Discussion Of Ptsd Diagnosis Discussion

[shimmerz]

none of that stuff that's pretty clearly "You could have been killed" stuff is a big deal.

I think for me that the 'you could have been killed' stuff, has already got a defined infantile type response burned into my nervous system. And at the time, I didn't really understand 'killed'. Which is why I think my cognition is off about what 'you could have been killed' means.

I think a big lot of a therapists job is to catch us up on what we are doing, as adults, to stop the disconnect and understand that 'killed' whether we allow others or ourselves to push us to that limit, is a thing that we no longer have to live with or accept.

I would find it difficult to articulate any standard type of criterion for this. It bleeds out in so many ways.....

 

[Chava]

One other thought (then I'm off to work..yay!): I still wonder if down the road it might end up making more sense to branch traumatic stress disorders into a broader category, like mood disorders, personality disorders, dissociative disorders, psychotic disorders, etc. These all have major categories. Trauma runs a wide spectrum too. Judith Herman proposed sort of replacing BPD with CPTSD. In some cases, that probably makes sense. But there are a whole lot of people with childhood trauma that exhibit different symptoms and would be better served by DTD. For example, Sebern Fisher noticed that the earliest abandonment and abuse lended itself to shutdown in several areas of the brain, especially frontal cortex, and traits that we might associate with adult anti-social personality. In the end that still might be the case for some individuals. But as kids, these little ones rack up laundry lists of diagnoses really just detailing their behavior problems (oppositional defiant disorder, ADHD, etc).

All traumatic stress ("traumatic" not just "stress") results in nervous system dyregulation, like the parts of the autonomic nervous system fail to balance themselves out properly. That's the common thread, and the piece the neuoropsychs are chipping away at. But to treat a four-year-old, who has problems with regulation in areas of behavior, emotions, and attention, as well as failure to connect socially, with PTSD does not quite make sense. If we even tried to fit this into the PTSD diagnostic criteria, it would become insane. But to not allow childhood trauma its own diagnosis fails to even recognize and treat it for what it is. So, in my imagination, in my imaginary world of redrawing the lines to fit this all in, Traumatic Stress Disorders (or whatever you'd call it) would be its own category, just like mood disorders and all the others. Within that: PTSD, CPTSD (adult), DTD (child or adult with those symptoms), and possibility of overlap or duel diagnosis. Maybe something else, but just breaking some of this up a bit for the differences between early shock trauma, and particularly chronic trauma within the home, and the trauma experienced in adulthood.

We know that early trauma more likely creates globalized symptoms (psychological, physiological, social, cognitive, etc) and ongoing dissociative symptoms, as well as more entrenched patterns and features of personality disorders (and not just BPD). Early trauma is also associated with symptoms of attachment disorders, which can impair functioning on various levels for life, depending on severity. With new proposals still happening, I imagine our further study of trauma eventually lending us a category for trauma disorders so we can have been diagnostic range, and yet more appropriate diagnoses, within that.

 

[shimmerz]

One other thought (then I'm off to work..yay!): I still wonder if down the road it might end up making more sense to branch traumatic stress disorders into a broader category, like mood disorders, personality disorders, dissociative disorders, psychotic disorders, etc.

Not to mention addictions, inability to perform properly at work (chronic unemployment), many learning disabilities as well as physical illnesses (how do we tie the physical component into the DSM?).

I think when much of this is looked at from a 'trauma-esq' point of view, those who care to look deeply enough will notice that the majority of mental and physical illnesses stem from early familial dysfunction.

 

[Chava]

I think for me that the 'you could have been killed' stuff, has already got a defined infantile type response burned into my nervous system. And at the time, I didn't really understand 'killed'. Which is why I think my cognition is off about what 'you could have been killed' means.

Cognition not at all necessary. It has nothing to do with emergency trauma responses, even in adults. Your amygdala was fully formed and fully understood life-death threat, which was real in your case.

I would find it difficult to articulate any standard type of criterion for this. It bleeds out in so many ways.....

