Differentiation between the Healthy Process of Grief and Depression

This information is lifted off the Diagnostic and Statistical Manual of Mental Disorders ( DSM 5).  Interestingly, this passage, which I consider to hold very important information, is written as a footnote on page 134 of the Manual.

What is the difference between grief and major depression, anyway?

For one thing, grief is a natural, healthy reaction to loss. It is an emotional response to something that has happened in our lives. We cannot escape encountering losses, and we cannot escape feelings of grief when it happens. Just because one feels terrible in a state of grief, does not mean that one has a mental / psychological disorder.

My reason for highlighting this, is with the hope that in grief, one one learns to find the right kind of self-support: find someone to talk to, try to not be alone, cry, find creative outlet and let time heal the wound (although it may leave the scar).

A potentially detrimental method of avoiding grief is to turn to drugs or narcotics, blame the self/self judgement for feeling bad, or any kind of harming the self or others.

grief and depression psychotherapy
Grief vs. Depression

Here’s what is written in the DSM-5 footnote:

“In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in a MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of a MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of a MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in a MDE. In grief, self-esteem is generally preserved, whereas in a MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “’joining” the deceased, whereas in a MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.”

Psychomatics: Binge Eating Disorder

Psychosomatic Disorder: Overeating associated with other psychological disturbances

Overeating is considered a behavioral disorder that is attributable to psychological disturbances. This behavior has its physiological consequences. Obesity, which is measured by a body mass index [BMI ≥ 25], is all but a consequence of this behavior. Depending on genetic factors, some people who develop overeating behavior disorder may not become obese. Other physical problems, however, eventually afflict long-term overeaters. This include metabolic syndrome, a chronic disease suffered by millions worldwide which result in morbidity and mortality. Despite much attention put into the worldwide “obesity epidemic” the problem of over-nutrition is difficult to grasp. This is attributed to the fact that the cause of the problem is multifactorial, with environmental and psychosocial influences in play (Agras, 2005).


Different Subtypes of Eating Disorders

Eating disorders are grouped together in the ICD 10 and DSM-V system. This include Anorexia Nervosa (AN) and Bulimia Nervosa (BN). Unlike AN and BN, together with other forms of Eating Disorder Not Otherwise Specified (EDNOS), overeating is a disorder associated with over-nutrition and has the opposite effect. The sufferer does not compensate for the habit by doing activities like purging in order to lose the calories consumed. As opposed to these eating disorders it is not clear if the root of over-nutrition is psychological or physical, i.e. if obesity, and other affects of over-nutrition is a cause of overeating or vice versa or both ways (ibid. p. VII).

Categorization in the ICD-10 does not specify or name the condition “Binge Eating Disorder” as in the DSM. Within the ICD-10 there are at least 3 related conditions that could relate to the condition. The closest is F50.9 which is basically Essattaken ohne Erbrechen, F50.4 which if the condition coincides with emotional disturbances. As a consequence, it could also relate to F55, addiction to non-addictive related substances.


General Description and Diagnostic Considerations

Binge Eating Disorder (BED). The behavioral problem of overeating is classified in diagnostic manuals within the category of eating disorders. Only since DSM-V has BED been recognized with its own category. Prior to this, in DSM-IV, BED was relegated to an appendix alongside EDNOS, BED is defined “as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with BED may eat too quickly, even when he or she is not hungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This disorder is associated with marked distress and occurs, on average, at least once a week over three months” (American Psychiatric Publishing, 2013). BED also does not result in compensatory behaviors like purging (Tuschen-Caffier & Schlüssel, 2005).  It is separated but intertwined with obesity and is generally known to have emotional underpinnings (Masheb & Grilo, 2006).


It may be useful to note that BED is considered to be a separate condition from the general phenomenon of overeating according to the DSM. In the ICD, there is a condition identified as “overeating associated with other psychological disturbances” (F50.4) a situation of overeating in the presence of emotional stress or setback. Studies have shown that obese individuals with BED differ from individuals who are simply obese (Grilo, 2000).


