By Dr. Julianne Ludlam
For most people, traumatic reactions are associated with the diagnosis of Posttraumatic Stress Disorder, or PTSD. This is understandable, given that it is the primary trauma-related diagnosis in the Diagnostic and Statistical Manual for Mental Disorders, currently in its fifth edition (DSM-5). However, it may be useful for attorneys and legal professionals to understand the limitations of the current diagnostic system as it relates to trauma, and to be aware of various ways that reactions to trauma can manifest.
The PTSD Diagnosis
We sometimes use the word, “trauma,” to refer to negative experiences (i.e., “That halftime show really traumatized me,” or “Traffic today was so traumatic!”). Importantly, the actual definition of trauma in the DSM-5 was carefully constructed to ensure that not every bad experience would be classified as a traumatic one. The DSM-5 (American Psychiatric Association, 2013) lists specific requirements that define a trauma in order to avoid subjective assessments; it must involve exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Thus, the DSM-5 describes, in detail, the context of the exposure to a trauma; it must involve having one’s life threatened or having direct, personal experience of seeing someone else being threatened, killed, or hurt. We may casually use the term to describe any stressful or upsetting event, but diagnostically, trauma has a specific definition. The requirements above are collectively referred to as the “stressor criterion” and are considered a form of gatekeeper. The stressor criterion was intended to restrict the diagnosis of PTSD to individuals experiencing serious and horrible events, not merely unpleasant ones. The diagnosis of PTSD was not meant to include indirect or impersonal experiences of trauma, such as watching, from the safety of one’s living room, a news report of a catastrophe occurring to strangers.
Other Trauma-Related and Stressor-Related Disorders
Aside from PTSD, there are other specific trauma- and stressor-related disorders in the DSM-5. Acute Stress Disorder is most closely related to PTSD and differs primarily in timeframe. Acute Stress Disorder is diagnosed when an individual experiences symptoms between three days to one month after the event; PTSD is diagnosed when symptoms last longer than one month. Because many individuals may have symptoms in the immediate aftermath of a trauma, the minimum number of days of symptoms was set at three; it is the persistence of problems after that timeframe that define diagnosable traumatic reaction. Approximately 80% of cases of Acute Stress Disorder appear to develop into PTSD, but many cases are not identified and diagnosed, despite the possibility of ongoing functional impairment.
Other disorders in the DSM-5’s “trauma- and stressor-related” category include Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. These disorders are diagnosed in children and adolescents and are considered reactions to neglect and deprivation experienced in childhood; they generally involve disturbed attachment behaviors. The prevalence of these disorders is unknown, and both are diagnosed relatively rarely. Both emphasize social neglect by caregivers rather than any other form of traumatic experience.
Other diagnoses in the category include Adjustment Disorder, which is considered a mild, temporary condition resulting from an external stressor, and “Other Trauma- and Stressor-Related Disorders.” The latter diagnosis is used when individuals do not meet full criteria for a disorder in the category but exhibit enough symptoms to merit clinical attention. Unfortunately, disorders that fall into this “other” diagnostic grouping are typically stereotyped as minor or less pathological, despite the fact that they can still be quite problematic for individuals; this issue will be discussed in more detail in the third article.
While diagnostic clarity at this level is not always be necessary for treatment purposes, it is important in forensic and psychological evaluations. Individuals can engage in therapy without a formal diagnosis, and in some cases, an over-emphasis on diagnosis can distract clients and therapists from focusing on emotions and behaviors, processing grief, or developing coping skills. In forensic or psychological evaluations, however, diagnostic specificity is key, given the necessity of clear recommendations and conclusions to guide decision-making in legal settings.
Overall, the diagnosis of PTSD requires that several specific criteria be met, including a detailed and rather restrictive criterion that defines a “trauma.” Although there are other diagnoses in the DSM-5’s “trauma- and stressor-related” category, these are limited by their timeframe, emphasis, or severity. When individuals have symptoms that do not meet criteria for any of these diagnoses, there is an “other” category that can be used. Problems falling into this “other” category may tend to be ignored or discounted, and this important issue will be addressed in the third article in the series. The second article in this series will explore severe forms of trauma that many researchers feel are not adequately captured by our diagnostic system.
The Problem of Complex Trauma and Polyvictimization
Researchers have identified some ways that the negative impacts of trauma may not be fully captured by the current diagnostic system. One major issue is that PTSD and related diagnoses do not appear to describe the experiences and impairments associated with complex trauma and polyvictimization. These two terms have some overlap in their definitions; they are current, working constructs used in clinical research to describe similar problems.