I'm not even going to try. Van Der Kolk could do it. But also, Fisher and Heller, while they have not proposed official criteria, do list common symptoms that are seen across large studies of early trauma, primarily in their own direct work with clients. I really connect to what they have both written. Heller even noted that early trauma can show up as a feeling of being very threatened by feeling alive. That does not actually sound like a neat piece of criteria at all, not saying that, but I absolutely relate. If these kinds of developmental trauma experts could keep studying, compiling hundreds of profiles, they could get something together. It would not quite be like Herman's set of criteria, but similar in many ways. The over-arching issue is dysregulation, but probably with more pronounced issues of "self", derealization, etc. I'd love to see that come together. I've worked with kids who weren't adopted until they were nearly a year old, spent months hospitalized only to go home to an addict mother, etc. They have a shitload of diagnoses. None of them account for the very basic fact of traumatized, dysregulated nervous system which affects their behavior, attention, cognition, and social interaction (or lack of).

 

[Chava]

I think when much of this is looked at from a 'trauma-esq' point of view, those who care to look deeply enough will notice that the majority of mental and physical illnesses stem from early familial dysfunction.

I agree. But I'm not talking trauma-esque, but rather childhood criterion A trauma (shock trauma, near death, abuse, major neglect). Those features are very different than, say, adult depression that might stem from growing up in a semi-dysfunctional home. Childhood Trauma (capital T).

 

[shimmerz]

I'd be okay with thebidea that the surgeon treating me had never had one themself.

Agreed, but dealing with a brain tumor is mainly a technical endeavor. The components involved with psychological wounding are too complex for normal human theoretical intervention imho. It affects body and mind (at minimum) and soul.

But I'm not talking trauma-esque, but rather childhood criterion A trauma (shock trauma, near death, abuse, major neglect). Those features are very different than, say, adult depression

Yes, agreed. I am sorry, I thought that was a given in this conversation. Keeping in mind that many with Trauma issues cannot articulate (as Scout mentioned) that there were even problems in the home as they were either too young or it was seen by the client as 'normal' and no big deal. A good Trauma therapist can see what the client doesn't and a great Trauma therapist can ease us into seeing what the client doesn't and help us work through it. I expect that the criteria for PTSD as it stands can be used as a catch all for trauma-esq (yes, small t) behaviour and then, with a qualified big T therapist available, the deeper issues can be teased out. I don't believe most psychiatrists allow themselves to see the big T stuff. None that I went to did, anyway.

I'm not even going to try.

Right. So PTSD (a car accident) or a singular trauma which has been dealt to a person with no Trauma in their background is VERY different than a person with big T in their background.

A totally different set of criterion, some which may seem exaggerated given the 'single trauma' that they experienced. It isn't always about the immediate trauma. This is where the 'perception' thing comes up. If a car accident wasn't actually all that bad but a previously Traumatized person felt like their life was in danger because of it, it is possibly going to bring up all sorts of old Trauma behaviour that just won't seem to 'fit' the current event. Whereas the other person who was in the same accident may well breeze through it.

PTSD is not DTD nor is it CPTSD. It is an animal unto itself imho. It seems to me like many of us who have DTD, major neglect and abuse in our backgrounds are caught with the diagnosis of PTSD and then there is a hope and a prayer that we or someone else recognizes that the big T issues lurk and we are able to get help with those issues using another tier (T-docs).

Having said that, we could get help earlier, before our inevitable breakdown perhaps, (imho) if there was a set of criterion that could catch us earlier. Identify that we need help BEFORE the car crash.

Love Hellers work. I wish this was all taken much more seriously.

 

[Chava]

PTSD is not DTD nor is it CPTSD. It is an animal unto itself imho.

Yes, whatever we ultimately call or frame the distinctions as...the end goal is the treatment. A kid with a laundry list of behavioral and emotional problems typically ends up in special education. Sometimes they also get good services aimed directly at their regulation, with an empathetic understanding that they are actually traumatized, not bad kids. Just way dysregulated. And for childhood "T" trauma, the symptom set may look wide and like too much...but that doesn't mean its easier or more sensible to break into separate symptom-diagnoses. Actually, the nervous system dysregulation underlies all of it. So if there are the broad symptoms of this kind of dysregulation, and especially if known Trauma, then what you are really treating is the dysregulation of the the nervous system, as well as the ability to relearn safety within (therapeutic) relationship. Ability to gradually control behaviors, form friendships, learn...all of this would improve if it is a real case of childhood trauma. Treat the dysregulation (#1) and impaired social trust.

