Abusing ‘Normal’

Alternately titled: Yes, but isn’t EVERYBODY kinda mentally ill? What is mental illness anyways? Aren’t we just pathologizing being weird?! BUT SO MANY PEOPLE SEEM TO BE MENTALLY ILL NOW!

If you talk about mental health and mental illness long enough someone is going to pull one of these.

 You know, aren’t we all just different?

It seems like everyone has a mental illness. 

I mean, like, isn’t everyone sad/anxious/depressed/a little obsessive-compulsive?

Yes, but mental illness is just a social construct! We just decide what behaviors we don’t like and those are the ones we treat! 

I mean, it’s all just a bell curve!

I’ve always imagined myself shouting BECAUSE REASONS!!11!1, and then promptly brandishing a list at the offending questioner. This post is the internet equivalent to that word waving. Beware of snark.

1) The ‘Useful Heuristic’ Explanation

We, as humans, categorize things, then use shortcuts to understand what’s going on in our world. These can break down and aren’t always helpful (see every racist, sexist, heterosexist stereotype ever) but they do save cognitive time and space and increase processing speed. “Having X mental illness” or even “having a mental illness” is a useful heuristic that conveys specific information. I don’t have to tell you that I am statistically more likely to find food anxiety-provoking, while also having significant distorted bodily perception, obsessive behaviors related to food and drink consumption and discussion of the aforementioned–I can just tell you (or anyone else) that I have an eating disorder.

2) The ‘Special Snowflake’ Explanation

The experiences of those with mental illness are quantifiably different from those without mental illness. In fact, when people respond with “Oh, I get/understand/could imagine [whatever aspect of mental illness I was talking about].” I’m actually faintly uncomfortable. Because no you don’t.

By attempting to cheerfully shoehorn the experiences of the mentally ill into your Just Like Me box, you’re actually ignoring their experience–and also refusing to acknowledge that the ways in which they inhabit the world are fundamentally different from yours. You don’t understand it, and you can’t, and that’s fine. The solution is to get used to it, not to pretend you’re the same people with slightly different idiosyncracies. Mental illness not having a membership to a Special Club for the Quirky. It’s overwhelming, distressing, and the vast, vast majority of people with it spend their time wanting it to go away, now.

And for heaven’s sake, mental illness is not a cute little talent like juggling geese, rearing its head when convenient.

3) Dammit, It’s Hard to Do Research Without Diagnoses

Without some way of quantifying the clusters of symptoms that make up different mental illnesses, we’d have extraordinarily poor research. The anxiety surrounding food in anorexia is different from the anxiety of a phobia or the anxiety of PTSD. The You’re Ostracizing People Who Are Just Different crowd usually fail to consider that research lies almost entirely in developing and learning from divisions of differentness.

4) The Medical Model has Some Uses. 

Before I have a riot on my hands, this is not me throwing my support to the medical model of mental illness. (Medical model redux: Diagnose via a checking boxes on a list of symptoms, find appropriate fix.) I don’t particularly like it for any sort of understanding about actual illnesses. Go biopsychosocial!

But the model is useful for explaining why being neurodivergent is not the same as being neurotypical. By equating mental illness to physical illness, (Another note: I’m not endorsing mind-body dualism here either–or the excessive use of parenthetical notes.) we’ve benefitted greatly. You can say “someone with cancer has physical differences from someone without cancer!” and then substitute ‘depression’ for ‘cancer’, and people wil get it. Not only that, but they’ll understand why treatment is a necessity, why it should be covered under insurance, and why people with depression alter their lives around it. Pretty sure no claims office shelled out for “being a different kind of normal”.

So.
[Dusts off hands.]
Mental illness is A Thing.

Abusing ‘Normal’
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Psychopathology Sum-Up: Types of Antidepressants

Weekly series! As per previous discussion, I will be publishing a big information blog on each Friday. Unfortunately, it’s midterms for me, which means a shorter post for you. Blame the paper(s) and exams and readings and stuff. I promise to be back on schedule next week. Also, I’ve commissioned a post on bulimia from Tetyana, who runs the spectacular Science of Eating Disorders blog, a skeptical look at research on ED’s.

Anyways, today we look at the types of antidepressants.