Complex trauma involves exposure to multiple or prolonged forms of trauma often of an invasive, interpersonal nature; exposure is often described as “severe and pervasive” and beginning early in life (Cook et al., 2005). For example, a child may experience ongoing physical or sexual abuse in the context of continual neglect by parents. Complex trauma is believed to disrupt a child’s development as well as their ability to form a secure attachment, since the experiences often occur in the context of the child’s relationship with a caregiver. Children exposed to multiple, chronic traumas often have more severe and complex responses, including a range of mental health symptoms and functional impairments. Adults who have experienced complex trauma in childhood appear to have problems with regulation of emotions and behaviors, problems with attachment and interpersonal functioning, issues with attention, cognition, and dissociation, and difficulties with physiological functioning and sense of self (Kisiel et al., 2014).
Polyvictimization is a similar but more specific term, solely referring to the experience of multiple types of traumatic experiences. Generally, a “polyvictim” has experienced or witnessed six or more forms of violence or abuse, such as physical abuse, sexual abuse, emotional abuse, domestic violence, or traumatic loss. (The requirement of six forms is not always consistent; some studies have set cutoffs of four or seven or have used a percentage of the sample, as there is not yet consensus on an exact numerical threshold.) The reason for the creation of this term involves the fact that children exposed to one form of violence are more likely to have had multiple exposures to violence. The 2014 National Survey of Children’s Exposure to Violence (NatSCEV III), a comprehensive national survey of youth age 17 and younger, found that while 67.5% of its total sample reported experiencing or witnessing at least one form of violent exposure, half (50.0%) had been exposed to more than one form (Finkelhor, Turner, Shattuck, & Hamby, 2015). In the NatSCEV III, 10% of the youth were classified as polyvictims. Youth experiencing polyvictimization have been found to be more distressed than other victims in general, and they display more distress than those victims who experience frequent victimization of a single type (Finkelhor, Shattuck, Turner, Ormrod, & Hamby, 2011).
Researchers have suggested that both complex trauma and polyvictimization are inadequately represented by the diagnosis of PTSD; the problems that stem from these experiences may instead underlie a range of mental health diagnoses (Kisiel et al., 2014). The concern is that youth with these issues may be mislabeled and receive diagnoses not connected to their trauma, and as a result, may receive treatment or services that are not trauma-informed. Identifying these particular issues within the current diagnostic system is difficult. For example, many measures of trauma require a clinician and a client to identify one traumatic event that was most influential or is most problematic; that single event is used to make a diagnosis, which can result in a limited understanding of an individual’s experiences. Because of these concerns, there have been attempts to establish a new diagnosis for complex trauma in children, referred to as Developmental Trauma Disorder (DTD; Kisiel et al., 2014). Again, evidence to support a potential different diagnosis comes from studies showing that children exposed to complex trauma (interpersonal violent traumas + attachment-based, non-violent trauma, like neglect) or polyvictimization (multiple forms of trauma) had more severe functional impairment and posttraumatic stress symptoms than children with any type of trauma alone (Kisiel et al. 2014).
As mentioned in the first article in the series, diagnosing specific disorders related to trauma may not always be necessary, but complex trauma and polyvictimization tend to make diagnostic clarity more important. For example, a client with complex trauma and polyvictimization who is being seen in therapy may receive appropriate treatment without those experiences being specifically identified. However, in some cases, the severity and complexity of these conditions can lead to incorrect or incomplete diagnoses, which can lead to unhelpful or even harmful treatments. Identifying these experiences in forensic and psychological evaluations is necessary and important; these particular traumatic experiences can result in greater distress and increased impairment in behavior and functioning, both of which are informative in legal contexts.
Overall, this article has described the ways in which the diagnosis of PTSD does not fully capture traumatic experiences that are prolonged or complex – particularly those that involve multiple types of trauma. These problematic experiences can lead to higher levels of distress and impairment, and a range of psychological diagnoses (not simply PTSD) may be the result. The final article in this series will address other psychological diagnoses that can follow trauma as well as the difficulty of diagnosing those who do not meet full criteria for PTSD.
