Developmental trauma disorder in adults
Adult victims who were subjected to years of abuse and betrayal as children, and who believed important caretakers could not be trusted, often remain guarded as adults. Some of the most significant consequences of DTD in adults are inner conflict regarding emotional self-regulation and an inability to develop and maintain healthy interpersonal relationships.9 The aftereffects of childhood maltreatment are thought to be the result of an unconscious compulsion to preserve or resolve past trauma.6,9,13 The 4-F survival skills are expressed inappropriately as a consequence of imprinted trauma experiences and habitual reactions within the brain, or from vague or repressed memories of trauma.1,6,13 A psychologically ingrained cycle of abuse continues long after a victim is free from his or her original abuser(s). According to van der Kolk, “In behavioral re-enactment of the trauma, the self may play the role of either victim or victimizer.”13
Examples of trauma re-enactment include enduring domestic violence or dysfunctional relationships, consistent feelings of helplessness or possessing a dependent personality, drug or alcohol addiction, suicide, chronic pain and fatigue, depression, anxiety, and panic or phobic disorders.1,7,9,13 Among sex offenders, 75% report a history of childhood incest or sexual assault.1 This particular type of trauma is a major reason why victims engage in prostitution or pornography, both of which serve to perpetuate past abuse.12 Unfortunately, many mimic the offender’s destructive conduct, engaging in illegal activity or violent behavior and crimes, encompassing the majority of inmates residing in our prison and juvenile detention systems today.1,7,10,13 In addition to victims reenacting their abuse, they have an urgent need to avoid it; this coupled with their societal mistrust, causes the emotional and physical isolation that many DTD victims endure.1
One of the largest research analyses regarding the frequency of childhood trauma and its effects in adults is the Adverse Childhood Experiences (ACE).14 The ACE study was led by Kaiser Permanente (KP) and the Centers for Disease Control and Prevention (CDC) and included 17,337 KP members aged older than 50 years. A questionnaire regarding childhood neglect and abuse and other family dysfunction was offered to each participant. Omitting a third of the subjects who denied a history of childhood maltreatment, survey respondents reported physical abuse (26%), sexual abuse (21%), emotional and physical neglect (20%), and emotional abuse (10%).14 In addition, 28% were subjected to a caretaker who abused a substance, 20% were exposed to a caregiver with mental illness, and 13% witnessed violence against a maternal figure.13 It was also discovered common for more than one of these types of maltreatment to co-exist in the same person.14
In summary, ACE researchers concluded that a history of childhood neglect and abuse is often under-recognized in adult victims, and the consequences are substantial.1 Many of the subjects reported depression, suicide attempts, drug use, alcoholism, sexual promiscuity, domestic violence, cigarette smoking, obesity, and sexually transmitted diseases.13 Furthermore, a history of childhood trauma carries a 10% to 15% increased risk for developing heart and lung disease, cancer, and diabetes.10,14 It is also linked to liver disorders, stroke, and bone fractures.1 Victims’ frequent use of medical and psychological services are typical.9 Also noted, because of societal taboos regarding the topic of child maltreatment, healthcare providers are often reluctant to discuss histories or issues of neglect and abuse with patients or their families.1,14 In essence, this averseness only serves to exacerbate a victim’s solitude and self-justify his or her mistrust of others.
Unfortunately, DTD is a permanent condition, and without treatment, adult victims exhibit a multitude of emotional, social, and health-related complications, and are highly prone to replicating generations of traumatized families.
Developmental trauma disorder and the Diagnostic and Statistical Manual
Van der Kolk and colleagues submitted an in-depth proposal to the board of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) advocating for the inclusion of DTD as a diagnosis, specifying the following in their statement of purpose:7
“The goal of introducing the diagnosis of Developmental Trauma Disorder is to capture the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma and thereby guide clinicians to develop and utilize effective interventions and for researchers to study the neurobiology and transmission of chronic interpersonal violence. Whether or not they exhibit symptoms of PTSD, children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems are ill-served by the current diagnostic system, as it frequently leads to no diagnosis, multiple unrelated diagnoses, an emphasis on behavioral control without recognition of interpersonal trauma and lack of safety in the etiology of symptoms, and a lack of attention to ameliorating the developmental disruptions that underlie the symptoms.”
In May 2013, despite vast support from experts in the psychiatric community for the recognition of DTD as a diagnosis and more than 20 years of relevant clinical research and practice indications, the DSM-V committee elected not to include DTD as a formal diagnosis. Consequently, there is no current diagnostic criteria that entirely describe the unique effects of chronic maltreatment occurring in children and adolescents and in whom other numerous primary disorders are often misdiagnosed.1,7,9
Examples of such disorders include depression, BPD, ADD, attention-deficit/hyperactivity disorder (ADHD), bipolar and attachment disorders, separation anxiety disorder (SAD), and oppositional defiant disorder (ODD).7,9,15 Symptoms of these conditions often reflect the dysfunctional coping skills of DTD victims, such as hyperactivity and poor attention span in ADHD and self-mutilation in BPD.1,7 For instance, patients in whom BPD is diagnosed have mainly a history of childhood trauma, especially sexual and/or physical abuse.1,5,7,15 It is believed that chronic child maltreatment causes a risk for most of the personality disorders listed in the DSM, including psychosis, BPD, ADD, ADHD, depression, and addictive personality.1,6,9,11 An unclear or inadequate analysis may lead to treatment that is insufficient or unnecessary, such as psychotropic drugs, because treatment is often focused on a patient’s symptoms or behavior rather than a patient’s trauma experiences.1,7,9
In contrast, among various possible reasons why DTD was not accepted as a diagnosis in the DSM-V is that clinicians may focus too much on trauma history causing a misdiagnosis, particularly in patients without a history of child maltreatment or in those who possess a biologic or congenital basis for mental illness.15 In addition, opposing views speculate that DTD comprises an array of symptoms related to other DSM-specified disorders, such as BPD, attachment disorder, and ODD.14 However, as mentioned, many patients diagnosed with these, and other psychological disorders, often have histories of child maltreatment.1,6-7,9,15
Deliberated further, DTD develops during specific phases in a child’s life, but the diagnosis fails to address distinct symptoms for each stage.14 However, a precise list of signs may lack in other disorders, due to limited capacity for subjective reporting and the capacity of self-analysis in children.7,15 Regardless of a professional vindication for DTD as a sole diagnosis, at the present time, debate and resolution for DSM acknowledgment continues.