As I mentioned earlier in a post that is probably too long-winded to actually be of much use to anyone skimming for info/resources, there is some controversy over the existence and diagnosis of complex PTSD.  That post outlines part of why the complex PTSD diagnosis has come to exist: the DSM manual has a list of symptoms and things to look for that inquire about and search for “the event.”  Thus the intake checklists and questionnaires, and thus the diagnosis, and thus the treatment that follows, often vary depending on whether or not a psych professional and/or a person looking for help can point to “an event.”  I have had PTSD ruled out before. I have ruled it out myself.  I currently have a t-doc and p-doc who concur on the diagnosis.  I personally don’t know what I believe, but I can tell you that the treatment strategies that are or can be on the table now are a lot more helpful for me than any of the strategies I’ve tried before.  Right now that’s good enough for me.  And because a psych doc will sign a piece of paper giving me a Proper Categorical Description, my insurance will pay for me to go to a t-doc and a DBT group.  If that psych doc didn’t “believe in” complex PTSD – in PTSD without the single defining “event” — then my insurance wouldn’t pay for my therapy (it would be happy, however, to keep paying for my drugs.  I happen to not want to be on drugs, though, and therapy costs them more more, so I can’t tell you how relieved I am to have finally found a p-doc that listened to me when I said that Prozac made my life unbearable and that worked with me to find some alternatives).

Here’s part of the deal: complex PTSD is not in the DSM.  This leads some people to say it’s a non-existent thing.  But the DSM is prescriptive, not descriptive.  Diagnosis starts with matching symptoms to checklists, and continues with the differential (and that is a shaky spot for psych stuff, and an honest psych doc will admit that).  But we aren’t talking about a liver whose enzymes we can measure with a test and a machine. We are talking about people who are big complex dynamic combinations of nerves, organs, feelings, memories, attributes, temperaments, etc.  We are talking about a profession that insists it is scientific and that things are quantifiable at the very same time that our only data points come from self-reporting and subjective experience (and the descriptions of p-docs who aren’t sitting in the skin of the person they’re categorizing).

And diagnosis has a big part in shaping how we conceive of and categorize stuff.  Once upon a time, there was “no such thing” as PTSD, if its inclusion in the DSM is the criteria for something being a “real” disorder.  Right now, there’s a “disorder” in the DSM called “Gender Identity Disorder” and another called “Transvestic Fetishism.”  Now, as far as I’m concerned, this is 17 shades of fucked up and what we *ought* to be treating as pathological is a society that can allow the sort of bullying and institutional prejudice and abuse it allows towards transgendered people.  To me, the cultural and scientific perspectives that produce the DSM are what’s in need of treatment, with its authoritative pathologizing of affect and desire and identity of non-white, non-middle-class, non-first-world, non-hetero worldviews.  The DSM prescribes based on deviations from the norm. But the norm is itself a construct that the DSM itself helps construct.  It’s a big serpent-eating-tail phenomenon.

But one of the good things that comes from Gender Identity Disorder existing as a diagnostic category for the psych profession is that it validates the experiences and feelings of a lot of people who might otherwise be dismissed, electro-shocked, shamed into repression or suicide, ridiculed, etc.  Does that mean “yay, hooray for pathologizing difference!”  No.  but there is very much a way in which its inclusion in the DSM makes it “real.” I don’t just mean in people’s heads.  I mean in ways that are tied to reforming laws, to allowing access to therapy and surgeries, to making some lives tolerable that were intolerable before (because something that isn’t “real” can’t be responded to as if it’s real, and like it or not, inclusion in the Holy Scientific Tome of the DSM-IV makes things “real” on some levels, in some areas of life and politics and medicine and praxis and ethics).

(Of course, this shades over into very real concerns about the potential for abuse of fuzzier or more labile diagnostic approaches, and a real concern is that changing the DSM will mean allowing for more disability claims fraud and courtroom proceedings bullshit.  “It’s not my fault I murdered my wife because my daddy used to spank me.”  I’m aware of this problem.  But even this should underscore just how “real” the DSM can make something, what I mean when I talk about the power of this manual and the power of Prescribing.)

(Of course, there are some people who believe that entire concept of the DSM is flawed and people would all be better off if we returned to good old-fashioned family values, but those people are not my audience here. I’ve done enough trying to teach pigs to sing to waste my time with those folks.)

I bring up Gender Identity Disorder in the DSM by way of example (though if you ended up here because you want to know more about that, here’s one place to start.)  In a way, *everything* in the DSM is “made up.”  The psych and med professions are constantly modifying the damned manual. And they should be – our categories and vocabulary should adapt as we learn more shit about more shit.  The DSM should be a tool, not holy scripture.  And the psych professionals who are talking about complex PTSD are doing so from a good place – from a place where they see how some aspects of trauma reaction are formative in a person’s psyche but how the PTSD checklist doesn’t quite apply.

I know the arguments for resisting complex PTSD as a category.  Some of them are better than others.  This blog post and the comments on it introduce you to a wide array of positions and thoughts on the issue.  But the point here is, in my opinion, it’s not so much a question of “right” and “wrong.” We can’t say “here’s the definitive proof that this is the right diagnosis” in the same way that we can say such a thing of leukemia (and in many cases, the “proof” that something is the wrong diagnosis comes because the “proper” medications for that diagnosis did not do the expected thing.  SSRIs do not do what they are supposed to do for me, which has led at least one person to say “Oh, you must not be depressed then- you must be bipolar.  And the reason you don’t have x, y, and z from the bipolar checklist is because [fill in the rationale].”  Lo and behold, now there are different types of bipolar to account for people who don’t have the textbook symptoms of “classic” bipolar.  Bottom line: this shit changes all the time.  Psychiatry may have plenty of science in it – but there is some stuff about it that isn’t and can’t be measurable and provable in the same way things can be in the other sciences.  And if it’s changing in response to more knowledge and if the center of those changes is helping individuals instead of making everybody fit neatly into a rigid box, then those changes are good from where I’m calling them.)

Do I have PTSD?  Complex PTSD? Is there a real difference?  Beats the everliving shit out of me.  I know a hell of a lot of people who have it a hell of a lot worse than I do.  I’ve never been one of those people who’s been comfortable defining myself in terms like that anyway, because I think the whole concept of this kind of diagnosis has some inherent problems.

But. Are the treatments that I have access to now that I have a PTSD diagnosis helping me more than the treatments for “Depressive” and “Anxiety” helping me?  You bet your ass they are.  Are they helping me understand and find a way to change some of the things about me that have never made any sense to me before?  Hell yes they are.  At the end  of the day, I don’t really care what label I have.  I just want to improve my quality of life and not live in a body, with a brain, that I sometimes don’t have any control over.  So I personally advocate the separate existence of complex PTSD as a category – because the DSM’s current checklist for PTSD leaves some people out who maybe shouldn’t be left out, because the DSM is not the freakin’ Inspired Word of God, and because the psych profession and the people who seek help from it are fallible human beings who are ideally doing the best they can with what they’ve got.

I’d rather modify the shoe than cut my freakin’ toe off to fit in it.


Here’s a discussion of proposed changes for the DSM-V.  It touches on a few hot topics I bring up briefly above, and it also touches on some ways that treatment and models might change without subsuming everything under the heading of PTSD.

Pete Walker on multi-modal approaches to PTSD and trauma treatment

My page on PTSD resources.