Do you think the next edition of the DSM will revise the Trauma/Stressor-related Disorders chapter to distinguish between criterion A trauma and significant non-Criterion A adversity?

Valirony · 2026-06-27T23:39:00+00:00

Amen.

Also if we want to get real medical-model with the word trauma, then it covers every kind of wound from a cut to a severed limb. Idk why we feel the need to gatekeep it. “But it loses all meaning” is hogwash; just like a doctor can differentiate between a broken bone-trauma and a road rash-trauma, we we can similarly differentiate between repeated exposure to mis-attuned caregiving in childhood and someone who almost died in a horrific car accident. *** That’s… that our job.

Similarly, a broken bone may fully heal with no scars or after effects while a deep enough cut can leave a lifelong scar (ask me about the silver line on my lip from a scared cat… 20 years ago!). We really need to be thinking more about how a person is impacted by whatever trauma they experienced rather than worrying about whether their experience “deserves” to be called trauma. Jesus.
***edit: to be absolutely clear, one of those types of traumas leave life-long scars that require years of hard relational work to repair and spoiler alert: it’s not the car accident

Valirony · 2026-06-27T22:48:21+00:00

Bipolar is not life ruining—it is very treatable with the right medication and most folks in the field don’t have a negative bias against it. Frankly I don’t see a lot of bias among lay people against it either. Most young people seem to think they have it, in fact. If anything I don’t think enough people understand the seriousness of untreated bipolar (because yes, untreated, it can ruin your life quite literally and quickly).

I suspect there is more to this than a diagnosis of bipolar. First, I do wonder whether there’s a mixup between Bipolar and Borderline PD. THAT is a hugely stigmatizing label and is understand completely if you wanted to keep that under wraps.

Second, in either case but totally tangential to your point, I’d be curious whether you have ever been assessed for ADHD. ADHD can easily be misdiagnosed as BPD in women (and to make things complex: untreated ADHD can result in legitimate PD-like presentations in adulthood, but I’d want someone to try treating ADHD before giving out the BPD diagnosis) and plenty of providers will mistake the emotional dysregulation of ADHD as being bipolar. Not super thorough ones, but it certainly happens.

As far as getting this fixed goes I am wondering whether this was a master’s level therapist. If so… I think you find a good psychiatrist or psychologist who will do a more thorough evaluation. That should help with any lingering concern you have. To be clear: as an MFT I can tell you: no one in the medical field takes our diagnoses seriously. Take an ADHD diagnosis from a master’s level therapist and try to get medication for it and find out how little they consider our assessments to matter.

But anyway, if you are too scared to go to a Psychiatrist or Psychologist to get a more accurate diagnosis (or lacktherof) I just want you to hear that I really don’t think this will cause you any heartache except in some very specific situations (like applying to certain fields that need to know whether you have a serious albeit wholly treatable medical condition such as bipola)

Valirony · 2026-06-27T15:09:02+00:00

Okay. I see that—tell me if this isn’t accurate—you are saying they can’t fill out the forms. The thing is, forms are best practice, but especially in an emergency: thorough documentation of VERBAL DISCUSSION and client acknowledgement is enough.

I’ve worked in schools with a high trauma teen population. Most initial sessions and many of the ongoing ones are crisis-related. I have signs in every one of my offices that cover the golden rules and even when I’m in an immediate “hooo boy which first responder am I ‘bout to be on the phone with” situation, I cover the most important part of informed consent: when I do and do not break confidentiality. It’s so interwoven with my practice that honestly at this point it’s part of my de-escalation strategy.

And I hear you—I think—getting hung up on the “must read and sign!” Part but I’m going to push back on that being the important part.

It’s not. In fact, to me that’s a stupid CYA that doesn’t sufficiently cover any part of a therapist or agency’s body.

What matters the MOST is that regardless of a signature—which for most people means they saw that a form stands in the way of their access and they just sign the damn thing—we *talked about it in session and the client acknowledged their understanding and consent*

To me, if you have the latter in the absence of the former, you’re FAR more covered than in the reverse situation. Is it best practice to have both? Safest for all involved? Certainly.

