Everyone Is Stressed. Not Everyone Has a Stress Disorder.

What a stress disorder actually is, why so many people rule themselves out of PTSD, and what therapy is for

ADHD readers, or anyone whose attention is already drifting: the condensed version is at the bottom under The Cliff Notes. Skip ahead. That is what it is there for.

Ask almost anyone how they are doing and stress shows up somewhere in the answer. Work, kids, money, aging parents, the news, the car that is making the noise again. Most of us carry some version of it most of the time, and we have learned to call that normal, because for most of us it is.

That is exactly why the phrase stress disorder gets misunderstood. If everyone is stressed, a stress disorder sounds like more of the same, a heavier load or a bad year that will pass if you can hold on long enough. Clinically it means something different. A stress disorder is not defined by how much stress is in your life. It is defined by what has happened to your ability to manage it.

Two ways the system breaks

Under ordinary conditions, the body registers a threat, responds to it, and then settles. When I call something a stress disorder, I mean that cycle is no longer working, and the way a person manages stress has become clinically dysfunctional. In my experience it breaks in one of two directions, and they look almost nothing alike from the outside.

The first is overwhelmed. Everything is too much. The smallest thing sets the nervous system off, and once it is set off, it does not come back down on its own. A tone of voice, a change in plans, a sound in the next room can take the rest of the day. People living this way usually know something is wrong, because they feel it constantly.

The second is overcontrolled, and it is much harder to see, including for the person living it. Stress has been so constant, for so long, that it has stopped registering. Everything is held together through control, and the control works well enough that these are the people who tell me, sincerely, that they are not stressed. In a sense they are right. They do not feel it. What they have lost is the ability to tell what stress is, where it starts, and how much of it they are carrying.

The overwhelmed person knows they are struggling. The overcontrolled person often does not know they are struggling at all.

The same blind spot shows up with PTSD

That second pattern explains one of the most common things I hear about post-traumatic stress, which is some version of nothing that bad ever happened to me. People picture a single catastrophic event, a combat deployment or a serious accident, and when they cannot point to one, they rule themselves out.

I want to be honest about both halves of this, because it is the most confusing part of the diagnosis. Formally, PTSD does require exposure to something seriously threatening. Both major diagnostic systems say so. Both also allow that exposure to be repeated rather than single. The ICD-11, the World Health Organization's system and the one I prefer, describes it as an extremely threatening or horrific event or series of events. Plenty of people who rule themselves out have a series. They never counted it, because each piece seemed survivable on its own.

What the diagnosis is really describing is the response. There may be an initial event, but often there is not one moment so much as a long stretch of them, and what develops over that stretch is an inability to manage stress. Eventually it becomes relational. You stop trusting your own reactions and your read on a situation, and then you stop trusting other people.

When it becomes clinical

I have written before about The Difference Between Clinical and Just Being Hard, and the same line applies here. A hard experience, even a terrible one, is not a disorder on its own. It becomes one when it is pervasive, when it reaches into most areas of a person's life instead of one: relationships, health, sleep and eating, the ability to function at work and at home, and the ability to enjoy much of anything.

That pervasiveness is also why stress disorders so often get called something else. When sleep, appetite, mood, and enjoyment are all affected at once, it looks like depression. When the nervous system is on alert all day, it looks like anxiety. Those are usually the names it gets, and I think a stress disorder is a very different thing.

The diagnostic manuals have been moving in the same direction. Until 2013, PTSD was classified as an anxiety disorder. The current DSM moved it into its own chapter of trauma- and stressor-related disorders, and the ICD-11 groups it with the other disorders specifically associated with stress, including adjustment disorder and complex PTSD. The stress disorder family is larger than PTSD, and not meeting the criteria for PTSD does not mean nothing is wrong.

What therapy is for

The first job of therapy here is sorting. Is this mood and anxiety, is it a stress disorder, is it relational, or is it some combination. Those are different problems that call for different work, and a good part of what happens early on is figuring out which one you are dealing with.

The second job is mostly not about coping skills. People often come in expecting to be handed tools, breathing and grounding and a list of strategies, and those have their place. But if the way you manage stress has broken down, another skill layered on top of the broken system does not reach the problem. What helps is awareness, learning to recognize this is the way I experience things. For someone who is overwhelmed, that awareness is what makes regulation possible again. For someone who is overcontrolled, it is often the first time the stress becomes visible at all.

Complex PTSD, which exists in the ICD-11 and not in the DSM, deserves far more than a paragraph, and I will be writing about it at length in an essay series starting soon. For now, if you read the description of overcontrolled and thought that is not me, I am not stressed at all, that thought may be worth looking at with someone.

The Cliff Notes

You skipped down here. Reasonable. Here is the whole argument without the scenery.

• Being stressed is ordinary. A stress disorder is defined by what has happened to your ability to manage stress, not by how much of it is in your life.
• It breaks in two directions. Overwhelmed: the smallest thing sets the nervous system off and it does not settle on its own.
• Overcontrolled: stress has been constant so long that it stops registering, everything is held together through control, and the person sincerely reports feeling fine.
• The overwhelmed person knows they are struggling. The overcontrolled person often does not.
• Many people rule themselves out of PTSD because they cannot name one catastrophic event. The diagnosis does require serious threat, but both diagnostic systems allow it to be a series of events.
• Over time the problem becomes relational: first you stop trusting your own reactions, then you stop trusting other people.
• It becomes clinical when it is pervasive, reaching relationships, health, sleep, eating, functioning, and enjoyment, which is also why it gets mistaken for depression or anxiety.
• PTSD was an anxiety disorder until 2013. It now sits with the other stress-related disorders, including adjustment disorder and, in the ICD-11, complex PTSD.
• Therapy's first job is sorting out what you are dealing with. Its second is building awareness of how you experience stress, which coping skills alone do not reach.

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This post is for general education and is not a substitute for individualized care. If you are in crisis, call or text 988.