Symptom Development Modeling

1. Demetrios Peratsakis, LPC, ACS
© April 2017

2. “Anxiety, and its various forms of fear -dread, panic, worry, hesitation, and Depression, along with its myriad
shades of sadness -remorse, grief, despair, despondency, are fueled by Guilt and Shame and the corresponding
feeling of Anger (GAS). Their root cause is unresolved emotional pain from Trauma, Loss or Betrayal. It’s
ensuing damage, or psychological injury is, to varying degrees, a sense of discouragement, helplessness, and
worthlessness, and harm to one’s self-esteem in relation to Trust and Intimacy with others. Symptoms may
develop as a means to gain or re-gain control, to stabilize and organize the individual and their relationships.
As such, they accumulate meaning and Power, the ability to influence outcome in one’s favor. Over time, this
may concretize into established transactional patterns or habits (symptoms) that become rigid and resistant to
change. As psychotherapists, we are concerned that these may then serve as a means of controlling, perhaps
even punishing others, or as an effective, often socially acceptable, method of excusing or avoiding
responsibility for change.” – Demetrios Peratsakis, LPC, ACS, 2017

3. Emotional Pain
Trauma
(fear)
Loss
(sadness)
Betrayal
(anger)
Psychological Injury
Guilt
Anger
Shame
Primary Symptoms
Depression Anxiety
Demetrios Peratsakis, LPC, ACS © 2016

4. Psychological Injury and Emotional Pain
Demetrios Peratsakis, LPC, ACS © 2017
Type Feeling/Tone Distinguishing Feature Preoccupation Injury Symptoms
Trauma Vulnerability Fear; Need for Safety Avoidance Trust; Intimacy Anxiety/Depression
Loss Emptiness Grief Replacement Trust; Intimacy Anxiety/Depression
Betrayal Power Struggle Anger; Rage Revenge Trust; Intimacy Anxiety/Depression
Emotional pain is fueled by Guilt, Anger, and Shame (GAS).
It diminishes our sense of Worth, which is inextricably tied to others.
1
2
3
4
Unresolved, we seek remedies that circumvent the pain but that may not reconcile the injury.
Perhaps the greatest injury is borne by betrayal.

5. Trauma, Loss and Betrayal result in Psychological Injury and Emotional Pain.
An interlocking pattern of Guilt, Anger, and Shame (GAS) fuels Depression (sadness, grief, remorse) and Anxiety (fear, worry,
dread). Unresolved, it results in the dysfunction we call symptoms or syndromes.
Rumination
Demetrios Peratsakis, LPC, ACS © 2016

6. Trauma, Loss, Betrayal
Guilt, Anger, Shame
(GAS)
Depression, Anxiety
Secondary
Symptoms
Demetrios Peratsakis, LPC, ACS © 2016
Psychological Injury occurs when Trauma, Loss or Betrayal occur, resulting in Emotional Pain expressed as Depression and Anxiety.
These are fueled by continual thoughts and feelings of Guilt, Anger and Shame (GAS). Secondary Symptoms evolve as protective
mechanisms, which in turn can create unresolved problems and stifle adaptive growth.

7. Psychological
Injury/Emotional Pain
Trauma
Loss
Betrayal
Fear/Dread
Complications Adjusting
to Change
Marital/Partner Discord
Impairment in Partner
Impairmentr in
Child(ren)
Severe Power-Plays
Emotional Cut-off
(rejection/expulsion)
Domestic Violence
Revenge (infidelity,
treachery, suicide, etc)
Inadequacy (failure,
depression, etc)
Symptom Development
1. Symptoms are hardened patterns of interaction
around which relationships organize and individuals
define their roles, rules and myths.
2. Presenting Problems are representative of the
difficulties encountered while struggling to adapt to
change. The History of the Presenting Problem
inform of who participates and how; these are the
same members that uphold the behavior. In that
regard, the behavior is purposive and is a shared
identity, an imagined reality.
3. Symptoms invariably result in Depression and
Anxiety which are fueled by Guilt, Anger, and Shame
(GAS)
Symptom Development
Symptoms develop as adaptive responses to injury and distress. When Power Struggles dominate intimate relationships, mutual injury
occurs and severe action is taken in the forms of Power-plays for punishment or revenge.
Demetrios Peratsakis, LPC, ACS © 2016