Obesity is not the only physical consequence of BED, and many sufferers may not show significant signs of adiposity. There exists evidence of risk of metabolic disease arising from the behavior, with a higher percentage of newly diagnosed type 2 diabetics having experienced problems with binge eating compared to other groups who have not that experience. Recurrent binge eating can also make diabetes difficult to control. (Kenardy, Mensch, & Bowen, 1994)


Food Addiction. Could the cause of over-nutrition be the result of addiction to food or certain food ingredients? Is addiction to food, and/or the phenomenon of food craving related to, or contributory to BED? Food craving is known to be a cause of uncontrolled eating, which lead the scientific community to recognize food substances to be potential triggers of addiction, similar to the effect of drug addiction (Pelchat, 2009).  Refined foods have been implicated to cause addiction, whereby loss control of intake of such food is a cause of health concern (Ifland, et al., 2009). There are also arguments that unlike drug addiction, what is often food “craving” has a biopsychosocial aspect that is not synonymous with addiction (Rogers & Smit, 2000). In the ICD, depending on severity of dependence to the food substance, we may, arguably, consider the classification under “Abuse of non-dependence producing substances” (F55).


From a biological standpoint, the idea that “non-dependence producing” could be questioned. Long-term chronic over-eating leads to metabolic disorders, which is related to the endocrine system. Insulin resistance caused by constant high levels of glucose and fructose intake results in not only physiological effects on the patient, but also psychological effects. While sugars are not considered directly “psychoactive”, glycemic levels do affect the mental state. Sufferers of metabolic disorders have problems dealing with the homeostasis of blood glucose, and face with uncontrollable craving, hunger and other emotional side effects, like stress and depression (Goebel-Fabbri, et al., 2005). Looking at the situation holistically, one can observe a vicious cycle of uncontrollable behavior resulting in physiological problems that add to more difficulty in managing the behavioral impulses (Vaidya, 2006, S. 76).


Criteria notwithstanding, for this paper, I discuss the phenomena of uncontrollable over-nutrition, since sufferers exists in varying degrees and since as psychotherapists, we may encounter many clients with difficulty controlling their tendencies to over-eat, and need help regardless of whether their symptoms fulfill the criterion stipulated in the manuals or not. As with most eating disorders, that while the symptoms may seem similar amongst patients diagnosed with the same disease, the underlying mental causation for each case is individual-specific. The challenges exist with such clients since there lies not only emotional grounds for the occurring situation, but also physiological causes.


Physical Symptoms vs. Psychological Symptoms

Table 1. lists the differences between the somatic and psychological symptoms of BED and general disorders related to over-nutrition like food addiction.


Condition Physiological Psychological
BED and “Overeating associated with other psychological disturbances” Over-nutrition, consuming too many calories.

Possible Adiposity.

Long term result in Insulin Resistance, Metabolic Syndrome, and complications therefrom (Goebel-Fabbri, et al., 2005, S. 143).

Possible alimentary canal, teeth stomach injury.



Uncontrollable need to consume food. Feeling lack of control over behavior.

Pre-occupation with thoughts of food.

Emotional reaction to condition: anxiety, stress, shame, frustration.

Psychosocial problems, loneliness, loss of normal social activity caused by habit.

Emotional stress caused by illness as a result of over-eating. Comorbidity with mood disorders, high rates of major depression, personality disorders

(Yanovski, Nelson, Dubbert, & Spitzer, 1993).

Vicious cycle of dealing with weight gain and medical problems.


Food Addiction/Craving Over-nutrition, consuming too many calories.

Possible Adiposity.

Possible toxicity from abused food substance.

Long term result in Insulin Resistance, Metabolic Syndrome and complications therefrom.




Stress caused by weight-loss efforts.

Body image shame.

Yo-yo dieting.

Table 1 Physical and psychological symptoms


Case Study

The case study cited here is a self-report by Kimberly, who posts her story online in the form of videos, otherwise known as vlogging. One can access her videos via her in a YouTube Channel @kimberlyuhles1 (Uhles, 2014). I have decided to use this material because the accounts are directly reported by sufferer. Unlike other material we may find, the case studies do not come from first person perspective and are often edited and reworded. I find it more challenging this way, partly because this “client” does not present herself as someone in the victim position, but rather, a survivor of a disease. The sufferer, in her early twenties at the time of recording, seemed to have found a way to cope with her affliction. At the time of writing this paper, Kimberly is 23, and still vlogs regularly on the same channel. With this, one can simulate a situation with a client whose journey still continues.


