Bessel van der Kolk – Developmental Trauma Disorder: The Nexus of Attachment, Trauma and Brain

Prior to 1980, hundreds of thousands of veterans returned from Vietnam with symptoms that did not fit into an existing diagnosis. The introduction of the PTSD diagnosis in the DSM III made it possible for their condition to be recognized and treatments to be developed. Today we are in a similar situation. Every year, there are ten times as many children in the US reported to be victims of domestic violence, neglect and abuse than combat soldiers from Iraq and Afghanistan diagnosed with PTSD. However, these children live in a diagnostic void because the current DSM-IV conceptualization of PTSD does not reflect the symptoms experienced by the vast majority of these children. For when trauma occurs within the context of what is supposed to be a safe interpersonal attachment, the trauma picture takes on a profoundly different shape and has profound effects on brain development and the formation of the self. So, instead, abused and neglected children receive such widely disparate diagnoses as bipolar disorder, conduct disorder, ADHD, and other anxiety disorders. All of these diagnoses are etiologically unrelated to trauma and lead to pharmacological and behavioral control at the expense of dealing with the fear, shame, terror and rage that derive from real threats to these children’s survival. The lack of proper diagnosis also has profound implications on insurance reimbursement, treatment development and clinical research. Thus these children are condemned to receive treatments that are likely to be ineffective and therefore put them at risk to grow up to be unproductive, expensive, potentially dangerous, and long-suffering members of our society.

In response to this neglect of our nation’s greatest public health threat, the National Child Traumatic Stress Network’s DSM-V Task Force has proposed a new clinical syndrome, Developmental Trauma Disorder, based on a literature review of about 100,000 chronically traumatized children and direct systematic observations of 20,000 traumatized children. This diagnosis describes the five clusters of symptoms that characterize many children who have suffered repeated trauma in an interpersonal context: (1) affect and impulse dysregulation; (2) disturbances of attention, cognition, and consciousness; (3) distortions in self-perception and systems of meaning; (4) interpersonal difficulties; and (5) somatization and biological dysregulation.

This presentation will review the development of DTD as a diagnosis and give an overview of the field trial for DTD for eventual inclusion in the DSM-V.