Complex Trauma Or DESNOS Increasing in Inpatient Eating Disordered Populations

In inpatient settings I have been seeing much more serious trauma in clients who are currently admitting for treatment. In fact we’re seeing so much trauma that we think that all clinicians should be trained in EMDR, one of the most effective trauma interventions used at this time. Experienced clinicians are needed when it comes to working with PTSD and childhood trauma and they should have the best tools available. Because so many people with trauma are admitting with severe trauma, I have been doing vast amounts of research on new information available in regards to trauma and its treatment.

I have found that the subject of complex trauma or DESNOS, a diagnosis of extreme stress not otherwise specified is in fact much more common than a diagnosis of straight PTSD.

PTSD was originally developed as a diagnosis in the 1970s to explain the symptomology of Vietnam veterans returning home after the war. Research has shown that men are traumatized most frequently by accidents, war, assaults, and natural disasters, single event occurrences.

Women are most frequently traumatized by childhood sexual abuse. B.A. van der Kolk (2005) reported that between 17 and 33% of women in the general population had histories of sexual-physical abuse while women who were in psychiatric treatment reported 35 to 50%.

PTSD has captured only a partial snapshot of posttraumatic psychopathology. The PTSD diagnosis does not capture the facets of long-term, repeated trauma. People with a history of physical and sexual abuse over long periods of time report many psychological problems such as substance abuse, borderline and antisocial personality disorders, eating disorders, impulsivity, self-mutilation and suicidality. They will be chronically depressed with dissociative episodes of varying lengths of time. Extreme aggression and impulse control difficulties are also present.

PTSD clinically has referred to these other problems as co-morbid conditions, as if they have occurred apart from the PTSD symptoms. As a result the authors of the DSM-IV began to separate these other symptoms under a category of extreme stress not otherwise specified (DESNOS). They found that the earlier the trauma the more severe the symptoms of DESNOS. Studies also have shown that it is possible to experience DESNOS without having PTSD, certainly above and beyond PTSD.

DESNOS represents a psychological injury from long-term social and/or interpersonal trauma that is characterized by lack or loss of control, disempowerment, and the victim is unable to escape.

In many situations such as caring for a mentally ill person at home, a care- giver may develop symptoms themselves of traumatic stress from prolonged exposure to traumatic stress.

When a patient admits to treatment, pre-treatment testing is needed, such as the Beck Depression Inventory, the Eating Disorder Inventory III, the SCL-90 including testing for trauma and dissociation. If the client has a history of trauma, clinicians should immediately focus on stabilization techniques.

The therapist must have the attitude that nothing is more important than safety and stability. The therapist must assume the role of teacher or guide for the client. Trauma survivors cannot teach themselves how to be safe and stable because

they have no baseline, no meaningful experience of what the words “safe ” or “stable” mean. This is where a strong, centered, grounded therapist is necessary to be the teacher. They help the client learn to ground herself and to find a safe place where she can go and be protected under any circumstances.

The therapist teaches the client that no recovery from trauma is possible without paying attention to issues of safety, learning to care for herself, making connections to other human beings, and a finding a renewed faith in the universe. The therapist’s job is not just to be a witness to this process but to teach the patient how.

Why Everyone in Recovery Must Be Trauma-Informed – For Women and Children’s Sake (Part 3)

My passion in looking at men and trauma comes primarily from my personal experience as a young boy, first growing up in a violent alcoholic home and then having to deal with the impact of that trauma long into my thirties – and long into my sobriety. I still have vivid memories sitting on the top stair outside of my parents’ bedroom, hearing my mother screaming and crying as I was trying to get up the nerve to open the door or bang on it, once they/he had finally gotten smart enough to lock it. Or crying myself to sleep through the only slightly muffled sound of my parents yelling, cursing, and belittling each other – only to pretend like nothing had happened the next day. Or my Dad grabbing me by my leg as I was trying to get away from him,pulling me down the stairs and then proceeding to hit me. I could go on.

Believe it or not, I had a lot of confusion as to whether what I had grown up in was actually violent. It was only until I got into relationships with people who did know the difference that I began to see that how I grew up was far from normal – even though, sadly, far too many children experience the same thing and even worse. With that in mind, it would be completely irresponsible of me not to talk about the effect that men’s trauma has on women and children. While compassion for men is essential, we have to be careful that compassion does not become enabling or minimizing of the horrific violence that women and children are enduring on a daily basis because of men acting out due to unaddressed trauma.