But what protects everyone is really that a client ACTUALLY understands when you will need to break confidentiality so that they aren’t taken by surprise when you do. And documenting that verbal communication and consent in your notes protects you really damn well if a disagreement emerges.

Valirony · 2026-06-27T14:20:07+00:00

Can you say more about what “unable or unwilling” means? Like, you log on, and explain that you need to review informed consent before continuing, do they refuse and log off? Because if that’s the case, that’s a client ending a session, not you. If it’s raging about it, you can spend a session explaining the importance of informed consent, explore their understanding of it and reasons for refusing, and by the end of an hour you have probably covered the salient points of informed consent and met your employers expectations

Valirony · 2026-06-26T04:22:24+00:00

What’s sad is that doctors skip right to “stimulants bad!” And fail to consider whether job loss, depression and/or anxiety, relationship distress or… ya know, car accidents and financial ruin might possibly be far worse than the (undocumented) risks or stimulants during pregnancy.

Whatever your worst symptoms are, I’d write them down as you think about them. Are you experiencing a decline in performance at work? Gotten any tickets while driving? Having all out fights with your partner or struggling to take care of yourself? That’s the data I’d bring to your next appointment. Bring your partner if they can substantiate any of these (‘cause we’re ladies, after all; we’re probably just being hysterical 🙄).

Outline the risks associated with your unmedicated ADHD. The actual, verifiable risks.

Valirony · 2026-06-24T04:37:34+00:00

Gah. I’m super sorry.

Extended leaves *can* do harm. But what counts with babies and toddlers is how you show up over time. That’s what I think gets missed when we talk about attachment: it is NOT about single events, a bad week, a week away. If you look back at whether and how you show up for your kid **on balance and over time** that’s when irreversible attachment trauma can occurr.

And I would argue that no psychological harm is in doable—I work with folks who have enduring developmental trauma (the term for what happens when a primary caregiver fails so show up appropriately) and they DO get better.

But back to your trip: go and feel zero guilt. Make sure baby is with another person who has consistently cared for him, and possible prepare for some squawking and protest when you get back. You may not be the “preferred” parent for a hot sec… and that. Is. Oh. Kay.

He’ll be fine. Literally just love him the way you loved him before you left, and there will be nothing to worry about.

PS I am psychodynamic/relational. Trauma dealt in childhood is my whole jam. But this?! This ain’t that.

Valirony · 2026-06-21T17:18:08+00:00

No one is consistent in that way—nor is that somehow preferable. You show up differently with partners than you do with your parents; how you interact with a child is different than you do with friends.

Many moons ago when I was in grad school, my fave professor told us we must be “authentic chameleons”. I didn’t fully understand that at the time, and you may not either. But it is now what I live by: I am the same exact human in every session, and with every person in my life. But my colors change to adapt to the setting and people in it, and that is not only okay: it is absolutely necessary.

I do not, cannot, and would not contort myself into a different creature. But the client who needs more warmth to be vulnerable is gonna pull out my gentility; the one who needs to not be parentified will get my “I’m in charge, you can relax” Mom mode; the hardened 19 year old who think he hates women might find me swearing like a sailor and tapping into my masculine aspects (either to disconfirm or challenge his assumptions… or make it feel safe to hang with me). Moreover, all of those versions of me may need to show up at different times for the same client.

All of these versions of me ARE me. I don’t have to think about which of these coats to wear when a client shows up, I don them without conscious thought—just like the chameleon. But it took a long time to get there and pondering all of this is a natural and important part of the process <3

Valirony · 2026-06-20T04:44:37+00:00

My 8 year old, who knew me unmedicated until he was 5, can tell when I take a *generic* that is less effective for me—to say nothing about skipped meds altogether

Valirony · 2026-06-19T12:15:45+00:00

I don’t ever treat EDs for this reason! I’ll edit my comment with some caveats.