Family History

Kimberly has two sisters. When she was 9 years old, her father left home for another family. Kimberly reports that he took everything, including material items for their home. As a child, she says she could not understand why her father left. In the process, her mother had to spend time at work, leaving the children to their own devices at home. They ate and did what they liked. Kimberly recounts later on not having the food that she wants to eat at home. Her mother, in effort to control her children’s weight, kept only healthy foods in the house, and disallowing any junk food. Kimberly felt deprived, especially in school watching other children eat whatever they liked (mostly tastier junk food). She also said she felt left out, or the odd one out because of the food she was given for lunch, and that which was not allowed her. She started sneaking to buy junk food herself, which she would eat quickly so that her mother would not catch her eating them. At 12 years old, her mother put her on a weight-loss regime, sending her to a gym even when she was too young to be allowed in that gym. She had to lie about her age to the trainer. When she was caught eating junk food, her mother would punish her with workout. When she turned 17, her realized sense of “freedom” meant that she was free to eat whatever she wanted. Her experience of having her first car was that of having the freedom to eat. Henceforth, she recounted really being addicted to food. She would eat as much as she could while sitting in the car. Her subsequent weight gain (she was reported to weigh about 300lbs) caused depression. She tried to get gastric bypass surgery but could not afford the treatment. She tried unsuccessfully to make herself throw up, but stopped doing it shortly after realizing that it did not help with her weight problem. She reported feelings of depression and self hate.


Current Situation

It seems that Kimberly managed to cope with her situation through her vlogs, which she has done so regularly for almost three years. Much of what she has talked about were her eating disorder, the emotional triggers, and her efforts to self help through diet and exercise. She also likes to give advise to others. Kimberly is also in a long-term relationship, and has recently found out that she is pregnant. She reports her pregnancy to be a happy situation.



Clinical Practice

From the case presented above, one can appreciate the process that triggered such an eating disorder in a young person. The problems started in childhood and progressed over more than a decade, and is a culmination of situations from which one can hypothesize:

At 7 years old having feelings of loss and betrayal because of father’s leaving.

Feelings of further loss because of mother’s reduced presence at home because of work, and possibly mother’s emotional state.

  • Probably lack of food in home (because mother was not home) and associating this with loss of parental presence and loss of emotional support.
  • Stress from mother’s negative reaction, and harsh remedial actions in response to children’s weight gain (probably caused by mother’s own guilt feelings).
  • Feeling alienated at school. It could have been caused by shame because of parent’s situation, but client associates it with the food she got for lunch.
  • At 17, she associated freedom with having food. At the same time, realizing she was addicted, then judging her own state of mind.
  • Stress and depression from dealing with being overweight.
  • Compensatory measures attempted by client does not fit that of sufferers of Bulimia Nervosa (BN), since the client claimed that she tried it, but found that it did not suit her.

Intervention Questions

These are intervention questions for client at the present time. The client seems to have coped with her initial situation of over-eating and she has found an outlet for her problems through what Freud considers “sublimation” in the form of vlogs. Exercising is also a compensatory measure (and the voice of her internal mother). I believe that dealing with the client at this point is a more challenging task. The personality of the client is one of an independent person who meets up to personal challenges. She also intellectualizes her inner existence through self-analysis. She has not got counselling, and may may not have had time to deal with experiences that underlie feelings of loss, betrayal and need to be shown love. In a video in the channel where she talked about a breakup with her boyfriend, she repeated that she wasn’t given the love that she wanted even when she knew he loved her (they got back together and are having the baby). My impression from watching the video is that this need for “assured signs of affection” reflects the mistrust felt from earlier abandonment, and could be good direction to take in treatment. I would ask these questions (in italics), and try to get the phenomenological experience of the client. What I would try not to do is to talk about physical symptoms or the over-eating habits that the client is already aware of and is ashamed of, unless the client brings it up.


