The diagnostic criteria for PTSD, as conceptualized in the current editions of the DSM (DSM IV-TR, 7) and the World Health Organization’s International Classification of Diseases (ICD-10, 8), include a stressor dimension, three core symptom clusters, and duration and disability specifications.

The first criterion for the PTSD diagnosis relates to the nature of traumatic exposure. DSM IV-TR specifies that the person should have directly experienced or witnessed an event involving actual or threatened death, serious injury, or threat to physical integrity or learned about unexpected or violent death, serious harm, or threat to physical safety experienced by a loved one (criterion A1). Furthermore, the person’s response to this event should have involved intense fear, helplessness, or horror (criterion A2). ICD-10 also delineates the nature of the stressor; however, like earlier versions of the DSM, it describes these events as exceptionally threatening or catastrophic and likely to cause distress to almost anyone.

The three core symptom clusters of PTSD capture the dialectic between hyperremembering and forgetting that characterizes the daily experience of many survivors of extreme trauma. The first cluster specifies that the traumatic event should intrude into the person’s present functioning, causing the person to reexperience the event constantly. Reexperiencing or intrusive symptoms include distressing memories (thoughts, images, or perceptions), recurring dreams about the event, and a physiologic fear reaction or intense psychological distress when exposed to reminders of the trauma. Although less common, dissociative flashback experiences in which the trauma survivor actually relives aspects of the trauma in the here and now, in vivid sensory detail, are often considered to be the hallmark symptom of PTSD. The second symptom cluster requires that the person, in addition to having vivid remembrances of the event, also avoids reexperiencing the event. Avoidance symptoms may involve active efforts to avoid thoughts, feelings, and conversations about the trauma and activities, people, and places that are reminders of the trauma. Although avoidance may initially focus on direct reminders of the trauma (e.g., the actual place where it occurred), through a process of behavioral conditioning it may eventually generalize to a broad range of stimuli associated with these reminders (e.g., places similar to that where the trauma occurred and any stimuli that come to be associated with these places) (9). Avoidance symptoms may also include amnesia for important aspects of the trauma and emotional numbing that results in an inability to experience either painful or pleasant feelings. Also categorized under avoidance symptoms are a reduced interest in significant activities, feelings of detachment or estrangement from others, and a sense of a foreshortened future. The final symptom cluster specifies that the person should be in a state of persistent physiologic hyperarousal (as if permanently poised for fight or flight), as indicated by difficulty falling asleep, impaired concentration, hypervigilance to threat, an exaggerated startle response to loud noises or sudden movements, and irritability or outbursts of anger. ICD-10 requires intrusive symptoms to be present in order to make the diagnosis, but avoidance and hyperarousal symptoms are not required.

Since many of these symptoms are commonly experienced by trauma survivors in the days and weeks following the event, a diagnosis of the disorder according to DSM IV-TR further requires that the three symptom clusters should be
present for longer than one month following the trauma and should cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Both DSM IV-TR and ICD-10 also provide for a diagnosis of acute stress disorder (ASD), in which PTSD symptoms are present for less than one month following the trauma. According to DSM IV-TR, the person must have experienced a number of dissociative phenomena during the traumatic event in order to meet this diagnosis, whereas ICD-10 emphasizes the depressive and anxiety components of ASD and the mixed and labile nature of the symptoms.

Among both men and women, PTSD is seldom the sole diagnosis; comorbid diagnoses are common. The following comorbid disorders are highly prevalent among women in the general population who also meet diagnostic criteria for PTSD (10,11): major depressive disorder (17%-23% of women with PTSD), panic disorder (13%), specific phobia (36%), generalized anxiety disorder (GAD) (38%), and substance abuse (28% for alcohol abuse and 27% for drug abuse).

A perusal of the three symptom clusters of PTSD reveals a substantial degree of overlap with the symptoms of these comorbid disorders, including the withdrawal, emotional numbing, and vegetative symptoms of depression; the physiologic reactivity and behavioral avoidance that characterize panic disorder and specific phobia; the physiologic hyperarousal of generalized anxiety disorder; and the obsessive ruminations of obsessive compulsive disorder (OCD). These diagnostic overlaps present several pitfalls for accurate diagnosis and treatment of female trauma survivors. Upon assessment, the presence of comorbid disorders may mask the presence of PTSD, resulting in a failure to diagnose and treat the latter (12); alternatively, when the person being examined has a known history of trauma, the clinician may be too quick to attribute all reported symptoms to PTSD, thus failing to assess the person for other comorbid conditions that may require treatment.

