Thursday, April 26, 2007

The combinatorics of BPD

I was going to write a serious post responding to the issues raised by Polly in her comment on my previous post and in a subsequent post of her own, but as threatened, the language is leaving me - not via disintegrative psychosis as first suggested, but a sad and sorry case of simple schizophrenia, yet another condition I didn't know I had until yesterday. I was going to discuss the diversity inherent in the concept of BPD, and of those diagnosed with BPD, which is something I'd normally do in qualitative terms - and assuming the near certainty of achieving a full remission, I will no doubt get around to doing so soon. But in the meantime, given my 'inability to meet the demands of society', I present the following 'impoverished' observations and analysis.

From DSM-IV, the criteria for Borderline Personality Disorder:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3. identity disturbance: markedly and persistently unstable self-image or sense of self

4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

7. chronic feelings of emptiness

8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9. transient, stress-related paranoid ideation or severe dissociative symptoms

Right, if we require five or more of the above criteria to diagnose someone with BPD, then there are


different ways of being borderline. Cool, huh? But let's assume for a minute that BPD wouldn't be diagnosed in the absence of Criterion 5. Strictly speaking, I've got this the wrong way around, as an impressionistic diagnosis of BPD is often made on the basis of someone meeting Criterion 5, without regard to whether they meet enough of the other criteria. But what the hell, I'm going to assume that all people diagnosed as borderline meet Criterion 5. Which now means that there are


ways of being borderline.

Now, let's assume that we have 163 borderlines who, apart from Criterion 5, each embody a unique subset of four or more of the other criteria listed above. They are all in the day room in 'Borderline House' at Mount Misery:

Then I noticed Blair Heiler, watching from the doorway. He took a first kick-step into the jungle of Borderlines, and all hell broke loose. He reached his office door, turned, and said, 'You poor sonsabitches', and closed the door behind him.

....

Heiler entered and stood for a moment inside the door, staring down at us with palpable contempt. A dismayed shake of his head seemed to set his pelvis in motion, and one leg kicked from his hip, and then another...

Suddenly Thorny was in his face, screaming - 'All you are is a life-support system for a dickhead' - and Zoe too, and then all the others. To their rage, his reaction was a cruel smile. By the time he'd shut the door behind him, the ward had once again been transformed into two dozen Borderlines from Hell, the worst patients in the world, proving the Borderline Theory.

I relaxed. When Heiler was with patients, no matter how they really were, they would act towards him like classic Heiler borderlines, lurching into rage, fear, projection... Not only do psychiatrists specialise in their defects. I thought, they evoke them in their patients...

-Samuel Shem, Mount Misery

In the book, the junior psychiatrists attempt to pair up the borderlines as part of a 'Buddy System', so that they may support each other post-discharge, which is sneakily arranged while Heiler is away. There are


ways of choosing two borderlines from among the 163 borderlines currently steaming up the windows. Take the first borderline, set aside, and allow to cool. Take the second borderline... please. Now, having been allowed some time out, assume that the first borderline meets just four (and and no more) of the criteria in addition to Criterion 5. Make a similar, uncharacteristically charitable, assumption about the second borderline. There are just


possible ways for the criteria set for the second borderline to be such that it does not overlap (except for Criterion 5) with that of the first borderline. So the probability of being able to choose two borderlines from the set of 163 borderlines who, apart from Criterion 5, each embody a unique subset of four or more of the other criteria, such that the two borderlines each meet a subset of the criteria that does not overlap with the other, except for Criterion 5, is


Which is almost as low as 1/200. Yeah, so much for diversity, I guess they pretty much are all the same.

Wednesday, April 25, 2007

A stigma wrapped in a history inside another stigma - that will probably never make it onto a t-shirt

Polly at Polarcoaster has designed herself a cute 'Bipolar Princess' t-shirt (click here for a photo). She writes 'I don’t know if I’ll ever wear it outside of my apartment or my friends’ apartment, since it’s like wearing something that says “LOOK AT ME! I’M AN ATTENTION WHORE!”'

I might be wrong here, but this seems to imply that the stigma of being perceived as an attention whore is greater than the stigma of being diagnosed with bipolar. Which leads me to ponder... how many people in the broad consumer/ex-user/psych survivor community (hereon referenced as c/s/x for brevity) would be prepared to publicly sport a t-shirt proclaiming 'Borderline Personality' or 'I Hate You, Don't Leave Me', especially in a context where a lot of people would understand the reference?

