Comorbidity Of DSM-IV Disorders Among Women Experiencing Traumatic Events
Marylene Cloitre, Ph.D.
NCP Clinical Quarterly, 7(3): Summer 1997
To date, very few methodologically sound research studies exist examining comorbid disorders among traumatized women. The limited research suggests the salient presence of substance abuse, major depression and other anxiety disorders among women with trauma histories and/or post traumatic stress symptoms (1). Data from our trauma recovery clinic, which specializes in the treatment of women with a history of sexual assault and childhood abuse, indicated the clinic's first 100 clients averaged 3 DSM-IV disorders comorbid with PTSD. The most common of these co-morbid disorders was major depression (35%), followed by social phobia (27%), generalized anxiety (27%) and panic (22%). In addition, 33% of these clients had a diagnosis of past substance abuse.
There are several difficulties related to studying co-morbid disorders among women with trauma histories. One major problem has been the tendency in clinic and research settings to overlook the potential connection between between current symptoms and a history of trauma, leading to the underdiagnosis of PTSD and the overdiagnosis of other disorders, such as generalized anxiety disorder with which PTSD shares some symptoms. A second significant problem has been the complexity of the PTSD diagnosis and disagreement in the traumatology community about the adequacy of the PTSD diagnosis itself.
Problem Of "False Negatives" In PTSD Reports
Clinic or research settings that do not routinely inquire or assess trauma history are not likely to consider PTSD as a diagnosis because no stressor (Criterion A event) has been identified. Instead, patients or study respondents are likely to be characterized as having multiple subsyndromal characteristics of a variety of disorders which share some of the symptoms of PTSD such as major depression, generalized anxiety disorder and obsessive compulsive disorder. The absence of sensitivity to the pairing of a traumatic life event to the diagnosis of PTSD was recently demonstrated in a clinical study of 409 consecutive female inpatient admissions to a general psychiatric facility (2). While 45% of the total sample reported some form of childhood abuse and 22% reported at least one adulthood sexual assault, a review of medical records indicated that no patient was given post traumatic stress disorder as a primary diagnosis and only two patients were given PTSD as a secondary diagnosis. This "false negative" rate may occur because clinicians admitting acutely disturbed patients in general psychiatric hospitals tend to focus on the emergent psychopathological warranting admission (e.g., psychosis, suicidal depression) without assessing its relevance to the patient's history.
This report demonstrates that the study of PTSD and its comorbidities is hampered in a way that the study of other disorders may not be. Often, a neglected disorder can be given a boost simply by going back to large scale epidemiological or clinical studies and re-analyzing data in a way that organize the symptoms according to the diagnosis under question. However, in the case of PTSD, this task is not likely to be easily achieved because the data about trauma history may be impoverished or there may have been little effort to identify a relationship between the traumatic events and specific symptoms. Thus, accurate assessment of PTSD and its comorbidites will require initiation of diagnostic studies from the ground level.
Of note, the skewed diagnostic patterns reported for PTSD and its comorbidities has clinical consequences. For example, in the above inpatient study, one might surmise that the absence of the identification of PTSD would impede appropriate long-term treatment planning. This problem could be mitigated by PTSD specialists providing educational programs to general psychiatric services and by setting up mechanisms for PTSD related consultation with inpatient and outpatient programs.
Complexity Of PTSD
Many clinicians and researchers within the community of traumatology contend that the clinical phenomenology of DSM-IV criteria does not adequately capture the range of post-traumatic stress symptoms resulting from common chronic life traumas among women (i.e., childhood sexual abuse, physical abuse and domestic violence). Data from the DSM-IV field trials for PTSD have been enormously helpful in addressing this concern (3). Results indicate that PTSD is indeed a salient, if not core component of the complex of symptoms related to chronic trauma. However, in addition to the "cardinal features" of re-experiencing, avoidance, and increased physiological arousal, symptoms of dissociation, somatization and affect regulation co-occur in the majority or traumatized individuals in both clinical and community samples, leading to the formulation of a variation of PTSD called "complex PTSD."
Treatment Implications Concerning Complex PTSD And It Comorbidities
Although the exact relationships among PTSD, complex PTSD and additional comorbidities remain to be determined, the emerging picture suggests the presence of a significant challenge to our clinical resources. The complexity of the clinical problem suggests the importance of multimodal or multistaged treatment. A core component of treatment should be PTSD-symptom specific and involve the emotional processing of the trauma. However, additional and perhaps prerequisite treatment stages should included the development of skills which facilitate this work, such as awareness and regulation of feeling states, ability to tolerate distress and to utilize social support. Development of these skills may generalize or have cross-over utility as different symptom profiles emerge during the course of trauma recovery. Techniques which target especially troublesome symptoms to the particular individual such as breathing retraining for panic attacks and role play for social phobia can be integrated into treatment. In addition, medication can also be effective in reducing depressive and arousal/intrusive symptoms and allow more effect use of other interventions.
In sum, it appears that in the past PTSD as well as complex PTSD have been underdiagnosed and other related disorders overdiagnosed. This problem is being corrected via ongoing diagnostic studies assessing the full-range of DSM-IV disorders among trauma populations. In addition, there are concurrent efforts to develop treatment programs which recognized the complexity of PTSD. For the individual clinician, misdiagnosis may be mitigated by routinely inquiring about a patient's trauma history. When a diagnosis of PTSD is established, the complexity of the disorder requires comprehensive, multimodal, multistaged treatment.
References
1. Davidson, J.R. & Fairbank, J.A. (1993). The epidemiology of posttraumatic stress disorder. In J.R. Davidson and E.B. Foa (Eds.), Posttraumatic stress disorder: DSM-IV and beyond. Washington, D.C., American Psychiatric Press.
2. Cloitre, M., Tardiff, K. Marzuk, P., leon, A.C. Portera, L. (1996). Child abuse and subsequent sexual revictimization among female inpatients. Journal of Traumatic Stress, 9, 473-482.
3. Van der Kolk, B.A., Pelcovitz, D., Roth, S., Mandel, F.S., McFarlane, A., & Herman, J.L. (1996). Dissociation, somatization and affect dysregulation: The complexity of adaption to trauma. American Journal of Psychiatry, 153, (July suppl.), 83-93.
Marylene Cloitre is the Director of the Anxiety and Traumatic Stress Programs in the Department of Psychiatry of New York Hospital-Cornell Medical Center, New York.
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