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Complex PTSD or DESNOS

Experts in the fields of trauma and human development have identified clusters of symptoms that some call “complex trauma” (Herman, 1992) or “disorders of extreme stress not otherwise specified” (DESNOS) (Ford, 1999;  Luxenberg, Spinazzola, and van der Kolk, 2001).  These disorders include symptoms that extend beyond the diagnosis of PTSD into a category that includes complex, interrelated problems that interfere with the fundamental ability to trust (van der Kolk and Pelcovitz, 1999). 

Ford (1999) described the concept of DESNOS as one that offers a framework for understanding and a clinical framework for assessing several effects often experienced by survivors of extreme trauma:

  • Extreme difficulty regulating feelings and impulses (e.g., rage, suicidality, self-destructiveness, uncontrolled sexual activity)
  • Dissociative symptoms that cause so many problems as to qualify for the term “pathological”
  • Somatic or physical symptoms
  • Alexithymia (difficulty understanding, processing, or expressing emotions)
  • “…fundamentally altered beliefs concerning self and relationships” (Ford, 1999, p. 3).

According to Ford and Kidd, DESNOS develops when extreme trauma “compromises the fundamental sense of self and relational trust at critical developmental periods.”  In studying a sample of veterans in treatment for chronic posttraumatic stress disorder, Ford and Kidd found that a history of early childhood trauma was “prevalent and highly correlated with Disorders of Extreme Stress Not Otherwise Specified” (Ford and Kidd, 1998, p. 743).  They also found that veterans who were survivors of childhood trauma tended to have stronger intrusive PTSD symptoms; more problems controlling emotions (rage, shame) and impulses (self-harm, risk taking);  more difficulty with relationships (intimacy, trust, assertive communication), self-efficacy, and  self-esteem;  and pathological dissociation (Ford and Kidd, 1998).

Those who are familiar with the diagnosis of “borderline personality disorder” (APA, 1994) will recognize many elements of that diagnosis in this condition.  In many circles, the terms “complex trauma” and “DESNOS” have replaced “borderline,” though the official name of the diagnosis has not changed. 

In a world that also includes the full spectrum of childhood and developmental experiences, an understanding of the ways in which severe traumatic experiences interact with developmental factors is essential for understanding post-deployment stress effects.  This is not to say that veterans who develop DESNOS after service actually had these disorders before service due to their childhood experiences.  No matter what the level of vulnerability might be, the disorder begins when the disorder begins, and that might even be long after deployment and years of conventional PTSD symptoms.  But an understanding of DESNOS is an important element in shaping treatment responses for people who present with these more complex challenges.

Next: Somatic Effects


The material on all of the Clinical Pages is taken directly from the draft version of Finding Balance After the War Zone:  Considerations in the Treatment of Post-Deployment Stress Effects, a manual under development for the Great Lakes Addiction Technology Transfer Center and Human Priorities.  This draft is copyright © 2008, Pamela Woll.  Reprint permission is universally granted, but attribution is requested.
Click here for References and Other Resources.
Click here to link to a PDF file of the current version of the clinician’s manual draft.
Click here to link to a PDF file of the accompanying booklet for veterans.

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