first chapter, entitled ‘the spread of diagnostic culture’, starts with the provocative statement that each year in Western countries, around a quarter of the population will suffer with a mental disorder. Should we interpret this as evidence for the progress of psychiatry in identifying and treating mental illnesses that have always existed? Alternatively, might it be the case that modern life somehow creates new conditions, or social pathologies? Brinkmann argues that a third, more fundamental explanation is needed: the development over recent years of what he calls ‘diagnostic cultures’. Increasingly, psychiatric diagnoses have become the lens through which people in Western societies understand ourselves and our suffering. They have substantially displaced religious and moral conceptions, and have also come to play an important role in our bureaucracies and our broader social arrangements. Partly, Brinkmann argues, this has been driven from above by those with a vested interest in these explanations, for example psychiatrists and drug companies. However, he also contends that citizens themselves are increasingly pushing for ‘pathologisation from below’, seeking diagnostic explanations for the various problems that we encounter in our lives.
Part of me would be more comfortable with the term ‘condition’ than ‘disorder’ because of the judgement implicit in the latter. But ‘disorder’ to me is an important acknowledgement of the havoc frequently, but not always, created by extreme manic, depressive or psychotic episodes. These states result more easily in some than in others. When and how this happens is a result of myriad dynamic, interconnected factors, some personal and biological, many of them circumstantial and social. However, my lived experience leaves me with the firm conclusion that there is an intrinsic, physiological way in which at least some people who experience mania and certain forms of depression are different from most people. That difference is not, in itself, a disorder. It’s just a difference. But it is a difference that makes those experiences more likely to happen to me than to others.
Insisting that disorders are not real (and/or that there is no congenital physiology involved) erases this difference and elides the complexity of my identity and my experience. Akiko Hart has written eloquently and comprehensively about this. It is much more useful to criticize the construct of psychiatric disorders in terms of the normative and invalidating power being deployed depending on when, how and why the term ‘disorder’ is used. Broad acceptance of a purely biomedical understanding of psychiatric disorders can condemn people to an existence defined by pathology. The construct of “personality disorder” is particularly abusive in this regard. At the same time, it is critical to recognize that some people find the term ‘disorder’ helpful and representative of aspects of our experience or even of our selves.
John Cassian, a monk and theologian wrote in the early 5th century about an ancient Greek emotion called acedia. A mind “seized” by this emotion is “horrified at where he is, disgusted with his room … It does not allow him to stay still in his cell or to devote any effort to reading”. He feels:
“What unsettles us is not only fear of change. It’s that, if we can no longer trust in the future, many things become irrelevant, retrospectively pointless. And by that we mean from the perspective of a future whose basic shape we can no longer take for granted. This fundamentally disrupts how we weigh the value of what we are doing right now. It becomes especially hard under these conditions to hold on to the value in activities that, by their very nature, are future-directed, such as education or institution-building.That’s what many of us are feeling. That’s today’s acedia.” From: https://www.cnn.com/2020/09/22/opinions/unrelenting-horizonlessness-of-covid-world-couldry-schneier/index.html
It’s not enough to say it is disordered. That’s merely upholding the status quo. I have said before that attempting suicide is like jumping from a burning building. Your life is on fire and crumbling around you, you feel no options are left to you other than to jump. Suicide prevention as a field often catches people, but then too often has nothing to say, but give them a diagnosis and then return them to a building still on fire. A diagnosis is not an answer in any real sense. It has nothing to say on why the building is on fire, how the fire started, if the building has any emergency exits, if the person is able to put the fire out themselves or get help to do so. It just shepherds us back to the front door and says nothing.
Because last month was #MentalHealthAwarenessMonth and this month is #PTSDAwarenessMonth, let’s talk about classic PTSD, and another related mental illness, which is c-PTSD, or complex PTSD. A thread.
“If you do the math, according to the PTSD criteria in the DSM-5, you can have 636,000 different combinations of symptoms that that describe PTSD,” says Danny Horesh, head of the Trauma and Stress Research Lab at Bar-Ilan University in Ramat Gan, Israel. Given all the traits in people with autism that may overlay these permutations, “you have a lot of reason to think that their version of PTSD might be very different,” he says.