Now, I know that this is a diagnosis that has been severely tarnished by its use by psychiatrists as a 'trash can' for the 'treatment-resistant' and as a way of 'explaining' the behaviour of therapists who take advantage of their clients sexually. (The apparently irresistible pull of the 'seductive, needy' borderline and the fear of 'borderline rage' if the patient's overtures are denied, etc etc etc. If borderlines didn't exist, psychiatrists would have to invent them.) I know that BPD often might as well stand for 'Bitch Pissed Doc', and that it has a hot-potato effect, causing the unfortunate patient to be referred from shrink to shrink to shrink, rendering her chance of ever developing a therapeutic relationship with any of them near impossible by the prior communication of the damning diagnosis. So there's a whole stack of reasons why you would want to avoid being lumbered with it, if you have any interest in obtaining the best and most respectful treatment possible for yourself. But, sadly, nothing I've noted above makes the phenomena, each considered individually, of fear of abandonment, difficulties with close relationships, anger management issues, or short-term, highly reactive mood swings, rare or non-existent among those who've spent some time at the mercy of the mental health system. (Heck, if you do have issues like these, your time in 'the system' might even be a contributing factor.)

But few people ever want to admit to them, and so they probably shouldn't, if they're sitting anxiously in the office of a strange psychiatrist. But what about here, where we're anonymous and online, or in real time, talking to other c/s/x people? How many times have c/s/x (particularly bipolar) people declared to me, unprompted, that they've never been diagnosed as borderline? The subtext appears to be: I might be sick, but at least they've never called me that. It seems that not only are those diagnosed with BPD the niggers of the mental health system, they are the niggers of the c/s/x movement as well. And that worries me - a large group that, while rightfully resisting its stigmatisation as a whole, implicitly stigmatises a subgroup of itself, by accepting uncritically the attitudes of some rather weak and callous psychiatrists who, unable to deal with the frustrating but logical emotional and behavioural consequences of intense suffering, have somehow infected their entire discipline, and possibly now the c/s/x movement, with their bigotry.

Don't kid yourself - if you've cut yourself just once, or made a cry-for-help suicide attempt back in the days when neither you or anyone else had the faintest clue what was wrong, or even just argued with your shrink, 'borderline' will have almost certainly made a guest appearance - or even qualified for a regular slot - in your files. If you were young and female at the time, it's pretty much a done deal.

Of course, we're all free to judge individual examples of a person's behaviour, infer a pattern from them, and decide that we'd rather not deal with them if we so wish. But don't do this backwards, and indulge in the kind of wanton borderline-bashing that shrinks do both in semi-public 'places' such as professional journals, and behind closed doors, possibly under the influence of alcohol or other disinhibiting substances - not that some of them would need them, as they're clearly quite happy to let those bitches have it any time.

Tuesday, April 24, 2007

No more 'I love yous'... the language is leaving me...

Another batch of medical records arrived in the mail today. To my already fairly comprehensive list of misdiagnoses listed below, I can now add autism and, even more curiously disintegrative psychosis, a.k.a. Heller's Syndrome or Childhood Disintegrative Disorder (CDD). This condition is described as an especially malignant, delayed-onset variation on autism, such a that a child with CDD appears to develop normally for the first 2 - 10 years, only to undergo a sudden regression that often results in severe mental retardation. Ironically enough, I am at a loss for words.

Sunday, April 22, 2007

The Acronymphomania Pharmacopoetica

Firstly, a big hat tip to Stephany, who originally alerted me to this wonderful parody of a self-help website . Someone has clearly put a lot of effort into maintaining a detailed, intricate catalogue of the many types of juvenile misbehaviour that warrant heavy-duty psychopharmacological intervention, as well as updating it regularly with witty 'posts', supposedly by parents of children who are "oppositional, defiant and resistant to parenting".


The mystery author cleverly satirises those who construct their identities and those of their offspring around the limited (and limiting) notions of saint, martyr, patient, manipulator or victim, by associating each putative poster with a particular 'signature'. The 'signature' lists the diagnoses and medications for every fucking member of the putative poster's family - even the putative pets often get a look-in. Pure genius.