The Problem of Subclinical Symptoms
As mentioned in the first article in this series, the “stressor criterion,” often referred to as the gatekeeper of the PTSD diagnosis, restricts the condition to individuals who have direct, personal experience with trauma. But exposure to a trauma alone is insufficient for a diagnosis of PTSD; there are several additional criteria that must be met. An individual must also show symptoms that involve each of the following categories:
The required number of symptoms from each of these groupings can be limiting; individuals may have experiences that result in some symptoms of PTSD but exhibit less than the required amount. While these individuals can be diagnosed with different (and potentially less useful) diagnoses, it is important to realize that these “subclinical” symptoms can be, and often are, problematic, causing impairment and distress. In other words, some symptoms alone may be clinically significant and meaningful, despite not being clearly diagnosable with a well-known label. For example, a young woman assaulted in her community may avoid leaving her apartment but show few other symptoms; this avoidance alone may result in impaired functioning.
Interestingly, it is rare for youth and adolescents who have experienced trauma to receive the full diagnosis of PTSD; they are more likely to present with such subclinical symptoms. For this reason, there continues to be ongoing debate about whether the symptoms used to diagnose PTSD adequately capture posttraumatic stress in youth (Gutermann et al., 2016). Researchers and clinicians now emphasize the importance of assessing and treating subclinical symptoms of PTSD in youth and consider them sufficient for study and treatment.
Trauma Can Result in Other Disorders
A final point about the limitations of PTSD involves the variability of traumatic responses; PTSD is not the only possible response to trauma. After a traumatic experience, individuals can develop all kinds of disorders. The most common disorders that can occur as a result of trauma include disruptive disorders (like AD/HD), substance use disorders, anxiety disorders, and depressive disorders.
The Adverse Childhood Experiences (ACE) studies provide strong evidence that trauma can result in a myriad of negative outcomes (Felitti et al., 1998; Gilbert et al., 2010). Childhood trauma has been directly linked with an increased risk for many psychiatric conditions (including depression, anxiety, and addictive disorders, as mentioned above, but also bipolar disorder and schizophrenia, eating disorders, dissociative disorders, and personality disorders) as well as chronic diseases and health problems (including chronic bronchitis, hepatitis, skeletal fractures, heart disease, cancer, and lung disease). Adverse childhood experiences were also linked to problematic health-related behaviors starting in childhood and adolescence, including smoking, sexual activity, drug use, adolescent pregnancy, and suicide attempts. The ACE Studies have demonstrated clear evidence of a dose-response model – the more adverse experiences, the higher the likelihood of negative outcomes (Felitti et al., 1998; Edwards, Holden, Anda, & Felitti, 2003), and this direct relationship has been shown for all types of trauma (e.g., Follette, Polusney, Bechtle, & Naugle, 1996).
It is also worth noting that highly traumatized individuals tend to have more than one disorder; these are referred to as “co-morbid” disorders. In the National Survey of Adolescents, for example, adolescents exposed to multiple trauma types were three times more likely to have PTSD than adolescents with no exposure, as one might expect. However, they were also twice as likely to have major depressive disorder and five to eight times more likely to have co-morbid disorders (Ford, Elhai, Connor, & Frueh, 2010).
Trauma-Informed Evaluations and Treatment
Trauma-informed psychological evaluations can assess for the many possible responses to traumatic events. Such evaluations can show if clients are struggling with complex trauma or polyvictimization, with subclinical but still problematic symptoms, and/or with other disorders caused by stressful or traumatic events. Trauma-informed evaluations can provide a diagnosis, but importantly, they also provide a comprehensive overview of the ways in which an individual’s functioning and behavior have been impacted. At KKJ, all of our evaluations are trauma-informed, and when traumatic stressors are identified as potential issues for a client, specific assessment tools may be added in order to fully clarify referral questions. Because an individual’s trauma history is likely to be uniquely difficult to explore, we strive to make our evaluations as sensitive and compassionate as possible. Specific recommendations, such as for trauma-informed treatments, are included in all evaluations. Depending on the problems to be addressed, many forms of treatment may be appropriate; while there are specific trauma-focused therapies, individuals with subclinical symptoms or other diagnoses may benefit from a variety of therapeutic approaches.
When considering whether a client’s presentation meets criteria for PTSD, it is important to understand the limitations of the diagnosis and the complexities of traumatic reactions. Although we tend to think of PTSD as synonymous with trauma, there are many ways that individuals can react to a traumatic experience. In addition, our diagnostic system may be inadequate to describe the experiences of certain groups. It may be useful for attorneys and legal professionals to understand the requirements for a PTSD diagnosis, the limitations of the current diagnosis (particularly for complex trauma, polyvictims, and subclinical presentations), and the various manifestations of trauma responses. Trauma-informed evaluations can provide diagnostic clarity, detailed information on behavior and functioning, and recommendations for treatment.