Theory Vs Diagnosis (structural Dissociation)

[BlueOrange]

There is value in understanding the difference between different kinds of ideas.

My view (and I'm unlikely to be swayed) is that 'Structural Diagnosis' is a theory of pathology, and that the diagnoses that it informs are PTSD, DD-NOS and DID. This is the view expressed in The Haunted Self, and therefore it seems very defensible to me.

Of course, a diagnosis is also a theory - it's a shorthand way of saying "I have formed the view that the pathological mechanism at work in this case matches the mechanism described by the label." Or, in the case of syndromes "I believe that the pattern of symptoms exhibited in this patient fits this label more closely than it fits any other label."

One of the big problems that we have in mental health is that we don't have strong models of how the mind works (physiology), and we don't have strong models of how the mind breaks (pathology). This is why we end up saying annoying things like "It's not clear why some people get PTSD and other people don't." We tend not to say "It's not clear who gets smallpox and other people don't," because we know a lot about smallpox, and how it works, and how the body defends itself against viruses.

So a mental health diagnosis tends to be a 'syndrome' diagnosis (you have this cluster of symptoms that tend to occur together), and not a 'disease' diagnosis (a specific pathogen has acted on you in a certain way, disrupting normal functions in a way that produces a cluster of symptoms). This, for me, is the revolutionary and wonderful thing about the theory of structural dissociation, it explains the way in which normal mental function is disrupted by the trauma.

Importantly, the progress of the pathological mechanism in the theory of Structural Dissociation provides a very important clue as to why some people get PTSD, and other people get Adjustment Disorder. You cannot fulfil the criteria of Structural Dissociation unless there is at least one Emotional Part, and that the Apparently Normal Part has a phobia of the Emotional Part. In other words, some people come out of a traumatic event in a way that makes them frightened of their own mental processes - it is the fear of your own mental processes that defines and differentiates Structural Dissociation from other pathologies.

 

[Suzetig]

I think the distinction between theory and diagnosis is important, in that one helps you understand what might be happening and the other carries a label that can be both a help and a hindrance.

I'm not sure I agree that we don't have strong models for how the mind works and psychopathology - the issue is possibly the variety of models out there. For example the concept is "disease" represents the medical model of there being something wrong that needs to be fixed with medication, therapy etc but that ultimately the doctor is aiming for a cure. The social model of mental illness basically says that the way society is organised contributes to a individuals mental health and the way they manage or cope - ie that our minds do what they need to do and it's only problematic because of societal norms that don't accommodate differance. There are lots of other models for understanding mental illness generally but those two camps tend to be most prevalent.

When you get to trying to understand why we "break", there are as many models to inform our understanding as there are people, so structural dissociation is one, but there are others that help us understand what PTSD is and why people may or may not get it. Attachment theory, congnitive distortion, shattered assumptions, person centred theories, configurations of self all have something to say about how we respond to trauma. The benefit of there being so many different theories is that there are some that sit better than others with different people.

By way of example, I know I dissociate. I'm not DID and DD-NOS doesn't really fit either but theory around configurations of self really helps me understand what happens with me. So, I don't "fit" either diagnostic criteria, but I have a theory that helps me demystify what's going on and gives me a framework to work with (in my case learning how to accept the different parts of me as being part of me). I don't see myself in the theory of structural dissociation, but others do and it's helpful to them, which is great. I honestly think it's a case of finding whatever works for us, helps us understand ourselves and make sense of what's happening with us while knowing there's no one great answer that fits everyone.

 

[watundah]

This is very helpful as I toss around some things my T has been suggesting. Thanks for posting.

 

[Rani G2]

By way of example, I know I dissociate. I'm not DID and DD-NOS doesn't really fit either but theory around configurations of self really helps me understand what happens with me. So, I don't "fit" either diagnostic criteria, but I have a theory that helps me demystify what's going on and gives me a framework to work with (in my case learning how to accept the different parts of me as being part of me). I don't see myself in the theory of structural dissociation, but others do and it's helpful to them, which is great.

Thanks for writing this. I will write it down. ;)

 

[Kailani]

Love the clarity you brought to the subject! Thank you!

 

[Seasounds]

it is the fear of your own mental processes that defines and differentiates Structural Dissociation from other pathologies.

The terrain between adjustment disorder and a personality disorder is just exactly this.

I relate to this, greatly. On one hand I have a foothold on reality enough to be aware of the tortuous memories that can get triggered at any moment, sending me into hell until I can swim out of it.

My fear is evidenced by my sheer tenacity of challenging my therapist at any inkling of his words that hint at 'getting over it'; after 15 years of nightmares, due to stuffing feelings, I start to panic when I think of having regular nightmares again. Fortunately, my therapist is respectful.

