Case 3, Episode 3: Diagnostic Possibilities – Psychosis, PTSD, or Institutional Adaptation?
“They call it a disorder. But it’s how I survived.” — Cynthia, 62
By now, you’ve walked with Cynthia through her first appointment, then through the story of her life—layer by layer.
She hears a voice (her grandmother’s).
She’s wary of being watched.
She avoids enclosed rooms.
She doesn’t express emotion easily.
And she believes certain “people” are still trying to control her.
But here’s the question:
Is this psychosis… or something else entirely?
And more importantly:
What do we risk when we get the diagnosis wrong—or too fast?
The Danger of Diagnostic Overreach
When a person presents with “hearing voices” or “paranoia,” the default often becomes:
Schizophrenia
Schizoaffective disorder
Delusional disorder
But for someone like Cynthia—who’s endured trauma, institutionalization, and forced compliance—the line between symptom and survival is blurred.[1]
We need a framework that allows us to hold multiple diagnostic possibilities in mind—without collapsing too quickly into certainty.
Three Overlapping Possibilities
Let’s walk through the most likely diagnostic frameworks in Cynthia’s case—and how to approach them without reducing her to a label.
1. Chronic Psychotic Disorder (e.g., Schizoaffective, Schizophrenia)[2]
Clues that support this:
Persistent auditory hallucinations
Paranoia not clearly linked to a specific trauma
Flattened affect, limited insight
History of psychiatric care and forced medication in prison
Questions to ask:
Have the voices changed over time, or remained consistent?
Do they command or comment?
Is there disorganization in thought or behavior?
Is there a family history of psychotic illness?
Approach:
Consider trial of low-dose antipsychotics only with shared decision-making
Monitor response before assuming permanence
Prioritize trust over compliance
2. Complex PTSD with Dissociative Features
Clues that support this[3]:
Childhood trauma, prolonged neglect
Voices are familiar, comforting (grandmother)
Flashbacks or hypervigilance tied to past experiences
Avoidance, numbing, and difficulty trusting others
Symptoms worsened in high-stress or institutional environments
Questions to ask:
What does the voice say? Is it frightening or soothing?
When did the “paranoia” begin—before or during incarceration?
How does she describe her own sense of self?
Is she aware of emotional “cutoffs” or time loss?
Approach:
Use grounding, narrative, and trauma-informed care
Avoid pathologizing coping mechanisms
Normalize dissociative experiences as part of the adaptation
3. Institutional Adaptation Syndrome[4] (Not in DSM—but real)
Clues that support this:
20 years of incarceration
Learned hypervigilance, compliance, and emotional flattening
Fear of autonomy, overwhelmed by daily decisions
Expectation of surveillance or control
Detachment from community norms
Questions to ask:
What’s most difficult about being “free”?
What’s her routine like? How does she structure her time?
How does she feel in spaces without rules or authority?
Has she ever lived in a setting that felt safe?
Approach:
Structure care around predictability and autonomy
Allow time to unlearn institutional rhythms
Offer peer support from others with reentry experience
The Case for Holding All Three
Here’s the truth:
Cynthia may have chronic psychosis, trauma-induced dissociation, and institutional adaptation—all at once.
These are not mutually exclusive.
They are interwoven expressions of experience.
Her “symptoms” are not just brain-based.
They are body-based, story-based, survival-based.
So What Do We Call It?
Whatever diagnosis you document, make sure your treatment plan reflects her context, history, and dignity.
It’s okay to use a provisional diagnosis.
What matters more is that your approach:
Is trauma-informed
Is collaborative
Is adaptable over time
Avoids blaming or forcing
Cynthia doesn’t need you to name her condition.
She needs you to see her fully—and stay.
Coming Up Next: Episode 4 – Medication and Consent
In our next episode, we’ll ask:
What happens when someone who may benefit from medication refuses it?
How do you balance autonomy with care?
What does trauma-informed prescribing actually look like in practice?
And how do you build trust without coercion?
Because healing doesn’t begin with a pill.
It begins with a partnership.
Reflective Prompt for You
Have you ever been wrong about a diagnosis—only to realize the person made perfect sense once you knew their story?
What changed in you as a result?
The most accurate diagnosis is often the one we’re humble enough to revise.
References:
[1] Herman, Judith L. Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror. Basic Books, 1997.
[2] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. 5th ed., Text Revision, American Psychiatric Publishing, 2022.
[3] World Health Organization. International Classification of Diseases, 11th Revision (ICD-11). World Health Organization, 2018.
[4] Chow, Winnie S., and Eric Y. H. Priebe. “Understanding Psychiatric Institutionalization: A Conceptual Review.” BMC Psychiatry, vol. 13, 2013, p. 169. PubMed Central, https://doi.org/10.1186/1471-244X-13-169.