But browsing the website presents a challenge similar to that of reading A Clockwork Orange: just as one is distracted from Alex's awfulness by constantly having to flick to the back of the book for a translation of his quasi-Russian slang, the website is drenched with indecipherable acronyms that ooze through it like a bowl of alphabet soup upended over a naughty two-year-old's head. 'GFG' looks like the notation for a composite mathematical function, which I guess threw my imagination a bit. And to start with I could only infer that DH referred to the man of the house - Deadbeat Husband? Fortunately, however, a glossary is provided.

"Sadly to say my gfg (before being a day student) pooped on the floor in his dorm room, we've found poop under his bed at home and I've caught him smearing his feces in the shower, when I asked him why, he told me he didn't know and then asked if I was mad. And honestly, I don't think he did know why. Thankfully the last episode was over a month ago, I hope it lasts. He also cleaned the shower without me telling him to do so.
I, too, think they just don't think.
_________________________
Joanne anxiety/depression, panic disorder, burner, NVLD, type 2 diabetes, high blood pressure, high cholesterol, arthritis. Geodon 60mg BID, Ativan .5mg BID, Avandia 8mg, Benicar HCT 40/25mg, Lantus Insulin, Zocor 40mg, Norvasc 5mg, Prandin 2mg, Prilosec 20mg, WelbutrinXL 300mg, Buspar 5mg TID, Ambien 10mg at bedtime.
DH 22 years and still strong, believed to have ADHD as a child, but undxd.
gfg: 14/m 98% bilateral hearing loss (he's deaf), mild cerebal [sic] palsy, insulin dependent diabetes, mild MR, PDD, as of 3-16-07 mood d/o NOS, anxiety NOS
meds: NPH & Humalog Insulin, Geodon 80mg BID, Lithium 300mg AM, 600mg PM, Remeron 30mg nightly, Ativan .5mg 3 daily if needed, Zyprexa 5mg nightly."

I must admit that I found this particular parody 'post' rather cruel and tasteless when I first read it, until I remembered that it wasn't a parody 'post' on a site called 'cerebralpalsy.com' or 'hearingimpaired.com', but conductdisorders.com. And at the risk of steaming a runny joke dry by overanalysis, what does give it its satirical bite is the notion that someone would roll their shit under the bed or smear it around in the shower simply out of sheer thoughtlessness. I mean, when people defecate in inappropriate places, it is usually either a deliberate act of extreme hostility or symptomatic of a complete breakdown in bodily and/or mental functioning. But clearly our mystery author, too, thinks that a lot of people just don't think.

GFG is your Gift from God (your problem child)
PC is (are) your Perfect Child(ren)
DH is your Dear Husband
DW is your Dear Wife

Who says Americans can't do irony? Note that the relative lack of DWs referred to in the forum suggests that the author believes the behaviour s/he is parodying is more common in females.

And here's a non-exhaustive list of acronyms of the diagnoses supposedly being made:

ADD/ADHD: Attention Deficit/Hyperactivity Disorder
AS: Asperger's Syndrome
BPD: Borderline Personality Disorder
COBP: Childhood Onset Bipolar Disorder
CD: Conduct Disorder
DAMP: Deficits in Attention, Motor control and Perception
MDD: Major Depressive Disorder
GID: Gender Identity Disorder
IED: Intermittent Explosive Disorder
LD: Learning Disabilities
NVLD: NonVerbal Learning Disorder
OCD: Obsessive-Compulsive Disorder
ODD: Oppositional Defiance Disorder
PANDAS: Pediatric Autoimmune Neuropsychiatric Disorder
PDD: Pervasive Developmental Disorder
PTSD: Post Traumatic Stress Disorder
SID: Sensory Integration Disorder
TS: Tourette's Syndrome

I was having so much fun reading this site that I decided to compose a genre 'signature' that my mother might have used, back when I was 'oppositional, defiant and resistant to parenting'. (I still am, actually, it's just that no one can really do anything about it.)

Me: 40, undx'd OCD, histrionic PD. No friends, hobbies or outside interests to speak of.

DH: 43, married 20 years, sits in front of TV, drinks beer and doesn't answer when I speak to him, but remains supportive by disciplining GFG (will throw her across room if necessary).

