Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness

This is a cross-post from my professional blog, where the most updated version of this will be.

The field of mental healthcare has its roots in medicine. The earliest mental health professionals were doctors—psychiatrists. Like medicine, psychiatry and clinical psychology are based on the process of assessing patients’ symptoms, performing some sort of test if needed, assigning a diagnosis, and creating a treatment plan based on that diagnosis.

This is a very sensible approach for most medical issues. If I appear at my primary care doctor’s office complaining of persistent headaches, she shouldn’t just treat the headache by prescribing a painkiller. She should refer me to someone who can figure out what’s causing the headache, and then treat that condition, whether it’s extreme stress, a head injury, a bacterial infection, a brain tumor, or some other problem.

Even though we’ve been treating mental health issues this way for at least a century, it’s not the best way to treat them. And many psychiatrists, therapists, and researchers are starting to realize that.

That’s why we’re finally starting to see approaches to assessment and treatment of mental illness that move away from the much-argued-about diagnoses in the DSM, and sometimes away from the concept of mental illness altogether. Psychologists such as David Barlow, Rochelle Frank, and Joan Davidson have been working on so-called transdiagnostic approaches[1]; the newest edition of the DSM includes a chapter about a proposed new way to diagnose personality disorders that’s based on specific personality traits rather than broad, stigmatized labels[2].

I’m looking forward to the day when the field as a whole has shifted to these types of approaches entirely. For now, I needed a tool I can use with clients to help them (and myself) understand what they’re dealing with and access helpful resources and support. So I created my own informal dimensional assessment.

This assessment is a list of 33 (and counting, I’m sure) ways in which our brains can get in our way. You could think of them as symptoms, but I prefer to think of them as painful patterns, or building blocks of mental distress. Everyone has at least some of these; many people have a lot of them and don’t necessarily suffer greatly for it. It’s all a matter of degree.

Most of these terms are actual mental illness symptoms that appear in the DSM or in other clinical psychology texts. Some of them I coined from existing words because they aren’t really being talked about very much yet. Each of them shows up commonly with at least one established diagnosis, and most relate to quite a few of them.

In creating this list, it was important to me to try to get at the ways in which people who aren’t therapists or scientists might actually think of these experiences. So each building block has a statement with it. The way I plan to use this clinically is to show clients a list of the statements and ask them to rate each one on how much they agree or disagree with it. That would give both of us a sense of what their psychological landscape looks like, regardless of which DSM diagnoses it might resemble.

The initial feedback I’ve gotten is that folks find this really helpful for communicating with their therapists and psychiatrists about what they’re dealing with. I think that’s a great way to use this tool. Therapists know specific interventions that target many of these things; coming to a session and saying that you’d like to address your amotivation, emotional disregulation, and tendency to ruminate is bound to be more helpful than just saying that you want to be less depressed.

  • Agitation: “I often feel so on edge that I need to be moving constantly, as if I want to crawl out of my skin.”
  • Amotivation: “I struggle with getting myself to actually do things, even when I want or need to.”
  • Anhedonia: “I don’t get any joy out of things I used to like.”
  • Attention disregulation: “I can’t seem to choose when to stop or start paying attention to something.”
  • Avoidance: “I find myself trying to avoid things that bring up painful thoughts or feelings.”
  • Cognitive inflexibility: “When things don’t go the way I wanted or planned, it’s very difficult for me to adjust my expectations or make a new plan.”
  • Compulsiveness: “Sometimes I feel like I need to do an action or ritual in order to feel okay, and I feel awful if I try to force myself not to.”
  • Depersonalization: “Sometimes I feel like I’m not really in my body, or I don’t know who I am.”
  • Disordered eating: “I have a hard time controlling what or how much I eat; or, I need to control it so carefully that it’s hurting me.”
  • Dissociation: “Sometimes I experience a memory so strongly that I’m not sure who, where, or when I am.”
  • Distress intolerance: “I don’t feel like I can handle strong emotions. I need to make them go away.”
  • Dysmorphia: “I seem to see my body differently than other people do.”
  • Emotional disregulation: “When I have strong emotions, it’s very difficult for me to manage them and calm myself down.”
  • Emotional lability: “My mood can change quickly between extremes.”
  • General anxiety: “I often think about things that could go wrong in the future.”
  • Guilt: “I feel guilty even when I didn’t do anything wrong.”
  • Helplessness: “I don’t really believe that there’s much I can do to help myself feel better or improve my life.”
  • Hopelessness: “I feel like things won’t turn out okay.”
  • Hyperactivity: “Having to sit still and not move makes me extremely uncomfortable.”
  • Hypervigilance: “I’m always on the lookout for possible danger, and often I sense danger where there isn’t any.”
  • Identity disturbance: “I don’t have a strong sense of who I am; it depends mostly on the opinions of the people around me at the time.”
  • Impulsivity: “Sometimes I say or do things without thinking about them first, and afterward I can’t always tell you why I did them. When I have an urge to do something, it’s very difficult to keep myself from doing it.”
  • Inattention: “I can’t make myself focus on things I need to do.”
  • Irritability: “Little things annoy me so much I want to yell or snap at people.”
  • Mania: “I have periods of time during which I feel extremely energetic, irritable, or ‘high,’ and during these periods I tend to sleep little, talk too fast, accomplish a lot of things, or do things I later regret.”
  • Obsessiveness: “I have intrusive thoughts that bother me and I can’t make them stop.”
  • Panic: “Sometimes, my breathing speeds up and my heart starts rushing, and I feel like I’m going to die.”
  • Psychosis: “I perceive or believe things that feel very true to me, but aren’t true according to everyone else.”
  • Rejection sensitivity: “I feel like I can’t deal with it if someone dislikes me, or says no to me. I’m constantly on the lookout for potential rejection, and I probably sometimes see it when it isn’t really there.”
  • Rumination: “When I start thinking about something negative, I tend to keep thinking about it over and over and feeling even worse.”
  • Social anxiety: “When I’m around people, I worry about how I’m coming across or what I should say or do.”
  • Splitting: “I tend to see people either as extremely good or extremely bad, and I can switch quickly from one to the other.”
  • Suicidality: “I have thoughts that I want to die, or that I wish I could just not exist.”

Although I’ll probably never be able to turn this into an Official Research-Verified Published Thing or anything like that, I do hope to keep refining it and making it useful to my clients—and to any other therapists who want to give it a try.


[1] https://www.newharbinger.com/blog/transdiagnostic-psychology-why-we-need-transdiagnostic-road-map

[2] https://www.psychologytoday.com/us/blog/fulfillment-any-age/201303/whats-new-and-old-in-the-dsm-5-personality-disorders


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Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness
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Stuff I Read That You Might Like, Vol. 1

An e-reader with a cup of coffee, a notebook, a pen, and a pair of reading glasses.
Photo by Aliis Sinisalu on Unsplash

For a long time I’ve used Tumblr primarily to share quotes from my favorite articles that I read online (and sometimes books, too). Since I’m no longer using Tumblr due to their atrocious, sex-negative decision about adult content, I haven’t been able to find a better way to do this. Most so-called Tumblr “replacements” are pretty barebones and/or nonfunctional.

So, clunky as it is, I’ll be doing it here! Every so often I’ll post some quotes and links to stuff you might like.

Starting off with a very topical one:

Tumblr made sex a community experience.

—Vex Ashley, “Porn on Tumblr — a eulogy / love letter

Now that the full scope of this administration*’s political vandalism and base criminality is largely being copped to in broad daylight in various federal courthouses, a good chunk of the elite political press is moving into the Hoocoodanode? stage of political journalism. This is best exemplified byThursday’s New York Times podcast, the headline of which—“The Rise of Right-Wing Extremism, and How We Missed It”—got dragged like Hector’s corpse all over the electric Twitter machine until someone at the Times sharpened up and changed the last half of it to “…and How Law Enforcement Ignored It,” which is a little better, but not much.