Questions directly addressing binge eating disorders and the somatic aspects:

  1. Help me understand your relationship to food. How often do you eat? What do you like to eat? Etc.
  2. When you were a child, in what way does food play a role?
  3. Did your family eat together?
  4. When did you realize that you have a “problem” with binge eating? When did it happen, where were you, how did you feel?
  5. You mentioned you got hungry when you were alone, can you help me understand how you felt as you reached for the refrigerator?
  6. When you had your first car, help me understand how it felt to gather the food and eat it.
  7. Imagine yourself in the car, please say what your experience is like.
  8. After the session of eating, please tell me what it was like for you.
  9. What are the physical effects? Do you feel discomfort? Where in your body?
  10. How long did the discomfort last?
  11. What are you feeling about this now as you are telling me this?
  12. Are there long term effects of this habit?
  13. What have you done in efforts to overcome the effects (weight gain)?
  14. How has this affected your relationships/life/work?
  15. What can you imagine you would have done have you did not binge eaten?


The following are questions I would ask considering methods in Gestalt therapy. If the client does not acknowledge binge eating as a problem, or if he/she is convinced that he/she has it under control but still shows signs of dependency issues in relationships, these questions may be a way to help work the client towards the issue:


  1. Congratulations on the baby. Tell me what having this baby means to you? What is it like for you to be a mother? What is it like to hold the baby?
  2. What do you want for your baby? What is your wish? The client may express aspirations for her child, or for her family.
  3. Very nice. Lucky baby. Look for phenomenological expression. On this remark. Is she touched? Eyes moist? Smiling? I wouldn’t ask question but state what I observe. E.g. I notice you were touched/ your eyes are moist/you were smiling when I said this. Then wait for response.
  4. If client makes reference to her past experience as a child, e.g. “I do not want my child to bear the same problems,” then ask about it. Otherwise, stick with the moment of happiness with having the baby. Dwelling with the positive makes for good rapport.
  5. If client talks about disappointing childhood, say, tell me, what happened when your father left? What did that mean to you then?
  6. Imagine you were back there, what would you like to say to him? What would you like to ask him? Use empty-chair if client is okay with it, and guide client through experience. One may also continue with discussion on the client’s father, but with focus on what the client feels about him, look for emotional queues on the face and body language.
  7. Tell me, what is your father’s response now? This question one can ask after empty chair or some kind of constellation technique. This is to help client gain insight into the father’s motives/weakness.
  8. So he said this. What do you take from it? Usually client will experience that father’s leaving was not her fault and/or that it is his weakness and/or this is how grown ups behave…etc.
  9. I can see that this is happening right now. I feel… Acknowledge client, allow her to experience this with someone empathizing along with her.
  10. Imagine yourself as the child, and your father just left suddenly. What do you want to say to your mother? Again, empty chair or phenomenological discussion. This is to establish client’s idea of what was going on with mother.
  11. How did you feel being alone at home without her? It is to help client find out Was it fear? Anger? Hunger? What? Then allow the client to take it in.
  12. I can see that this is happening right now. I feel… Acknowledge client, allow her to experience this with someone empathizing along with her.
  13. As an adult, here and now, tell me what you think of this little girl?
  14. I think she’s ……too! Repeat the positive things client says about herself as a child.
  15. Give us one word to describe this session. This is to crystalize the insight, at the same time to put distance again from the past and return to the present.




While many people may face the same kind of childhood trauma, only some children develop, for example, Anorexia Nervosa. Others may do the opposite and become binge eaters and /or become obese. For others, eating disorders do not become a problem, but they develop an array of physiological symptoms as a result of anxieties, phobias and internally directed aggression. Question that arise are: is there ever a psychological problem that does not have somatic implications? Are there ever somatic symptoms that do not affect the psyche? What has personality—what many would agree to be caused by the ego— got to do with the physical attributes of a person? Does personality, then, correlate in some way to the manner of physiological disorders an individual might contract? For that matter, is every individual really unique, and what can personality traits tell us about the motivation behind these disorders?

We may find some good advice from pioneer Gestalt therapist, Erving Polster (1987); he has trained therapists of the modality to see, and value every persons’ life as a novel. This idea may be very helpful, because it puts the therapist on a mindset of valuing the clients’ life as something interesting and worthwhile to investigate. When the therapist is interested in the life of someone, he/she would naturally ask appropriate questions and go beyond the stories he/she tells, or that of his/her doctors. The therapist would be able to work authentically without fear of seeming unprofessional, losing the client to other therapists, making the client angry or other problems we have discussed at class.  In dealing with dialogue, I’d often refer to the works of Lynn Jacobs, one of which tackles shame (of both client and therapist) in the therapeutic dialogue (Jacobs, 1995). What one can infer from Jacob’s argument is the possibility that shame (or unrecognized shame) in therapy prevents the therapist and client from getting to the heart of the matter, thus leaving problems to persist and the therapy ineffective. One can only imagine that ineffective therapies, especially encountered by clients dealing with somatic symptoms, can be intolerable and frustrating. This leaves for interesting work and more detailed efforts into psychotherapy process research.

