vill give you a delicious strudel, and you vill like dis too.”
We then went on for several minutes until we were both laughing hysterically. Once we gained our composure, I asked Ross to go through the story again in his regular voice. He was amazed that he was able to tell it several times without any sign of panic. The next day, he successfully gave blood at his doctor’s office and reports having no problems with it ever since.
Play and humor are amazing cures for anxiety because they reduce perceived threat. It’s nice to know effective therapy does not have to be so serious!
**The name and identifying details have been changed in this story to protect privacy.
Courtney Armstrong is a Licensed Professional Counselor who specializes in trauma therapy. She has a private practice in Chattanooga, TN and also trains mental health professionals in creative ways to treat trauma. To contact Courtney, visit her website at www.courtneyarmstronglpc.com
Jon Connelly, me, and some fellow RRT practitioners
Rapid Resolution Therapy™ is my treatment of choice when it comes to clearing the negative effect of traumatic memories.
This innovative method was developed by Dr. Jon Connelly and often yields results in just 1-3 sessions.
Below are some of the elements of RRT that I love:
1. Start with the solution
In RRT, you start by having the client connect to you and collaborate with them to create an image of their desired way of thinking, feeling, and responding. You use elements of hypnosis to guide them there and have them experience this desired response in a deep sensory way.
2. Keep the client emotionally present
The above process has the effect of creating a positive space where the client can stay connected and present. Then, you have the client describe “just-the-facts” of the traumatic event while remaining emotionally present to the current experience of being with you.
In my opinion, this concept of “emotional presence” is the key to clearing the troubling effect of a traumatic memory. You do not have to have the client move their eyes back and forth, or re-experience horrific feelings as old exposure therapies encouraged.
3. Use of playfulness and humor
Dr. Connelly is masterful at using play and humor to diffuse fear, anger, and shame. For example, we might have the client speak with a Valley Girl accent as she describes a disturbing event. It’s amazing how well play and humor disrupt anxiety responses Clients who came in crying, are able to laugh and find joy.
4. Use of metaphor and stories
In RRT we use lots of stories and metaphors to give clients new ways of seeing themselves and thinking about things.
One of my favorite metaphors is to consider that who you are is not your body, your thoughts, or your beliefs. Let’s think of who you really are is a being of Light at your center. A Light of peace, wisdom, and excitement. Nothing can harm a beam of light. Someone can shoot at a light beam, curse at a light beam, or try to chop it with an axe. Yet, that Light keeps on shining. It is resilient, clean, and clear. Someone may have messed with your body, but they didn’t touch that Light. That “Light” can only be touched by love that you welcome.
If you want to learn more about RRT, click here for a series of videos that will introduce you to the method.
In addition you can visit Dr. Connelly’s website at www.cleartrauma.com and check out upcoming dates for his 3-day training courses.
Courtney Armstrong, LPC, NBCCH
Hi. Thanks for joining me here. I am a Licensed Professional Counselor who started this blog to connect with other therapists. I was looking for a place where we could share ideas, the latest research, and some success stories. However, you don’t have to be a therapist to join us here. All are welcome.
I have a private practice in Chattanooga, Tennessee. My specialty is treating trauma, grief, and anxiety. I also lead training workshops for mental health professionals.
Although rewarding, trauma therapy is hard work, and I believe we can all benefit from little lifts, insights, and encouragements to keep us going.
I hope you will find useful information, inspiration, and support here. Please feel free to share your comments on posts.
You can also share your ideas, suggestions, or success stories by emailing me through my website: www.courtneyarmstronglpc.com.
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