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Because I specialize in treating complex patients, I often see people who come to me with four, five, sometimes six psychiatric diagnoses. Often these patients think that they lost the genetic lottery; how else could they be so unlucky as to have five or six separate biological brain disorders?
To help people understand why I think that they do not have a terrible genetic destiny, I talk about Whac-A-Mole, the arcade game where a player whacks a plastic mole as it pops out of a hole, only to have it disappear and be replaced by another mole somewhere else. Sometimes, psychiatric symptoms are like the moles. You whack down the suicidality, and restrictive eating pops up. You whack down the restrictive eating and obsessions and compulsions pop up. You whack those down and mania pops up, then self-harm behaviors. Then paranoia and hallucinations pop up. Then back to restrictive eating, and so on. Does this person have: 1) major depressive disorder, 2) anorexia nervosa, 3) obsessive-compulsive disorder, and 4) schizoaffective disorder? This is exactly how many people come to me, with multiple serious psychiatric diagnoses under their belt.
But the issue with the Whac-A-Mole game isn’t the moles; it’s the machine in the box under the moles. It turns a crank that pushes the moles out of the holes. You can whack them down as much as you want, but as long as the crank is turning, more moles are going to pop out.
In my long experience with hundreds of complex patients, the machine driving the crank is usually trauma. More specifically, it is frequently early trauma — abuse, neglect, and sometimes insecure or disorganized attachment that occurred before the person’s sense of self was fully established, and sometimes before the child could use language to describe their experiences. Instead of being described with words, the trauma becomes inscribed as symptoms. And these symptoms emerge as communications to the person and others to attempt to describe unrelenting and unprocessed distress. The symptoms themselves are like a language from the wordless, unconscious mind, and they are saying “Help me, I am suffering and I can’t fix this alone.” They are not unique illnesses. But in our era of biological psychiatry, they are often treated as distinct disorders, each needing a specific medication or specialized therapy.
Instead, I treat these symptoms as the communications I believe them to be, and the patient and I together come to ask, from a place of safety and curiosity: What is this symptom trying to tell us? As we continue to remain curious, non-reactive, and non-judgmental together, slowly the machine slows down and the moles stop popping up. Trauma is a machine that drives many symptoms. We must look inside the box of the Whac-A-Mole game to shut it down.
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