Selective Serotonin Reuptake Inhibitors (SSRI’s)

[Note to neurobiologists: I am simplifying massively here. I know that.]

These are the most popular medications for depression, and include a bunch of names you probably recognize: Zoloft, Prozac, Paxil, Celexa, Lexapro.

How do they work?

A general sketch of two neurons.
A general sketch of two neurons.

Neurons don’t connect directly to each other–they have a very tiny space (the synaptic cleft) between each end of one and beginning of the next. Neurotransmitters (like serotonin, dopamine, GABA, etc) are released from the presynaptic neuron, and partially absorbed by the postsynaptic neuron. The neurotransmitter that isn’t absorbed is mainly taken back by the presynaptic neuron. SSRI’s work by blocking the reuptake mechanism for serotonin, leaving more available serotonin in the brain, which seems to relieve depression in some people.

But, this is grossly oversimplified, and depression is not as basic as not having enough serotonin. In the words of Ozy, brain chemicals are not fucking magic.

Side effects of SSRI’s can include lack of sex drive, hyperactivity or lowered energy, etc. In some, these are so life-disrupting that other medications are preferred.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s)

SNRI’s include Cymbalta, Effexor, and Pristiq. They work very much like SSRI’s, except they inhibit both the reuptake mechanism for norepinephrine and serotonin.

The effectiveness of SSRI’s lends support to the Monoamine Hypothesis–an incomplete explanation for depression, suggesting that several neurotransmitter systems (including serotonergic) are responsible.  The hypothesis does hold up to scrutiny, but doesn’t explain why many antidepressants also help with anxiety and obsessive-type disorders.

Tricyclic Antidepressants

Color me happy to have done my research before publishing–turns out I didn’t have all of my facts straight. Tricyclics are antidepressants that operate somewhat like SSRI’s by inhibiting the reuptake of serotonin–but they also have a laundry list of possible side effects, and, like MAOI’s, are used more and more rarely.

Monoamine Oxidase Inhibitors (MAOI’s)

MAOI’s can be super effective! However, they come with hefty diet restrictions, and resultingly, are used rarely–mostly as a last resort.

People taking MAOI’s need to avoid all sorts of things, like pickled foods, most cheeses, wine, decongestants, and SSRI’s. Failure to do so can cause a stroke–the result of buildup of tyramine in the brain. Since other antidepressants are available, MAOI’s have fallen out of favor.

Norepinephrine and dopamine reuptake inhibitors (NDRIs)

Wellbutrin! NDRI’s are good because they usually don’t have the sexual side effects. They too, lend support to the Monoamine Hypothesis, by altering the dopaminergic and norandronergic pathways.

St. Johns Wort

Okay. This is alt-med, but it’s been gaining mainstream popularity. It’s one of those that might work on mild to moderate depression. And if taken without doctor supervision and with other medications it can cause you all sorts of problems. In combination with SNRI’s, it can cause Serotonin Syndrome–an excess of the neurotransmitter which overloads the central nervous system. It also appears to decrease the effectiveness of oral contraceptives, might cause problems if you’re breast-feeding, and oh, right, as an herbal supplement, isn’t all that regulated. What I’m saying is, self-prescribing this stuff is not a great idea, and right now, there’s not evidence that it works for major depression. But some people do use it, so I’ll include it.

Psychopathology Sum-Up: Types of Antidepressants

Psychopathology Sum-Up: Specific Phobias

It’s Friday, which means a mental health summary. This post is about so called ‘specific’ phobias, which excludes social phobia. Another Sum-Up will deal with that. 

The Overview:

Specific phobias are a category of anxiety disorders. (Anxiety disorders also include OCD, Post-Traumatic Stress Disorder, and Generalized Anxiety Disorder, among others.) Specific phobias are can be seen as the Mad Libs of anxiety: “fear of [insert a noun here]”. The fear is paralyzing, and often interferes with normal functioning, but most are easily cured. In fact, this makes them unusual–one of the only disorders where upon discovery, we know what to do, and we know you’ll most likely be cured.