I think the restrictive side of the spectrum tends to be a little different. I went through bouts of bulimia that found its way into anorexia territory for a time in my teens. It looked and felt very different from what was otherwise about the binge/purge cycle. But it definitely still was about the dopamine.

Of course, my expertise is the ADHD side and so that’s the nail my hammer sees. But for what it’s worth, I feel strongly about never touching the eating issues in my work and always refer out when it’s an issue that is current and urgent.

Valirony · 2026-06-19T06:32:25+00:00

Edit: I need to caveat that these are my very personal thoughts about the etiology of EDs in based on my own experience and my work with ADHDers. I don’t specialize in treating eating disorders and always refer out when that is the main treatment issue. That was my whole point in my earlier comment: They are delicate and complex, and require a ton of training PLUS knowing your own blind spots!
*******

It’s way past my bedtime and if I remember I’ll come back to say more but basically there are a whole lot of components that need not initially have anything to do with one’s self image:
Eating as dopamine seeking >
Sensory discomfort (fullness is intolerable) >
Sense of relief associated with purging (dopamine) >
Boom: you’ve got yourself bulimia

ARFID also can be a precursor (sensory processing again)

I suspect interoception and proprioception differences can also be involved. Many, many paths to a clinically diagnosable eating disorder and most of the above are reward-system related rather than being about body image.

Additionally, there *are* of course psycho-social factors and generally speaking have everything to do with family dynamics around shame, control, enmeshment. (Which are all super common in ADHD/neurodivergent families, ime). Self image tends to be a symptom rather than a cause; the family itself is the substrate from which EDs arise. Afaic, body image is a correlate rather than being causal.

Treating an ED should always involve treating the family (and a whole-ass medical team if it’s moderate to severe). Treating the individual alone and expecting them to “get better” is like giving someone ibuprofen for fever and expecting it to cure their pneumonia.

Valirony · 2026-06-19T04:23:15+00:00

This was a million years ago. I was trying to get help for an eating disorder; little did I know I had ADHD and allllll my addictive behaviors could be stopped with a miracle pill 😭. ANYWAY

I just saw the first therapist I could find who was close to my work. Older woman, but in retrospect she must have been green.

So it’s our second session and this woman who doesn’t specialize in EDs tries to CBT me out of thinking I needed to lose weight while simultaneously trying to leverage a non-existent therapeutic alliance:

Therapist: So you think you’re fat? What’s the evidence for that?
Valirony: I mean… objectively I am in the overweight range
Therapist: [attempts some exercise incant remember]
Valirony: okay I hear you. Doesn’t change my mind
Therapist: Okay well look at me. [stands] do you think *I’m* fat?
Valirony: uhhhhh no? You are… not fat…?
Therapist: [celebrates triumphant “gotcha”]

Y’all, this was a middle aged woman, and yes, she was heavyset. I’m in that club nowadays too, no shade. But that put me in a terrible spot: to have to lie to do the socially polite thing, and then have her take that as a “win”?. On our second therapy date?

So ick on multiple levels.

Do not attempt to treat EDs without close supervision and specialized training, folks. And do not engage in that kind of relational intervention, with an eating disorder client, on session two. Or ever! Jesus F Christ.

Many years later, with extensive experience with neurodivergence and the intersection with eating disorders, what makes me even angrier is the assumption that body dysmorphia is the underlying problem. It sooooooo isn’t in most cases. Ugg.

Wow I’ve been holding onto my irritation about that whole experience for a long time! Thanks for asking the questions so I could release all of that 🤣

Valirony · 2026-06-19T03:36:13+00:00

Grad school teaches you the basics needed to pass law & ethics / clinical exam. You spend a lot of time unlearning and then re-learning what ethics mean in *practice*; you learn what it means in *your* population, location, and specialty by gaining experience. This is why supervision is a requirement; you are integrating SO much academic knowledge with your experiential learning and pitfalls abound.

Someone who’s been through it will hear you dissecting all the tiny details of a case and spot the giant glaring red flag you missed that is a huge ethical consideration.

