Archives for : July2015

The Book of Woe, and why NIMH said goodbye to DSM-5

IMG_1078This book review and comment are a little off my beat, for they are about DSM-5 in general, not just its diagnosis of trauma, which I addressed in my post of January 20, 2015, http://traumatheory.com/?p=86.

The full title of Gary Greenberg’s book is The Book of Woe: The DSM and the Unmaking of Psychiatry. Greenberg is a psychologist and journalist. Some of the juiciest pieces of this book appeared in The New Yorker between 2010 and 2013 (Google Greenberg + DSM + New Yorker; they are all there).

The book begins with a story about Sandy, one of Greenberg’s patients. When Greenberg first saw him Sandy could barely go out of his house. By the end of therapy, Sandy had a job, a girlfriend, and what most of us would call a life. Sandy and Greenberg exchanged emails after Sandy moved halfway across the country from Connecticut. Eventually, the emails stopped. A couple of years later Greenberg received a call from Sandy in the middle of the night. It ran something like this.

You’ve got to help me. They’ve sucked all the bones out of my body. I’m here in this hotel room and my bones are gone. My mother and my father and James. They’ve done this to me. And I don’t want to die. Please don’t let them kill me. You’re the only one who can help. Good-bye. Good-bye. (p. 9)

Greenberg tried to call Sandy back at the hotel he had called from, but there was no answer. He never heard from Sandy again.

The book turns on what to make of Sandy’s phone call.

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Whatever happened to DESNOS?

DESNOSDESNOS stands for Disorders of Extreme Stress Not Otherwise Specified, about as clumsy a diagnosis as one could imagine, and an only slightly better acronym. It owes its existence to the persistence of Judith Herman, who in her classic Trauma and Recovery, argued for a special category of trauma she called complex PTSD (C-PTSD). C-PTSD = DESNOS for all practical purposes.

It has long been recognized that there are different types of trauma, but no one has figured out what to do about it as far as PTSD is concerned. Rape, a serious car accident, most wartime trauma takes place during a specified period of time, and often results in the familiar symptoms of PTSD, such as flashbacks, nightmares, sleeplessness, hypervigilance, and a gradual retreat into a smaller world in which the victim is less likely to encounter situations reminding him or her of the original trauma.

But, some trauma doesn’t fit this pattern, generally because it is prolonged, frequently happens at an early age, and often involves people with whom the victim has an intimate relationship. Child abuse is exemplary, but prolonged captivity and confinement of any type also fits the pattern. This includes emotional and physical abuse in marriage or other relationships.

The about to be released International Classification of Diseases, ICD-11, which serves as the DSM for the rest of the world, includes C-PTSD, but only if the victim first fulfills all the requirements of a diagnosis for PTSD. DSM-5 includes most of the symptoms of C-PTSD, achieved in part by enlarging the number of symptoms to twenty. In addition, it includes a dissociative subtype and a pre-school subtype. As with the ICD-11, the basic requirements of PTSD must first be met. DSM-5 does not officially recognize C-PTSD, but one professional’s comment on PTSD in DSM-5 gets it right, remarking that it has become more “DESNOS-ish.”

Here’s the problem

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How trauma works: by destroying the inner other (revised, 7/12)

How Trauma Happens

B00007701. Throughout our lives we need an inner other. We need someone with whom we can carry on an internal dialogue. An inner other is different from an internal object.

Unlike Melanie Klein’s internal object, the inner other is not a projection of innate love and hate, subsequently modified by the real world, before being reintrojected. The inner other reflects the need to be understood. The inner other is created in interaction with others. It is always already a relationship. In this regard it comes closer to John Bowlby’s “internal working model.” The inner other is a relationship, and a relationship takes two.

Unlike Heinz Kohut’s selfobject, the inner other is separate from the self. The inner other is not experienced, even as a young child, “as nonautonomous components of the self,” which exist to serve the self’s need to be mirrored. Nor does the inner other exist in order to be idealized. It exists in order to draw the child into the world. Without the otherness of the inner object the world would be empty of value and joy. See the quote from Daniel Stern below (number 3). The same principle applies to adults.

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