Read also: What is Psychosomatics?


Agras, S. (2005). Preface. In S. Munsch, & C. Belinger (Eds.), Obesity and binge eating disorder (pp. VII-IX). Basel: Karger.

American Psychiatric Publishing. (2013). Feeding and Eating Disorders. Retrieved from American Psychiatric Publishing: http://www.dsm5.org/documents/eating%20disorders%20fact%20sheet.pdf

Goebel-Fabbri, A., Musen, G., Sparks, C. R., Greene, J. A., Levenson, J. L., & A.M., J. (2005). Endocrine and Metabolic Disorders. In Textbook of psychosomatic medicine (pp. 495-497). VA: APPI.

Grilo, C. (2000). Binge eating disorder . In F. CG, & B. K. (Eds.), Eating Disorders and Obesity: A Comprehensive Handbook, (2 ed., Vol. 54, pp. 178–182). NY: Guilford Press.

Ifland, J. R., Preuss, H. G., Marcus, M. T., Rourke, K. M., Taylor, W. C., Burau, K., & Manso, G. (2009). Refined food addiction: a classic substance use disorder.  . Medical Hypotheses, 72(5), 518-526.

Jacobs, L. (1995). Shame in the therapeutic dialogue. Retrieved 2016, from http://icpla.edu/wp-content/uploads/2013/09/Jacobs-L.-Shame-in-the-Therapeutic-Dialogue.pdf

Kenardy, J., Mensch, M., & Bowen, K. (1994). A comparison of eating behaviors in newly diagnosed NIDDM patients and casematched control subjects. . Diabetes Care , 17, 1197–1199.

Masheb, R. M., & Grilo, C. M. (2006). Emotional eating and its associations with eating disorder psychopathology among overweight patients with binge eating disorder. International Journal of Eating Disorder, 39, 141-146.

Pelchat, M. L. (2009). Food addiction in humans. The Journal of nutrition, 139(3), 620-622.

Polster, E. (1987). Every person’s life is worth a novel. Gestalt Journal Press.

Rogers, P. J., & Smit, H. J. (2000). Food craving and food addiction: a critical review of the evidence from a biopsychosocial perspective. Pharmacology Biochemistry and Behavior, 66(1), 3-14.

Tuschen-Caffier, B., & Schlüssel, C. ( 2005). Binge Eating Disorder: A New Eating Disorder or an Epiphenomenon of Obesity? In M. S, & B. C (Eds.), Obesity and Binge Eating Disorder (Vol. 171, pp. 138-148). Basel: Karger.

Uhles, K. (2014). My story: Why I weighed over 300 lbs. Retrieved from YouTube Video Channel : https://www.youtube.com/user/HOPEANDSMILES/featured

Vaidya, V. (2006). Psychosocial Aspects of Obesity. In V. Vaidya (Ed.), Health and Treatment Strategies in Obesity (Vol. 27, pp. 73–85). Basel, Karger: Adv Psychosom Med.

Yanovski, S., Nelson, J., Dubbert, B., & Spitzer, R. (1993). Association of binge eating disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry, 150(50), 1472–1479.

CPTSD: Complex Posttraumatic Stress Disorder and Child Abuse

While PTSD is a typical response to a single stressor in adulthood, Complex posttraumatic Stress Disorder ( CPTSD ) is the result of childhood experience of abuse.


Complex Posttraumatic Stress Disorder CPTSD occurs in neither ICD nor DSM, but it has been proposed for over two decades (p.190). Adult victims of CPTSD suffer lifelong effects of emotional and physical instability of varying degrees of severity, making them also vulnerable in the face of stressful life situations.

Consequences of CPTSD:

Another name proposed for this disorder is “developmental trauma disorder.” CPTSD compromises an individual’s identity, self-worth, and personality; emotional regulation and self-regulation; and ability to relate to others and engage in intimacy.

