The diagnosis of ‘PTSD’ has significant shortcomings, especially with regards to the diagnosis of children. The main shortcoming of simple PTSD as outlined by psychologist Judith Herman is the fact that it is formulated primarily on the occurrence of a single, circumscribed traumatic event: namely rape, disaster, and combat. However, survivors of chronic trauma — which, unfortunately, encompasses a massive quantity of children all over the world — often manifest symptoms in different ways, including drastic changes in personality.
The Complex PTSD put forth by Herman includes a range of diagnostic tools not present in the PTSD outlined in the DSM. These include but are not limited to: recognition of chronicity of trauma and the effects it has, changes in personality, various unhealthy coping mechanisms due to self-blame and hatred (including self-hypnosis, denial, numbing, and dissociation), unreasonably positive and powerful personality attributions to the perpetrator of abuse, and an overall sense of complete despair and helplessness in life.
Taking this into account, it is clear that the addition of Complex PTSD and Developmental Trauma Disorder, to the DSM would result in a positive impact on survivors of trauma. As is, the diagnostic tools are simply too narrow, which means that many people do not receive the treatment they need. To demonstrate why this is so harmful, I will outline what many survivors of chronic, especially childhood, trauma deal with and how that affects their daily lives.
Herman continually used a fitting analogy throughout her writings: abused children are like prisoners at home, subject to unthinkable acts of malevolence while also almost always being unable to do anything to better their predicament. This puts them in a unique situation of absolute hopelessness, for the very people the child looks to for guidance, support, and growth are the people also responsible for the child’s fear and anguish. It is in the child’s nature to love his or her parents, even though the parents may do terrible things. It is easy to see why this puts the child in a pitiable situation; they either must recognize the brutality of the person or people tasked with caring for them, or they must conclude that their parents are not so bad, and in fact, they themselves are ultimately to blame for their own misery.
Many children end up choosing the latter, for the former results in too hopeless a worldview. Predictably, then, the children end up harboring exceedingly negative views of themselves, believing themselves to be vile people deserving of abuse and maltreatment. This heartbreaking view of themselves persists even to adulthood, when they already have the rational faculties to realize that their abuse was not their fault; this is a clear manifestation of the personality changes Herman refers to.
This negative self-cognition is responsible or partially responsible for the expression of a range of other harmful symptoms, including dysphoria and self-mutilation. Furthermore, childhood abuse has been categorically shown to correlate strongly to further victimization in adulthood. This makes sense, as when a child is abused, it becomes the baseline of his or her existence; at a time when they learn about the world, the child learns that abuse is a fact of their particular life, and will naturally come to expect it in the future.
It has also been shown that survivors of childhood trauma have disproportionately high rates of being diagnosed with borderline personality disorder, somatization, and multiple personality disorder. Strikingly, Herman notes that 81% of those diagnosed with borderline personality disorder suffered childhood trauma. To make matters worse, many of these diagnoses are questionable, in large part due to poor understanding of how survivors of chronic trauma express symptoms. In addition, these diagnoses arguably hurt patients in many cases, because they do not adequately recognize and respect the fact that trauma occurred in the first place. This is very harmful when one takes into account that recognition of trauma is absolutely crucial to the trauma recovery process.
Beyond these diagnoses, the list of sufferings for survivors of childhood trauma goes on. Herman states that some statistics suggest that a majority of patients seeking psychiatric treatment suffered childhood trauma, and they often report high rates of insomnia, suicidal ideations, anxiety, depression, and substance abuse. Every facet of life is haunted by the survivor’s adverse childhood experiences — clearly, this is a matter of utmost importance.
For this reason, I believe that the use of the overly-narrow diagnostic criteria of PTSD in the DSM is beyond irresponsible: it is outright harmful. Uncountable people are not receiving the treatment they need — how can they possibly receive the necessary treatment without first receiving an appropriate diagnosis? Simply put, all of the recent advancements in the understanding of trauma and childhood trauma point to the need for a new entry in the DSM.
Real lives are at stake; real people are suffering. Although nothing can be done to make amends for the many people that have been failed by misdiagnoses and the shortcomings of the DSM, the future is open: it is still possible to treat future survivors of trauma with the treatment they both need and deserve, and acknowledgement of their symptoms can, hopefully, result in swift intervention and preventing the abuse from occurring in the first place.