Specific phobias are also fairly common, and occur most often in adolescence. When the phobia interferes with functioning, people are quite good about seeking treatment. Otherwise, most people avoid the trigger (sometimes going to great lengths), and live their lives. Common phobias include flying, enclosed places, heights, dogs, escalators, spiders, and snakes. (NIMH)

Phobia Treatment:

Blood/Injury/Injection Treatment: Fear of needles, blood, wounds, injuries, or some combination thereof is known as BII. In severe cases, just reading about injuries, even in fiction, can cause wooziness. Treatment is actually different from other phobias, because it’s hard to unlearn fainting. Clients are taught to tense all of their muscles at once when triggered, which raises blood pressure.

Exposure Therapy: Exposure therapy can work in a single day, which is kinda cool. Of course, it takes all day, but no other therapy is quite so simple. Client and therapist both decide on a series of experiences from mild to very scary, and work through each. For instance, looking at a picture of a snake, then talking about snakes, imagining a snake, being in the same room as a snake, being near a snake, and finally, holding a snake. Update: Cuttlefish expands on this very very well–there’s a few types of ET, and they’re very different from each other.

Cognitive therapy: Talking through excessively fearful thought processes and challenging them. This is often combined with exposure therapy.

Medication: Never been shown to be effective.

Important Note: Just because phobias are irrational fears and easily treated does not mean you should badger, mock, or otherwise force someone to face their phobia. It’s rude and callous. Don’t do it.

Things Specific Phobias are Not:

Disliking things: hating dogs is not the same as being scared of them.

Rational fear: I think we can all agree that it’s rational to fear the idea of a plane crash, or developing a terminal illness. However, it’s slightly less rational to refuse to look at planes because of a fear of plane crashes. Phobias are irrational fears.

If any information is incorrect, please note it in the comments! However, I am going to ask for citations. I have access to journals as a student, so no worries if it appears behind a paywall. Also, please chime in with your own experiences, misconceptions, myths you’ve heard, and any book suggestions!

Previous Psychopathology Sum-Ups:
Bipolar Disorder

Psychopathology Sum-Up: Specific Phobias

Antidepressants and Suicide: The Rant

[Content Note: This is 618 words about suicide. If that’s triggering, there’s nothing you could enjoy in this post. Take care of yourself.]

Antidepressants do not cause suicide.
Antidepressants do not cause suicide.
Antidepressants do not cause suicide.

There’s plenty of reasons that people with depression don’t take anti-depressants (AD’s have uses for other psychiatric illnesses, but we’ll focus on depression here). For one thing, they’re only effective for about two-thirds of those who try them. The side-effects aren’t always fun either.

So what I’m saying is, not everyone takes or is helped by antidepressants. But, there’s also a dangerous trope that continues to circulate–that taking psychiatric drugs can cause you to commit suicide. Mercola (of course) is perpetuating it. Psychiatrist–sputter–Dr. Peter Breggin is saying it. And saying it again–this time to Congress.

Except…it’s not true.

So why this type of warning?

Prozac-black-box1

Here’s what we know. During the first few weeks of anti-depressant use, teens and children experience a slightly higher risk of attempting suicide. As of this time, no study has ever found antidepressants responsible for suicide, nor has any participant in studies of antidepressants ‘successfully’ completed an attempt. (FDA)

Why? Why just a brief risk period?

First, The Background. Suicidality comes in a few levels of risk:

Ideation: This comes in a spectrum from not wanting to be alive to wanting yourself dead. It can vary from the occasional passing thought to invasive, pressing, and overwhelming.
Planning: The thoughts have are specific. Varies from having a preferred method to  saving medications or buying a weapon. (Women tend to pick less successful methods, such as pills, men, more lethal. Women are far more likely to attempt, men are more likely to succeed.)
Attempting: Some suicidal action is intentionally taken. This can range from making an intentionally unsuccessful attempts–such as taking too few pills to be lethal–to making every effort to die. Attempts do no occur in a vacuum;  one attempt makes a second all the more likely.

Okay. Back to depression. (This is not a cheerful post.)
People suffering from depression often find themselves without motivation–unable to muster the energy for friends, work, etc. Ally of Hyperbole and a Half has a long description and illustrations that cover it perfectly.

This gets really interesting when you look at the ways antidepressants begin to work in children and adolescents. Often, they experience heightened levels of activity and drive…while still feelings the emotions of depression. Then, more slowly, antidepressants decrease depression.