To take the simplest argument first, “we,” of course, did no such thing, unless “we” is a very limited—and very white—plural pronoun. The violence on the right certainly made itself obvious in Oklahoma City, and at the Atlanta Olympics, and at various gay bars and women’s health clinics, and in Barrett Slepian’s kitchen, and in the hills of North Carolina, where Eric Rudolph stayed on the lam for five years and in which he had stashed 250 pounds of explosives for future escapades.

—Charles P. Piece, “‘We’ Did Not Miss the Rise of Right-Wing Extremism. You Did.

Inspired by online recipe sites, he’d sit down to dinner and then let me know what rating I earned. “If I give you five out of five, you’ll quit,” he joked. And I laughed because when I was in my 20s, I believed that you were supposed to laugh when someone hurt your feelings. I thought you were constantly supposed to be trying harder.

—Lyz Lenz, “Now That I’m Divorced, I’m Never Cooking for a Man Again

“As you become more acclimated to the cold, your body becomes more effective at delivering warm blood to the extremities, your core temperature goes up, and all that contributes to being more resistant to the cold,” Leonard told me.

That means the only cure for hating winter, unfortunately, is just more winter.

—Olga Kazan, “Why So Many People Hate Winter” (ugh.)

Mattis saw it up close. He bore it as long as he could, in hopes of mitigating the damage. But when Trump broke America’s promise to the Syrian Kurds, he stained Mattis’s honor, too. That, apparently, Mattis could not accept. He leaves and takes his honor with him. And now the question for Congress is: The Klaxon is sounding. The system is failing. What will you do?

—David Frum, “No More Excuses

It’s called Star Wars. Not Star Trek, not Star Peace, not Star Friends, not even Star Tales. This gargantuan fictional universe is labeled with a title that guarantees the ability to travel space… and near-constant warfare.

We can debate the relative okay-ness of this focus from a moral standpoint, sure. But in reality, I think that Star Wars is accidentally teaching us the greatest lesson of all: It’s depicting what a universe looks like when you dedicate all of your research and technological advancements to war and destruction, and unwittingly showing us what an incredibly dark place that universe is. Because the Star Wars universe is a fun fictional playground for sure, a great place to build weird and wonderful stories… but it’s not a good place. Not by a longshot.

—Emily Asher-Perrin, “Star Wars is Really a Cautionary Tale About Devoting All Technological Advancements to Death

It’s no longer socially acceptable to believe that women are somehow less than especially not during a time when feminism is wielding so much cultural power. But arguing that women are just naturally better at caretaking or domestic work has become a clever way to shirk living up to progressive values while claiming you are simply complimenting women on their stellar ironing skills.

One way to combat this line of thinking is to highlight how fully capable men are in the private sphere. It is true that American culture relishes in portraying men as dolts when it comes to parenting and cleaning, and it’s an unfair stereotype.

But for women to make real progress in and out of their homes, men must give something up: the backwards dream of holding onto their feminist bona fides while seeking out female partners willing to limit their own aspirations to the home.

—Jessica Valenti, “The ‘Woke’ Men Who Still Want Housewives

So yes, forced birthers and [Status Quo Warriors], if you’re going to play it like that, I am OK with the idea of a world into which you, personally, were never born. I am equally as OK with the idea of a world where I don’t exist, either. Neither you nor I personally matters that much in a universe so vast and a sea of human experiences so rich. You and I both are accidents in our existence, possibly unhappy ones.

I would’ve rather your mother not have been forced to carry a pregnancy she didn’t want to term. I would’ve rather your father had approached your mother respectfully in an appropriate setting, or not at all. I dare to love your mother as a fellow human being more than you do and to dream of a better world for people like her. It’s rank misogyny and not very humanist at all to think otherwise.

—Heina Dadabhoy, “Why I Don’t Care If You Wouldn’t Have Existed

It is maddening to watch adult men respond to revelations of endemic sexual harassment in the workplace by instituting a series of ludicrous personal codes, rather than by learning the relatively straightforward lesson on offer: Don’t sexually assault or harass anyone.

At best, these “rules” are reflective of employers’ woefully incomplete approach to sexual harassment. Employers have long done the absolute minimum to comply with the law, relying on trite videos focused on what you can and cannot say or do in the workplace (“don’t give back rubs” or “don’t offer promotions in exchange for sex”) and sexual harassment policies designed primarily to protect them from lawsuits. The sweeping scale of the Me Too movement makes it clear that no mere set of rules is sufficient to prevent workplace harassment, especially when those rules fail to speak to all of the various power imbalances that make the critical distinctions between genuinely consensual workplace romances and harassment.

—Tahir Duckett, “Avoiding Women At Work Is A Childish, Cowardly Response To #MeToo

When you are terribly afraid of being held responsible for the emotional well-being of others, it feels very mature and responsible to decide that you should “work on yourself.” It becomes both a way of retroactively absolving yourself (wow, can you believe all of the ways my issues manifested before I decided to work on them) and a rather elegant little trick to exonerate ongoing bad behavior (dang, those pesky issues again! I guess I must keep working on them). This is especially true for those too-clever-by-half motherfuckers who think that nobly warning someone in advance they “are working on their issues” mitigates any way in which they might disappoint or harm. And even with the best of intentions, it obviates the fact that relationships themselves are a process of being made ready, not something you come to static and fully formed.

[…] We need each other desperately, in ways none of us can be ready for.

—Brandy Jensen, “Ask A Fuck-Up: I’m still in therapy. Should I be dating?


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Stuff I Read That You Might Like, Vol. 1

How Big is Your Hard Drive?

Close-up of a hard drive.
This is relevant, I swear.

This is a cross-post from my professional blog.

Some friends and I were talking recently about the concept of “emotionally unavailable” people. Most of us have had a friend—perhaps ourselves—who has tried to date someone who seemed into them, but just wasn’t quite present. Sometimes this type of partner is upfront about their ability to commit and/or be there. Sometimes, they aren’t, and their behavior seems confusing and contradictory. These pseudo-relationships can drag on for years until we are finally able to move on, understanding that however much the person enjoys our presence, they are not interested in making things more committed or structured than they currently are.

If I knew what to do in these situations I’d probably be retiring a millionaire, but I do have an analogy that might be helpful. I thought of it on the spot to give my friend some advice. (If you’ve ever been my client, you know how much I love a good geeky analogy.)

Computers come with different hard drive capacities. If yours doesn’t have enough space for you, you can maybe buy and install a new one—but for the moment, you’re stuck with the one your computer came with. Maybe you can’t afford a new one right now.

Different hard drives also have different things stored on them, and these things take up different amounts of space. I know people whose hard drives pretty much just contain the system files, maybe a few extra apps. These people use their computers mainly to get online. Maybe computers aren’t very important to them and they don’t use them much at all.

Some people have a lot to store—photos, music, videos, complex projects they’re working on. These folks are buying hard drives in capacities I didn’t even know existed. (This year, the world’s largest solid state drive hit 100 terabytes. What are they storing on that hard drive???)

Don’t think of the hard drive as your brain. Those analogies are really reductive, and usually insulting to us humans. The hard drive is a symbol, and it represents something I call your capacity as a person. That encompasses a lot of things—time, energy, physical and mental ability, willpower (which isn’t really a thing, but that’s another article; it’s useful here as a concept), tolerance for uncertainty or negative emotion, and much more. For instance, not everyone has the capacity to be a therapist. Being a therapist requires having a lot of space to hold other people’s pain. Not everyone has enough space for that. Unfortunately, some therapists end up without enough space to hold their loved ones’ pain, or even their own.

