Considering all of the possible traumas and personal histories available, it is no surprise there are different reactions to stress. The age, gender, genetics, and background of each person interact with the specific trauma to create a unique set of problems and solutions. The DSM V team tried to separate them out, but they left some survivors in the cold.
Currently Recognized DSM V Stress Related Diagnoses:
- Acute Stress Disorder:
- Adjustment Disorders
- Post Traumatic Stress Disorder:
- Sub-type: Dissociation.
- Dissociative Disorders
- Dissociative Identity Disorder
- Dissociative Amnesia
- Depersonalization Disorder
- Dissociative Disorder NOS (now in 2 parts)
Wikipedia does an excellent job of describing these if you want more information. This blog looks at the survivors left behind.
I. Military soldiers and veterans who do not meet full PTSD criteria.
These men and women often have significant problems with hyper-arousal (hyper-alert, easy startle, irritability, trouble sleeping) but don’t exhibit enough symptoms of re-experiencing (flashbacks) or avoidance and negative affect and cognitions to qualify for a PTSD diagnosis.
They might better fit the diagnosis of Acute Stress Disorder, but their symptoms may last longer than the one month allowed. It’s been suggested they deserve a different label, like “Battle Stress” since their arousal symptoms are indicative of high levels of stress chemicals produced when the sympathetic nervous system is overactive. These symptoms can be beneficial in battle, but they are also precursors to PTSD and violence.
Not everyone who has hyper-arousal will go on to develop PTSD. Most returning combat soldiers have some arousal symptoms that will gradually diminish after they return to safety. But that process requires a supportive environment and may take several months to be complete.
And if the sympathetic nervous system fails to adapt, re-experiencing symptoms can suddenly occur when the soldier or veteran meets a triggering event. The resulting confrontations with family or police may pave the way to other problems.
Should we treat everyone with partial symptoms to, hopefully, prevent PTSD, or should we wait until the full diagnosis is established?
There are arguments both ways. Those who suggest waiting point out that it stigmatizes normal soldiers to treat them for a nonexistent illness. Those who suggest treatment argue that careful observation, counseling, and medication (as needed) are preventative behaviors that reduce their risk of serious illness and regrettable behavior. So far there is no research to support either side, but close observation of veterans with marked hyper-arousal symptoms is probably a safe middle-ground.
II. Complex PTSD (C-PTSD), also known as Disorder of Extreme Stress (DOES)
Complex PTSD Symptoms:
- Problems with emotional regulation: persistent sadness, suicidal thoughts, or explosive anger.
- Changes in consciousness: forgetting traumatic events, reliving traumatic events, episodes of detachment from one’s mind or body.
- Changes in self-perception: helplessness, shame, guilt, stigma, and feeling different from other human beings.
- A distorted view of the perpetrator: as totally powerful, as very important, or as someone who needs to be destroyed.
- Relationship problems: isolation, distrust, in search of rescue
- Loss of meaning in life: loss of faith, sense of helplessness and despair
Traumas commonly associated with these symptoms:
- Concentration camps
- POW camps
- Prostitution brothels
- Child exploitation rings
- Long-term physical and/or sexual abuse
- Long-term domestic violence
- Prolonged kidnapping and hostage situations
- Forced conscription of youths into military service
Complex PTSD was not included in the DSM V as a separate diagnosis, instead many of the symptoms were added to the PTSD list. But a PTSD diagnosis requires other symptoms, such as re-experiencing or flashbacks, and lacking those symptoms can leave these badly traumatized folks without access to help.
Most treatment professionals agree that abuse perpetrated by a controlling person or group over a prolonged period of time is the most difficult to treat. Long-term outpatient therapy is standard, often with medication, as the diagnoses of depression and personality disorder often accompany Complex PTSD.
Therapy in Complex PTSD progresses slowly. At first the focus is on building a relationship that is strong enough that it can weather stress, teaching the client techniques for self-soothing and self-grounding, dealing with dissociative events and/or parts, and learning to recognize and regulate emotions. Only when those basic coping skills are in place can the therapist start working on the trauma.
Whether any of the new experimental treatments currently being tested for PTSD will be helpful to those with C-PTSD remains a still unanswered question.
III. Co-Morbid PTSD:
The problem here is misdiagnosis. Because most people with PTSD have several co-existing psychiatric diagnoses, the physician can get stuck treating those problems and totally miss the PTSD.
Depression and Substance Abuse are the most common co-morbid illnesses, but bipolar and anxiety disorders are also frequent, as well as certain personality disorders, and paranoid psychosis.
When a patient presented with multiple psychiatric problems, it was always a warning sign for me. When I saw that, I started asking questions about trauma. When the underlying PTSD is not diagnosed and appropriately treated, the person is unlikely to recover.
To protect yourself from misdiagnosis, make sure you always mention a past history of trauma, even if it doesn’t seem immediately relevant to you.
Research comparing different groups and diagnoses:
1) In a study of hospitalized veterans with chronic, severe, PTSD the researchers did detailed assessments of both PTSD and complex PTSD symptoms, military and childhood histories of trauma, and utilization of medical services.
Although 31% the veterans met criteria for both, there were 29% who only had PTSD and 27% who only had C- PTSD symptoms (13% had neither).
Comparing the groups, they found that Complex PTSD symptoms were significantly associated with childhood trauma, while the PTSD symptoms were significantly associated with war trauma. The witnessing of atrocities was common among those with PTSD, but participation in atrocities was limited to those with C- PTSD.
They also found that veterans with C- PTSD had utilized more services than those with PTSD.
(Ford, et. al. February 1999 issue of Journal of Consulting and Clinical Psychology, 67(1), 3-12.)
2) Research done in the production of DSM V found that 92% of the people who met Complex PTSD criteria also met criteria for PTSD, so they chose to combine the diagnoses. This statistic contrasts sharply with the research done by Ford (#1 above) suggesting that a lot of folks were left out in the cold.
We are just beginning to learn how different traumas effect different types of people and the physical changes that occur inside their brains. We still don’t know which treatments will work best for any given group.
Rather than stretch the PTSD diagnosis to include folks with only partial symptoms, it might be better to add in two new categories, Battle Stress and Complex PTSD. That would clarify the differences and allow treatment of folks who now fall between the cracks.