Which leads to a little bit of a common theory about why suicide risk go up in the first few weeks of teen AD use. Take Theoretical Jane:

TJ has been depressed for a few months. She can’t always bear to get out of bed in the morning, and feels like she’s sleepwalking through class. She’s had some thoughts about suicide, and considers it at least once a day. TJ starts taking Prozac. For the first couple of weeks, it’s just starting to get working. She still has suicidal ideation–but she also doesn’t have trouble with exhaustion or lack of motivation. So we have someone who doesn’t want to be alive, but suddenly has all the energy and drive to be able to do something about it. I think we can see where this would be a problem, yes? Luckily, Prozac starts to help with the depression fairly quickly, and our Theoretical Jane starts to feel better.

——-

So. There’s what we know, what we think causes it, and then blanket misinformation about a link between antidepressants and suicide. Antidepressants do not cause suicide. Yes, sometimes people who take antidepressants commit suicide. That might have to do more with why they’re taking them in the first place. Let’s stop making it harder for people to take them in the first place.

Antidepressants and Suicide: The Rant

Psychopathology Sum-Up: Bipolar Disorder

[Content note: brief discussion of suicide]

Weekly series! As per previous discussion, I will be published a big information blog about a specific mental illness on each Friday.

I know, today is not Friday. I’m publishing early because I’m excited, and also I want to get lots of feedback. Tell me what I’m not including, what other things you want to know, etc. If there’s enough questions, I’ll do a second follow-up post. Lastly, tell me if there’s terms I’m not defining that I should be. I really really don’t want to get wrapped around jargon here–it helps nobody.

The idea is to talk about what the diagnoses are and aren’t, common misconceptions, what treatment and outcomes look like, and so on. Though not all therapeutic orientations (the theory and approach behind a course of treatment) depend on or use diagnoses–and there’s some very good arguments against using the medical model of diagnosis–we do use labels to conduct research, and it’s worth learning what a mental illness is. I’m going to try to include any changes to diagnostic criteria as well as current debates.

This post is massive and organized in informational sections, so I’ve put it behind a jump.

Continue reading “Psychopathology Sum-Up: Bipolar Disorder”

Psychopathology Sum-Up: Bipolar Disorder

A National Database of the Mentally Ill

Subtitled: Has Anyone Here Heard of Client/Patient Confidentiality? No? No.

Today, the National Rifle Association had a press conference.

Wayne LaPierre, the Executive Vice President spoke, and I, recently relocated back to Texas for the holidays, slept through it.

Then I saw the transcript, sat bolt upright in my bed, and got ranty on the internet.

The relevant bit (emphasis mine):

 The truth is, that our society is populated by an unknown number of genuine monsters. People that are so deranged, so evil, so possessed by voices and driven by demons, that no sane person can every possibly comprehend them. They walk among us every single day, and does anybody really believe that the next Adam Lanza isn’t planning his attack on a school, he’s already identified at this very moment?

How many more copycats are waiting in the wings for their moment of fame from a national media machine that rewards them with wall-to-wall attention and a sense of identity that they crave, while provoking others to try to make their mark.

A dozen more killers, a hundred more? How can we possibly even guess how many, given our nation’s refusal to create an active national database of the mentally ill? The fact is this: That wouldn’t even begin to address the much larger, more lethal criminal class — killers, robbers, rapists, gang members who have spread like cancer in every community across our nation.

So, since the NRA seems long on rhetoric and short on facts, I thought I’d clear some stuff up for them.

Patient confidentiality exists even if you have mental illness.

Funny how that works, where you have rights still, when you have mental illness. Psychiatrists still have to follow HIPPA rules. In fact, notes on psychotherapy that are kept separate from medical charts are given even more protection. Was the NRA suggesting that we trounce all over patient confidentiality and require all diagnoses to be reported? Just the “dangerous” ones? Would someone like to clarify for me which ones those are?

Therapists are already required to report anyone who makes a credible threat, and warn any possible targets.

This is largely based on the Tarasoff Rule, which came out of Tarasoff v. Regents of the University of California. In essence, when a psychologist or therapist hears a client threaten harm, they are obligated to warn those people who may be in danger. “Protected privilege ends where the public peril begins.” This is one of several exceptions to confidentiality, which can be summed up as confidentiality except in instances of harm to self or others. (Which includes reports of child abuse while another child is in the home, risk of suicide, elder abuse, and any threats or injury or death to another.)