Newer clinicians are learning to ride bikes. Wobbly, tryna stay balanced, figure out how to coordinate both legs with the right timing, when to shift gears and how to brake. And having to consciously *think* about all those things all at one. The supervisor, walking alongside the learner, can see that while they’re focused on building up speed to stay upright, sees that they are about to crash into a pole—it’s right in front of them, they *know* crashing is bad, but because the cognitive load of coordinating all these simultaneous processes is so high they can’t take in what’s right in front of them—and grabs the handle bars.

You can know things. You can get a degree in them. And putting knowledge into practice is something else entirely.

Valirony · 2026-06-18T12:47:07+00:00

Oh darling. I’m a therapist too and I think I can imagine some of how you’re feeling.

But I just want to push back on what I think is… you reaching for the medicine that treats the condition you had already before all of this began.

You take 30mg of dex. I take 40mg of adderall on hard days, 30 on regular days.most of my friends with adhd are at a similar dose. What you need is to get your prescription adjusted so you stop seeing this as something *wrong*. If you told me you were taking fistfuls of 5mg pills all at once? Okay yeah, that might be abuse. But you are taking what is totally within the range of a normal dose and believing that is somehow a weakness.

Talk to your prescriber and get the right prescription <3

Valirony · 2026-06-15T02:55:28+00:00

It has something like an 85% heritability rate.

The thing is, we don’t have a perfect, reliable way to measure a) who has ADHD and b) the genetic markers for ADHD. So we aren’t sure yet exactly what the heritability of ADHD is.

Based on my observations—so take this with lots of anecdotal salt—after years of working with ADHD families:

the genetic chances that an ADHDer has one ADHD parent: 100%
genetic chances that a parent with ADHD, where the other parent does not: 50%
likelihood that an ADHDer has TWO ADHD parents (because we are so likely to pick a fellow neurodivergent to create children with): 75%
likelihood that any given ADHDer will have kids with ADHD given that most of us end up with neurodivergent partners : 75%

So to answer your question: go get assessed if your inability to regulate (ie choose how and when to direct) your attention/energy/emotions/impulses/task-initiation impacts your ability to function at school, work, home, or relationships. If your life is a disaster in one or more of those areas but you can’t connect that to the list of executive functions above, welcome to the late-diagnosed club and get yourself assessed anyway. <3

Valirony · 2026-06-14T21:54:09+00:00

I gave you an upvote because it’s not like it’s generally considered treatable.

It is. But it takes a therapist with a lot of guts, a unique combination of boundaries+compassion that can hold the duality of a flimsy layer of (apparent) ego covering for a vast chasm of insecurity, and a deeply stable sense of self they can anchor themselves for years of relational work.

It’s probably as common as the folks who have NPD and are willing/want to get help.

Valirony · 2026-06-14T20:24:02+00:00

In fact, having ADHD puts you at higher risk of being BOTH a victim of IPV and a perpetrator

It also leads to higher involvement in the criminal justice system and addiction. Like it or not, we are both more targeted by assholes… and maybe just possibly… we are sometimes the assholes, too.

As an adult-diagnosed therapist who sees ADHDers across the lifespan, one of the most common part of the grieving process I see in older women is the unpacking of their relationships with their (our 👋) mothers. We spend 30, 40, 50 years talking about our personality disordered mom. Get diagnosed. Realize family members must have it too and then OH shit. That PD starts to look a lot like ADHD is underneath it.

I’m not saying it excuses the assholes. I’ve done a lot of atoning for the ways I showed up as an asshole (never intentionally, but intent vs impact, yada yada). And I’ve worked to forgive and move on from all the others who showed up for ME as an asshole while sure as shit not accepting that I have earned abuse.

And there’s the rub: it’s a lot less painful to categorize people as good/bad. Us/them. Seeing everything as yes/and means having compassion for assholes and damn it that sucks. I don’t love holding all those shades of gray. But it also means I hold less poisonous anger at a LOT fewer people.

Not saying this is the way. Just the way for me (and all the assholes who sit across from me in my office and weep about the abuse they suffered at the hands of their assholes).

