British Medical Journal Features Tavistock Trauma Service: The Challenges & Problems of Diagnosing Complex Trauma & PTSD | London Trauma Psychotherapy

The BMJ (British Medical Journal) recently published an article from our Trauma unit at the Tavistock, co-created with people who previously used the service. Diagnosis is a complex, fraught, and highly political arena. In the trauma unit, we are often critical about the nature of diagnosis and operate a low threshold, low gate-keeping policy, a difficult ethical stance to hold in the ultra-diagnostic-led NHS. Many of our patients will have previously received multiple diagnoses, sometimes administered hastily and defensively by clinicians who are struggling to manage the anxiety of emotional contact with those affected by trauma.

Joanne Stubley, Beverley Chipp Marta Buszewicz

Multiple diagnoses and even the idea of diagnosis in general have huge problems baked in. To begin with, the idea carries medical associations of disease and cure. As much as many of us wish it were as simple as mending a broken bone, psychological suffering is not like this. This isn’t to diminish mental suffering but rather to distinguish its complexity.

However, for some, a diagnosis can help reduce isolation around their suffering as well as make something feel validating and

more ordinary. This can be important as internal pain is invisible.

Diagnostic labels can also be helpful for people to pin their suffering to a piece of terminology. This is temporary but can help, particularly when people are early on in understanding something about themselves. It acts as a kind of temporary membrane of meaning. However, labels can quickly limit subjectivity and will never explain anything beyond a cluster of symptoms for an individual. They carry no meaning beyond this and can at times be unhelpfully clung to as an explanation; however, this becomes a problem. Diagnosis rapidly becomes a tautology: why do I feel anxiety? Because I have an anxiety disorder. But why do I have an anxiety disorder? Because I feel anxiety… round and round we go... this can lead to frustration for the diagnosed and a deadlock in meaning.

Diagnosis can rapidly become a tautology - why do I feel anxiety? Because I have an anxiety disorder. But why do I have an anxiety disorder? Because I feel anxiety.

Diagnoses are best when understood as short, brief, broad, and as a helpful, simple way of communicating clusters of symptoms amongst clinicians for care planning. However, as so often is the case, issues arise when they are used to describe personality organisations and intrapsychic structures by those not trained to understand these processes and operating from medical models, often privileging a causal reductionism. They can also be used to attack patients, and we can see trends of certain terms that have become a pejorative shorthand.

Diagnoses are often a messy fiction. Necessarily, many diagnostic criteria, particularly in the DSM, are a muddle of earlier psychodynamic theories of internal structure muddled together with behavioural symptoms. Particularly those about 'personality disorders'. An issue is the total absence of any notion of unconscious process when dealing with DSM criteria. Ironically enough, ideas of unconscious process are implicit in all models of the mind, though this is denied in most mainstream psychological discourse. Take the idea of a 'cognitive distortion' or any manner of implicit bias or belief. Here we are in the realm of unconscious process, which lies at the heart of psychological function and distress, yet has been elided or expunged from the many mainstream discussions.

Diagnosis also moves in social trends, it is not indivisible from the social, it is cultural and contextual. Take the history of hysteria, for example, a once broad diagnostic category, it no longer exists for all sorts of reasons. Though a complicated term and one with a fascinating history, we could see presentations of somatic problems that might have once been understood in this way. Now we see these issues clustered into sub-categories; terms such as functional neurological disorder, chronic fatigue, long covid, and other medically unexplained symptoms. Arguably, having these more specific sub-categories is more helpful, but I think the disappearance of unconscious dynamics in their explanations is a huge problem. This is a complex topic, but the removal of internal dynamics as an area of explanation places a great deal of excessive guilt upon patients. Lots of ink has been spilled over this topic; see here for some further reading: 'From paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era'.

However, for some, a diagnosis can help reduce isolation around their suffering as well as make something feel validating and more ordinary. This can be important as internal pain is invisible.

These days, there is a clamour for autism or ADHD diagnosis, particularly within London services. We might ask ourselves some questions about this. Is this because there is a better identification and understanding of certain psychological presentations, and we are now only just catching up with being able to appropriately identify them...? or have these diagnoses become the latest label to explain and draw a parameter around certain complexity, therefore managing anxiety for clinicians, the individual, and society? I’m not suggesting the answer is a simple one.

There is also tension between what we might think of as an etiological style diagnosis and structural or behavioural ones. The idea of a complex trauma diagnosis heads towards etiology. This brings different complexities and difficulties, but when it comes to survivors of trauma, particularly early relational trauma, it at least starts from a position of belief and recognition of the serious impact of neglect and abuse on the psyche.

Read the BMJ article here