Individuals can experience ongoing despair, lack of meaning, and a crisis of spirituality.


Children are Victims of CPTSD

While PTSD is an atypical response in traumatized adults, developmental trauma may be a very common (and thus the typical) response in traumatized children. Such trauma often goes unrecognized, is misunderstood or denied, or is misdiagnosed by many who assess and treat children.

Children are, due to their immaturity and helplessness, are more prone to being traumatized than adults.  They are also easy targets for narcissistic abuse.

Types of Abuse in CPTSD

CPTSD is generally associated with a history of chronic neglect, trauma, and abuse over the course of childhood. Neglect in early childhood compromises secure attachment and tends to result in avoidant or resistant/ambivalent attachment—or, most severely, toward the disorganized/disoriented attachment style that leads to significant dissociative pathology.

This neglect sets the stage for trauma in early childhood, which further interferes with normal affective maturation and the verbalization of feelings, leading to anhedonia, alexithymia, and intolerance of affective expression. Children and adolescents are more prone to dissociate than are adults.

Experience of Betrayal

Dissociation is especially linked to betrayal trauma—the neglect that allows for, or passively tolerate, more active trauma.

In the face of continued betrayal trauma, dissociation is the child’s best life-saving strategy.

The Bystander Parent

Repeated trauma in childhood involves a perpetrator and victim, but also a parent who permits the trauma to occur; is uninvolved, oblivious, and neglectful; or else is paralyzed by fear into inaction. Patient and therapist may find themselves playing any of these roles and their opposites.

Psychotherapeutic Treatment of CPTSD

When a client comes to therapy, it is often not apparent that he/she suffers CPTSD. Adult clients visit therapy for an array of symptoms that include (but not exclusively) depressive, anxiety, obsessive-compulsive, posttraumatic, dissociative, somatoform, eating, sleep-wake, sexual, gender, impulse-control, substance and non-substance dependency disorders and personality disorders.
There is a danger that therapists who are not aware of CPTSD overlook childhood experiences and spend too much focus on the diagnosed symptom.
If the therapist were to treat the trauma of CPTSD itself, this treatment if successful can ameliorate all the symptoms. This requires that the childhood abuse experiences be recounted and worked through.

The Therapeutic Process

It is common that the patient who has CPTSD will not be able to recollect the events of abuse. If he/she did, he/she may not be able to experience the feelings associated with the time. This is because of the dissociation of the child who was in the situation. Freud explains that what the client does not remember, he acts out. It is important for the therapist to be observant to the repeated behavior of the client in the interaction with the therapist.

The trauma and neglect of CPTSD are essentially relational, and so the therapeutic relationship itself becomes the principal vehicle of change. How the therapist feels, thinks, and acts depends on what aspect of the neglect/trauma drama is being played out with the patient (p.191).

Dealing with childhood trauma is a complicated process in therapy. There may a degree of enactment in the transference and this can be confusing. What is really necessary is a sound therapeutic alliance based on trust. Within the transference relationship, the client a therapist experience the client’s enactments and attitudes towards the abusing parent, the bystander parent and the client as victim and perpetrator. For this reason, the therapist has to be alert to the phenomenology and the here-and-now of what unfolds in the therapy sessions.


Lingiardi, Vittorio. Psychodynamic Diagnostic Manual, Second Edition (Page 192). The Guilford Press. Kindle Edition.


Adjustment Disorders: Causes and Symptoms

The diagnosis of adjustment disorders covers a wide range of maladaptive responses to psychological stress, which could be acute, chronic or repeated. These may be responses to illness, changes to family life, developmental milestones such as puberty, marriage, relocation, changes in employment etc.

Adjustment disorders are often exhibited as (sometimes a combination of) anxious moods, depression, behavioral disturbances, psychosomatic pains and ailments. withdrawal, mental inhibition.

How are Adjustment Disorders Experienced?

  1. Affective states. This varies from individual to individual, depending on the individual’s mental wellbeing and personality. They manifest as anxiety, depression, and conduct change. There may be experiences of apprehensiveness,  due to pervasive sense of uncertainty.
  2. Cognitive patterns. The individual with adjustment disorder may be overly preoccupied with what they are facing, or they may defenisvely avoid it.
  3. Somatic States. It depends of how the individual deals with the situation emotionally, adjustment disorder can manifest itself in physical symptoms.
  4. Relationship patterns. Relationship with significant people may be affected due to the stress caused by the disorder. How a person reacts in relationship depends on the individual situation.

