DIAGNOSTIC ISSUES SURROUNDING COMPLEX TRAUMA

DIAGNOSIS -- An introduction

In clinical research and practice, data is obtained, and treatment is provided, on the basis that someone (research participant or patient) is a member of a "known group" -- groups (sometimes of 1!) believed to possess some set of characteristics, on the basis of biological tests, or pattern of signs and / or symptoms, on the bais of which often a "diagnosis" is assigned, often with differential possible diagnoses also being listed (called "differential diagnosese"). Ccurrently there are no specific biological or biochemical tests to aid in this decison of whether or not someone is a member of a "group" for a number of disorders, in particular psychiatric disorders (although the same can be said of the physical disorder Acquired Immunodeficiency Disease -- AIDS -- as one example of a physical disorder). Currently, for clinical disorders, there are two principal diagnostic "systems" -- the American Psychiatric Association's (APA) Diagnostic and Statistical Manual (DSM), with Version 5 due to appear in June 2013; and the United Nations' International Classification of Disseases (ICD), which is often designed to be "in step" with the DSM. The DSM in particular, especially its proposed Version 5, has attacted a great deal of criticism from people outside of the APA -- and in fact fro at least one prominent member of the APA, e.g.  [LINK].

The Dominant Psychiatric Diagnostic Systems

• the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) currently in its Fourth edition, with some text revisions from its original publication (DSM-IV-TR) but a Fifth edition (DSM5) is due for publication on June 1st, 2013. The DSM takes a medical approach to diagnosis. In short, this means that a ‘patient’ is assumed to have an underlying ‘pathology’ that manifests as various ‘symptoms’ that are assessed to make a ‘diagnosis’ and then apply a ‘treatment’ to said diagnosis. This approach basically makes various human conditions into ‘illnesses’ that need ‘interventions’ like medication or cognitive behavioral therapy.

• the United Nations International Classification of Diseases (ICD) currently in its 10th Edition (ICD-10) -- an optimistically phrased view of possible developments in the ICD is found here, from the APA Monitor [LINK]. This article points out the "inadequate and inappropriate" treatment that often results from improperly applied diagnoses.

Many organisations have criticised the propsed DSM5, including the British Psychological Society [LINK]. In particular, the Society has criticised the proposed criteria for placing the etiology of disorders within individuals (such as, say, grief of longer than tgwo weeks duration; or "personality disorder", to cite only two of many examples) rather than within common social phenomena. One such "phenomenon" could be said to be childhood interpersonal abuse and trauma, which traumatologists such as Bessel van der Kolk regard as the Number 1 Public Heal5h Problem, in the United States at least. Recently, however, the proposed Version 5 of the DSM has come in for some particularly strident criticism from an unexpected source, psychiatrist and former lead member of the team responsible for DSM IV, Dr Allen Frances [LINK].

Are Adult Survivors of Childhood Trauma "Personality Disordered"?

This issue was considered as part of the submission regafding the introduction of the diagnosis "Developmental Trauma Disorder" to the American Psychiatric Association -- available here [LINK] -- more recently, see other material here by   Schmid et al  [LINK]   and   Wylie   [LINK].

When discussing differential diagnosis of personality disorders, the DSM-IV states that “when personality changes emerge and persist after an individual has been exposed to extreme stress, Posttraumatic Stress Disorder should be considered” (p. 688). However, DTD represents more fundamental and chronic changes in the developing personality than PTSD. Though personality disorders include disturbances in affect, behavior, and relationships, personality disorders: (a) presuppose a fully formed personality which is not consistent with ongoing personality development throughout childhood; (b) separate symptoms that are addressed in an integrated manner in DTD into several different disorders involving distrust and suspiciousness (paranoid), affective and relational instability (borderline and narcissistic), social avoidance (schizoid), and disruptive behavior (antisocial) differ from DTD in the presentation of alterations in attention, consciousness and cognition. The strongest empirical relationship between childhood interpersonal trauma and personality disorders in adulthood has been found with borderline and paranoid personality disorders (Golier et al., 2003). Paranoid personality disorder does not address affect or behavioral dysregulation except as secondary to paranoid beliefs, and does not address negative self-perceptions. Borderline personality disorder does not present with problems with affect awareness, labelling, or dissociation (except indirectly in the form of transient dissociative states), avolition, or disorganized forms of interaction with primary caregivers (except indirectly secondary to abandonment fears and alternate idealization and devaluation). DTD may be found to be a precursor to these or other adult personality disorders if formalized as a childhood diagnosis.
Golier, J. A., Yehuda, R., Bierer, L. M., Mitropoulou, V., New, A. S., Schmeidler, J., Silverman, J. M., et al. (2003). The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. The American Journal of Psychiatry, 160(11), 2018–2024.

A valuable discussion of the issues surrounding diagnostic practice, which discusses an alternative to the DSM and ICD is provided by Robert Gordon, developer of the Psychodynamic Diagnostic Manual [LINK] (Powerpoint presentation). For information on the Psychodiagnostic Manual [LINK]

Alternative approaches to traditinoal diagnostic systems also exist within other theoretical models of disorder, often couched in terms involving presumed core underlying processess. One such system, arising from Acceptance and Commitment Therapy, is based on the ACT model of underlying processes the Hexaflex Diagnostic [LINK] (pdf file), first spoken about by Kelly Wilson (see section towards the end of the pdf for relevant worksheets).