GFG: f/16 dx panic disorder*, dissociative disorder, MDD, hx of truancy, failure, flouting school rules. Believed to be prodromal for schizophrenia - have bought her earplugs to keep out the voices. Denies that she has a problem. Will not keep room tidy, not interested in watching TV or attending football matches with rest of family. Insists on reading books and engaging in other anti-social activities instead. Meds: Aurorix 300mg, Xanax 2mg, Aropax 40 mg, Largactil 50 mg nocte for insomnia. Frequently discontinues medications without my or Dr God's permission.

PC: f/14 GID in early childhood but seems to have cleared up. Played only with boys back then but now has no interest in them at all. Has several very close female friends who will hopefully introduce her to their older brothers.**

2 cats, 1 male, 1 female, both strays. One female stray (2 y.o.) has particular attachment to GFG and this is reflected in cat's behaviour. Short bowel with lactose intolerance, often makes mess indoors. Cat ingested 0.25mg of GFG's Xanax the other day and a definite improvement in cat's behaviour was noted. Despite neutering, male cat frequently attempts to achieve sexual congress with PC's leg. Both cats orally fixated, particularly with respect to jewellery. DH says female cat will lick any man's ring.

And yes, the site is interactive, so you can create your own profile and 'signature', and post away about your four-year-old son's bipolar temper tantrums and (I kid you not, there is a precedent) your dog's undiagnosed ADHD.

* Where all the research money was at the time.
** Of course, PC eventually came out, and became not such a PC after all.

Friday, April 20, 2007

Thinking Bloggers





I've just received a 'Thinking Blogger Award' from D at Bipolar Chicks Blogging and Breaking My Own Rules. I've actually received one before, from Gianna at Bipolar Blast, but as I was so out of it at the time thanks to Zoloft withdrawal that it kind of failed to register. Thanks guys.

I'm told the rules for accepting the award are as follows:

1. If, and only if, you get tagged, write a post with links to 5 blogs that make you think.

2. Link to this post so that people can easily find the exact origin of the meme.

3. Optional: Proudly display the ‘Thinking Blogger Award’ with a link to the post that you wrote.

It's actually hard to nominate 'a top five', with so many blogs, written in so many styles, offering so many perspectives, so I'm going to do what I always do, and interpret the rules in my own way. At the moment, there are blogs I check almost every day, and have done so since I began blogging four months ago, and blogs that I'm just beginning to delve into, usually as a result of recommendations / comments made at my more regular haunts.

Stuff I always read:

Bipolar Blast

Gianna at BB was the first person to comment on my blog, and gave me heaps of encouragement and advice when I was beginning to feel as if I was talking to myself in the bath in the dark with a roaring hairdryer threatening to topple off the sink and fry me in my own random ruminations.

Her blog is unique in the way that it beautifully captures her day-to-day engagement with all the issues involved in reconceptualising herself and her 'illness': drug withdrawal, the damage done, finding things that work for her, and all the ups and downs that go with it. It gives her blog a freshness and immediacy that the blogs of a more polemic nature lack.

Furious Seasons

Apart from Philip Dawdy's investigative reporting that the rest of us wouldn't have a clue about doing, and long 'windy' reflective pieces that inspire so many comments and/or posts elsewhere, this blog is a bit like a giant cyber-coffee shop such that if you don't stop by at least once in a while you run the risk of being seriously out of the loop when it comes to what's hot and what's not. The recent 'Media Madness' posts have proved especially useful in netting new blogs a readership and provoking debate among the regular commentariat.

Just last week Philip suggested that he may expand the scope of the blog by posting on gender relations as well as mental health issues. Whether or not this will work is yet to be seen - such posts are likely to provoke more emotionally charged and diverse responses from the rank and file, and it will be a challenge for everyone involved to remain open to new ideas and to respond in an intelligent and engaging way to those with very different opinions. (Thus far, the clientele of this cyber-coffee shop have tended to agree on most of the broader issues - that the tactics of Big Pharma suck, that shrinks who put small children on cocktails of absurdly powerful drugs suck, etc - so I would expect to see some interesting 'side-effects' if this status quo is disrupted.)

Clinical Psychology and Psychiatry: A Closer Look

This is great for a non-bitchy, no-bullshit analysis of Big Pharma, academic psychiatry and the implications of the latest of either's policy statements, research 'results' and marketing ploys. Read this before swallowing that.

Stuff I've looked at occasionally for a while but am now starting to read more closely:

Polarcoaster: This is a relatively new blog that is intelligent, straightforward and thoughtful by a young Canadian woman who was diagnosed as bipolar in her late teens.