So, say there was a high correlation between being mentally ill and being violent. (There’s not.) And then say the Connecticut shooter was mentally ill and in treatment (As far as we know, he wasn’t.) And then, say he’d confessed his plan… oh wait, there’s already methods in place to deal with that. So your database does what now, NRA?

Not everyone with mental illness is diagnosed. 

So would you be requiring everyone to be tested for mental illness then? I mean, I’d be all over that if you didn’t then require that  the mentally ill be registered in a database à la sex offenders. 

Mental illness isn’t exactly uncommon. 

Twenty six percent of American adults meet criteria for a diagnosable disorder in a given year. That, for those of you inclined towards fractions, is one quarter of the population. Since I’ve noticed that it’s somewhat less than a quarter of the population that’s having trouble committing violent crimes with guns, I’m going to posit the radical notion that having mental illness and being near weaponry does not a killer make. Of course, there are some mentally ill people who shouldn’t be near guns. I’ll agree to that easily. There’s also some mentally sound people that we’d rather not have near guns.

Discrimination against the mentally ill is actually a problem. 

Nifty research here. (Abstract only if you’re not at a university, sorry.) Basically, the neurodiverse are more likely to be discriminated against by their employers and coworkers, as well as facing disadvantages in competing for jobs. So maybe we could try to avoid making that worse? Like say, by avoiding the creation of a searchable database of those with mental illness?

Note: I’m fully aware that some people with mental illness are violent. So are some neurotypical people. I’d be all over a psychometrically sound test of impulse control/aggression/etc, that tested abilities related to using a gun responsibly. Using science to determine safe gun owners–great! Using a highly stigmatized population to avoid discussing gun control–jerk move.

A National Database of the Mentally Ill

You are Not His Mother

This is excerpted and edited from something I put on Facebook. 

There is a horrible article going around. I am Adam Lanza’s Mother, it says.  It’s the story of a mother who has a mentally ill child.

I live with a son who is mentally ill. I love my son. But he terrifies me.
[…]
We still don’t know what’s wrong with Michael. Autism spectrum, ADHD, Oppositional Defiant or Intermittent Explosive Disorder have all been tossed around
[…]
I am sharing this story because I am Adam Lanza’s mother. I am Dylan Klebold’s and Eric Harris’s mother. I am Jason Holmes’s mother. I am Jared Loughner’s mother. I am Seung-Hui Cho’s mother. And these boys—and their mothers—need help. In the wake of another horrific national tragedy, it’s easy to talk about guns. But it’s time to talk about mental illness.

No.

She is not. She is the mother of a mentally ill child who is NOT the shooter.

She is taking the story of a child, who is, by her own narrative, quite scary to mother, and deciding to generalizing that to a man she knows nothing about.  When you do that, when you repost it or share it or hold it up as so inspiring and raw and important to relate to this tragedy, you are saying this:

“People who behave in the way that I am describing are just like Lanza”
“Children who do these things that I am describing turn into Lanza”
“My child has something like X/Y/Z Disorder and I think they’re just like Lanza”

Because when you say that the narrative of your child just like that of a mass murderer, and then you describe some characteristics, things we *do not know* of Adam Lanza’s behavior, you are perpetuating some dangerous beliefs.

Please, please stop.

I’m not going to EVER defend the actions of the shooter.

But I will defend to all hell the people who you’re painting with the same brush.

And in case it wasn’t clear already, I will not accept “but any discussion about mental health is important!”. Nope. Discussions that speak over those who suffer from mental illness, that make them The Other, or that stigmatize them and paint them as gangly children with overbites, are harmful, and nothing more. Please stop.

Secondly, if you are going to discuss Autism Spectrum Disorder/Asperger’s here, please go educate yourself first. I suggest here and here, but I would gladly welcome more links in the comments. 

You are Not His Mother

Responding

Brief post today, as I write a not-so-brief paper and study for finals. 

I’ve been writing a lot about what not to do with respect to mental illness disclosure, so this quote from Jesse on how to respond when a friend shares, is a useful counterpoint.

So the best thing to say forever and always (no matter how repetitive it sounds) is “I love you, I care about you, and I am sorry you struggle with this. I hope to see you get better/am glad to hear that you are recovering.”

