Facts You need to know to protect Yourself

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Notes on Developmental Trauma Disorder (DTD)


My notes are based on extracts and summaries of longer articles by leading authorities including Dr. Bessel van der Kolk and Dr. Allan Schore UCLA Psychiatry Department and my own training with Pia Mellody and the team at “The Meadows” Wickenberg Arizona USA.

See reading references at the end of this page:


Definition: The concept of DTD is based on a wide array of research data that comprises tens of thousands of clients across multiple research studies. The name for this group of problems is still not standardised. Psychiatrists, psychotherapists and counsellors are still coming to terms with the profound realisation that continued or regular traumatic experiences during childhood produce a wide range of symptoms in adulthood that may appear to be separate and are often diagnosed as different disorders, but are in fact linked to the same common cause. Current terms being used include:


Developmental Trauma Disorder

Childhood Developmental Trauma.

Complex Childhood Trauma

Repeated Childhood Trauma

Early Relational Trauma


DTD results from growing up in an interpersonal context of ongoing danger, maltreatment, unpredictability, and/or neglect. Experiences that embed “hidden traumas” in the child include caregiver interactions that are neglectful, intrusive, unpredictable, threatening, aggressive, rejecting, or exploitive.

“These interactions convey that the world is a dangerous, unreliable, and/or indifferent place that offers little or no safety. Given the highly limited capacities of infants / young children to assess risk, this lack of physical and/or emotional safety quickly rises to the level of a subjective survival threat (annihilation anxiety) even though the objective nature of the event may not actually be at that level.

For this reason, such events do not warrant a diagnosis of PTSD because the events were not “imminently life threatening”, a criteria for PTSD. However, it is subjective perception, and not objective lethality, that determines trauma. Using PTSD criteria, the element of trauma gets missed, and the erroneous diagnostic process has begun”. (Bessel van der Kolk )


In non-psychological terms repeated childhood trauma:

1. Damages or destroys a number of skills needed to operate as a functional adult.

2. Blocks learning of essential life skills that would help the client “master” the kinds of everyday problems that life serves up to them.

3. Results in a wide range of behaviour that are the direct outcome of absent life skills.

4. May involve failure of different brain sectors or functions to develop fully.


Types of regular or repeated childhood trauma /abuse

Physical, Mental, Verbal, Emotional, Spiritual, Sexual, Violence, Shaming, Distorted Reality, Abandonment, Engulfment, Hidden secrets, Dishonesty from primary care givers, Excessive control or negativity by primary care givers.

Feelings connected with regular childhood trauma /abuse

Lonely, hurt, sad, angry, fear, shame, guilt, worthless, frustration, pain, betrayed, defeated, helpless, hopeless, lost, shut down, devastated, embarrassed, smothered, annoyed, enraged


Adult behaviour patterns resulting from regular childhood trauma /abuse

Hyper-arousal – either excessively busy, unable to relax, hyper-vigilant, excessive agitation or irritability, regular states of extreme rage and or aggression, but what we often see as well is

Hypo- arousal – in which a person disengages and dissociates under stress - “In this state the brain’s ‘red phone’ compelling the mind to take action, is dead.” (Dr. Allan Schore UCLA Psychiatry Department and Bessel van der Kolk)

Loss of the life skill called “mastery” “Mastery is most of all a physical experience,” writes Van der Kolk, “ the feeling of being in charge, calm, and able to engage in focused efforts to accomplish goals.

Clients who have been traumatized, experience the trauma-related hyperarousal and numbing on a deeply somatic level”.


Criteria for DTD:

Black and white thinking or flipping between two opposite positions. Either “I love my job or I hate my job” with nothing in between.

Repeated self defeating patterns of behaviour.

There are seven major diagnostic criteria for DTD.

Witnessing or experiencing multiple adverse interpersonal events involving primary caretaker(s) for at least one year during childhood.

Affective and physiological dysregulation.

Attentional and behavioural dysregulation.

Self and relational dysregulation.

Chronically altered perception and expectations.

At least two post-traumatic symptoms.


Functional impairment- at least two of the following areas: academic, family, peers, legal, health.

Developmental impacts of DTD: DTD can have wide ranging impacts on development, which if not addressed, can distort the developmental trajectory for the remainder of the individual’s life span.


Dissociation: In traumatized states, emotion, sensation, perception and thought are dissociated into separate fragments. This literally blocks understanding of what is happening which disturbs later memory processing. This sets the stage for learning to ignore the body and what is going on within it. DTD clients organize themselves around “not experiencing”. Because these experiences are simply “not present” a good deal of the time, clients with DTD do not reliably take in new information nor do they internalize information accurately across time. This clearly is highly relevant to learning from past experience, and to future planning skills. These impairments rob these clients of important tools everyone needs for self-regulation.


Fragmentation / disorganization: We know from object relations theory that whatever is communicated as being off limits to an infant’s caretaker is also off limits to the Self. Infants quickly pick up implicitly, what their caretakers do not want to see, will reject, are afraid of, will retaliate against These elements become “off limits” which lays the groundwork for fragmenting the child’s Self construct.


This fragmentation of the Self produces a pervasive state of internal disorganization that causes further fragmentation as time moves forward, and so the disorganization is both effect and then cause.

This internal disorganization impairs integrative processing such that the integration of sensory, cognitive, emotional, and behavioural experience into a congruent picture does not occur and so clients with DTD can appear very different across time and situations.

This, in turn causes significant confusion for the adults interacting with these clients on an ongoing basis. Given their confusion, the adults are prone to respond inconsistently to the client, thereby validating the client’s view of the world as unpredictable.