Say I have a 1 TB hard drive that’s full of music and photos. Maybe there’s 300 GB left over. Then a friend asks, “Could I put some of my videos on your hard drive? I need somewhere to store them for a while.” I say sure, but then they come over with their external drive and I see that they have an entire terabyte of videos. That’s not going to fit on my hard drive. I could probably store some of their videos, and that might still be helpful for them. But maybe they really needed to store the entire drive’s worth. I don’t have the capacity.

This kind of thing happens in friendships and relationships all the time. You might have a good amount of your own shit to deal with, but that doesn’t mean you can’t listen to your friends vent about their own problems from time to time, or give them advice about a work situation, or treat them to a nice dinner while they’re going through a breakup.

You might not be able to be a friend’s primary source of support as they navigate a serious illness, however. First of all, the time factor would be prohibitive—you may not be able to drive them to all of their medical appointments, be at their house enough to care for them when they can’t care for themselves, and so on. The stress of being a full-time caregiver would be way too much. Holding their anguish as they face the possibility of death or disability is also, well, a lot. Your friend needs more people on their team.

Some people are carrying a lot of trauma, hardship, or personal responsibilities with them already. No matter how large their hard drives happen to be, there may not be space there for you.

Not only that, but some people have pretty small hard drives to begin with. I’ve known many people who just don’t seem to have a lot of space for others in their lives. They don’t tolerate much emotional turbulence when it comes to other people. They may be interested in sex, casual friendship, or even romance, but they don’t have the capacity to build interdependent, long-lasting relationships with others—at least not until they do some work on themselves, and get some bigger hard drives. Some people want to do that work; others are perfectly content as they are.

Here’s where this analogy really breaks down—buying a new hard drive is a million times easier than increasing your capacity for holding other people. And while you can buy a larger hard drive for your friend whose computer you’re always wanting to store your videos on for some reason (this is weird), you cannot increase others’ capacity for them. They have to choose to do it for themselves, and they may not want to. Or it may take them a long time, or they may not be able to do it at all.

If you are hoping for a deeper relationship with someone whose hard drive seems to be too small—or who has way too much data on it already—you have to ask yourself whether or not it’s likely that this person is going to have more space for you anytime soon, and whether or not they want that space to be yours.


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How Big is Your Hard Drive?

Intuitive Eating Made Me Miss My Flight

(But, in the words of the great Rebecca Bunch, the situation’s a lot more nuanced than that.)

Rebecca Bunch from Crazy Ex-Girlfriend

Last night I was supposed to be on a flight to DC. I arrived at the airport straight from work with some time to spare, checked my luggage, went through security, bought a snack, and arrived at the gate to find that the flight had been delayed by two hours. It was 7 PM. My usual dinner time. I ate some of my almonds but found my hunger worsening. With the delay I would not arrive in DC until about 11 PM, plus a half-hour ride from the airport, so it would be nearly midnight by the time I could finally have a hot, nutritionally complete meal—my first since lunch at noon. What to do?

Lately I’ve been working with a dietician[1] on intuitive eating, a radical (but not new) approach to food in which you learn to pay attention to your body’s hunger cues and eat things that feel good to you. No numbers are involved in this process at any point. It’s not a weight-loss program, or even a “health” program, really. It’s more of a “rebuild a healthy relationship with food and be more mindful” program.

Most people, even those who have a relatively healthy body image and few issues around food, have taught themselves to ignore bodily cues like hunger, satiety, and energy. That’s because bodies are inconvenient and our society demands that we run on its schedule, not on our bodies’ schedules. If lunch is at noon then you eat at noon. If you have a lot of work to do and don’t have time for eating, you keep working until you can stop. If we’re eating now then you eat now even if you’re not hungry. If dinner is meatloaf and broccoli then you clean your plate before you can leave the table because of [insert racist and classist cliche here]. If salads leave you feeling weak and tired but salads are clean and healthy and you need to eat clean and healthy, then you eat salads and feel weak and tired and tell yourself it’s because of something else. If the flight is at 7 PM and there’s no time for dinner beforehand, then you grab a snack and head to the gate, and if the flight is delayed and there’s no one with you to text you updates, then you stay at the gate in case the flight leaves suddenly and you worry about your worsening hunger later.

Recently finished chemo? Recently had a double mastectomy? Recently started hormone suppression meds that put you into early menopause, causing hot flashes, fatigue, weakness, and confusion, especially if you don’t eat properly? Don’t worry about it! Wait at the gate.

Needless to say, I didn’t do that. I went to a pizza place not far from the gate, ordered myself a small pizza with olive oil, bacon, onions, and mushrooms, listened for any flight announcements, did not hear any flight announcements, refreshed the flight info on Google, and missed the flight anyway.

“Should’ve stayed at the gate,” the gate agent said when I appeared half an hour before the flight’s rescheduled departure and inquired what the fuck.

But I was exactly where I needed to be—taking care of my body so that it takes care of ME on my trip.

Now it’s the morning after, and I’m on my rebooked flight to DC, somewhat frazzled but nevertheless feeling energized enough to enjoy my weekend. Because last night when I started to feel really hungry, I had a complete meal with carbs, fat, protein, and fiber, along with hot tea and later water.

Bodies are inconvenient. I’ve tried the thing where you replace your meals with “healthy snacks” because you can’t make time to eat meals. It doesn’t work. I’ve tried the thing where you grab greasy fast food and bring it on the plane with you because you don’t have time for anything else. It doesn’t work. I’ve tried ignoring the problem. It doesn’t work.

What works is paying attention to my body’s physical sensations and responding to them with a combination of carbs, fat, protein, fiber, water, rest, physical activity, and sleep.

In fact, that’s probably the only thing that ever would’ve worked. But until I got so sick that I HAD to stop and pay attention to it, I ignored it like almost everyone else does.

(No, ignoring my hunger did not cause my cancer, but having cancer caused me to stop ignoring my hunger.)

When you start noticing your body’s cues and responding to them appropriately, you may also start missing flights. Or turning down opportunities, or no longer eating some foods you thought you liked but turned out to actually make you feel bad, or being late to things because you realized you needed to eat first but you weren’t hungry early enough to eat early enough to not be late. You may decide that you can’t be vegan after all, or that you don’t need to eat meat after all. You may notice that you don’t get hungry at 7 AM, 12 PM, and 6 PM. You may get hungry at totally different times. You may need to adjust your work schedule to accommodate this.

You may find a way to avoid many of these potential problems by being strategic about bringing snacks with you or taking breaks from things. But sometimes you’ll forget, or it won’t be enough.

You may also find yourself feeling better, physically and mentally. You may stop sending yourself on guilt-trips over food. You may realize that stopping at Dairy Queen for an ice cream cone after work is actually a great way to boost your mood and make sure you don’t get hungry until you’ve had time to make dinner.

You may even find yourself noticing other types of bodily cues more, too—for instance, that the party is loud and you need a break from the noise, and if you take a break now, you won’t be overwhelmed and will be able to return and stay for the rest of the party and enjoy yourself. Or that these shoes are so uncomfortable that it actually impacts your mood and productivity, so wearing them just isn’t worth it anymore. Or that you always feel vaguely uncomfortable and on edge around this particular person and maybe it’s time to try to figure out why.

Yeah, it’s inconvenient. It makes me feel over-sensitive, fragile, high-maintenance, and a lot of other things we often label women with. It’s difficult that at a moment when I most need to get past my preoccupation with my body’s weakness and vulnerability, the self-care I need the most seems to just highlight those things more and more.

