It may help to think of trauma related disorders on a continuum. Although it’s not quite as black and white as that, I will cover each condition starting from least to most severe. I’m using overall functioning as a measure of severity, but obviously this does not factor in individual differences and resiliency. Also, it’s important that I say this: I honestly don’t consider any of these conditions as “disorders.” From the clinical sense they are, because they affect functioning and quality of life, and we need labels to bill insurance companies. But from a human perspective, these are understandable responses to trauma. It’s believed that over 50% of Americans will experience or witness at least one traumatic event in their lives. So unfortunately there are a lot of people who develop acute stress disorder or PTSD. It’s an understandable response to trauma.
Acute Stress Syndrome
Acute stress syndrome differs from PTSD in that it occurs from 3 days to 4 weeks after the traumatic event. This is a condition that used to be referred to as “shell shock” when describing soldiers’ experiences during war.
Symptoms include mild dissociation (forgetting the event or details of it, seeing yourself from an outside perspective, or being in a daze), negative mood, intrusion symptoms (re-experiencing the event through distressing memories or nightmares), avoidance symptoms (avoiding places, people, thoughts, etc that remind them of the trauma), and hypervigilance (irritability, insomnia, and difficulty concentrating).
If these symptoms last for more than one month, the person will most likely be diagnosed with PTSD.
PTSD (Post Traumatic Stress Disorder)
Criterion A: You were exposed to one or more event(s) that involved death or threatened death, actual or threatened serious injury, or threatened sexual violation. In addition, these events were experienced in one or more of the following ways:
- You experienced the event
- You witnessed the event as it occurred to someone else
- You learned about an event where a close relative or friend experienced an actual or threatened violent or accidental death
- You experienced repeated exposure to distressing details of an event, such as a police officer repeatedly hearing details about child sexual abuse
Criterion B: You experience at least one of the following intrusive symptoms associated with the traumatic event:
- Unexpected or expected reoccurring, involuntary, and intrusive upsetting memories of the traumatic event
- Repeated upsetting dreams where the content of the dreams is related to the traumatic event
- The experience of some type of dissociation (for example, flashbacks) where you feel as though the traumatic event is happening again
- Strong and persistent distress upon exposure to cues that are either inside or outside of your body that is connected to your traumatic event
- Strong bodily reactions (for example, increased heart rate) upon exposure to a reminder of the traumatic event
Criterion C: Frequent avoidance of reminders associated with the traumatic event, as demonstrated by one of the following:
- Avoidance of thoughts, feelings, or physical sensations that bring up memories of the traumatic event
- Avoidance of people, places, conversations, activities, objects, or situations that bring up memories of the traumatic event
Criterion D: At least two of the following negative changes in thoughts and mood that occurred or worsened following the experience of the traumatic event:
- The inability to remember an important aspect of the traumatic event
- Persistent and elevated negative evaluations about yourself, others, or the world (for example, “I am unlovable,” or “The world is an evil place”)
- Elevated self-blame or blame of others about the cause or consequence of a traumatic event
- A negative emotional state (for example, shame, anger, or fear) that is pervasive
- Loss of interest in activities that you used to enjoy
- Feeling detached from others
- The inability to experience positive emotions (for example, happiness, love, joy)
Criterion E: At least two of the following changes in arousal that started or worsened following the experience of a traumatic event:
- Irritability or aggressive behavior
- Impulsive or self-destructive behavior
- Feeling constantly “on guard” or like danger is lurking around every corner (or hypervigilance)
- Heightened startle response
- Difficulty concentrating
- Problems sleeping
Criterion F: The above symptoms last for more than one month.
Criterion G: The symptoms bring about considerable distress and/or interfere greatly with a number of areas of your life.
Criterion H: The symptoms are not due to a medical condition or some form of substance use.
DSM-5 PTSD Diagnosis: In order to be diagnosed with PTSD according to the DSM-5, you need to meet the following:
- Criterion A
- One symptom (or more) from Criterion B
- One symptom (or more) from Criterion C
- Two symptoms (or more) from Criterion D
- Two symptoms (or more) from Criterion E
- Criteria F through H
Complex PTSD is not an official diagnosis and is not in the DSM 5, but many clinicians who work with trauma believe it should be. Whereas PTSD can be caused by a single traumatic event, Complex PTSD is usually caused by repeated, chronic trauma. Although not everyone who experiences chronic trauma develops this condition, it’s very common among survivors of chronic child abuse and neglect. People can also develop Complex PTSD from other chronic traumas like repeated exposure to violence during war.
Complex PTSD includes all the usual PTSD symptoms listed above, but there are also other symptoms seen in individuals that suffer from this condition that are not discussed in the DSM 5. It would be nice if one day the DSM 5 could do a better job of categorizing and describing trauma disorders.
These other symptoms include:
Negative self perception, changes in consciousness (mild to moderate dissociation), problems with relationships, difficulty regulating emotions, somatic issues related to trauma, distorted perceptions of the abuser(s), and loss of system’s meanings (views of the world, religion, etc).
OSDD is short for Other Specified Dissociative Disorder, formally called DDNOS. This category applies to presentations in which symptoms are characteristic of a Dissociative Disorder, but individuals do not meet the full criteria for any of the disorders in the Dissociative Disorder class.
According to current research, OSDD is similar to DID in that it’s a dissociative disorder caused by severe childhood abuse. The only difference between these two conditions, according to Treating Trauma Related Dissociation, is that people with DID have more than one part of the personality that functions in every day life. Individuals with OSDD have parts with distinct identities, but they may be less developed that those with DID. These parts are usually stuck in trauma time and don’t take control of the body. As a result, people with OSDD generally experience less amnesia than those with DID.
DID (Dissociative Identity Disorder).
I’ve explained my experience with DID, but here it is in clinical terms: Disruption of identity characterised by two or more distinct personality states. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play. The symptoms are not attributable to the physiological effects of a substance (e.g. blackouts from drinking alcohol).
A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person’s behavior.
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance(e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, thesymptoms are not attributable to imaginary playmates or other fantasy play.
*I want to note another issue that the DSM 5 misses. It doesn’t include conversion symptoms in the diagnostic criteria for DID even though it’s extremely common. According to Treating Trauma Related Dissociation, “Many patients with a complex dissociative disorder have severe somatoform dissociative symptoms; they may present in the mental health system with paralysis, unexplained intrusive pain or other sensations, or pseudoseizures. However, in DSM-5 these are labeled as conversion symptoms or disorders and are not considered to be dissociative—a view criticized by many (e.g., Bowman, 2006; McDougall, 1926; Kihlstrom, 1992; Nemiah, 1991; Nijenhuis, 2004, 2015; Van der Hart et al., 2006).” (Steele, Van der Hart, & Boone, 2017).