dcyphr | Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma


Trauma manifests in many behavioral and psychological disturbances in children and adults alike. These manifestations, however, do not always allow for a diagnosis of PTSD by clinicians. Of particular interest are the problems that result from early traumatic experiences with relationships. Such experiences can lead to disturbances in how one interprets social information, defines oneself, emotions, and memory. They can also result in the manifestation of physical symptoms without traceable cause(s). This raises important considerations into the nature of diagnostic criteria for PTSD. 


PTSD as a diagnosable disorder (in the DSM-III) emerged out of Vietnam War Veterans’ struggles after the war, so its diagnostic criteria largely surrounded war-related trauma. The fact that most of the trauma experienced by women has to do with sexual and interpersonal trauma, most of which occurs during childhood, presented problems for PTSD diagnosis. Childhood trauma does not necessarily lead to PTSD. However, it can result in a myriad of other psychological and physical disorders and issues. Many of these issues resulting from interpersonal trauma have been viewed as being separate from PTSD, generating many problems with treatment, research, and conceptualizations of the disorder. 

The DSM-IV field trial for PTSD was employed to clarify whether these problems of childhood abuse were better accounted for by a diagnosis of PTSD or Disorders of Extreme Stress Not Otherwise Specified (DESNOS). 


A list of 27 symptoms of trauma that came up often, but were not captured by DSM-III criteria was categorized for DESNOS symptom criteria. Structured interviews including one that mirrored DSM-III criteria and the High Magnitude Stressor Events Structured Interview were used on participants. 


Only a very small sample of participants qualified as having DESNOS without PTSD, showing that it is rare for people showing symptoms of DESNOS to not suffer from PTSD. There is no statistically significant evidence that the age of onset for trauma (childhood or later in life) or the kind of trauma (i.e., sexual abuse vs. natural disaster) result in a pathology distinct from PTSD. Also, an earlier traumatic experience is tied to more symptoms (including a combination of DESNOS and PTSD symptoms) than a later traumatic experience. Similarly, the longer someone is exposed to trauma, the more likely they are to develop both PTSD and DESNOS. 


Interpersonal trauma that is prolonged during childhood will result in problematic symptoms that go beyond ‘just’ PTSD, which are captured under the DESNOS construct. This does not mean that these symptoms are separate from PTSD; instead, they add to it. The designation of DESNOS symptoms under PTSD, and not as a separate co-occurring condition, will allow clinicians to formulate more comprehensive treatments for patients. DESNOS as a construct functions to clarify the multifaceted and devastating nature of trauma. DESNOS is important for treating PTSD as it is a sign of a worse outcome for traumatized patients. Furthermore, patients showing DESNOS symptoms need particular attention to problems of dissociation (i.e., depersonalization) and emotional regulation as they result in more pressing problems of functioning in daily life. In short, attention should be directed to patients who have suffered from trauma that was interpersonal in nature (i.e., sexual abuse) and occurred during early childhood for a prolonged period of time.