But every time I make the decision to honor my body’s cues rather than ignore them, I can feel that I’ve taken another small step towards well-being. Towards working as a team with my body rather than fighting it every step of the way. Towards feeling at home in myself again.

A missed flight starts to seem like a small price to pay.


[1] If you live in Ohio, you may be able to work with my dietician! Find her here: https://www.kristenmurrayrd.com/

More info about intuitive eating here: http://www.intuitiveeating.org/


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Intuitive Eating Made Me Miss My Flight

And Suddenly, Life

My tomato seedlings.

And just like that, it’s over. The surgeon said there’s no evidence of cancer remaining in my body, my hair is growing back, my new boobs are growing steadily until I decide they’re big enough, and I’m trying to grasp that thread of my life that I left dangling over half a year ago and tie it to the one I’m holding now.

As anyone who’s had cancer knows, you’re never really “done” with it. Even after successful treatment, there’s always the possibility of recurrence, the long-term consequences of chemo or radiation, and, in my case, a slew of reconstruction-related procedures and an oophorectomy in 8 years.

That said, now—when I’ve returned to work after my surgery—seems an appropriate moment for a post-mortem on the whole thing. (Sorry, poor choice of wording.)

For a brief window of time after my diagnosis I thought it would be my unraveling. I quickly realized that, instead, it would be my becoming. If a year ago I was in my intermediate Pokémon evolution, I’m now in what feels like my final one. (Don’t forget, though, that even fully evolved Pokémon continue getting stronger and learning new moves, and that eventually someone might “discover” mega-evolutions and I might change form again. I’ll leave it to you to decide which Pokémon I might be, before this analogy completely runs away from me.)

Before this I was essentially comfortable with who I was, with how I lived my life and conducted my relationships, with the career I had chosen, with the way I spent my time, and with that most fragile of things, my body. The illness transformed the way I saw all of these things, not in the sense that it made my views totally different, but in the sense that it strengthened, catalyzed, leavened, solidified them.

Any lingering doubts I had in myself or in the people who form my inner circle disappeared. Before, there was a part of me that really believed that when the time came to sit for the exam, the people around me would fail me, and more importantly, that I would fail myself, and that I would be alone in my darkest hour. But nobody failed.

Well, perhaps a few people failed. But their grades had been slipping for a long time, and some of them had really been failing already.

I no longer doubt that my friends and family will carry me forward when I can’t carry myself. But I also no longer worry that I’ll ever become completely unable to carry myself. I don’t struggle with imposter syndrome anymore, and I don’t worry that I’m not enough of an “adult.” What does that even mean for someone who has made the decision to carve up their body to save their own life? What does that mean for anyone, really?

What I keep coming back to every time I write about this strange episode of my life is simply how banal most of it was. It was so banal that I’m not sure I could even claim that I cried more, or was sadder or more scared, on average during this time than during any other period of my life. In fact, I will still say that the clinical depression I experienced from ages 19 to 22 was much worse and left me with so much fewer resources to help myself and seek support from others.

I would not repeat so much as a month of that experience for any price. The cancer, eh, fine, especially if we can do the surgery with proper pain management this time.

The point of that isn’t to pit depression and cancer against each other generally or adjudicate whether mental illness really is worse than medical illness or vice versa; it’s just to say, I already had unimaginably more strength than I thought I did. It just hadn’t been tested and proven yet.


After my surgery, which to me represented the culmination of most of my worst fears, people wanted to know if it was really “as bad” as I thought it would be. Of course, they wanted to hear that it wasn’t. Unfortunately, it was even worse than I thought it would be. It was worse than I had expected even at my most panicky moments. So this isn’t the story of how I overcame those phobias. It’s the story of how I learned that I can survive weeks of unrelenting pain, panic attacks, and suicidality and come out the other side essentially myself.

I’m comfortable saying that I’ve been traumatized by that experience. In dreams I wake up after surgery only to be told that something went wrong and it has to be done again, over and over. Most evenings, when I’m home from the life I’ve finally returned to, alone and in silence, an inexplicable sadness comes over me—so inexplicable that I know exactly what causes it.

It’s not that I “miss my old body,” though sometimes I do. What I feel goes much deeper than that. There are memories, images, that fill me with something I can only call grief—looking back at my parents as I was wheeled away to the OR; watching them cut up my food for me when I couldn’t; walking around on the deck of their house, back hunched, trying to explain to my mom a meditation exercise I was trying in which you breathe the pain in and then breathe it out; when my friends visited me at home two days after and I sat, again hunched, mostly unable to speak or even look at them; the first time I sat on the deck in good weather, no hat, and felt the sun on my skin again; and more, and more, and more.

All of this lives in me now, not compartmentalized or repressed but very much there, just beneath the surface. It ebbs and flows and sometimes retreats deeper and other times comes closer to my skin, where I can all but feel it with my fingers when I press them onto all the parts of me that no longer feel.

It hurts all the time, but it’s also, in its own way, completely normal and healthy. I now contain a lot more things than I did six months ago, and not all of them hurt.

Rather than feeling diminished by the experience, I feel expanded. Which is fortunate because it gives me enough room to contain all of the contradictions inherent to this process. My friends were probably hopelessly confused. One day I’d be crying about what an ugly scarred half-person I am; the next day I’d be marveling at how it feels to dance, to sit in the sunshine, to run my fingers over my healing incisions. One day I would say that my life has been standing still; the next I’d be talking about all I’ve learned, everyone I’ve met, everything I’ve planned.

And then there were the times, most of which I never found the words to explain to anyone, when I felt like I was experiencing something transcendent. I had feelings that felt completely outside of my normal existence and that I couldn’t have had any other way. I’m not a religious person, so I don’t think of it that way. Instead I think of them as moments when I felt the pulse of life. I felt how precious it was, how sacred. I felt overwhelming gratitude, both towards people who helped me in even the smallest ways and towards the universe itself. I felt like I could survive anything.

And then I’d go back to feeling like a broken old piece of crap nobody wants anymore.

Well, it may be confusing, but it’s also part of the experience of being ill—and, to a slightly lesser extent, of being human. I invite you to enter the contradiction with me and make yourself comfortable.


Besides work and spending time with friends, nowadays I’m often working on my garden. Last fall I decided I wanted to try growing fruits and vegetables in the spring, and I had all these ideas about buying all kinds of plants and building a structure to house the containers and starting seeds early indoors, and for obvious reasons that didn’t happen. So I started last week. It was probably slightly late to plant seeds, but it is what it is and it’ll be what it’ll be.

I’ve always loved plants, and always felt disproportionate grief when they sickened or died. Now it’s no different, except that I’m even more aware of the precariousness of life, of the journey seeds must undertake to become plants, and how perilous all of that is. Soil, water, warmth, light. And out springs something that nourishes.

I used to feel beautiful. Now I don’t, and it’s hard to fully imagine what that even felt like. But I think I’m finding my way back to it, slowly. In the meantime, I look around at my pots full of fresh soil and think, maybe I can still make something beautiful.

I understand how plants “work,” mostly, but the more fundamental part of my brain is still stunned every time a seed germinates. I’ve now planted everything I’m going to plant, and some of the seeds have sprouted–pulling themselves up through the soil, hunched over like I was right after surgery, slowly stretching themselves out to stand tall just like I did, and finally unfurling their first two leaves, just like the first time I felt well enough to bring my arms up and stretch them out from my sides as hard as I could, feeling them become a part of my body again.

I can never fully expect them to do it. Every time I’ve ever planted a seed I’ve thought, no way, there’s no way you can just stick these tiny hard things into the ground and a week later they turn into actual plants.

And yet, inevitably, they do.


