Whatever happened to DESNOS?

DESNOSDESNOS stands for Disorders of Extreme Stress Not Otherwise Specified, about as clumsy a diagnosis as one could imagine, and an only slightly better acronym. It owes its existence to the persistence of Judith Herman, who in her classic Trauma and Recovery, argued for a special category of trauma she called complex PTSD (C-PTSD). C-PTSD = DESNOS for all practical purposes.

It has long been recognized that there are different types of trauma, but no one has figured out what to do about it as far as PTSD is concerned. Rape, a serious car accident, most wartime trauma takes place during a specified period of time, and often results in the familiar symptoms of PTSD, such as flashbacks, nightmares, sleeplessness, hypervigilance, and a gradual retreat into a smaller world in which the victim is less likely to encounter situations reminding him or her of the original trauma.

But, some trauma doesn’t fit this pattern, generally because it is prolonged, frequently happens at an early age, and often involves people with whom the victim has an intimate relationship. Child abuse is exemplary, but prolonged captivity and confinement of any type also fits the pattern. This includes emotional and physical abuse in marriage or other relationships.

The about to be released International Classification of Diseases, ICD-11, which serves as the DSM for the rest of the world, includes C-PTSD, but only if the victim first fulfills all the requirements of a diagnosis for PTSD. DSM-5 includes most of the symptoms of C-PTSD, achieved in part by enlarging the number of symptoms to twenty. In addition, it includes a dissociative subtype and a pre-school subtype. As with the ICD-11, the basic requirements of PTSD must first be met. DSM-5 does not officially recognize C-PTSD, but one professional’s comment on PTSD in DSM-5 gets it right, remarking that it has become more “DESNOS-ish.”

Here’s the problem

An article by the Working Group on the Classification of Stress Related Disorders for the World Health Organization (the authors and publishers of ICD), states in its research summary justifying the new definition of PTSD that  people who were directly exposed to the events of 9/11 experienced no more PTSD than those who were not. The same can be said for those who experienced childhood abuse in the decades prior to 9/11. Those who reported abuse were no more likely to suffer from PTSD after direct exposure to the events of 9/11 than those who did not report abuse (Cloitre et al., pp. 7-8).

The authors use this study as justification for the ICD-11 decision to rely completely on self-reported symptoms of PTSD for the diagnosis, rather than upon the existence of an objectively stressful event.

While I think this is overall a wise decision, one can see why the editors of DSM-5 continue to link PTSD to objectively discernible traumatic events, even if the number and type make little sense. For example, it is considered sufficiently traumatic if you learn that a close friend was almost involved in a serious car accident (but wasn’t), but not if a close relative suddenly dies of natural causes (see my January 20 post on DSM-5, as well as stressor criterion A1, PTSD, DSM-5).

But if the DSM-5 demand for an “objective” traumatic event no longer makes much sense, the trauma study that backs up the new ICD-11 category of PTSD shows the risk of not requiring an “objective” stressor. The risk is that trauma is more about the vulnerability of the victim than the event.

Not only that, but once one allows C-PTSD into the mix, the symptoms begin to sound more and more like borderline personality disorder, characterized by insecure attachment and emotional dysregulation, two key symptoms of C-PTSD in ICD-11. In other words, C-PTSD has little to do with trauma as it is normally understood, and more to do with the subtle but severe traumas of childhood that lead to borderline personality disorder, such as lack of parental attunement, what D. W. Winnicott called being dropped by the mind of the mother.

Subtle but severe traumas are real, and trauma theory should take them into account. Possibly they should be given the status of PTSD, if only for honorific reasons: PTSD is the diagnosis du jour, the one that seems to get the most attention and respect. But let us not fool ourselves. We are no longer talking about trauma as it is ordinarily understood, but the subtle and terribly destructive traumas of childhood, the traumas of intrusion coupled with inattention and emotional abandonment.

What we should not do is what Judith Herman did in arguing for the diagnosis of C-PTSD (Herman is both the hero and the villain of this story): argue that most C-PTSD is being misdiagnosed as borderline personality disorder and associated dissociative disorders. She makes this argument on the basis of the claim that

The data on this point are beyond contention, 50-60 percent of psychiatric inpatients, and 40-60 percent of outpatients report childhood histories of physical or sexual abuse or both. (p. 122)

It sometimes seems as if Herman is still fighting Freud, who in a famous change of mind decided that the women in Vienna who told him about being sexually abused as children were making it up. There just couldn’t be that much child abuse going on among the bourgeoisie. If there were, said Freud, then even his own father would be culpable (Masson, quoting Freud’s letter to Fleiss, p. 264).

Conclusion

There are lots of ways to be severely traumatized. There is no need to lump them all together under the category of PTSD. Trauma is a useful lens by which to see the violence that the world inflicts upon us. Children are especially vulnerable. But it makes more sense to say that there are many traumas, rather than developing a new category of trauma, C-PTSD, only to link it back to PTSD, either by originating event, in the case of DSM-5, or by requiring that victims of C-PTSD first display all the symptoms of PTSD, as ICD-11 does.

What happened to DESNOS? It has been absorbed into the latest versions of the leading diagnostic manuals of the day, almost but not quite without remainder. In so doing DESNOS has lost any chance of leading us to a more subtle understanding of trauma. But perhaps that is not the most important thing. If DESNOS leads people to take some of the more subtle expressions of trauma more seriously, then that will be a good thing. Just remember that this is a political rather than “scientific” achievement.

References

Marylène Cloitre, Donn Garvert, Chris Brewin, Richard Bryant, and Andreas Maercker, “Evidence for proposed ICD-11 PTSD and Complex PTSD: A Latent Profile Analysis.” European Journal of Psychotraumatology, 2013, 4, pp. 1-12. [available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3656217/]

Judith Herman, Trauma and Recovery. New York: Basic Books, 1997.

Jeffrey Masson, editor. The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887-1904. Cambridge, MA: Harvard University Press, 1985.

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Comments (2)

  1. MS

    > The risk is that trauma is more about the vulnerability of the victim than the event.

    Yes, that’s my understanding as a professional. It is not the event, but the state a person’s nervous system is in at the time of an event and the resources/coping strategies they have available that determines if it gets stored as trauma or as a painful memory.

    • Yes, MS, trauma is the interaction of person and event. However, I’m convinced that some events are traumatic for almost everyone. How long the trauma lasts seems to be related to the ability to grieve. Organizations often stand in the way of grieving too Fred

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