How the ICD-11 Provides a More Useful Clinical Conceptualization Regarding Complex PTSD
Despite pressure from many parts of the U.S. mental health community, the Complex PTSD diagnosis was not included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Rather, the PTSD diagnosis was expanded to include symptoms such as alterations in cognitions and mood, impulsive and self-destructive behaviors, reactivity, and feelings of detachment or estrangement from others. The rationale for the expanded PTSD criteria was that core PTSD symptoms could be sufficiently addressed with evidence-based approaches (CBT or EMDR), followed by additional treatment for any symptoms that persisted beyond that.
But does this way of conceptualizing the impact of layered traumas make clinical sense?
Consider earlier research by Julian Ford and colleagues with inpatient veterans suffering from PTSD. They recognized that veterans who had suffered earlier trauma prior to war trauma were not improving with traditional inpatient treatment methods due to affect dysregulation, impaired systems of meaning, stuck negative self-perceptions, unhealthy relationships with others, and somatic complaints. Ford and others proposed Disorders of Extreme Stress Not Otherwise Specified (DESNOS) as a new diagnosis for this constellation of symptoms and worked to have it included in the DSM-IV.
Consider also the work of Bessel van der Kolk, PhD. Van der Kolk and colleagues recognized that children with numerous experiences of maltreatment had symptoms that became roadblocks in therapy, because the developmental impact of trauma had left them with problems such as dysregulated affect, impaired trust, negative moods, impulsivity, and skewed perceptions. Van der Kolk and colleagues proposed Developmental Trauma Disorder as a diagnosis to highlight the developmental etiology of these symptoms. Logic tells us that the impact of trauma on childhood development is also at the root of the symptoms associated with DESNOS.
Neither DESNOS nor Developmental Trauma Disorder has been accepted into any version of the APA diagnostic manual, but the work of these researchers highlights what those of us working with trauma patients see every day. Treatment for adults and children with layers of trauma is confounded by underlying functional problems. It is not a matter of simply treating the trauma and then treating the additional symptoms. A complex diagnosis conceptualizes the associated symptoms as a natural result of layered experiences and as the cause of clients’ reduced capacity to utilize therapy. Without a complex PTSD diagnosis, it becomes all too easy to blame the adult or child client for resistant or difficult behaviors, and to inadequately address the roadblocks before and during trauma treatment.
The ICD-11 offers a choice between a PTSD diagnosis and a complex PTSD diagnosis. The complex PTSD diagnosis includes the core PTSD symptoms of intrusion, avoidance, and hypervigilance, plus the symptoms Ford and van der Kolk observed in adults and children with layered trauma. This framing assists clinicians in conceptualizing and treating clients effectively by highlighting their symptoms as an unavoidable consequence of layered experiences.
With appropriate case conceptualization and advanced strategies, EMDR therapy is a natural fit for treating complex clients. Within both the preparation and reprocessing phases, therapists can apply methods to improve clients’ ego strength and their capacity to manage affect, bolster therapeutic trust, and shore up their store of adaptive information. They can strengthen clients’ capacity and willingness to safely access and experience the affect and perceptions their nervous system has carried forward from the past, enabling effective EMDR reprocessing of their most difficult memories.