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And Suddenly, Life

What ADHD Actually Is, Part 2

Since I wrote part 1 of this series, I’ve had a lot of wonderful positive feedback from people with ADHD and suggestions for topics to cover in the future. I’ll address more of those here!

(If you haven’t read it yet, part 1 covers the definition of executive function and how it explains ADHD symptoms, along with information about hyperactivity, depression and anxiety in people with ADHD, helpful resources, and how to go about getting a diagnosis and treatment. I recommend reading it first.)

What’s the difference between ADHD and ADD? 

Before 1994, when the DSM-IV came out, the acronym ADD was used to refer to what we now call the “inattentive type” of ADHD–that is, the type where you don’t have hyperactivity symptoms. [1] Now, however, the term “ADHD” is an umbrella term that covers all of the types. Just because the “H” is in there doesn’t mean you have to have hyperactivity symptoms to qualify for that label. “ADD” is outdated and only typically used by people who got diagnosed before 1994. But if it makes sense to you, you can obviously stick to it.

Personally, calling it ADHD regardless of type makes much more sense to me because very few people with the disorder don’t have any hyperactivity symptoms at all–they just might not look like the typical bouncing-off-the-walls stereotype, especially in girls and adults of all genders. Hyperactivity can also mean needing to fidget a lot, or preferring physical/manual activity to intellectual labor. It’s also possible for some people to suppress all of their hyperactive impulses, which means that their observable behavior wouldn’t qualify for the hyperactive type. That doesn’t mean the impulses aren’t there, though, or that it isn’t taking them lots of energy to suppress them.

Why is the prevalence of ADHD increasing?

It’s difficult to obtain accurate data on historical prevalence of mental diagnoses for many reasons–underreporting (especially when it comes to childhood disorders, which parents might want to keep under wraps due to stigma), different research methods, different diagnostic criteria, and so on. According to the CDC, ADHD prevalence really is increasing, but they caveat that claim in the same way I just did. [2]

There’s a difference between more people getting diagnosed with a disorder and more people actually having that disorder. Greater awareness and improved access to mental healthcare could both lead to increased rates of diagnosis, even if the actual prevalence of the disorder has remained the same. I do think that things like that are impacting rates of ADHD diagnosis.

But I also think that a greater proportion of people would qualify for that diagnosis than 50 or 100 years ago, and I think it has to do with the greater role that executive function plays in modern society.

If you think about the types of things most people did for a living prior to the mid- to late-20th century, they didn’t require that much self-regulation. Farming, factory work, housekeeping, mending–these jobs are physically (and often mentally) demanding, but not in the same way as forcing yourself to spend hours at a computer correcting errors in a spreadsheet or researching funding sources. In fact, today, many people with ADHD strive in professions that rely on physical labor, creativity, lots of small bursts of social interaction, or other things that don’t require sustained focus on one thing.

It’s no accident that so many childhood ADHD diagnoses happen because a child can’t sit still in a classroom. Although our current education system dates to the 19th century (and has had shamefully few updates since then), children in the 19th century didn’t necessarily sit in a classroom from 8 AM to 4 PM. They missed school to help on the farm, taught younger classmates (think one-room schoolhouse), and left school altogether at much younger ages than today’s kids are required to stay until.

That doesn’t mean that our education system is the sole cause of increased ADHD prevalence, and that if we went back to some imaginary historic ideal, the prevalence would drop. (Although our education system is pretty shitty for a variety of reasons.) It just means that school and its demands on executive function often reveal ADHD symptoms that might’ve otherwise stayed hidden until later in life–for instance, when the demands of adulthood push people with undiagnosed ADHD to a breaking point.

Didn’t you say that overdiagnosis might still be a thing?

Yeah, I did. I mentioned in the first part of this series that a disorder can be both over- and under-diagnosed if we look for it in places it isn’t and don’t look for it in places it is. One place where we may look for ADHD too single-mindedly is in children who are “disruptive” or “unfocused” in school.

Plenty of researchers and clinicians have observed that children from violent and chaotic neighborhoods often get diagnosed with ADHD because they present with many of its symptoms. [3] However, in children as well as adults, those symptoms might also be coming from trauma, especially the complex trauma that develops when severe life stressors are constant from early childhood on. [4]

When the role of trauma is ignored, these children (who are typically from low-income families of color) often get slapped with the ADHD label, along with its cousin, oppositional defiant disorder (ODD). [5] Unfortunately, for children who are already bearing the burdens of racism and classism, these labels often serve to add on more stigma rather than help provide effective treatment. If you look at the criteria for ODD, they describe behavior that is completely rational and adaptive if many of the adults in the child’s life are violent, neglectful, and inconsistent. And if you look at the criteria for ADHD, they also describe what happens when undiagnosed PTSD limits your ability to self-regulate.

PTSD symptoms put a huge cognitive load on the brain. People with PTSD are usually hyper-vigilant, constantly looking for potential threats (often without realizing they’re doing it). Small disturbances or unpleasant surprises can cause strong reactions that seem excessive to others. When trauma comes from psychological abuse rather than physical violence or disaster, it can be even harder to notice when PTSD symptoms manifest.

A child who has complex trauma as a result of growing up amid violence and abuse is going to have serious issues paying attention in class and remembering their homework, along with maintaining healthy relationships with teachers and classmates and regulating their own emotions. On the surface, that can look like ADHD. But ADHD medication won’t help, and inappropriate use of ADHD medication on children can lead to those “zombie” symptoms everyone talks about. These kids need trauma-informed interventions, along with real structural changes that address racism, gun violence, poverty, and all of those myriad interweaving variables. No psychiatric label could possibly encompass that.

What’s the connection between ADHD and autism?

A lot of my friends have pointed out that they have been diagnosed with both ADHD and autism, and wonder what (if any) the connection between them is. I’ve also had lots of clients with both, although I obviously also know people with one or the other.

These disorders do co-occur more commonly than they would by chance alone. [6] Unlike mental illnesses, they both manifest in childhood and last for life (this is true even for people who don’t notice their ADHD symptoms until adulthood). They both involve executive dysfunction, and research suggests that some similar neural pathways may be involved in both. [7] They both tend to impact all areas of a person’s life, including school, work, relationships (platonic, romantic, familial, and others), self-care, personal pursuits, and so on.

This can make people stressed about figuring out which disorder they have, or if they have both. If this concerns you, remember that we made up these disorders and assigned sets of symptoms to them. They aren’t natural categories. Although diagnoses can be important for accessing treatment and support, the most important thing is identifying what it is that you struggle with and getting help with that.

If you have executive function issues, medication and/or coaching might help. If you have problems with talking over people and talking too much about your niche interests, it might help to get legitimate social skills advice (for instance, the excellent blog Real Social Skills [8]) or to seek out people who interact in similar ways to you. If you feel depressed or anxious as a result of the ways in which your disability impairs you or creates consequences for you in our (ableist) society, counseling can help.

Although there’s a lot of cool research going on involving brain scans and other relatively new techniques, that doesn’t actually explain why some people develop ADHD and/or autism and others don’t. It’s possible that the same set of root causes, both biological and environmental, can contribute to the development of both disorders.

Why can people with ADHD sometimes focus really well/get things done?

Remember, ADHD isn’t about being “unable to focus” or get things done. It’s about executive function. When a lot of executive function is needed to complete a task, people with ADHD will struggle with it. But when it isn’t, they may do very well.

Some situations in which people with ADHD may be very efficient or productive include:

  • when they’re really interested in the task
  • when it’s about to be due and panic kicks in
  • when it involves working with others
  • when they’re given a lot of structure

So, let’s examine each of these. Everyone has an easier time focusing on things they’re really interested in as opposed to things they find boring, and everyone generally finds it effortful to exercise their executive function. People with ADHD just find it harder than others. When you’re really interested in the task, you may not need to use executive function to do it. (You may need it to plan for or structure the task, though, which is why people with ADHD sometimes have difficulty accomplishing their over-arching goals even with stuff they’re really interested in.) Unfortunately, having issues with executive function can also make it more difficult to tear your focus away from something, which is why people with ADHD are prone to what’s called hyperfocus–spending too much time immersed in something to the detriment of other things that need to be done, including basic needs.