 

[Sandstone]

it is the fear of your own mental processes that defines and differentiates Structural Dissociation from other pathologies.

This was the lightbulb distinction for me. It is the phobia of the mental processes, of the emotional response to the trauma that prolongs my PTSD. It explains the bizarre logic of that nonsensical set of inner thoughts that facing my trauma could kill me, so it s best to kill me to avoid it. "All" I need now is a T who can help me break through that.

My reading of SD is that this phobic division develops at the time of the trauma, but I wonder if it is present earlier. Do families that don't acknowledge or allow the expression of emotions create that separation between the events and the associated emotions?

 

[BlueOrange]

My reading of SD is that this phobic division develops at the time of the trauma, but I wonder if it is present earlier. Do families that don't acknowledge or allow the expression of emotions create that separation between the events and the associated emotions?

(I'm being a bit speculative here, and I don't have authorities who can back me up on what I'm about to say.)

That's a really interesting question. I can certainly see how a great many families and societies train their children to dissociate ("boys don't cry" is a very widespread saying that encourages boys to dissociate from sadness). However, I don't think that 'a tendency to dissociate' is enough to cause a disorder of structural dissociation on its own. You have to simultaneously deny a part of yourself and also desperately need a part of yourself.

So, a man who is raised to believe that crying is weak and who never cries would not become afraid of his own tendency towards sadness, because he'd be confident that it doesn't exist. Only when he had a desperate need to cry that he could not suppress, would he have a reason to be afraid.

When we are directly confronted with death, there's a chemical change in the brain - when you go into the cortisol response, randomly-selected bits of your memory are turned off, and you become extremely good at recording new memories. This is useful from a survival point of view; it means that your established memories and habits (which presumably got you into this trouble) no longer control your behaviour, and you're learning very fast and very hard about how to survive the situation that you're in. Effectively, the encounter with death creates a new 'part'.

If the new part is highly compatible with the existing mind, then there's no problem. If the new part is not compatible, then you'll try to reorganize your mind - this is Adjustment Disorder, Reactive Depression, that sort of thing. If the effort to reorganize is unbearable (too frightening, too depressing, too disabling), then we dissociate from the effort to repair the dissociation, and form a Structural Dissociation.

 

[theshadowoftheliving]

@Sandstone I think that my own family of origin and their subsequent "don't ask, don't tell" policies primed me for being phobic when a bigger trauma occurred. They probably weren't the ultimate cause for me to fragment, but I'm sure that those learned communication methods reinforced the structural dissociation.

When I'm trying to say through my own experience - I think people become phobic at the moment of trauma, but some are prepped to see that as an option through their previous life experiences. It's the same reason that, once you have PTSD, it takes a less-than-criteria-A trauma to reactivate and trigger it.

 

[Suzetig]

I'm not sure about life threatening trauma always creating a new "part" - that would suggest that everyone who has experienced trauma goes on to experience some form of disorder which is simply not backed up by research. The vast majority of people will, after a period of processing trauma, go on to recover fully and have no long term adverse impact.

While we all dissociate to some extent (the classic example of driving arriving some where and not remembering the journey) it is generally not problematic to people and not trauma related. Trauma related dissociation is generally accepted as a consequence of early childhood trauma, experienced before the age of 7/8 and seems to be caused by the split experienced by a child needing to make sense of having their survival needs met by someone who presents a significant threat to them ie as a way to retain an attachment relationship in the face of unpredictability and extreme danger. After the age of 8 the brain has developed different ways to protect and cope so dissociation becomes less likely and as an adult an experience of trauma isn't likely to cause dissociation to start without a childhood trauma being in there somewhere (ie the pathway was already in place, so to speak).

There's a lot of literature out there on dissociation both in terms of diagnosed dissociative disorders and more phenomenological approaches, eg starting with what people feel is their lived experience. It might be worth reading more widely that structural dissociation because that's only a very small part of the story, it's really easy to extrapolate a theory that makes sense to you but that doesn't mean it applies necessarily in the way we think it might.

 

[Katherine Moss]

The terrain between adjustment disorder and a personality disorder is just exactly this.

I relate to th...

I relate to it so much that I'm avoiding reading about what I'm avoiding. I'm terrified every day of it going back to "normal". Normal has become the abnormal. This attempt makes me so tired.

 

[mamachick]

I think I actually have fear of being happy and productive again. I don't feel like I can emotionally take my comforts being taken away again. You can't destroy a person that is already destroyed. I am very tired. Sorry!