With specific reference to the nature of "Complex Posttraumatic Stress Disorder" (Complex PTSD) Weiss has addressed this issue in his editorial to the issue in which a recent review by Resick in the Journal of Traumatic Stress (Volume (25(3)) [LINK], the relevant sections of which can be summarised as:

One core issue in the debate about PTSD is its symptomatic presentation, linked questions about its structure, and the special characteristics of exposure to traumatic stressors. The discussion about CPTSD in Resick et al. (2012) suggests that the analysis of CPTSD as a candidate for inclusion in the DSM-5 (and by extension the ICD-11) is best examined using the notion of construct validity (Cronbach & Meehl, 1955). This is a debatable proposition because this implies that PTSD is a construct, like intelligence, not a diagnostic entity, disorder, or disease. Indeed, Meehl himself (Meehl, 1995) did not take the view that the classification problem was one of construct validity. Instead, Meehl advocated distinguishing between evidentiary and definitory criteria, and drew upon the examples of diseases in clinical medicine, where constructs are not a part of the discussion: “The...medical model does not identify disease taxa with the operationally defined syndrome; the syndrome is taken as evidentiary, not as definitory” (p. 267). A disease entity in medicine outside of psychiatry is a circumstance of pathology and etiology, and, as Meehl points out, is why one can be asymptomatic, but still have a disease — Magic Johnson and AIDS being one well-known example.

Meehl’s conceptualization led to the development of taxometrics (Waller & Meehl, 1998), one of several approaches (Meehl, 2004) aimed at determining whether category or dimension fits the pathological phenomenon. Hyman’s worry about reification of diagnoses is just an example of the tendency to introduce simplicity or shorthand labels (e.g., hypertension) even where everyone knows there is no category. It is more pernicious, however, in thinking about psychiatric or mental disorders and is the same cognitive habit of using cutpoints to analyze dimensional data.

The literature in PTSD about the phenomenology has, in my view, suffered greatly by the popularity of latent models and easily available software to conduct confirmatory factor analyses and the concomitant confining exploration of the co-variance structure of symptoms to measures that contain only the DSM-IV symptoms themselves, such as the versions of the PCL (Weathers, Litz, Herman, Huska, & Keene, 1993). Any serious attempt to look for subtypes of PTSD, or to understand the full spectrum of symptoms triggered by exposure to a traumatic stressor requires casting a much larger net than the 17 symptoms. Such studies do not look at the structure of PTSD, they look at the structure of the measures of the codified diagnostic criteria. Indeed, I would argue that the idea that there is a structure to PTSD misunderstands that manifest symptoms are probabilistic and a rare symptom not measured redundantly will not survive such analyses, but can nonetheless be among the most pathognomic indicators. Discussions of the criteria for most other disorders in the DSM-5 do not focus on the results of confirmatory factor analyses. Rare, but important symptoms cannot survive such analyses; nevertheless, they may be fully evidentiary in Meehl’s sense. Hopefully, committee deliberations will recognize that the essential core of a disorder or disease must allow not only for atypical manifestations and rare symptoms, but also will recognize that when a non-rare manifestation appears to accompany a limited set of exposures, there may indeed be a difference in kind.

Cronbach, L. J., & Meehl, P. E. (1955). Construct validity in psychological tests. Psychological bulletin, 52(4), 281–302.
Meehl, P. E. (1995). Bootstraps taxometrics: Solving the classification problem in psychopathology. American Psychologist, 50(4), 266–275. doi:10.1037/0003-066X.50.4.266
Meehl, P. E. (2004). What’s in a Taxon? Journal of Abnormal Psychology, 113(1), 39–43. doi:10.1037/0021-843X.113.1.39
Waller, N. G., & Meehl, P. E. (1998). Multivariate Taxometric Procedures: Distinguishing Types From Continua. Thousand Oaks, CA: Sage.
Weathers, F. W., Litz, B., Herman, D., Huska, J., & Keene, T. M. (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX.

DISORDERS ARISING FROM TRAUMA -- A DIAGNOSTIC QUANDARY

The diagnosis of trauma disorders in those with histories of childhood abuse and neglect remains controversial and a subject of developing practice. A valuable discussion of some issues surrounding the diagnosis of complex trauma in adults was contained in the submission written by the National Child Traumatic Stress Network, of which Bessel van der Kolk is a prominent spokesperson, which is available here

More recently, in July this year, I privately emailed Wendy D'Andrea in response to her article Understanding Interpersonal Trauma in Children: Why We Need a Developmentally Appropriate Trauma Diagnosis [LINK].

Well, I got the following email from Regina  Musicaro, Clinical Research Coordinator, at The Trauma Center, Justice Resource Institute, Brookline, MA, USA:

"The field trial is still in progress and data collection will not likely end until late fall.  Then we have to analyze data across all seven sites nation-wide.  In my experience, projects of this caliber take very long to complete (much longer than we want!) and my guess is that the full results will be out in a year.  This is just a guess, of course, and the goal is to be ready much sooner.  Thank you for your interest in the field trial and I hope to get better answers ASAP."

This means, unfortunately, that the diagnosis probably will not, yet, be appearing in the new edition of the Diagnostic and Statistical Manual, Version, of the American Psychiatric Association.  Sadly, this might also mean that doctors will be reluctant to use the diagnosis when the field trial results are in, regardless of what the results are, with negative implications for chances of reducing the inappropriate and inadequate treatment children currently receive due to not having a "recognised" disorder, as discussed in the original submission (see above link).

The nature of "Complex PTSD" and its possible inclusion in the DSM 5 has been discussed by several articles in the Journal of Traumatic Stress -- see here   [LINK]