Remember, getting really into things you like doesn’t mean you don’t have ADHD. In fact, it could be good evidence that you do have it.

These principles also explain why so many people with ADHD procrastinate. It’s not just that they can’t get themselves to do the task in advance–it’s that procrastination works, but at a cost. When it’s the night before the 15-page paper you haven’t started is due and you’re completely panicking, executive function may no longer be necessary to get yourself to do the task. Other brain regions and processes take over–perhaps, for instance, the amygdala, which is involved in the processing of fear.

Social tasks can also be easier for people with ADHD to complete. The other people in the group may help them with staying on task, structuring the project, and perhaps doing the really boring parts that they don’t want to do. When working independently on a task, people with ADHD are liable to get stuck when they can’t motivate themselves to do a particularly boring or difficult task, or when they simply don’t know what the next step should be and get distracted by something more interesting before they figure it out. A team member may help them cross this hurdle.

Finally, people with ADHD may do very well with tasks when they’re given a lot of structure rather than having to create that structure for themselves. A person with ADHD may love their work (or studies, or whatever) and have few issues focusing on it, but effectively completing complex tasks requires being able to structure them–break them down into smaller tasks, put those tasks in the right order, and keep the big picture in mind rather than getting bogged down in one specific tiny part of the project. (Sometimes called microfocus, this can really get in the way of one’s goals.)

That kind of mental task requires executive function, too. Many people with ADHD do better in high school than in college because there’s more structure built in. For others, college provides enough structure, but work doesn’t provide enough. Still others luck out and find jobs in which structuring your own tasks isn’t required. That’s why many people with ADHD do well in or even enjoy working in retail or food service–as long as they can regulate their emotions well enough to avoid lashing out at irritating customers.

In sum, there are all kinds of situations in which the role of executive function is more minimal than it is in others, and many people with ADHD can thrive in these situations. That doesn’t negate the fact that they have a disability, or that it might still take them lots of effort and trial-and-error to get to that point.

People with ADHD can also learn to utilize the exact types of things that are hard for them–remembering to write things down, using planners, and so on–to make up for what they’re lacking in executive function. That, along with some other stuff I promised to get to (i.e. gender and ADHD), will be discussed in a future installment of this series.


[1] https://www.additudemag.com/slideshows/add-vs-adhd/

[2] https://www.cdc.gov/ncbddd/adhd/timeline.html

[3] https://www.theatlantic.com/health/archive/2014/07/how-childhood-trauma-could-be-mistaken-for-adhd/373328/

[4] https://www.nctsn.org/what-is-child-trauma/trauma-types/complex-trauma

[5] https://www.additudemag.com/oppositional-defiant-disorder-odd-and-adhd/

[6] https://www.additudemag.com/is-it-adhd-or-asd/

[7] https://nyulangone.org/news/tracing-neural-links-between-autism-adhd

[8] https://www.realsocialskills.org


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What ADHD Actually Is, Part 2

What ADHD Actually Is

ADHD (or ADD, as it used to be called) is such a misunderstood disorder, especially among adults, that I figured I’d dedicate an article to clearing up misconceptions and helping folks who suspect they have it figure out what to do next.

First, some general principles that organize my thoughts on ADHD:

  • ADHD is a developmental disability, not a mental illness. (More on this later.) This means that it begins in childhood and lasts for life. Individual symptoms might wax and wane, and your environment may be more or less conducive to the way your brain works, but ADHD doesn’t get “cured.”
  • Therefore, you do not “age out” of ADHD. If you were (accurately) diagnosed with it as a child, you still have it.
  • It’s possible for a condition to be both over- and under-diagnosed. That’s not contradictory at all. It just means that we’re looking for it in places it isn’t, and we’re not looking for it in places it is.
  • Having ADHD does not mean you have to take medication, and not being helped by ADHD medication doesn’t mean you don’t have ADHD. Those are separate questions, and there are effective strategies for ADHD besides medication.
  • ADHD has neural substrates [1] (I hate using jargon, but there’s honestly no better way to say “a specific thingie happening in your actual physical brain blorb that relates to the behaviors or subjective states you experience and others observe,” so from now on, that’s what “neural substrate means), but like all disabilities, it’s also socially constructed in many ways. That means that culture and community influence how ADHD symptoms are expressed and understood. That means that we shouldn’t be surprised when ADHD presents differently in women, people of color, etc. Rather, that’s exactly what we should expect.

So, what is ADHD exactly? Here’s the only explanation that matters:

ADHD is a disorder of executive function.

That’s it. ADHD is not about being hyperactive, forgetting things, interrupting people, losing your homework, or any other specific symptom. You can have ADHD without exhibiting any of those classic behaviors, but everyone with ADHD experiences impairment of their executive functions.

What is executive function?

Executive functions are the brain processes that help you decide what to do and when to do it. Many of these processes take place in the prefrontal cortex, a region of the brain that evolved relatively recently and helps us with higher-order cognitive tasks.

There are lots of different executive functions, especially if you get really specific with it, but here are some examples:

  • inhibiting impulses that you don’t want to act on
  • temporarily storing information that you need to use or process (a.k.a., working memory)
  • choosing what to pay attention to
  • ignoring distracting stimuli, whether internal or external
  • figuring out what steps it would take to accomplish something
  • having a sense of how long things take (for instance, when you should start getting ready in order to leave on time in order to get somewhere on time)
  • sorting relevant information from irrelevant information
  • switching smoothly between thoughts or tasks (a.k.a., cognitive flexibility)
  • adapting quickly when a plan falls through or new information becomes available
  • paying attention to and noticing your feelings and impulses

All of us, including people with executive function issues, do these mental tasks all the time. Often they happen without conscious effort. For instance, when you read a book without getting distracted every time a car drives by outside, you’re using executive function skills. When you get dressed and leave the house in the morning, you’re using executive function skills.

There are many different components to executive function and they involve different parts of the prefrontal cortex, and other brain regions too. Executive function can be impaired by many other things besides ADHD, such as autism, inebriation, sleep deprivation (or, in my case, narcolepsy), and basically any mental illness. However, when you have depression, the executive function issues resolve when the rest of the depression symptoms do. When you have ADHD and depression, the mood issues might go away but the executive dysfunction remains.

How does executive dysfunction explain ADHD symptoms?

Let’s look at some typical symptom descriptions from the DSM-V criteria for ADHD [2]. First of all, I hate these because most of them are worded in a way that’s specific to children, and most of them just sound really negative and stigmatizing. But it’s what we have for now.

For instance, the phrase “makes careless mistakes” often comes up. “Careless” implies that the person does not care enough about the task, which is why they made the mistake. But that’s not how ADHD works. A person with ADHD might make a “careless” mistake for a number of reasons:

  • They were having trouble choosing what to pay attention to, and did not notice that they were making a mistake.
  • They didn’t realize that the area in which they made the mistake was relevant. It may be obvious to you, but it wasn’t obvious to them, so they didn’t make an effort to avoid the mistake.
  • They forgot a crucial piece of information that they would’ve needed to avoid the mistake and didn’t know how to go about finding out, or didn’t notice that they’d forgotten until it was too late.
  • They couldn’t make an accurate estimate of how long the task would take, and made the mistake or allowed it to remain in their rush to get the task finished.