Here are some sobering statistics that are important to always keep in mind when we are talking about men and trauma:
• Approximately 1.5 million women are raped or physically assaulted by an intimate partner each year in the United States. Because many are victimized more than once, approximately 4.8 million intimate-partner rapes and physical assaults against women are committed annually (Bureau of Justice Statistics, 2000).

• Women aged sixteen to twenty-four experience the highest per capita rates of intimate violence (19.6 victimizations per 1,000 women) (Bureau of Justice Statistics, 2003; National Coalition Against Domestic Violence, 2009).

• One in every four women will experience domestic violence in her lifetime. Eighty-five percent of domestic violence victims are women. Most cases are never reported to the police. (National Coalition Against Domestic Violence, 2009)

• In 2007, approximately 5.8 million children were involved in an estimated 3.2 million child abuse reports and allegations. [Most cases are never reported to the police.] (National Child Abuse Statistics, 2010)

• About 30% of abused and neglected children will later abuse their own children, continuing the horrible cycle of abuse. (National Child Abuse Statistics, 2010) [My uneducated guess is that this number is actually much higher when we think about how much violence and abuse still lives in the shadows.]

The first thing that needed to happen in order for me to better see and understand my behavior was that I had to realize that violence was so much more than what I thought it was. I was often so focused on my internal experience that I did not look at my external behavior. “How can I be scaring anyone when I feel so afraid?” I would say, angrily yelling, after having been confronted. Or maybe I would laugh that patronizing laugh that we, men, can have that essentially says: “Stop being such a baby” (echoed from the mouths of so many who we had followed into manhood). Like my alcoholism, so long as I maintained a fixed definition of violence then it meant that I was not violent. But, in fairness, I was not shown what love and peace really looked like – or better, felt like. I did not understand what it really meant to feel safe. I did not realize that punching a wall was an act of violence – I thought it was avoiding violence!

Here are some other examples of violence that many may not consider to be technically abusive but that create an environment of fear for loved ones:
• Raising your voice at your partner in an effort to intimidate or silence.
• Using your physical body to intimidate in any way by size and strength alone. Most men are intimidating to women and children, and few men understand this.
• Slamming doors.
• Threatening harm to yourself or to your partner.
• Punching or kicking a wall or door with someone else in the room.
• Taking car keys or doing anything else to prevent your partner from leaving your presence or your home, or doing any other act that prevents your partner from seeking safety.
• Chasing your partner as he or she tries to leave or escape from you and your threatening behavior.

The last thing I ever wanted to do was continue the cycle of abuse. I hate violence, have a pure heart, and never wanted to see anyone in pain. Yet, I found the same words coming out of my mouth with the same anger and violence from which I used to cower. I behaved in ways towards others that were exactly the same kind of behavior that still had me afraid of being in the dark as a goddamn grown man! While it is hard to write these words, I feel as though I must, because until we men begin to truly own our behavior and call it what it really is nothing is going to change. We must shine an honest and compassionate light on this topic. Nobody wants to be an addict; to become that which so many of us swore we would never be. And, maybe that is the same fear that gets in the way for so many of us men in acknowledging the impact of abuse on our lives: the fear of being our fathers (or whoever it was that abused us.)

Of course, with all the junk we have about being a man in our society, a man acknowledging the pain of abuse sometimes feels comparable to admitting he is not a man at all. There is still a part of me that feels like a [fill in the epithet] for writing these words. There is no question that at the heart of the vast majority of abuse is a stagnant well of toxic shame corroding the spirits of some very good men.

There is so much to discuss on this topic alone but I am only able to hit the tip of the iceberg here. The reality is that it is not unreasonable to assume that most men, especially those of us in recovery from any addiction, have had some experience of trauma. I believe this should be an expectation, not considered an exception as it often is now. But nothing guarantees that sobriety will stop a man’s violence or heal the trauma destroying so many people’s lives. Helping a man to understand that his experience was indeed traumatic is not easy. The way we still raise boys to be men overlaps far too much with violence and abuse, which leads many of us to confuse that kind of mentality and behavior with Love. With that in mind, we should also assume that most men in recovery do not have a full understanding of violence, and so it is incumbent upon those of us who have come to a different understanding to share it, and to even take an unwavering stand against violence against women and children – and men! One of the greatest ways for me to heal has been the commitment to peace and safety I have made to my wife and my daughter – and even our little Shih Tzu, Haley. The more I am able to be the man I always hoped to be, the more I can see that is who I have always been.

In the field of recovery, we make one thing clear throughout – even strongly encouraging clinicians to put this message up in their offices and their group rooms: Whatever happened to you as a child – no matter what you did – was not your fault; and, whatever you do or have done as an adult that has harmed another – no matter what someone else has done – it is your responsibility and it needs to stop.