Developmental trauma disorder versus posttraumatic stress disorder

Theories regarding human psychological trauma became increasingly recognized in the mid-1970s, due to emotionally distressed Vietnam veterans, and eventually led to the concept of PTSD.9 However, interpersonal childhood trauma did not become the focus of attention within the mental health community until the late 1980s or early 1990s.4,5 PTSD is defined as being caused by a single event or specific type of trauma, such as experiencing the effects from war or rape.16 However, DTD, also paralleled with complex PTSD (CPTSD),5-6,9 is caused by chronic and multifaceted traumatic events that occur during childhood that permanently influence a developing brain, affecting emotional and cognitive function and behavior. Traumatized children meet the DSM diagnostic criteria for many disorders, such as PTSD, but the various symptoms of DTD or CPTSD are not completely listed in the PTSD criteria and are often labeled as comorbidities.1,9,15 Common symptoms that distinguish PTSD and CPTSD are listed in Table 2.17

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Most recently, DSM modifications for PTSD included a subtype group for children aged younger than 6 years.18 Research has shown when diagnostic criteria that are sensitive to child developmental stages were used, together with an appropriate behavioral assessment, more children qualified for a diagnosis of the child PTSD subtype than any other PTSD groups.18 Child PTSD evaluation include a lack of verbal skills in reporting abuse and the manner in which trauma-related symptoms and memory are expressed.18 For example, decreased interest in routine activities and play or “restricted play” are considered, and severe temper tantrums are noted to represent increased arousal behavior.18 Other childhood signs of PTSD include “loss of interests, restricted range of affect, detachment from loved ones, and avoidance of thoughts or feelings related to the trauma.”18 These symptoms are tyical for children but are less distinct in adults with PTSD.18 

In short, victims of childhood trauma exhibit many symptoms of PTSD, including dissociation, guilt, and hopelessness, but the diagnostic criteria for PTSD does not accurately include all the important indicators of DTD.1,5,6

Support and treatment

In 2000, Congress developed the National Child Traumatic Stress Network (NCTSN) to offer education and resources to victims and families and to increase public and professional awareness regarding childhood trauma.19 In addition, NCTSN provides patient assessment tools for non-mental health professionals to help them identify specific types of trauma and initiate appropriate remedies. 

Treatment options for victims provide new and safe ways for them to experience the world and increase their self-awareness and self-esteem. Play or art therapy encourages young children to emote safely, while allowing victims to express trauma experience according to their language capacity and maturity level.1,10 Educating victims in alternative ways of relating to themselves and others, rather than inaptly engaging in the 4-F personalities, is crucial1,6,10 and helps to break destructive habits regarding personal and social interaction, restructure disorganized brain patterns, and offer a sense of self-empowerment.1,6 

Psychotherapy with a certified trauma specialist is essential for evaluating and grieving past damaging events. It is also beneficial for identifying self-defeating and trauma-related thoughts and behaviors, reducing dissociative tendencies, and improving the ability to manage emotions.1,5,6 Common psychotherapeutic methods include cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and eye movement desensitization and reprocessing (EMDR).4,18

In addition, medications may be used appropriately to regulate mood without causing further dissociation or dulling the emotions required for personal growth and recovery. Yoga can be included to enhance integration of the mind, body, and spirit, and to improve a patient’s overall affect.20 Meditation or mindfulness techniques are used to increase self-connection with feelings and sensory and physical sensations, improve ability to control emotions, and reduce anxiety and dissociative or reactive tendencies, thereby greatly improving self-management skills.6,9,21 

Most importantly, the human brain is remarkably resilient, particularly the minds of children; therefore, early detection of a trauma history and instituting suitable treatment plans can significantly help avoid or minimize the various emotional, social, and medical issues that victims encounter.

Conclusion

Undoubtedly, a tremendous health and safety crisis exists within the vast population of maltreated children, many of whom suffer as adults. Frequently, the aforementioned effects of DTD will prevail without proper aid and support. Establishing DTD as a distinct syndrome may prevent confusion with other psychiatric illnesses, offer more insightful solutions for victims, and create a compassionate consciousness among professionals and the public regarding the numerous problems childhood trauma produces. Furthermore, awareness of DTD may offer healthcare providers trauma-focused consideration that may enhance treatment or referral options and improve the prognosis of common ailments encountered in their practice. 

Although negative aspects regarding DTD have been considered, such as enmeshment of other DSM-defined disorders, there remains the dilemma of formulating an explicit condition for the enormous population of abused and neglected children—many of whom tragically lost their lives due to caretakers who were trauma victims themselves. According to Bremness,22 there is an urgent requirement for a more flexible diagnostic system regarding environmental influences and for DTD philosophy, including serious recognition from the DSM officials. Often, the only voice trauma victims possess is an empathetic and astute professional, and it is vital that appropriate action and interventions are implemented.

Maureen Kilrain, MS, PA-C, is a practicing physician assistant in the Cleveland, Ohio, area.