Writhe Safely: A blog written by someone very smart and very pissed off. That should go a long way to explain why I like it. Some really interesting stuff about PTSD went up last week that I intend to reflect upon and post about here.

Depression Introspection: A blog with a great layout that combines personal pieces and useful information on topics such as suicide and anti-depressants, with a dash of investigative journalism. It had a terrific post yesterday on the Virginia Tech shooting. Otherwise, there's perhaps a bit too much religion for my taste, but then again I'm not from the States, so my tolerance levels are low!

Breaking My Own Rules: I'm looking forward to all those posts you've been promising, 'specially the dark-humoured psych ward story, D!

Soulful Sepulcher: Precise, prolific and poignant, and as Stephany says: "Knowledge is your best weapon".

And what ever happened to:

Neurotransmission? This is less a daily 'random thoughts' kind of blog than a series of lengthy, less frequent essays that explore topics such as the construction of DSM and the psychology of evil in great depth. Hopefully, Jason, the author, will post again soon.

Off topic: but here's a link to a blog whose author has just survived yet another near-death experience, this time as a result of a surgical error compounded by less-than-ideal post-op monitoring. OK, time for some statistics:

2.5 million people die in the US annually. The murder rate in 2004 was 5.5 per 100,000, which equates to approximately 16,500 murders. Now here are some estimates of the death rates as a result medical errors (full references here):

44,000 to 98,000 deaths annually from medical errors (Institute of Medicine)

225,000 deaths annually from medical errors including 106,000 deaths due to "nonerror adverse events of medications" (Starfield)

180,000 deaths annually from medication errors and adverse reactions (Holland)

7,391 deaths resulted from medication errors (Institute of Medicine)

Which kind of puts our fears of death by terrorist attacks or mass murder sprees into perspective, I think. But then again, I'm a thinking blogger!

Sunday, April 8, 2007

Blogging for Jesus

Manufacturers, marketers and prescribers of Zoloft, Zyprexa and Aropax/Paxil/Seroxat:


Actually, I was wondering this Easter Sunday morning, what would happen to Jesus if he came back? Given that there are a lot of people who go around saying they're the Messiah and end up locked up and/or on major tranquillisers, what if Jesus is actually one of them, languishing in some psych hospital somewhere? I suppose he could perform a miracle to prove to the doctors he really was Jesus, but Jesus wasn't really a showman if you think about it - he stayed up there on the cross, after all. Perhaps he could turn someone's contraband booze back into water, and then into liquid Largactil, but wouldn't that be so, oh, 2000 years ago?

Come to think of it, Jesus began to exhibit manic symptoms from a young age - running away from his parents while at the temple to discuss the finer points of theology with the elders, for example. Some clear-cut evidence of grandiosity and lack of impulse control there, ahem - could Jesus have been the paradigmatic Bipolar Child? While there is enough historical evidence to enable us to be confident that Jesus did in fact exist, unfortunately his Baby Book and medical records appear to have been lost, so we don't know whether he liked biting other children while on 'play dates' or was unable to stop masturbating. Perhaps we could get Dan Brown onto this, so we can get a definitive answer on this one. (UPDATE: Dan just emailed me to say that Jesus's pediatric medical records are buried underneath the Massachusetts General Hospital.) Undiagnosed and unmedicated, the poor guy apparently grew up to indulge in some really violent and bizarre behaviour, like cursing fig trees and upending tables in public buildings, not to mention suffering hallucinations in deserts and gardens.

The mental health or otherwise of Jesus was of enduring interest during the early years of last century with psychiatrists labelling him either epileptic, paranoid or ecstatic based on the Gospel accounts of his behaviour. Subsequently, according to a review in the Journal of Abnormal & Social Psychology * in 1923, the issue was put to bed by the publication of a book called The Psychic Health of Jesus by one Walter E. Bundy, a Bible scholar rather than a shrink. Bundy firstly argued that most of the so-called 'evidence' for Jesus's insanity emanated from the Gospel according to John, which had been largely discredited in the late 19th century as a reliable source of information about the 'historical' Jesus. His second objection, as summarised by the Journal's reviewer, James H Leuba, is more interesting:
In order to understood correctly, the apparently incriminating words and actions of Jesus must be placed in their historical setting. In several instances they then cease to appear abnormal or at least they lose much of their virulence. The belief of Jesus in his Messiahship assumes, for instance, a different cast when it is realised that the expectation of a Messiah was prevalent at the time and that, therefore, a belief which to-day [sic, 1923] might be regarded as a sign of insane credulity could then be entertained by sound minds.
Which kind of begs the question - are predictions of the imminency of the Second Coming more common now than in 1923? If so, should the claims of latter-day Messianic aspirants "assume a different cast" and be "entertained by sound minds"? Jerry Falwell and Jack van Impe both seem to think that Jesus will be back within the next decade or so, and the prophesies of Nostradamus and Edgar Cayce have been interpreted to mean that Jesus was born in 1999, which would make him a Ritalin-addled little brat of about seven or eight now, due for his first psychotic break more or less in accordance with Falwell's and van Impe's predictions.