It's not a neatly laid out method, like CBT, but the experts working with childhood and developmental trauma all seem to agree on a blend of "bottom-up" (sensorimotor, somatic, body-oriented), and "top-down" approaches. Bottom up is more important as it deal directly with issues of dysregulation. CBT, for example, would make almost no sense in treating a 6-year-old who has just been removed from a violent home. Anyway, the criteria would be sort of global, but all connected to the criterion A trauma (which included chronic neglect, fear of starving, etc for a very young child) and to the dysregulated nervous system in response to the trauma(s) or even having a young brain develop into a traumatized brain.

Treatment is the end-game of all of this. And it's pretty simple (and yet...not) if we look at the science connecting all forms of "T" trauma: major disruption and dysregulation within the autonomic nervous system. For little ones, this also frequently involves the vagal shutdown which prohibits them from even being able to connect with others, have empathy, etc, if severely traumatized. If we could recognized this earlier, Van Der Kolk figured we'd save billions in mental health, hospitalizations, incarcerations. It requires defining the traumatic stress disorder from the childhood perspective and treating the damage to the nervous system, which affects all levels of functioning. Would there be some gray area still? Of course. And that, like you say, would be for skilled providers/therapists to sort out.

ETA: children really are resilient and their brains/nervous systems are more plastic than adults. So if trauma symptoms are recognized early (whether by parents, daycare, teachers, other family), and treated, there is a better outcome. Currently we have no way to frame it, though a lot of child psychs understand when they are working with trauma. But leave it untreated and you get entrenched patterns that become very difficult to change in adulthood...also the whole pattern of retraumatization, like I am embarrassed to say I have found myself trapped in many times.

 

[shimmerz]

So then the question I must put out there is this.....

Can Criterion A for PTSD as it stands now be massaged into helping those with DTD and CPTSD/neglect etc? Or is it just a fluke that, when triggered off, those with Trauma issues conform to the criterion? MyPTSD forum, I have noticed, have many users that have suffered complex Trauma issues, of unspeakable types of abuse. Many do NOT come here because they have had a singular trauma. although some do and then, with therapy, realize that their issues are much, much deeper than they originally thought.

Does the criterion for PTSD as it is written now and as Anthony is attempting to adjust, aid CPTSD/DTD types directly or indirectly? And is this thread issue (about being specific in our input), another indicator that those without DTD are simply not understanding that the experience of early childhood trauma affected people's symptoms (thus criterion) may well be completely different than the current PTSD criterion?

 

[shimmerz]

the end goal is the treatment.

And this is another question. Is the ultimate goal of the DSM for treatment? Another user asked this and I think it was a very valid question. Who is the DSM meant to actually serve? The patient? The doctor? The insurance companies?

CBT, for example, would make almost no sense in treating a 6-year-old who has just been removed from a violent home.

Nor does it for a domestic abuse adult survivor who suffers from DTD (I can attest to this). But it is the first line of action taken (or was) by my psychiatrist and made my symptoms SO much worse.

I believe if I had been given the proper diagnosis I would not have gotten as ill as I did. I am still recovering from past treatment that was forced upon me. Which of course was due to my diagnosis. Which was correct in some ways (I did have PTSD) but fell short in so many other ways (failing to identify early childhood trauma).

I spent years working with psychiatrists who floundered around with me. I spent 10 minutes in my T-docs office and he had me pegged. Because he was looking for 'other things'. He saw big T and DTD written all over me. Which we were/are missing in the DSM IV/V, which is why my psychiatrists missed it.

Which led to my homelessness, my losing my business, my being unable to cope..... which all costs society in the end.

 

[KwanYingirl]

I believe that the DSM-V has a subtype category for children aged 6 or less. I'm at work and can't search now, but I will. I think attachments and neuroplasisity play a huge role in the ultimate state of PTSD. Plenty of people have post traumatic stress but it doesn't result in the disorder classification. Trauma is the operative word. In studying Human Development, stresses are quantified due to severity of suffering. #1 is death of a child, followed by death of a spouse ( or SO), loss of health, joblessness and so on. The list is just a broad view and a lens through which stress is measured. Trauma takes it to another universe. People really do die from a broken heart. People with PTSD statistically live 10 years less than non-PTSD peers, with PTSD being the only variable.

