From: Chapter 6: Diagnosing and Identifying the Need for Trauma Treatment, in First stage trauma treatment: A guide for mental health professionals working with women (© CAMH 2003)
The diagnostic construct of complex PTSD or DESNOS is not currently recognized in the DSM-IV as a freestanding diagnosis, but is instead presented as associated features of PTSD. Complex PTSD is expected to be included in the next edition of the diagnostic guidebook, the DSM-V. However, it is unclear if it will be given the name complex PTSD or DESNOS. Currently, both terms are referred to interchangeably in the clinical literature in this area.
Simple post-traumatic stress consists of changes to three areas of functioning, while complex post-traumatic stress consists of changes to six domains of functioning. The diagnostic criteria for determining the presence of complex post-traumatic stress entails that a number of specific changes (outlined below) are present in each of the six domains of functioning.
|Diagnostic criteria for complex post-traumatic stress responses|
(I) Alteration in Regulation of Affect and Impulses
(A and one of B to F required)
- affect regulation
- modulation of anger
- self-destructive behaviour
- suicidal preoccupation
- difficulty modulating sexual involvement
- excessive risk-taking
(II) Alterations in Attention or Consciousness
(A or B required)
- transient dissociative episodes and depersonalization
(III) Alterations in Self-Perception
(Two of A to F required)
- permanent damage
- guilt and responsibility
- nobody can understand
(IV) Alterations in Relations with Others
(One of A to C required)
- inability to trust
- victimizing others
(Two of A to E required)
- problems with the digestive system
- chronic pain
- cardiopulmonary symptoms
- conversion symptoms
- sexual symptoms
(VI) Alterations in Systems of Meaning
(A or B required)
- despair and hopelessness
- loss of previously sustaining beliefs
Luxenberg, Spinazzola, van der Kolk. Reprinted with permission from The Hatherleigh Company, Ltd., New York. www.hatherleigh.com, 1-800-367-2550. © 2001
Some therapists may assume that they can only apply a trauma treatment model with clients who have been officially diagnosed with ptsd. However, many experts in the field stress that a history of severe child abuse or neglect is sufficient grounds for using a carefully paced trauma treatment model, even if the client does not have a formal diagnosis of complex PTSD (Courtois, 1999; Saakvitne et al., 2000).
Stage-one or stage-two treatment?
There are two methods for assessing whether an abuse client requires stageone trauma treatment. While these methods are not measures of the construct of complex post-traumatic stress responses, they are nevertheless useful in capturing the elevated adaptations related to post-traumatic stress. These methods examine response severity and help in determining whether or not a client requires the first stage trauma treatment strategies of stabilization and response management.
i) The first method is the Trauma Symptom Inventory (TSI), developed by Briere (1996), which helps to assess a wide range of psychological impacts of abuse and other traumatic events and helps to monitor the client’s progress in therapy.
ii) The second method is a list of clinical indicators, developed by Andrew Leeds (1997), which also helps to determine if an abuse survivor requires the interventions and strategies of stage-one trauma therapy. If a client has a number of these indicators, it means that she needs more help in therapy with stabilization and response management.
|Indicators of a need to extend the client preparation and stabilization phase|
- Client history includes early neglect, abandonment or inadequate attachment to caregiver(s).
- Client has difficulty accurately naming and describing her feelings.
- Client reports or is observed to be easily flooded with feelings and is not able to identify the trigger(s).
- At times of emotional distress, client is unable to speak and cannot articulate her thoughts.
- Client does not use or know standard self-care methods (structured relaxation, establishing a safe place, soothing imagery or exercise).
- Client’s account of recent stressful events is unclear or vague and self-critical.
- Client is clearly dysthymic (has chronic, low-grade depression), but does not complain of feeling depressed and considers this just a normal way to feel.
- Client does not trust her own perceptions or feelings as information for deciding how to set limits, assert needs or cope with others.
- Client lacks adult perspective and culturally relevant models of basic human rights.
- Client lacks the skills to enable her to have access to social and economic support.
- Client uses alcohol and/or other drugs or self-harms as a means to regulate her emotional states.
Leeds (1997). Reprinted with permission.
In Diagnosing and Identifying the Need for Trauma Treatment