So, let us not ask "What would Jesus do?" but "What the fuck are we going to do to Jesus, this time round?"

Best wishes for a euthymic Easter break from a dysthymic atheist.

* Vol 18(3), Oct 1923, pp. 296-297

Saturday, April 7, 2007

But you're all right now, aren't you?

This is a response of sorts to a post entitled Slouching Towards Recovery by Philip Dawdy at Furious Seasons, which was also critiqued by Gianna at Bipolar Blast. Read these posts - although I'm going to address some of the issues they raise from the perspective of a 'survivor', as opposed to the 'empowered consumer', there's a hell of a lot of common sense there no matter where you sit on the critical psychiatry spectrum.

But you're all right now, aren't you? This question typically arises on the rare occasions whenever I discuss what I call my psychiatric mythology with anyone, and inspires much eye-rolling on my part (which my interlocutor may well assume is medication-induced). The befuddlement that my disclosure invariably produces is based on a number of factors - I present as neat, highly organised, fairly confident, and above all, competent, both work-wise and when it comes to giving other people advice on how to handle their personal problems, which I manage to give the impression that I do not share. On the other hand, I've still got my quirks, which people who know me well are familiar with, that same familiarity breeding contempt in accordance with the usual exponential formulae. But more about that later.
The biggest thing you've got to do is accept your diagnosis... or you are going to be wrestling with yourself a long time. It's not worth doing. You know damn well that something is up with you, so what do you intend to do about it?

- Philip Dawdy, Slouching Towards Recovery
I was diagnosed with bipolar disorder at 19, a diagnosis I did not then and still do not accept. In fact that was last diagnosis I received, having previously run the gamut of schizophrenia, major depression, dissociative disorder, panic disorder, and schizoid, anti-social, narcissistic and borderline personality disorders in my various sojourns under lock and key. After escaping 'the system' just prior to my twentieth birthday, I spent a year 'in recovery' from psychiatry, a year which more or less amounted to a combination of alcoholism and agoraphobia as I wandered about my rented room trying not to rehash the events that led to my downfall, and occasionally lapsing into what were presumably alcohol-induced waking terrors, when the knife I kept under the pillow in case the crisis team ever visited again was pulled out. I then cleaned myself up by sheer fucking force of of will (which I emphasise not to make a point about what a tough nut I am, but about how involving any so-called 'mental health professionals' in the process was simply not an option) and enrolled at university. Apart from a recent misadventure with Zoloft, I have been medication-free since I was 20, and in full-time employment since I was 21.

So unlike Philip, I don't accept any of my diagnoses, but that doesn't necessarily prevent me from knowing "damn well that something is up" and that something might need to be done about it. It's simply a matter of reframing notions of causality, course and recovery. I've come to believe that while I don't suffer from any of the above-mentioned mental illnesses or disorders, I do suffer from a variety of psychological injuries, many of which are a direct result of the time I spent under psychiatric 'care' and some of which pre-date it, and are in fact part of the reason I became enmeshed in the psychiatric system in the first place - to have these injuries treated, not to be slandered (oops, diagnosed), doped up, locked up, sleep deprived, physically and verbally assaulted, sexually harassed, emotionally manipulated and generally reduced to a ghastly mess of pure, cognitively unmediated impulse and emotion - in other words, madness.

