Self-Injury and Associated Mental Health Conditions - Post-Traumatic Stress Disorder

Written by Deb Martinson

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder refers to a collection of symptoms that may occur as a delayed response to a serious trauma (or series of traumas). More information on the concept is available in my quick Trauma/PTSD FAQ. It's not meant to be comprehensive, but just to give an idea of what trauma is and what PTSD is about. Herman (1992) suggests an expansion of the PTSD diagnosis for those who have been continually traumatized over a period of months or years. Based on patterns of history and symptomology in her clients, she created the concept of Complex Post-Traumatic Stress Disorder. CPTSD includes self-injury as a symptom of the disordered affect regulation severely traumatized patients often have (interestingly enough, one of the main reasons people who hurt themselves do so is in order to control seemingly uncontrollable and frightening emotions). This diagnosis, unlike BPD, centers on why patients who self-harm do so, referring to definite traumatic events in the client's past. Although CPTSD is not a one-size-fits-all diagnosis for self-injury any more than BPD is, Herman's book does help those who have a history of repeated severe trauma understand why they have so much trouble regulating and expressing emotion. Cauwels (1992) calls PTSD "BPD's identical cousin." Herman seems to favor a view in which PTSD has been fragmented into three separate diagnoses:

For an incredible amount of information on trauma and its effects, including post-trauma stress syndromes, definitely visit David Baldwin's Trauma Information Pages.

Dissociative Disorders

The dissociative disorders involve problems of consciousness -- amnesia, fragmented consciousness (as seen in DID), and deformation or alteration of consciousness (as in Depersonalization Disorder or Dissociative Disorder Not Otherwise Specified ).

Dissociation refers to a sort of turning off of consciousness. Even psychologically normal people do it all the time -- the classic example is a person who drives to a destination while "zoning out" and arrives not remembering much at all about the drive. Fauman (1994) defines it as "the splitting off of a group of mental processes from conscious awareness." In the dissociative disorders, this splitting off has become extreme and often beyond the patient's control.

Depersonalization Disorder

Depersonalization is a variety of dissociation in which one suddenly feels detached from one's own body, sometimes as if they were observing events from outside themselves. It can be a frightening feeling, and it may be accompanied by a lessening of sensory input -- sounds may be muffled, things may look strange, etc. It feels as if the body is not part of the self, although reality testing remains intact. Some describe depersonalization as feeling dreamlike or mechanical. A diagnosis of depersonalization disorder is made when a client suffers from frequent and severe episodes of depersonalization. Some people react to depersonalization episodes by inflicting physical harm on themselves in an attempt to stop the unreal feelings, hoping that pain will bring them back to awareness. This is a common reason for SI in people who dissociate frequently in other ways.

DDNOS

DDNOS is a diagnosis given to people who show some of the symptoms of other dissociative disorders but do not meet the diagnostic criteria for any of them. A person who felt she had alternate personalities but in whom those personalities were not fully developed or autonomous or who was always the personality in control might be diagnosed DDNOS, as might someone who suffered depersonalization episodes but not of the length and severity required for diagnosis. It can also be a diagnosis given to someone who dissociates frequently without feeling unreal or having alternate personalities. It's basically a way of saying "You have a problem with dissociation that affects your life negatively, but we don't have a name for exactly the sort of dissociation you do." Again, people who have DDNOS often self-injure in an attempt to cause

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themselves pain and thus end the dissociative episode.

Dissociative Identity Disorder

In DID, a person has at least two personalities who alternate taking full conscious control of the patients behavior, speech, etc. The DSM specifies that the two (or more) personalities must have distinctly different and relatively enduring ways of perceiving, thinking about, and relating to the outside world and to the self, and that at least two of these personalities must alternate control of the patient's actions. DID is somewhat controversial, and some people claim that it is over-diagnosed. Therapists must be extremely careful in diagnosing DID, probing without suggesting and taking care not to mistake undeveloped personality facets for fully-developed separate personalities. Also, some people who feel as if they have "bits" of them that sometimes take over but always while they're consciously aware and able to affect their own actions may run a risk of being misdiagnosed as DID if they also dissociate.

When someone has DID, they may self-injure for any of the reasons other people do. They may have an angry alter who attempts to punish the group by damaging the body or who chooses self-injury as a way of venting his/her anger.

It's extremely important that diagnoses of DID be made only by qualified professionals after lengthy interviews and examinations. For more information on DID, check out Divided Hearts. For reliable information on all aspects of dissociation including DID, the International Society for the Study of Dissociation web site and The Sidran Foundation are good sources.

Kirsti's essay on "bits" and "The Wonderful World of the Midcontinuum" provide reassuring and valuable information about DDNOS, the space between normal daydreaming and being DID.

Visit our Personality Disorders Community for more information.