Here’s another example: “often interrupts.” People with ADHD might interrupt others for different reasons, too:

  • They got so excited about what they wanted to say that they were unable to inhibit the impulse to speak.
  • They know that because of their impaired short-term memory, they will forget what they want to say if they don’t say it now–and they lack the cognitive flexibility to quickly find another way to solve this problem without interrupting.
  • They find it difficult to switch smoothly between speaking and listening.
  • They failed to pay attention to the fact that the other person was still speaking.

Other criteria for ADHD are simply examples of executive dysfunctions themselves, but sometimes diagnostic criteria aren’t very useful because they tend to describe how other people experience the person with ADHD, not how that person experiences their own life and their own mind. For instance, one of the most common things I hear from people with ADHD is “I just feel constantly overwhelmed, like I can’t manage my life and keep up.” That’s nowhere in the diagnostic criteria, and if you said it to a therapist they might assume depression or anxiety. (Which many people with ADHD have, more on that later.) But that’s the feeling that results when your executive functioning doesn’t match what your lifestyle demands.

What about hyperactivity?

Hyperactivity is kind of the red-headed stepchild of ADHD symptoms. Many people with the disorder don’t have it at all (though you wouldn’t know it from stereotypes and media representations), and it’s not necessary for the diagnosis. The DSM deals with this by dividing ADHD into “types”: inattentive type, hyperactive-impulsive type, and combined type. You can still have symptoms from the other category to be one of the “types,” you just have to be predominantly that “type.” It’s kind of confusing (and in my opinion, unnecessary).

Hyperactivity doesn’t initially seem to have anything to do with executive dysfunction, except perhaps in the case of impulsive behaviors. What about executive dysfunction would cause a person to need to fidget, or to talk very quickly or feel restless all the time?

I’m not convinced that ADHD as we currently think of it is all one disorder. I think it’s two that often go together: one that I’d call executive dysfunction syndrome, and another that some researchers already call reward deficiency syndrome.

(Unfortunately, one of these researchers is using the term to promote some dubious claims about genetics and substance addiction[3], but I’ll be using it more generally.)

I don’t want to get too derailed by talking about dopamine, but in a nutshell: when we do or experience things we enjoy, certain brain regions release the neurotransmitter dopamine–especially if the reward was unexpected in some way. The chemical is a sort of a signal to the body to seek out more of the thing.

We know that people vary in how much and under what circumstances their brains produce dopamine, as it’s linked to all kinds of neurological/mental conditions. But it’s possible, too, that there’s a sort of spectrum–for some people, a relatively small reward is enough to trigger a noticeable burst of dopamine, while others need much more.

Maybe people with hyperactive traits are those who need much more–so they’re always on the go, always moving, just to feel as engaged and interested as others may feel just from petting a cat or listening to the rain. And it would make sense, because dopaminergic pathways[4] are involved in executive function, too.

Anyway, that’s mostly (somewhat scientifically-based) speculation, and it doesn’t really matter. The point is, some people with ADHD struggle with hyperactivity, and some don’t. Executive dysfunction is really the core of the disorder.

And what about depression and anxiety?

If you have ADHD, you almost certainly have lots of symptoms of depression and anxiety, too. You may even qualify for the formal diagnoses of those disorders. Think about it: for your entire life, you’ve struggled to accomplish what others see as basic functions. You may have failed classes, dropped out of educational programs, gotten fired (or quit to avoid getting fired) from jobs, lost friends and partners due to executive dysfunction, and generally failed to accomplish what you want to accomplish. Worse, if you’ve been undiagnosed, you haven’t even had the language to explain to yourself (much less to others) why you failed at those things. You’ve probably internalized others’ opinions that you’re lazy, “stupid,” unmotivated, and unlikely to amount to much. Unless you come from a very privileged background, you’re probably terrified about your future and have no idea how you’re going to pay the rent given that you can’t “adult” well enough to get things together.

The thoughts that therapists consider indicative of depression and anxiety–“I’m a failure,” “Nothing’s ever going to work out,” “What if I lose this job/relationship/apartment,” “There’s no point in even trying anymore”–might actually be very “realistic” thoughts for a person with undiagnosed, untreated ADHD to have. Cognitive behavioral therapy teaches people with depression and anxiety to question their automatic thoughts and see how “irrational” those thoughts are. But what if you have very good evidence that you’re probably going to lose your job and alienate your partner, because that’s how it’s been for your whole life?

That’s why it’s very important for people who think they might have ADHD to dig beneath these thoughts and urge their mental health providers to do the same. Antidepressants, anti-anxiety meds, and therapy that’s focused on these symptoms can provide a bit of relief to someone with ADHD, but it won’t do much, and it won’t help with the ADHD symptoms. And that’ll only reinforce the belief that nothing will ever get better.

The good news is that medication, therapy, and lifestyle interventions that are targeted specifically at ADHD are very effective. Even knowing (or suspecting) that you have ADHD can immediately make things better, because it lets you stop blaming yourself and helps you access advice and support that’s helpful. So while your negative thoughts might be “accurate” in a sense–maybe you really have failed at basically everything you’ve tried, and maybe right now you’re failing too–with the correct diagnosis, all of that can change, and it can change quickly.

What should you do if you think you might have ADHD?

For starters, don’t invalidate your suspicions just because a professional hasn’t diagnosed you (yet). Most diagnoses happen because the patient noticed something first.

Unfortunately, when it comes to ADHD, a lot of medical professionals have their own biases which aren’t helpful to anyone in this situation. Be prepared to advocate for yourself a bit. The good news is that once you’re referred to the right professional, you shouldn’t have to keep advocating for yourself. They will advocate with you.

If you have a primary care doctor, tell that doctor about your concerns and ask to be referred for a neuropsychiatric evaluation.[5] These tests are performed by doctors with MDs or PhDs in clinical psychology, and they’re the primary way to diagnose ADHD. They’re also quite accurate because they measure neurological processes that can’t be faked or altered intentionally. So while some people feel nervous about not being believed when they say they have ADHD symptoms, these evaluations are a great way to put that concern to rest. You can’t fake these results just because you want stimulants.

If you don’t have a primary care doctor, but you have a therapist or psychiatrist, same thing. But if you’re not seeing any medical professionals, I’d actually suggest taking the counterintuitive route and setting up a primary care doctor first. They’re sometimes more likely to have a quick referral for a neuropsych eval available.

If you are uninsured, keep in mind that large medical systems and university hospitals often have substantial financial aid available. For instance, Ohio State’s Wexner Medical Center, where I get everything from my annual flu shot to my cancer surgery, provides assistance to anyone whose income is under 400% of the federal poverty line. Some people end up getting their care almost, or nearly, for free.

Most counties also have free or sliding-scale mental health services for uninsured residents. I’m employed by one of those. Our clients get counseling, case management, vocational assistance, psychiatry appointments, and other services mostly for free, and their medication is free, too, through a charitable pharmacy. The only issue with that is that charitable pharmacies won’t stock all psychiatric medications because some are very expensive. Stimulants tend not to be available, but that may not be true for every county.

(Also, here’s my regular reminder that until they have repealed the ACA, they have not repealed the ACA. If you can, apply for insurance this fall.)

Getting diagnosed can be helpful even if you don’t want medication. But even if you don’t get diagnosed, there are lots of ways to cope with your symptoms, whatever they’re technically called. If you have a therapist, explain to them that you’re struggling with executive function and ask them to work with you on that. If you can afford it, you can also work with an ADHD coach[6]. It’s an emerging off-shoot of life coaching that specifically focuses on the challenges faced by people with ADHD. (I actually hope to get trained as an ADHD coach someday when I can afford it.)

