The relationship between trauma and mental health has been evidently existent throughout time. The addition of Post-Traumatic Stress Disorder to the DSM served as an important milestone in cementing these observations. However, over the years, it has been explored that the dimensions of trauma are vast as well as deep, with a blanket effect over different areas of life. In the field of psychopathology, attempts to form specific diagnoses, foster clarity and prevent major overlapping, are ongoing.
One such attempt to classify a type of trauma was made by Bessel Van Der Kolk in 2005, where he introduced the term ‘Developmental Trauma’. He proposed a diagnostic classification called the Developmental Trauma Disorder which captures the multiple or ongoing exposure to interpersonal violence and disruptions in protective caregiving within a framework of developmental change and disrupted attachment (van der Kolk et. al. 2009). These were also supported by biological and neurological research (Denton et. al. 2016).
In his algorithm, he proposed the following criteria for DTD (including 3 symptom clusters);
- Symptoms of Emotional and Physiological Dysregulation/Dissociation
- Problems with Conduct and Attention Regulation
- Difficulties with Self-Esteem Regulation and Managing Social Connections
These clusters consist of symptoms including impaired normative developmental tendencies with respect to regulation of arousal, sustained attention, labelling of emotions, coping with stress, and their sense of identity in personal relationships. Dissociation, Somatization, Body Perception and Executive functioning may be compromised, along with a high risk of self-injury.
This diagnostic criteria was formally outlined with symptoms, duration, age etc. and submitted for inclusion in the DSM. However, it is still finding its way into documented manuals like the DSM and ICD.
Why do we need a Developmental Trauma Disorder (DTD) diagnosis?
As much as we are progressing towards this movement to eradicate labels, the necessity of an appropriate diagnosis cannot be undermined. In his book, ‘The Body Keeps Score’, Dr. van der Kolk explains how developmental trauma presents with a complex web of symptoms which usually leads to a string of diagnoses including ADD, ODD, Bipolar Disorder, BPD, Depression, Anxiety etc. being ascribed to the patient. These multiple diagnoses end up not supporting the patient enough and leave more scope for a tailored intervention. Interventions must begin with accurate identification of the issue, for which a formal diagnosis is necessary. Moreover, having a diagnostic criteria will also warrant extensive research and investigation into this complex disorder, which Dr van der Kolk calls the Hidden Epidemic. Yet again, absence of a formal criteria results in absence of statistical evidence which is why this epidemic is being called hidden.
Approaches for Treatment
The current approach to treatment is symptom based where appropriate techniques for every symptom/cluster of symptoms are being employed and explored. There is an array of approaches being tested and in the way of development however the efforts are limited by the absence of a formal diagnosis. Nonetheless, below described are some approaches reviewed and currently in use for every domain:
- Trauma-Memory Processing which targets narrative restructuring, consolidation of memories and memory retrieval using techniques from cognitive therapy, narrative therapy and EMDR.
- Emotional Regulation is a therapeutic target which includes Distress tolerance, Self-soothing, emotional awareness, labelling and expression of emotions. Here, emotion focused therapy for trauma, mindfulness therapies, complex trauma & addiction therapies, as well as EMDR can be used.
- Interpersonal Regulation shall include social problem solving, interpersonal assertiveness, resolution of insecurity & distrust and, reestablishing self-worth. Skills training in affect and interpersonal regulation can be implemented along with using brief eclectic approaches.
- Upliftment of Self-Perception will include cognitive reappraisal and self-compassion which may be targeted using experiential therapies, mindfulness, complementary healing, and sensorimotor psychotherapy.
- Somatic Regulation is also a therapeutic target which includes arousal regulation, body awareness, adaptive movement and creative expression, for which experiential and sensorimotor psychotherapies are being used.
- Reduction of Dissociation includes therapeutic targets like attentional focusing, cognitive reappraisal and body awareness for which structural dissociation psychotherapy can be useful along with other complementary therapies.
The above mentioned therapy approaches are drawn from a systematic review of the approaches currently in use. However, psychotherapy models continue to be created, adapted, refined and disseminated while also creating a need for valid psychometric assessments as well. Currently, the Developmental Trauma Disorder Semi-Structured Interview (DTD-SI), developed by Ford, Spinazzola, van der Kolk & Chan (2018) is one of the measures being used for DTD.
The future holds scope for many more intense investigations, exploration of developmental trauma disorder and development of reliable, valid measures as well as interventions. Most of it shall begin with the first step of cementing a formal diagnosis, which may surface as and when deemed necessary and relevant.
Clinical and Research Intern, PsychLine.in.
Denton, R., Frogley, C., Jackson, S., John, M., & Querstret, D. (2016). The assessment of developmental trauma in children and adolescents: A systematic review. Clinical Child Psychology and Psychiatry, 22(2), 260–287. https://doi.org/10.1177/1359104516631607
Ford, J. D. (2021). Progress and limitations in the treatment of Complex PTSD and developmental trauma disorder. Current Treatment Options in Psychiatry, 8(1), 1–17. https://doi.org/10.1007/s40501-020-00236-6
Ford, J. D., Spinazzola, J., van der Kolk, B., & Chan, G. (2022). Toward an empirically based developmental trauma disorder diagnosis and semi‐structured interview for children: The DTD field trial replication. Acta Psychiatrica Scandinavica, 145(6), 628–639. https://doi.org/10.1111/acps.13424
Schmid, M., Petermann, F., & Fegert, J. M. (2013). Developmental trauma disorder: Pros and cons of including formal criteria in the Psychiatric Diagnostic Systems. BMC Psychiatry, 13(1). https://doi.org/10.1186/1471-244x-13-3
van der Kolk, B. (2015). The body keeps the score: Mind, brain and body in the transformation of trauma. Penguin Books.