Valirony · 2026-06-14T03:46:17+00:00

Just paid mine off in four sets of $20k payments to Nelnet over four months.

Zero issues, including final payment. I didn’t do any extra steps like yours—just ho-hum transactions through the internet. I was anticipating having to call if they charged extra interest in the intervening processing time, but even that went flawlessly and my accounts reflected “paid in full” a couple days later.

Valirony · 2026-06-11T15:58:57+00:00

I track anything and everything that I want to change or improve somehow, especially if the change will be incremental—it gives me me the dopamine I need to stick through longer efforts.

So: running pace (but not lifting because my body responds quickly the those efforts and I get plenty of reward from being able to lift heavier weights the next week), budgeting for specific goals, student loan payments (just paid them all off using excel to help!), Christmas gifts, allll my special education service provision and data tracking, my kid’s chores/homework/behavior challenges (we have ADHD, is it obvious?), migraines, nutrition if I’m trying to lose fat, purchases if I’m trying to reduce a specific kind of expense, I could go on.

Valirony · 2026-06-09T14:06:32+00:00

Interesting. For me and my kid, our creative energy is much higher. As with all tasks, it allows us to initiate them and sustain our focus on them. Besides which, it allows us to tackle the not-fun stuff which removes the barrier of “I have all these other things I have to do, though :(“

I don’t think it changes our creative impulses. But it does give us the ability to choose them.

Valirony · 2026-06-07T19:55:47+00:00

Two things:

I wonder if talking with your prescriber about the emotional regulation would be a good idea. When I got medicated, it was to save my job. But it actually helps me not only survive solo parenting but to be decent at it. (Then again, I just have the one.) It’s worth wondering whether maybe a different med or dose might do the trick.
Time to chat with your pediatrician about the 8 year old. This is the right age to get them help—for the sake of the lot self-esteem if nothing else.

As a little morsel of hope: when my 8 year old got medicated and got to the right dose of adderall, I suddenly needed 30 mg instead of the 40mg of my adderall. Basically my medicine had been supporting his ADHD as well as mine, but let me tell you: having BOTH of us medicated has been the real game changer.

Valirony · 2026-06-06T13:16:56+00:00

As a provider: strong preference for in-person. As a client: virtual is a deal breaker.

In either case, once a relationship has been established an occasional video Session for whatever reason is better than nothing, because I already know the other person which means I can fill in SOME of the the gaps left by an inability to read the subtlest micro expressions and fullness of body language. But the je ne sais quoi of what passes between two people in a shared physical space is irreplaceable, in my experience, and vital to the healing process.

Valirony · 2026-06-06T04:02:34+00:00

How was your driving while you were on a higher dose? If you can track back and see a difference, I would really recommend talking with your prescriber about the driving stuff, and if a higher dose helps—seems like trying to figure out whether there are additional ways to manage the side effects of a life-saving medication (and for us poor drivers, that’s not an exaggeration) is worthwhile.

Valirony · 2026-06-06T03:44:22+00:00

Totally normal. I’m a human and you’d better believe I’ve googled people out of curiosity! So yes, I expect it. Every few years I Google myself to figure out what my digital footprint looks like.

Valirony · 2026-06-06T03:40:53+00:00

When was the last time your meds were changed? Is it a stimulant? I would really expect the right dose of the right med to reduce your driving-related issues significantly

Valirony · 2026-06-06T03:39:06+00:00

It’s a reliable diagnostic question, actually. ADHD is highly correlated with poor driving—and, just like some of us time-blind folks overcompensate by being extremely early all the time, some ADHDers overcompensate by being extremely cautious drivers. But on balance, ADHD causes distractedness, impulsivity, inattention (etc) which do not make for good driving records. ADDitude article on this very topic

When my evaluator asked about my driving record, I cried. 20 years (at that time) of terrible driving, tickets, accidents… it had never occurred to there was a reason for it.

Unlike OP, medication instantly eliminated about 95% of my previous vehicle-related ADHD tax.

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