References

  1. Van der Kolk BA. Developmental trauma disorder. Psychiatric Ann. 2005;35:401-408. http://www.traumacenter.org/products/Developmental_Trauma_Disorder.pdf. Accessed April 10, 2017.
  2. Child maltreatment 2014. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families Children’s Bureau website. https://www.acf.hhs.gov/sites/default/files/cb/cm2014.pdf#page=31. Accessed April 10, 2017.
  3. Child abuse and neglect fatalities 2015: Statistics and interventions. Children’s Bureau Child Welfare website. Accessed April 10, 2017.
  4. Spermon D, Darlington Y, Gibney P. Psychodynamic psychotherapy for complex trauma: Targets, focus, applications, and outcomes. Psychol Res Behav Manag. 2010;3:119-127. http://dx.doi.org/10.2147/PRBM.S10215. Accessed April 10, 2017.
  5. Herman JL. Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. J Trauma Stress. 1992;5:377-391. http://66.199.228.237/boundary/Childhood_trauma_and_PTSD/complex_PTSD.pdf. Accessed April 10, 2017.
  6. Walker P. Complex PTSD: From Surviving to Thriving: A Guide and Map for Recovering From Childhood Trauma. 1st ed. Lafayette, CA: Azure Coyote; 2013.
  7. Van der Kolk BA, Pynoos RS. Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. http://www.traumacenter.org/announcements/DTD_papers_Oct_09.pdf. Published February 1, 2009. Accessed April 10, 2017.
  8. Gabowitz D, Zucker M, Cook A. Neuropsychological assessment in clinical evaluation of children and adolescents with complex trauma. J Child Adolesc Trauma. 2008;1:163-178. http://dx.doi.org/10.1080/19361520802003822. Accessed April 10, 2017.
  9. Van der Kolk BA. The assessment and treatment of complex PTSD. In: Yehuda R, ed. Traumatic Stress. Washington, DC: American Psychiatric Press; 2001;1-29. http://www.traumacenter.org/products/pdf_files/complex_ptsd.pdf. Accessed April 10, 2017.
  10. Van der Kolk BA. The neurobiology of childhood trauma and abuse. Child Adolesc Psychiatr Clin N Am. 2003;12:293-317. http://bit.ly/2pe998H. Accessed April 10, 2017.
  11. Perry BD. Child maltreatment: A neurodevelopmental perspective on the role of trauma and neglect in psychopathology. In: Beauchaine T, Hinshaw SP, eds. Child and Adolescent Psychopathology. Hoboken, NJ: John Wiley & Sons; 2008:93-129. https://childtrauma.org/wp-content/uploads/2014/01/Perry_Psychopathology_Chapter_08.pdf. Accessed April 10, 2017.
  12. The science of early childhood development (InBrief). Harvard University Center on the Developing Child website. http://developingchild.harvard.edu/resources/inbrief-science-of-ecd. Accessed April 10, 2017.
  13. Van der Kolk B. The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatr Clin North Am. 1989;12:389-411. http://www.traumacenter.org/products/pdf_files/Compulsion_to_Repeat.pdf. Accessed April 10, 2017.
  14. Anda RF, Felitti VJ. Adverse childhood experiences study. Ace Reporter. 2003;1:1-4. http://thecrimereport.s3.amazonaws.com/2/94/9/3076/acestudy.pdf. Accessed April 10, 2017.
  15. Schmid M, Petermann F, Fegert JM. Developmental trauma disorder: Pros and cons of including formal criteria in the psychiatric diagnostic systems. BMC Psychiatry. 2013;13:3. http://dx.doi.org/10.1186/1471-244X-13-3. Accessed April 10, 2017.
  16. American Psychiatric Association. What is posttraumatic stress disorder? In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Publishing; 2013. https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd. Accessed April 10, 2017.
  17. Scheg KE. Complex posttraumatic stress disorder and emotional regulation. Core Transformation Counseling website. http://www.coretransformationcounseling.com/Complex_PTSD.html. Published 2016. Accessed April 10, 2017.
  18. Scheeringa M. PTSD for children 6 years and younger. PTSD: National Center for PTSD. U.S. Department of Veterans Affairs website. http://www.ptsd.va.gov/professional/PTSD-overview/ptsd_children_6_and_younger.asp. Accessed April 10, 2017.
  19. Assessment of complex trauma. The National Child Traumatic Stress Network. http://www.nctsn.org/trauma-types/complex-trauma/assessment. Accessed April 10, 2017.
  20. Emerson D, Sharma R, Chaudhry S, Turner J. Trauma-sensitive yoga: Principles, practice, and research. Int J Yoga Ther. 2009;19:123-128. http://www.traumacenter.org/products/pdf_files/IJYT_article_2009.pdf. Accessed April 10, 2017.
  21. Davis M, Hayes J. What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy. 2011;48:198-208. http://www.traumacenter.org/products/pdf_files/Benefits_of_Mindfulness.pdf. Accessed April 10, 2017.
  22. Bremness A. Commentary: Developmental trauma disorder: a missed opportunity in DSM V. J Can Acad Child Adolesc Psychiatry. 2014;23:142-145. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032083. Accessed April 10, 2017.

From the May 01, 2017 Issue of Clinical Advisor