Now the original traumatic context is being replicated in the present in a dizzying escalating spiral that carries profound implications for attachment.


Fragmentation / emotional awareness: The fragmentation of the Self disconnects clients from their own feelings. Consequently, they may not know what they are feeling and may not even realize they are having an emotional experience. This will block developing emotional regulatory skills. Being internally disconnected will also prevent clients with DTD from knowing what other people feel, with devastating effects on attachment and empathy skills.


Internal Working Model: Clients with DTD assemble an IWM that portrays the world as inevitably bringing hurt and pain, and themselves as “terrible, horrible…” So they come to expect continuing traumatic experiences. Hence, their behaviour is aimed at maintaining some sense of safety by reducing external threat and blocking internal experience and fragmentation. Yet, action that originates from themselves they often see as “evil or bad”, thereby creating an exquisite dilemma. Unfortunately this is frequently not understood by the adult world, and this survival behaviour is given stigmatizing labels such as “oppositional” which reinforces the destructive view of the Self. This actually blocks emotional healing, as healing requires enormous safety to do the integrative work of connecting traumatic memories to other neural networks such that the traumatic material is ultimately integrated into the overall autobiographical narrative.

Somatic effects: Trauma can affect appetite, digestion, excretory functioning, sleep, the immune system, and temperature regulation. The bodily sense of being unsafe tends to be concentrated most powerfully in the upper chest.

Speech + language: Speech is impaired, and this blocks being able to talk about a traumatic state while in it. Because the language areas in the prefrontal cortex are not well connected to the amygdala, traumatic emotion can’t be effectively talked through. Language, as a whole, can’t accurately convey the client’s internal experiences. However, the presence of emotion cannot be disguised out of the voice, as emotion is neurologically transported by the vagus nerve which runs right through the larynx.

Sensory systems: DTD can impair processing in one or more sensory systems if those systems were involved in early traumatic interactions. This can look like sensory based learning disabilities, but it isn’t. This is because the sensory processing system is compromised by the presence of a traumatic emotional charge embedded within it, like so much static in a radio station signal, rather than the processing system itself being impaired. Attentional system: DTD also dysregulates the attentional system. This, of course, looks like AD/HD and gets overwhelmingly labelled and treated as such. Trauma takes executive functioning skills off-line as well. The experience of trauma tends to blunt innate curiosity and exploratory impulses.


Symptomatic presentation of DTD: Given its multiple developmental interferences, DTD manifests in a wide array of symptomatic presentations.

A partial list includes dissociation, rejection of help from others, intense levels of affect, oppositionalism, impulsivity, distrust, poor boundaries, nightmares, attentional problems, physical aggression, psychosomatic disturbances, medical illnesses, depression, self-hatred, and self-injurious behaviour.

Traumatic memory: Recent trauma is remembered as the discrete sensory components that were part of it. As such, they are embedded in the discrete sensory events without any processing of them compared with normal adult memory, where there is active transformation of sensory events into a sensible narrative. Since sequential thinking is not functioning, the memories can’t be chronologically ordered.


Guilt & shame: Trauma victims carry guilt and shame about what they did or didn’t do, in response to what was done to them at the time (trauma / shame interface). Trauma victims may hate the little child within them who complied, and did not fight the abuser. This lays the foundation for a shame-based identity which reinforces the impact of fragmentation/disorganization of the Self.


DTD vs. Post Traumatic Stress Disorder (PTSD): PTSD stems from discrete, traumatic incidents rather than an ongoing pattern of embedded trauma. It manifests as specific responses to stimuli that are reminders of the traumatic incidents in childhood. In the absence of traumatic triggers, PTSD symptoms may be minimal to wholly absent. PTSD lacks the pervasive developmental sequelae of DTD. Since PTSD can’t account for all the symptoms of DTD, other diagnoses are often added to PTSD to cover the additional symptoms. This produces fragmented diagnostic thinking and the partial diagnosis phenomenon. Once again, it’s the Blind Men and the Elephant story. The part is mistaken for the whole, leading to a lack of understanding about the whole (systemic dysregulation resulting from developmental trauma) and a partially effective, clinical response at best.


On the other hand, the “hidden traumas” of DTD do not meet the DSM-4 definition of a “traumatic event” as they are not imminently life threatening. Evidence based treatments for PTSD do not adequately address the pervasive developmental impairments and attachment difficulties that come with DTD.


References:

1. Cloitre M, Stolbach BC, Hemnan JL, Kolk BV, Pynoos R, Wang J, Petkova E: A developmental approach to complex PTSD: Childhood and and adult cumulative trauma as predictors of symptom complexity.  J Trauma Stress 2009, 22(5):399-408

2. van der Kolk BA, Roth S, Pelcovitz D, Sunday S, Spinazzola J: Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. J Trauma Stress 2005, l8(5):389-399.

 

3. van der Kolk BA: Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. PsychiatrAnn 2005, 35(5):401-408.


4. van der Kolk BA, Pynoos RS, Cicchetti D, Cloitre M, D’Andrea W, Ford JD, Ueberman AF, Putnam FW, Saxe G, Spinazzola J, Stolbach BC, Teicher M: Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V.

 http://www.traumacenter.org/announcements/DTD papers Oct 20O9.pdf webcite


5. van der Kolk Bessel A, Fisler R. Disassociation and the fragmentary nature of traumatic memories: Overview an exploratory study. J Trauma Stress 1995; 9:505-525


6. Schore A. Affect regulation and the origin of the self: the neurobiology of emotional development. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994


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