How can Adjustment Disorder be Treated?

Individual psychotherapy and/or family therapy is helpful to alleviate the levels of anxiety and stress, by:

  • Helping the client to uncover the root of the negative affects.
  • Allowing the client to better cope with the new situation.
  • If necessary, to help the client take active control of his/her situation (if the situation is negative, e.g. joblessness).
  • To provide a safe environment for the client to be heard. Hence reducing depression and anxiety caused by loneliness.
  • For clients who are stable, to help uncover his/her personality structure / childhood experiences that renders him/her vulnerable to the changes.

Ultimately the goal of psychotherapy is to support the client to express his/her adjustment difficulties and fears, so that he/she may find his own resource to cope with the situation.

What does Dissociation in Psychotherapy mean?

Meanings for the term “dissociation” continue to evolve. Dissociation was originally seen as a type of hysteria, related to conversion, and distinct from depersonalization. It included amnesia, fugue, certain altered states (e.g., somnambulism), and multiple personality.

Dissociation is a criteria in DSM III for diagnosis of PTSD and ASD, as “flashback or dissociative episodes”. While flashbacks denotes sensing of something there that is not (positive symptoms), dissociative episodes denotes absence of sensing what is there –detachment, reduced awareness, derealization, depersonalization and amnesia (negative symptoms).

In Borderline Personality Disorder, dissociation in DSM-5 is described as “transient, stress-related…severe dissociative symptoms” with depersonalization as example.

3 distinct meanings of dissociative experiences (p.180):

  1. Dissociation of some of one’s mental functions or faculties. The DSM-5 definition: “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 291). “Negative” dissociative symptoms involve the withdrawal of something, such as dissociation of memory (amnesia), sensation (conversion anesthesia), or affect (emotional blunting). “Positive” dissociative symptoms involve the intrusion of something, such as the sensory reexperiencing of a trauma (flashback), or any other intrusion of affect, knowledge, sensation (in any modality), or behavior (action, unintended vocalization, etc.). Most of these symptoms may occur within a single consciousness.
  2. Depersonalization/derealization. These may be experienced as the withdrawal of the sense of reality. These are also considered as intrusions in the DSM.
  3. Dissociative multiplicity. This is a plurality of consciousness, in which the first two types of dissociation commonly co-occur; thus, there is always the possibility that cases featuring the first two types of dissociation may have covert multiplicity as well. The DSM-5 definition does not really work for multiplicity because once there is more than one self occupying the center of consciousness, there is more than one center of subjective experience and consequently more than one set of symptoms.

Dissociation in Childhood Experience of Abuse

Freud and his colleague Josef Breuer (1895) identified the root of hysteria in women as child sexual abuse, specifically incest. Freud eventually reversed that emphasis to focus on a child’s fantasies of sex instead of the reality of sexual abuse. Other contemporaries—notably Pierre Janet (1889) outside the psychoanalytic movement, and Sandor Ferenczi (1949) within it—retained a focus on the trauma of childhood abuse, positing dissociation rather than repression as the main method a child (and later an adult) uses to cope. They observed that if the trauma were not worked through and resolved at some point, its residual effects would often have a lifelong (and negative) influence across various domains.

Lingiardi, Vittorio. Psychodynamic Diagnostic Manual, Second Edition (Page 182). The Guilford Press. Kindle Edition.


Dissociative effects of PTSD

Dissociation is PTSD is not psychosis. The person has a flashback — a momentary out of sync with reality, and reliving an experience in a traumatic past experience.
Dissociation is an altered state of consciousness. Unlike psychosis, the individual is functioning but loose track of time/space, etc. The persons may also have a sense of watching him/herself and not being there.

Dissociative effects from Childhood Neglect

The video above addresses dissociation from own feelings. This happens to children of child abuse from narcissistic parent. Most likely the condition of suffering is not unlike complex PTSD.



Lingiardi, Vittorio. Psychodynamic Diagnostic Manual, Second Edition (Page 179). The Guilford Press. Kindle Edition.