This comes up quite a bit in session as does most of the stuff I write about. This one, however, I think is a pretty important concept that isn’t clarified enough. Maybe it just doesn't occur to us? So get you a snack and have a seat. Let's talk diagnosis- specifically multiple diagnosis.
As you know, I specialize in Post Traumatic Stress. This comes with a LOT of information and can snowball quickly. I've got to know a little about everything. I have clients with multiple diagnoses, though I generally just have PTS as their diagnosis in my records (if I put anything.) There isn’t a litany of labels in their chart. That has directly to do with what I’m talking to you about now.
I had a client put it pretty succinctly. (And I don’t feel like I’m outing this client because I’ve had several say the same thing. I don’t remember who it is, but I remember the verbage. So- if this is you, your secret is so safe with me that I couldn’t credit you if I wanted to! I’m willing to bet actually that several of you will claim this quote.)
We were in session and had unearthed yet another "diagnosis". They said that sometimes they wish that they hadn’t come to therapy because “we just keep finding more shit. "I came in for one pile of shit, and then we find another pile, and another pile, and we just keep making this GIANT pile of shit.” At first, I was sympathetic and simply mirrored the feelings that this is overwhelming. But upon further thought it hit me:
It’s all the same.
While any of these what we call "comorbid" (happening at the same time) diagnoses can be stand alone diagnoses in their own right, as it relates to PTS I see them as SYMPTOMS. Maybe someday I'll research or argue this, but for now, I'm just going to opine on my blog.
So, I have a few alternative diagnoses in my clinic but most of my clients start with PTS. Here are just a FEW things that could stand alone in diagnosis that I often unearth when i have a client who comes in with trauma:
- Self Harm (We call this Non-Suicidal Self Injury or NSSI)
- Suicide Attempts
- Anorexia and other eating disorders/behaviors
- Borderline and other personality disorders (MOST come from trauma. There are exceptions.)
- Sexual difficulties in all forms
- Impulsive and compulsive behaviors
- Hormone imbalances and Autoimmune disorders (again, there are exceptions.) Your body holds trauma and will express it in physical ways.
- Memory difficulties (not always exclusively from trauma. Exceptions.But this is often inattention/dissociation)
- Dissociative Disorders
- *Brain structure differences*- (YES, trauma changes how your brain grows!) Another one for the body holding trauma.
This isn't even a comprehensive list! It gets complicated fast.
So- I may have a client who comes in and I say "your diagnosis is Post Traumatic Stress." I, as always, explain and off we go. However, in the course of treating the PTS we may then realize the client has behaviors of anorexia AND addiction AND codependency AND depression AND anxiety.
At first, I didn't notice this phenomenon or realize what was going on with my clients and why they felt so "screwed up." I dind't understand why realizing another symptom would tailspin them. They would sink into a depression or anxiety spin, they would feel hopeless, and they would feel like they're never going to heal. And I would think "Why is this a thing? We already knew this."
Then it hit me! They see each symptom as an independent diagnosis!
In their mind it goes like this:
PTS + Anorexia + Addiction + Codependency + Depression + Anxiety= everything that needs treating.
Look at how overwhelming that is! No wonder!
In MY mind it goes like this:
PTS = everything that needs treating. BECAUSE PTS= all the other symptoms which include anorexia, addiction, codependency, depression, and anxiety.
See the difference? Perspective is everything I suppose.
Here's the absolute beauty of this: When one realizes that trauma is the root and aims there, treatment time and pain are drastically decreased!
Now this is not to say that treating the trauma alone always resolves everything. It'll do the bulk of the work but sometimes we still have to go resolve whatever remains of whatever is expressing itself. However, at least for me, it explains why just treating depression and not the real core of it, or just treating feeling anxious, or just treating hormones has people in inefficient and lengthy treatment programs. For me, the less we can drag you through the pain the better! I'm gonna go out on a limb and say you'll agree.
A word about diagnosis. I can only speak for myself (and the cool therapists I hang out with) but at least in my social group we see it as a tool. It's not an identifier. You aren't your symptoms. It's mostly something the insurance companies forced upon us- at least in its current form. We, as therapists, mostly use these terms to use as a jumping off point to discuss your difficulties most efficiently. Saying "the diagnosis is PTS" communicates everything that goes along with that label effectively. Otherwise, we'd end up taking forever to explain what's going on. The trouble is when one takes each symptom as its own diagnosis and feels buried under them. Not so- it's all part of the same, beautiful, resilient, survivalist system that no longer appears to be serving you. BTW It's fixable, and it's fixable without 12 million years of painful retraumatizing therapy. That doesn't mean therapy won't be painful, but it won't be AS painful, or as long.
Hopefully, if you're reading this, you now understand that 1) you developed this as a way to survive something awful, which is pretty strong, 2) it expresses itself in multiple ways, all with different names and 3) it doesn't have to take forever to heal.
If you've already started: You're awesome. I see you . Keep going!
If you haven't: We're here for you when you're ready. It can be lonely and overwhelming to navigate this alone. I promise you aren't as "screwed up" as you think you are, and it's all the same BIG pile of shit. You can heal.