Names on paper

In 2015/2016 a specialised trauma centre handed me four diagnoses.

I wrote about that moment in The Day I Got a Name for It. What I didn't write about was what those names actually meant. About what the clinicians were seeing when they reached for those particular words, and why three of the four came with the same qualifier: Not Otherwise Specified.

NOS is a clinical admission. It means: we see something, and it's real, but the categories we know can't hold it. The presentation doesn't tick all the existing boxes.

Complex PTSD was not a recognised diagnosis in any major classification system when I got it. Not in the DSM. Not in the ICD. It existed in clinical literature (Judith Herman proposed it in 1992) but it had no formal home. My trauma centre was ahead of the rest of the field. They could see what standard PTSD couldn't describe: the damage that doesn’t come from a single event but from sustained, repeated exposure during development. The distorted self-concept, the relational wreckage, the body that holds what the mind has archived or locked away.

It took the World Health Organisation until 2019 to formally adopt CPTSD in the ICD-11. The DSM-5 doesn't recognise CPTSD as a separate diagnosis. It offers a dissociative subtype of PTSD, which captures some of the picture but misses the core: that complex trauma reshapes your identity, not just your memory. So when I was diagnosed, my clinicians were naming something the field hadn't officially agreed existed. They knew it was there but the classification systems hadn't caught up.

Dissociative disorder NOS meant I was dissociating in ways that were clinically significant but didn't match the established categories. Not DID, not depersonalisation disorder in isolation, not fugue. During the assessments I told the clinicians how, when my parents were screaming at me or hurting me physically, I would retreat. The sound of their voices faded. My vision blurred as I watched myself sitting at the kitchen table while my father's index finger bore into my forehead and he screamed that I was stupid. That I was a bitch. That he was talking to a wall. I heard that last one a lot and now understood why: I wasn't at the table anymore. I was somewhere above it, watching.

Later, in the months before my diagnoses, while I was on the waiting list and then during the assessment itself, I found myself on the couch where the same retreat would happen without a trigger present. I would come out of it three hours later, completely unaware that so much time had passed. The mechanism that had once protected me from what was happening had started running on its own.

It is very common to get the diagnosis personality disorder NOS alongside the CPTSD diagnosis. The overlap between complex trauma responses and personality disorder presentations is one of the most contested territories in clinical psychology. People with prolonged childhood trauma frequently meet criteria for personality disorders not because they have a disordered personality, but because the diagnostic criteria for personality disorders describe what prolonged relational trauma does to a developing self. The categories were built without the concept of developmental trauma in mind. They describe the symptoms and call them character.

The ICD-11 has since abolished all categorical personality disorder diagnoses. Every one. Replaced the entire system with a dimensional model in which severity is rated as mild, moderate, or severe, then described across five trait domains. The old categories, including NOS, no longer exist because the framework that produced them was recognised as scientifically inadequate.

Dependency disorder NOS is the one most people misread. It has nothing to do with substances. In the context of complex trauma, dependency describes an attachment injury: the learned inability to trust your own judgment in relationships, the patterns that form when your earliest bonds taught you that your own perceptions were unreliable.

But here's what the textbook description misses. The dependency didn't make me cling the way it did for some in my therapy group. Of course there were exceptions but at my core it made me the opposite. I developed severe independence: I am strong. I can do everything alone. I don't need help. I can't ask for it. That's not the absence of a dependency pattern. It's the other side of the same coin. The attachment was disrupted so fundamentally that relying on anyone felt more dangerous than carrying everything myself. The dependency was there. It just wore a different suit.

I want to say something about what a diagnosis does. And what it can destroy.

For me, those four names on paper were a foundation. Before the diagnoses, I was fighting something I couldn't see. After, I could at least describe what I was up against. The names gave me access to literature. They gave me permission to stop pretending (and to stop believing my parent’s narrative) that the problem was motivation or character or insufficient willpower.

But I sat in waiting rooms and group sessions with people for who the same process did the opposite.