8. Psychological Injury and the Development of Depression and Rage
Trauma, Loss and Betrayal, including Abuse, Infidelity and Incest
8 6
Sense of Discouragement and Worthlessness
Anger, sadness and fear are natural responses to psychological injury. They result in feelings of depression and anxiety, which are fueled by thoughts of guilt and shame. Anger, which can provide a
faulty sense of power, is an attempt to counter-act the feelings of guilt and shame; to retain the anger, the harm or emotional pain must be continually reactivated (rumination), often, in the form of
self-pity or blame. This can result in feelings of helplessness and worthlessness or the desire to over-power, punish or seek revenge. Unresolved, the effects of trauma are cumulative and typically
erode confidence in self and trust and intimacy with others.
Treatment consideration for working with Depression and Anxiety:
1. Resolve conflict and disengage and redirect the power-play; practice enacting new ways of behaving and inter-acting. Challenge the meaning and the power of the depression and its
symptoms; examine how it avoids responsibility and controls others
2. Tap underlying fear and anger; seek acknowledgment and de-escalation; examine betrayal and work on revenge, forgiveness and redemption
3. Bridge emotional cut-offs; fill loss; and connect to meaningful activity and relationships; develop a sense of purpose and rekindle spiritual being-ness
4. Consider medication and safety/suicide planning, as needed. Look to self-care and general health.
Demetrios Peratsakis, LPC, ACS © 2016
Interlockingstrandsoffeelingsandthoughts

9. Anxiety Builds
Problem-solving
Remedies
• Collaboration/Alliance (win/win)
• Compromise (I bend/you bend)
• Accommodation (I lose/you win)
• Competition (I win/you lose)
• Avoidance (no win/no lose)
• Triangulation (win/win/lose)
Conflict
(natural to human
interaction)
Chronic Tension
Results in:
• Open Discord
• Stable, unsatisfying
• Unstable
• Impairment in a Child
• Attention Seeking
• Power Seeking
• Revenge Seeking
• Displays of Inadequacy
• Impairment in a Partner
• failure
• depression
• illness
• Detouring to an Identified
Patient (IP)/Scapegoating
Power Struggle
(important conflict
that remains
unresolved) Neutralizes or
Breaks the Impasse
(often results in trauma
or betrayal)
Examples:
•Treachery/Betrayal
•theft, disloyalty, sabotage,
incest, abandonment,
infidelity
•Revenge
•punishment, suicide, crime,
depression, addiction, eating
disorders, failure or acts of
inadequacy
•Violence
•warfare, bullying, threats,
rage, domestic violence,
abuse
•Escape/Emotional
Cut-off
•Expulsion/Rejection
Power Play
(frustration and
hurt lead to
desperate and
unhealthy
solutions)
Demetrios Peratsakis, LPC, ACS © 2016

11. Individual
Trauma
Family System
Stress
Symptom
Family Systems Therapy View of Symptom Development

12. Trauma, Loss, Betrayal
Guilt and Shame feelings
+
Anger at perceived injustice
by others
Emotional Pain
(Depression/Anxiety)
Psychological Injury
Damage to Self-esteem, Trust and Intimacy with others, sense of Power and Worth
Demetrios Peratsakis, LPC, ACS © 2017
Secondary Symptoms
protection against further pain and fear
Psychological Injury and Symptom Development

13. Duress/Trauma
Marital/Partner Discord
(Bowen)
Emotional Cut-off (Bowen)
could include expulsion,
escape and power-struggles
with in-laws, teens,
authority, etc
Dysfunction in One or More
Children (Bowen)
Dysfunction in Partner
(Bowen)
IPs/PPs serve as “Lightning Rods”; drawing the “lightning” to mitigate system stress.
The IP must actively construct the role for its purpose to be functional
Bowen’s Model of Symptom Development