The complex subtype is important from a treatment point of view. My therapists that I had before I found my current trauma specialist never put it all together. They never taught me that the body keeps the score or that mindfulness is a helpful coping style. They both wanted me to get into a DBT. Group and EMDR. I was not accepted by anybody because I was too dissociated, and tranced out most of the time. But I digress because treatment depends on diagnosis. Treatment is a dance. The architects of the revised DSM-V changed language to correct for gender bias and to use language that would make seeking help more palatable for veterans. It removed DID and made a separate category for that. It removed PTSD from an anxiety disorder and moved it to a new category-PTSD and other stress related disorders. In my mind, it may get victims into the helping arena sooner when more can be done to help her end up less impaired than someone like me, who was ignored my whole life.

 

[KwanYingirl]

http://www.ptsd.va.gov/index.asp
For childhood PTSD

 

[scout86]

I'm not sure why we'd need it. If people meet the criteria,

One of the things I'm kind of curious about is how accurate the criteria really is. The symptom part, I'm pretty comfortable with, but it's kind of a big, fluffy collection of things that seems flexible enough. It's the "What IS a trauma?" part that I wonder about. For a couple of reasons. My T has told me several times about an incident where 3 people in a vehicle hit an IED. One got killed, one ended up with a debilitating case of PTSD and one went back to the base, ate a good lunch and went on with life. Obviously not everyone's switch gets flipped by the same things. So I have no trouble accepting that being molested as a child can flip the switch. And yet, it often isn't violent. I remember "repulsive" among other things, but I don't remember any fear at all. COULD "bullying" be enough to flip the switch for some people? How do we know? People's individual personalities are so different. Their sensitivities, etc are so different, I wonder how accurate "criteria A" is. I'm not saying it's not. Not arguing any particular point at all, other than to say I wonder how accurate it really is and how do we know? Especially "how do we know?"

OK, what I did there was start a response and then realize there was stuff I hadn't seen yet..... (That happened a lot yesterday too.)

Even people who probably fall into your DTD category (me) can have different experiences of the Disorder. For example, I don't dissociate. I can get lost in a book, or lost in thought while driving, like anyone can. I NEVER dissociate the way most of you seem to. My T says he doesn't think I could dissociate if I wanted to. He says I'm too hypervigilant to dissociate. We've tried a few things that amount to teaching me to dissociate voluntarily. Can't do it. (yet) My symptoms, to the best of my knowledge, really DO fit those of PTSD, they are nowhere close to BPD. I'd read the suggestion to change the label for childhood trauma to BPD and I kind of wondered what they'd do with someone like me, in that case. (Fortunately, my T says he'll only be happy with the DSM when they break it down far enough that each individual gets their own label.)

And that last bit of his is something I agree with. I think this diagnosis business is only useful as a broad general guideline. It does mean there are clear lines between one "condition" and another.

.I have no idea why different people get different versions, even though the causes are similar. I think that's interesting and I really wonder what the reason is. Just like I wonder why one of those people who hit the IED got PTSD and the other just finished his sandwich and went on with life. There's a reason, we just seem to have no idea what it is, yet. I only have a couple people to make me wonder about this, and I have no idea if anyone has looked at it with larger number. I had a friend who was a Vietnam vet. Had PTSD, Killed himself. He also had a truly horrible childhood. I'd be quite surprised if he wasn't messed up long before he got sent to Nam. Another friend who got PTSD in Iraq. HE, by his own account, had a good childhood. I've met his folks. I believe him. But, near as I can tell, he struggled with some level of depression for at least a significant part of his adult life. Not to the extent that he wasn't functioning. In fact he was great a hiding it. So we never talked about it. But now, I can't help but wonder if somehow the things that caused the depression made him more susceptible to PTSD. There must be something that leads to some people getting it and others not. (And, I suppose that's "off topic". I'm hoping you all are ok with some "off topic" while we';re considering all this?)

Since we're dealing with a branch of the medical profession, I worry a little that they might take the DSM and use it as a one size fits all guide to treatment, like you would use a medical book to find out how to treat pneumonia. I don't think this is quite that kind of thing.