Brilliant and multipurpose.

Responding

How To Respond Badly

Sharing problems is hard to do. Our society values being “drama-free” over dealing maturely when drama–as it inevitably does–happens. We’re supposed to fix it ourselves, or just ignore it. Because that’s what you do, right? (If I ever meet whomever made up the stupid rules of society, we are going to have Words.) As a result, we somehow manage to avoid talking about how to respond helpfully to someone with capital ‘B’ Bad News. We’re self-indulgent creatures, after all, and we’ll do all sorts of mental gymnastics to avoid staring a situation in the face and recognizing that it’s just rotten. It’s less bad than you think it is! It’s fixable! You’re going to be fine!

No.

Some things are terrible, and all you can do is sit with them and look at how horrible they are. People hurt and die and damage each other for no discernible reason.
It’s just true.
It just happens.
Want to make it hurt less? When someone tells you something rough in their life, don’t do any of these:

Explain how you totally don’t have that problem.

Please, take a few seconds to picture this conversation for me:

Jane: I just got hit by a car! Can you come to the ER so I can have someone there to listen and hold my hand and make sure everything goes okay?

Jeff: Oh, that sucks! I totally look both ways when I cross the street, and I had a near miss last week with this awful driver, but Sally pulled me out of the way. In fact, I’ve never been seriously injured. I never want to be in that much pain or dealing with doctors, and I’ve heard that getting bones set is just miserable!

This is unlikely to the point of hilarity, right?

Right?

A lot of human interaction is trying to relate to each other, and when you simply cannot understand why someone has to deal with That Awful Thing that makes no sense, it’s quite easy to shift gears from sympathy to “but that’s never happened to me!”.

I catch myself in it all the time. One second I’m agreeing how awful it is when professors play favorites, and then suddenly I’m talking about the way my sociology professor always learns everyone’s names. That is the conversational equivalent of ignoring the bleeding person in front of you while you make sure you haven’t broken a nail.

Make an only-slightly-related joke to diffuse tension!

Disclaimer: this could actually, maybe, possibly work for people with a radically different sense of humor and conversational skills than me. I just haven’t met anyone like that. Ever. So factor that into your strategic deployment of humorous non-sequitors. 

When I’ve geared myself up to disclose something, it’s an emotional experience. I often practice before, write down important things, talk it over with trusted friends, and then stress, stress, stress. Sometimes that last step is so overwhelming it inhibits me entirely. So when I say something that makes me feel like I’ve been tangled up in knots, it’s a big deal.  Trying to rearrange my face into a pleasant laugh is so far down on the list of appealing activities it’s spending time with the penguins of Antarctica.

Give me advice I didn’t ask for.

I have to pause here, dear readers and tell you about one very well meaning acquaintance, who, upon hearing me off-hand mention that I was recovering from anorexic tendencies, looked very distraught. They stopped in their tracks and said, with a deadly serious expression, “That’s really bad! You should really try to eat more!” 

Luckily, they caught me on a very good day, and I burst into hysterical laughter instead of uncontrolled sarcasm. Eating more! As a solution to starving myself? Could it be?!

We’d all like to think we’re offering The Best Advice You’ve Never Heard Before. It’s going to fix every problem and cure cancer. Nope! By the time you’ve nerved yourself up to share something that leaves you vulnerable, you’ve probably…you know…thought about fixing it some.

We live in an individualistic society, and being strong and independent is valued. (If I had a nickel for every time someone told me they didn’t want to seek help for a medical or psychological condition because they were going to figure it out/push through it….I’d have really saggy pants.) Commit some variation of this phrase to memory:

That sounds [synonym for bad]! I’m really sorry. Do you want to talk more about it, or be distracted, or are you looking for suggestions for dealing with it?

The subtext: I heard you, I care about you, and I care so much that I’m going to do exactly what you think would be most helpful. And if that advice is completely new or original and you just cannot stand to let it go unsaid, begin here:

I think I might have an idea that could help. Do you want advice?

And then, if they say no, please, please, for the love of cheesecake and chocolate, please keep it to yourself. It’s not about you. It’s about your friend who hurts and needs you to listen to them and their needs. Your need to say some words is trumped by their need to be heard.

How To Respond Badly