Abuse, sexual assault, violence, natural disasters and wartime combat are all common causes of PTSD in the general population. Among autistic people, though, less extreme experiences — fire alarms, paperwork, the loss of a family pet, even a stranger’s offhand comment — can also be destabilizing. They can also be traumatized by others’ behavior toward them.
“We know from the literature that individuals with autism are much more exposed to bullying, ostracizing, teasing, etc.,” Golan says. “And when you look in the clinic, you can see that they’re very sensitive to these kinds of events.” Among autistic students, Golan and Horesh have found, social incidents, such as ostracizing, predict PTSD more strongly than violent ones, such as war, terror or abuse, which are not uncommon in Israel. Among typical students, though, the researchers see the opposite tendency.
Cumulative adversities faced by many persons, communities, ethno-cultural, religious, political, and sexual minority groups, and societies around the globe can also constitute forms of complex trauma. Some occur over the life course beginning in childhood and have some of the same developmental impacts described above. Others, occurring later in life, are often traumatic or potentially traumatic and can worsen the impact of early life complex trauma and cause the development of complex traumatic stress reactions. These adversities can include but are not limited to:Understanding Complex Trauma, Complex Reactions, and Treatment Approaches
◦ Poverty and ongoing economic challenge and lack of essentials or other resources
◦ Community violence and the inability to escape/re-locate
◦ Disenfranchised ethno-racial, religious, and/or sexual minority status and repercussions
◦ Incarceration and residential placement and ongoing threat and assault
◦ Ongoing sexual and physical re-victimization and re-traumatization in the family or other contexts, including prostitution and sexual slavery
◦ Human rights violations including political repression, genocide/”ethnic cleansing,” and torture
◦ Displacement, refugee status, and relocation
◦ War and combat involvement or exposure
◦ Developmental, intellectual, physical health, mental health/psychiatric, and age-related limitations, impairments, and challenges
◦ Exposure to death, dying, and the grotesque in emergency response
As the quest for perfection fails over and over, and as sustaining attachment remains elusive, imperfection becomes synonymous with shame and fear. Perceived imperfection triggers fear of abandonment, which triggers self-hate for imperfection, which expands abandonment into self-abandonment, which amps fear up even further, which in turn intensifies self-disgust…on and on it goes in a downward spiral of fear and shame encrusted abandonment. It can go on for hours and days…weeks in environmentally exacerbating conditions…and for those with severe PTSD, can become their standard mode of being.
Looping/ Over-Futurizing I will not repetitively examine details over and over. I will not jump to negative conclusions. I will not endlessly second-guess myself. I cannot change the past. I forgive all my past mistakes. I cannot make the future perfectly safe. I will stop hunting for what could go wrong. I will not try to control the uncontrollable. I will not micromanage myself or others. I work in a way that is “good enough”, and I accept the existential fact that my efforts sometimes bring desired results and sometimes they do not. “God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference” – The Serenity PrayerShrinking the Inner Critic in Complex PTSD
One common clue that we are in a flashback occurs when we notice that we feel small, helpless, hopeless and so ashamed that we are loath to go out or show our face anywhere.Frequently Asked Questions About Complex PTSD
Another common clue that we are flashing back is an increase in the virulence of the inner or outer critic. This typically looks like increased drasticizing and catastrophizing, as well as excessive self-criticism or judgementalness of others. A very common example of this is lapsing into extremely polarized, all-or-none thinking – and most especially into only noticing what is wrong with yourself and/or others.
A wealth of links to further info on trauma and C-PTSD.5 Ways to Lovingly Support Someone With C-PTSD
Put another way: prolonged helplessness and harm, with a dysfunctional reaction to that state, is the recipe for complex trauma.AM I ‘TRAUMATIZED ENOUGH’ FOR A COMPLEX PTSD DIAGNOSIS?