In response to 636,120 Ways to Have Posttraumatic Stress Disorder, Perspectives in Psychological Science, November 2013 vol. 8 no. 6 651-662 by Isaac R. Galatzer-Levy and Richard A. Bryant Let me suggest that 636,120 combinations for Posttraumatic Stress Disorder reflects a far deeper problem with the DSM5 than simply unintended consequences of well-intentioned tweaking. The entire edifice is absurdly cumbersome and off-base. Has the DSM5 ever heard of Occam’s razor? (Roughly translated, the simplest explanation for some phenomenon is more likely to be accurate than more complicated and convoluted explanations.)

In fact it is Trauma, i.e., deprivation and abuse, when sufficiently powerful that writes our character plays in the first place and rewrites them later in life. Trauma is the universal cause of creating symptoms in people of different temperaments. All symptoms are post traumatic by definition. The treatment for all trauma is through psychotherapy where the patient mourns the trauma in the context of engagement and trust in psychotherapy.

The full range of problematic human character presents a host of different symptoms that generate very different experiences of suffering. The varieties and types of plays show the entire symptomatology of psychiatric conditions. The arcane complexity of the DSM5 has arisen due to the misguided beliefs in pharmaceutical psychiatry and its ungrounded phantom diagnoses. It is a house of cards.

 I would suggest the following as an alternative to the DSM5. (Please note that I do not use the demeaning term psychopathology.) We can break down the degree of formative trauma on the development of character into roughly three groups: (1) In the context of moderate problematic mothering, with some good-enough mothering, we have four major types of character worlds, depending on which temperaments are in ascendancy— obsessional, phobic, compulsive, and dissociative characters. (2) In the context of severe maternal damage, the different array of temperaments generate schizoid and paranoid characters, sadistic and masochistic characters, narcissistic and echoistic characters, borderlinism, affective characters, anorexia, germ phobias, psychopathy, and psychotic depression. [In concert with the excellent comment from Jen Cromwell, please include fathers with the mothering]. (3) Finally, we have the psychotic character worlds in which there is a fragmentation of the intactness of the self persona and a rupture of the cohesion of the play itself. This derives from a damaged Authentic-Being, due to some combination of extremely early maternal damage, with some genetic predisposition, and possibly epigenetic effects, all still forged through the different temperamental orientations. The psychotic character worlds are hebephrenia, catatonic schizophrenia, paranoid schizophrenia, schizoaffective schizophrenia, manic depression, and paranoid state. We don’t even see hebephrenia and catatonia mentioned much anymore because they don’t fit contemporary models. But they did not disappear and are still there.

Robert Berezin MD is the author of "Psychotherapy of Character, the Play of Consciousness in the Theater of the Brain"

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