I watched people receive a diagnosis and build a fortress out of it. I am my diagnosis. This is who I am. The rest of the world can deal with me now. The label became an identity, and the identity became a reason not to change. There's a kind of comfort in it, when you think about it. You stop having to do the work of examining yourself because the examination has already been done. The name is the answer. You can stay ‘comfortably‘ yourself and let the world accommodate you. I saw this happening around me but I personally never felt its pull. I wanted to work, I wanted to understand, I wanted to take the diagnoses apart and see what was underneath them.

And then there's the system around the diagnosis. The machinery that kicks in once the names are on paper. The first response, too often, is pharmaceutical. Medication. Manage the anxiety. Flatten the mood swings. Suppress the dissociation. Treat the surface presentation and leave the root untouched.

A woman in one of my therapy groups lost her father. Overwhelmed by grief, she went to her doctor. He prescribed an antidepressant to take the edges off. Two weeks later she went back and told him she'd been having suicidal thoughts since starting the medication. The answer was to up the dose. She was dead a week later.

Grief hurts. Grief launches you into a depressed state all too often. After the autopilot shuts off, grief will leave you raw, in tears, numb and empty, raging and smiling about the small moments you can access, all at the same time or in rapid succession. And when you think you’re doing better two years later, a smell, song, memory or something someone says can pull you back like the sea pulls back from the shore. It is part of the human experience. When did we decide it needed to be medicated away instead of lived through with the right support?

I jumped in for my partner at the time. No diagnosis had been given. Two meetings with a psychologist, a ten-minute appointment with a psychiatrist and medication was the answer. I sat in the room and debated the psychologist (safe to say she didn’t like or appreciate what I did that much) mirroring the patterns my partner had in her thinking and approaching, arguing that medication should never be the first step. Later, after we were separated for many years and she was going through her own therapy, she thanked me for that protection. She felt medication would most likely have made her condition worse and it turned out she was never diagnosed with clinical depression.

Over-diagnosis feeds this. When every response to an abnormal situation gets labelled as pathology, the system produces patients faster than it can treat them. And when there are too many patients and not enough time, medication becomes the efficient answer. Because it scales. A prescription takes fifteen minutes. Trauma therapy takes years.

I was never medicated. I made that decision early and I've held it. The one exception was oxazepam; a benzodiazepine I used occasionally to stabilise during acute peak moments. It was a tool for when the nervous system exceeded what I could manage with the skills I had at the time. Other than that, nothing.

I'm not making an argument against medication. For some people it creates the stability that makes the deeper work possible. But when it replaces the deeper work, when the symptom is managed and the cause is never addressed, the diagnosis hasn't helped. It's created a maintenance plan for damage that was never repaired. And unfortunately, like for the woman in my therapy group, it creates new and sometimes irreversible symptoms just by taking them.

Years after those four names were written on paper, I'm sitting with an odd fact. Three of the four diagnoses were given in a language the field has since abandoned. NOS doesn't exist any more. The personality disorder categories have been scrapped. CPTSD has gone from unofficial to internationally recognised.

But here's the thing I can say now that I couldn't have said then. If I walked into the same assessment room today, I would not present with the same symptoms.

The dissociation that used to run on its own, the three-hour retreats on the couch, the mechanism firing without a trigger, that doesn't happen any more. Not because it's been suppressed but because the material it was protecting me from has been processed. The chronic pain that had me rolling off the mattress every morning has largely gone. The hyper-independence that looked like strength but was really a refusal to let anyone close enough to disappoint me: I've examined that pattern, and while it still surfaces, I can see it now. I can choose differently. The relational patterns that would have met criteria for a personality disorder presentation have shifted through years of work. I maintain complex relationships. I can sit with ambiguity, hold contradictions, feel deeply without being destabilised by it. I write about the hardest material in my life and I don't fragment.

The diagnoses were accurate. They described exactly what the clinicians saw. And the work that followed, years of it, without medication, without shortcuts, changed what there was to see.

That's what I want to leave here. Not that diagnoses are good or bad. Not that medication is right or wrong. But that a diagnosis is a photograph of a moment. It captures what's true at the time of the assessment. It doesn't capture what's possible after. The names on paper told me where I was. They didn't tell me where I could get to.

The work continues. It always will in some shape or form. But the person doing the work is not the same person who sat in that assessment room, waiting for someone to tell her what was wrong. I know what was wrong. I also know what I did about it.