But I digress. For a few years I was 'OK' - functioning well occupationally and academically, but a little less well socially - thanks to my hospitalisations I'd largely missed out on the time of life (the late teens and early university years) when one makes 'friends for life', and the rock-bottom self-esteem that an inappropriate entanglement with one of those so-called 'mental health professionals' had left me with no doubt contributed to my willingness to spend five years in a 'relationship' with a work colleague who would discreetly take me out to dinner and fuck me every now and then, all the while looking over my shoulder for someone older, better paid, better educated and more suitable to be introduced into his inner circle of urban 30-something MBA and PhD-educated friends as his 'girlfriend'.

I finally stopped returning Mr (oops, Dr) Snob's phone calls when I was 27, which removed the focus from my poor judgement when it came to intimate relationships, and redirected it to the work sphere, where the level of responsibility I 'enjoyed' was increasing, but the salary and credit I received for not having the brain the size of an amoeba wasn't. No matter what I accomplished, it seemed like every man and his dog thought they were my boss and I was their personal secretary, and sometimes it seemed like I was spending days on end kneeling in the mud, pooper-scooper in gloved hand. (And then the dog would decide to take a shit too.) I'm sure that when I first brought this unacceptable situation to the attention of my boss, I did so in the nicest possible way - but to no avail, of course, for the Social Darwinist attitudes about the roles of women and of "non-professionals" (more politely known as managers, administrators and support staff) in professional settings are so entrenched that even for him to ask his egomanic underlings to wipe their own arses instead of expecting me to do it for them was a bit like asking them to eat the toilet paper as well. So this was when I began to institute unilateral bans on dealing with particular people and eventually, to start bagging their shit and throwing it right back in their faces, which naturally garnered me a reputation as being "difficult to work with", which I'm told will haunt me down the years.

Even post-promotions and payrises, I still don't know how to deal with snide remarks, subtle put-downs or outright verbal abuse from senior colleagues apart from just throwing it back at them in spades and, more importantly, I still don't know how to put aside the all the fury and frustration at the end of the working day and enjoy what leisure time I have. Where all this comes from, who knows - years of being belittled and treated like an idiot by psychiatrists and their ilk, transference of feelings about abusive parents to all authority figures, my own natural and ample egotism, whatever - the point is, I need to acknowledge that I haven't worked out how to handle it yet. I doubt 'Educating Ruth' will be amenable to a 90-minute adaptation for stage or screen any time soon, with a syllabus that includes learning what kind of people push my buttons, and learning (usually the hard way) to stay away from them, not to try and change them or even to learn how to adapt to them; that there's often no need to obtain mastery over a given interpersonal situation if it can just be avoided. Then there's learning not to learn the hard way, not to piss on the electric fence, and learning everything that I missed out on learning as a result of my incarcerations, and re-learning everything that was un-learned in the onslaught of multiple medications and the clearly communicated expectations of my deterioration, lack of responsibility and even imminent death. And finally, there's learning how to trust, but I have a feeling this will make up most of the Advanced part of the course.
Two basic operating principles: No suicide. No giving up. Once you get those operating principles into your life, it gives you the ability to get down to the most important matter of all, which is environment. You must have as much control of your total human environment as you can possibly manage... Anyone with bipolar disorder, depression, schizophrenia who's had it for more than 15 minutes... knows that there are certain things and situations that don't work out well for them.

- Slouching Towards Recovery
Too fucking right. Privacy. Independence. Doors, without windows, that can preferably be locked from the inside. Avoiding relationships, either personal or professional, that replicate the level of surveillance I was subjected to as a psychiatric patient - people who want to know where I've been, where I'm going, what time I'll be back, who I'll be seeing, how much I'll be drinking. (One of the advantages of my current job is that I don't clock-watch, and no one clock-watches me - but it took much patience and many rabbits pulled out of hats for my boss to learn that the degree of supervision he was accustomed to providing was unnecessary and indeed counterproductive in my case.)
You've got to adopt a no-excuses mindset. That means you've got to stop blaming the illness alone when things get dicey. You've got to dispense with the learned helplessness that the mental health system in this and other countries impose on patients...

My own feeling is that you've got to approach bipolar disorder as a personality disorder - or even as an environmental disorder - as opposed to a strictly biologically based illness. You get to work on all the behavioural problems and cues and triggers then. I know that's a heretical thought, but so be it.