The relationship between the core symptoms of PTSD and the manifold comorbid symptoms that frequently accompany these in female trauma survivors is unclear. Two possibilities are that comorbid disorders such as depression and substance abuse may predate and create a vulnerability for trauma exposure and PTSD and that PTSD may enhance the risk of developing secondary disorders (e.g., women may develop major depression or substance abuse in response to the impairment and distress caused by PTSD). However, prospective studies are needed in order to establish the order of onset of PTSD and comorbid disorders (10).

Clinicians working with female survivors of child sexual abuse have long noted a range of presenting symptoms that are not captured by the criteria for PTSD diagnostic or those disorders commonly found to be comorbid with PTSD (1). In the past decade, there have been some attempts to include these phenomena in the psychiatric nomenclature. The DSM IV field trials found that people who had experienced childhood trauma and chronic traumatization in childhood or adulthood reported a disparate range of symptoms and psychological adjustments that are distinct from the symptoms of PTSD (5). These symptoms include impairments in affect regulation, alterations in attention and consciousness, somatization,
characterologic changes, and alterations in systems of meaning (see Table 16.1). Consequently, a diagnostic category of “disorders of extreme stress not otherwise specified” (DESNOS; 5), also referred to as complex PTSD (1), was proposed for inclusion in the fourth edition of DSM. The DESNOS symptoms were eventually incorporated into DSM-IV (13) in the section “Associated Features and Disorders” under PTSD rather than as a separate diagnostic category. A subsequent study of combat veterans (14) found DESNOS and PTSD to be distinct disorders that are often comorbid, but this finding awaits replication with female samples.

ICD-10 has captured many of the DESNOS symptoms in a diagnostic category for enduring personality changes after catastrophic experience, which includes permanent hostility and distrust, social withdrawal, feelings of emptiness and hopelessness, increased dependency, and problems with modulation of aggression, hypervigilance and irritability, and feelings of alienation.

What happens to female patients with a history of early or repeated abuse who present to the mental health system with the confusing array of symptoms described by the DESNOS criteria? Frequently, clinicians have diagnosed these patients with a mixed bag of borderline personality disorder (BPD), dissociative
identity disorder (DID), and somatization disorder, because the criteria for each of these disorders focus on some aspects of complex PTSD (DESNOS criterion A, criterion B, and criterion C, respectively), while de-emphasizing others (1).

The fact that there is no unitary diagnostic category that encompasses all the DESNOS symptoms has significant implications for diagnosis and treatment. There is the danger of misdiagnosis. For example, a recent study (15) found that while BPD may sometimes be a distinct comorbid diagnosis among sexual abuse survivors with complex PTSD symptoms, other survivors diagnosed with BPD could more appropriately be diagnosed with complex PTSD. Additionally, patients with DESNOS symptoms may find themselves labeled with a different diagnosis by different clinicians at different times.

The treatment implications of this diagnostic confusion are manifold. First, the link between the symptoms of disorder and their traumatogenic roots becomes obscured. Whereas a diagnosis of PTSD automatically identifies a traumatic experience as the central cause and an important focus for treatment, multiple non-PTSD diagnoses disguise the causal role of previous trauma. Without the recognition of a common etiologic root for the varied symptoms with which the patient presents, intervention becomes fragmented and unfocused and is unlikely to effect therapeutic change. Second, mental health practitioners and organizations are often reluctant to invest time, energy, and other resources in treating patients with diagnoses such as somatization disorders, BPD, and DID, which have notoriously poor prognoses, and may try to refer them elsewhere. Even when they attempt treatment, the association of these disorders with unstable and manipulative behavior on the part of the patient tends to impair the degree of empathy with which clinicians relate to such patients (1,5).

Because of the accumulation of these processes, it is common for clinicians to respond with wariness, frustration, and anger toward female patients with this diagnostic profile, which results in patients being medicated against their will, placed in seclusion, or transferred without warning to another facility (5). This retraumatization of the patient can partly be understood as an unconscious process in which the clinician or clinical team is drawn into the patient’s compulsion to recreate the original abusive relationship in the therapeutic relationship. However, the absence of an appropriate post-traumatic diagnosis precludes accurate recognition of this abusive reenactment and limits the possibility of establishing an empathic therapeutic relationship with the patient that acknowledges her past experiences of abuse and the ways in which her adaptations to this abuse impair her present functioning (1).