The real diagnostic axes

One day, not long ago, as I was singing a little sea chantey lament – “O why couldn’t I be a social worker?”* – I conceived this theory:

There are two axes of psychological dysfunction: injury in the mind-body and injury in development.  The two are always intertwined and mutually present.  And following the originating causal irritant (internal or environmental), each axis causes and exacerbates the other.  A corollary of the theory is that if a person has been psychically injured and acquires depression, anxiety, dissociation – neurosis or psychosis generally – he will also succumb to psycho-developmental failure at some level.  That is, failure to develop, mature, grow to genuine adulthood.  Fleshing out this idea, it would be true that many or most adults, even the brightest and highest, will not have ascended to true adulthood if they did not heal well from, basically exorcise, their childhood derangement.  They will be faking it unawares, living a front behind which lurks the undeveloped needy and pained child.

Another corollary is that in general, this developmental flaw leads to some level of personality disorder.  To live out of sync with one’s chronological timeline (to be, for example, an immature child in an adult Borderline’s body; to be an unloved little boy in a brain surgeon’s body) requires a seamless defense “attitude” which is the equivalent of a personality disturbance.  Therefore, as almost all of us were injured and not healed in our childhood, most all of us have a personality problem.

The extreme, and therefore most easily understandable condition in which psychic injury impedes development and grows an adaptive personality is early trauma.  Lenore Terr studied personality differences in individuals who suffered “type 1” (discrete) and “type 2” (protracted) trauma.  The latter associates with “interpersonal dependency” personality features.  She wrote:

“Personality takes a more extreme deviation when the trauma is long-standing or frequently repeated.  Instead of the relatively subtle personality rearrangements that a child will make after a single event, the reenactments of long-standing or repeated traumas pour out of the child so thickly, so frequently, that they amount to massive distortions of character.”  (Too Scared To Cry, p. 268).

Judith Herman, MD, in Trauma and Recovery, strongly suggests that “complex post-traumatic stress disorder” (her own conceptualization) is often mistaken for borderline, antisocial or histrionic personality.  She wrote:

“Survivors of childhood abuse often accumulate many different diagnoses before the underlying problem of a complex post-traumatic syndrome is recognized.  They are likely to receive a diagnosis that carries strong negative connotations.  Three particularly troublesome diagnoses have often been applied to survivors of childhood abuse: somatization disorder, borderline personality disorder, and multiple personality disorder.”  And: “Patients with all three disorders also share characteristic difficulties in close relationships.  Interpersonal difficulties have been described most extensively in patients with borderline personality disorder.  Indeed, a pattern of intense, unstable relationships is one of the major criteria for making this diagnosis.” (p. 124).

But if we can see that repression of the self-feeling – of one’s holistic energy – however it is caused, must take the real self off-line, then off the developmental timeline, and force a replacement identity, the door is open for any early pathogenic insult to lead to personality disturbance.  A shaming father who shuts down his son.  A narcissistic mother who glorifies her daughter’s talent while debasing her spirit.  Early and continued substance dependency.  Familial factors causing a child’s shyness or dissociation or anxiety (see blog post “Anxious Personality Disorder”) or ADHD.  I have seen a handful of men over the past two years who presented an inextricably integrated syndrome of attention deficit, hyperness, and boyishly immature, clueless behavior.  One man, a hospice nurse, welcomed a new employee with a large poster featuring sexually explicit humor.  This was not social gaucheness but an “ADHD personality” as immature and ego-syntonic as any Borderline’s.

This post will not be the place where I explain in depth my grasp of personality disorder, or my conviction that development aborts when the child’s needs are not met and the pain and reality of it must be repressed.  Though I will mention, with sadness, my experience with “Herbert,” a sixty-five-year-old who began a life of drinking at age five – when he would sneak sips of beer during his parents’ alcoholic parties – and didn’t emerge from it until he came for therapy as an old child.  Child, not man, because he had slept, dissociated and inebriated, through his entire life and never planted the feet of a growing person on the planet the rest of us share.  He died a few years after I saw him, curious about what had happened to his life.

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* Social workers (LISW) won the turf war against licensed counselors (LPCC) in Columbus, Ohio, and so it is better to be a social worker.