- Slouching Towards Recovery
It wouldn't take a feeling-slightly-defensive psychiatrist to point out that Philip's 'no-excuses' rule applies as much to me as it does to those who accept that they have an illness, given that I nevertheless see myself as suffering 'injuries' that just happen to be largely iatrogenic. Thus, I have to be careful not to blame my time 'beneath the ice' for my every interpersonal misdemeanour or, tempting as it often is, revert to the strategy of the rented room with a bottle of Vat 69 and a knife under my pillow. It can sometimes be hard to remain comfortably 'in the world' as just another flawed but basically functional human being when one is aware of people, places and procedures that may cause one's utter desecration, while enjoying full legal and social sanction.

Philip makes the point that research into people who 'do well' in spite of receiving diagnoses such as bipolar disorder or schizophrenia is sparse. At the risk of overgeneralising from my own case, could it be that many people who 'do well' are doing so as the result of having moved off the psychiatric (and thus the research) radar, having decided that the cure is worse than the disease? I find it rather irritating when the same well-meaning people who say but you're all right now, aren't you? say things like "It's really impressive how you've managed to pull yourself together and put your life back together," or some such shit, because it shows how little they've understood what I've been telling them - sure, I've had to put in some hard yards, but the 'secret of my success' lies mostly in my good fortune to have gotten out of 'the system', off multiple medications and away from doctors who wanted to diagnose me with everything under the sun and tell me I'll be dead by the time I'm 21 if I don't do what I'm told.

I'm 30 now. I might still kill myself yet, but it will be in the back of Dr Kevorkian's van after disease has ravaged my body, and not on the bathroom floor after the mental health system has again ravaged my mind.

Friday, April 6, 2007

Complicated vs. uncomplicated and some depressing levels of innumeracy

Furious Seasons recently reported the publication of a paper in the Archives of General Psychiatry, in which the authors argue, based on epidemiological data, that the current practice of disqualifying the recently bereaved from a diagnosis of Major Depressive Disorder should be extended to people who have recently suffered other types of losses, which would result in a reduction of the currently accepted lifetime prevalence rate of Major Depressive Disorder by 25%. This has caused quite a splash, resulting in media coverage in the New York Times, much blog commentary and mass mail-outs to every critical psychiatry / consumer group email list. (And for the non-mathematicians out there, saying that the 'official' lifetime prevalence of depression should be cut by 25% is equivalent to saying that it has been overstated by 33%, not 25% as reported, which should get everyone even more excited. Who said maths wasn't useful for anything? Number up!)

I've read the full paper, and it does confirm the common sense notion that sadness resulting from life traumas should not be considered categorically different than the sadness resulting from bereavement. But it does rely on making a distinction between 'uncomplicated' vs. 'complicated' depressive reactions. Which is fair enough from a scientific point of view, since DSM only considers 'uncomplicated' bereavement to exclude a patient from receiving an diagnosis of Major Depressive Disorder, and it is this 'uncomplicated' exclusionary space that the authors seek to have expanded to include 'uncomplicated' reactions to other losses or stressful events. But in spite of enabling the authors to re-calculate the lifetime prevalence of depression as 11.3% (originally reported as 14.9%), the feeling the paper left me with was of a 'soft' result (necessarily constrained by research protocols) that does not actually pose much of a challenge to the ideology masquerading as science that underpins the conceptualisation and diagnosis of depression.

'Complicated' episodes, whether triggered by bereavement or other forms of loss, were distinguished by the authors from 'uncomplicated' episodes by the existence of at least two of the following: morbid preoccupation with worthlessness, suicidal ideation, marked functional impairment (not being able to work or socialise) or psychomotor retardation, prolonged duration (> 12 weeks) or a suicide attempt. Such 'complications' would enable a diagnosis of depression regardless of any precipitating factors.

I think most of us would agree that someone suffering from at least two of the above might benefit from (and indeed require) some kind of intervention, although those of us who have been damaged and marginalised by the excessive emphasis that mainstream psychiatry places on biogenetic causes would have to seriously question whether psychiatric interventions would be of any use. I doubt that as a result of this paper, mainstream psychiatry will ever stop to consider whether the concepts of 'disease' and 'disorder' are still out of place even in 'complicated' responses to bereavement and other losses, and to begin to think in terms of 'injuries' instead. As the authors point out, false-positive diagnoses can lead to stigmatisation, but even 'true-positive' diagnoses could be reframed in a less stigmatising way.

Needless to say, it should come as no surprise that three out of the four authors of this paper are social workers, not psychiatrists.