Besides that, two books I recommend to everyone who has or might have ADHD are:

  • More Attention, Less Deficit by Ari Tuckman [7]
  • ADD-Friendly Ways to Organize Your Life by Judith Kolberg and Kathleen Nadeau [8]

Here are some articles that people I know have found helpful:

Many people also find the ADHD subreddit helpful.

This article is already getting super long, so I’ll save all my other thoughts for part 2. (A preview: why prevalence of ADHD is increasing, what connection (if any) there is between ADHD and autism, how ADHD affects relationships and emotional processing, and why people with ADHD are sometimes very good at getting certain things done!


[1] https://en.wikipedia.org/wiki/Neural_substrate

[2] https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_ADHD.pdf

[3] http://blogs.discovermagazine.com/neuroskeptic/2015/06/10/strange-world-reward-deficiency-syndrome-part-1/#.WrphwP0lExF

[4] https://en.wikipedia.org/wiki/Dopaminergic_pathways

[5] https://www.med.unc.edu/neurology/divisions/movement-disorders/npsycheval

[6] https://www.adhdcoaches.org

[7] https://www.amazon.com/More-Attention-Less-Deficit-Strategies/dp/1886941742

[8] https://www.amazon.com/ADD-Friendly-Ways-Organize-Your-Life/dp/1138190748/ref=dp_ob_title_bk


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What ADHD Actually Is

Where I Am and Where I’ve Been

Closeup of a frozen creek.
A scene from my favorite winter hike so far. Also an apt metaphor.

For weeks now I’ve been begging myself to write something, anything. But the words just don’t come.

It’s not that I don’t care anymore about the things I used to write about. Though I do click away from the news a lot of the time, I know I care, it’s just that my brain is usually too full with a buzzing sort of panic about my impending loss of autonomy, mobility, dignity, bodily integrity. That’s when I’m not panicking about simply dying.

I think about very little else anymore. The surgery. Researching everything I can about the surgery. Looking up and buying things for after the surgery, special clothes, pillows, anything to reduce my dependence on other people. Writing down lists of questions to ask some doctor at some point. I’m not always sure which questions should be directed to whom–the medical oncologist, the surgical oncologist, the plastic surgeon, the anesthesiologist, a social worker. Recounting to my parents my meticulous list of boundaries to retain whatever control I can over this impending horror–instructions about when they can and can’t see me in the hospital, when to give my phone back to me, who can touch or see what or how. Listing activities I may be able to do while I’m recovering–reading, writing, knitting, gaming, drawing–and making sure that I acquire everything I need for all of these things just in case something sticks. Planning out outfits that I will be able to dress myself in, independently. Asking the surgeon questions like, “Are you saying you don’t RECOMMEND that patients do this on their own, or just that they may find it uncomfortable and want to ask for help?” Because I will take the discomfort.

It has turned into a full-on obsession, and some part of me realizes it’s not healthy, but at the same time it’s also a coping method. It is easier, and probably healthier, to make packing lists than to let myself “be with” the fear, and imagine over and over being ripped open and stitched up again with tubes coming out of places they shouldn’t be and stuff that’s not supposed to be inside my body being inside of it and stuff that was supposed to be in there not being there anymore. And to be clear, I certainly imagine plenty of that. It comes completely unbidden. It’s a wild, untamable, primal fear. I’m like an animal being led to slaughter. My mind flings itself against the bars of its cage, over and over, despite the damage it does.

This is what it looks like to face down your worst, most paralyzing phobia. I used to say, half-jokingly, that if I ever required the sort of surgery that involved general anesthesia and opioids, I would refuse and simply die. Life called my bluff. I’m not dying, at least not yet.

Plenty of people have pointed out that there’s something maddeningly counter-intuitive about treating early-stage breast cancer, and that’s that it often feels like poisoning and mutilating a perfectly healthy body. I had no symptoms aside from an innocent-looking lump that nobody, not me and not the doctors who initially observed it, really thought could actually be cancer. Now that lump is gone thanks to an overwhelming response to the chemo, and I have to face the idea of having part of my young and tumor-free body hacked off so that I don’t die later. There’s also the thought that if I hadn’t noticed the lump, I might very well be dead now, or rapidly getting there.

The thought keeps going through my head: “And for what?” But I know for what. It’s so that I don’t die. That’s literally all. And though a double mastectomy doesn’t guarantee a cancer-free future, it at least offers a strong hope for one. Without it, that hope would be quite frail.

At the same time, and perhaps because I never exactly felt “sick” or thought of myself as sick, it feels like I’m sacrificing an awful lot just to have what I always naively assumed I’d have anyway–a reasonably long and healthy life. The surgery doesn’t feel like a treatment; it feels like the disease itself. I’m not healing from cancer, I’m healing from something I elected to have done to me, for reasons I can’t quite remember some days.

And yet, being the sort of person I am, I never seriously considered not doing it. Anything other than the double mastectomy seems like a betrayal of who I am, not to mention a betrayal to my loved ones who would have to spend the rest of their lives, like me, fearing recurrence. None of us deserves that kind of fear.

The surgery is a sacrifice that present me is making for future me, for some version of myself I can’t quite envision yet but will have to eventually become. That person will have accepted her new body, or at least gotten used to it. That person will, like the women in my support group, joke cheerfully about the awkward things that happen when you have no sensation left in your chest anymore. That person will maybe date new people again and find some way to explain the breasts, or not. That person will still think about cancer but not every single day.

That person will no longer believe that she’d rather die than get surgery. That person will also be much older than her years.

Don’t get me wrong, this isn’t the way I’d recommend doing exposure therapy for your medical phobia. But this is the way I’ll have to do it.

This is my longest, darkest winter, the winter time stood still. You don’t move forward when you’re fighting something like this; you’re just planting your feet, pushing back, and hoping not to be thrown off the ledge. My career is at a standstill—I have no idea when I’ll get enough supervision hours for independent licensure now. I forget the last time I met a new interesting person; it used to happen every week. I exercise and yet my body grows no stronger. I don’t really get to try and learn new things anymore. Everything I’d planned to do—practicing on the motorcycle, starting a vegetable garden, volunteering at the humane society or the botanical garden, planning a future coaching business, looking into selling my bread at the farmers market—is now delayed indefinitely.

That I knew something like this was probably coming doesn’t help much. For the two years leading up to my diagnosis—the two years since I moved to Columbus—I loved my life so much that I knew it couldn’t last. “Something’s going to happen to fuck this up,” I thought. I’d spent most of the first 24 years of my life pretty miserable, and now I finally wasn’t, and it couldn’t last.

And it didn’t.

And yet, unbelievably, it also did.

There is so much joy still in my life, if not every day then enough to carry me through. I spend entire days with friends sometimes, or else catching up on my library books with the cats cuddled up against me. My parents and sister and I laugh till our sides ache as my brother demonstrates parkour on the lawn in front of my house. Letters and cards arrive weekly in the mail from distant friends, some of whom I’d honestly thought had forgotten me by now. The teapot whistles urgently on the stove. Snow falls, and then rain, and then more snow again. There’s an orchid show at the botanical garden, and I went with my camera, struggling to kneel to take the pictures and stand back up but doing it anyway. It’s 8 degrees, but we go hiking anyway. The regulars at my yoga studio are starting to recognize me, and to know what the hat means. My older brother in London sent me a Switch for my birthday; now when I close my eyes I see beautiful scenes from Zelda instead of body horror. My body aches unbearably sometimes from chemo, so people bring me things. My oncologist calms my panic with his presence the moment he enters the exam room. A coworker finally learned to text just so she could check in on me when I didn’t answer the phone.

And, outside, the days slowly lengthen, and the January chills are gone. Three seasons will have passed by the time all of this is even on its way to being over. The mint in my backyard will have grown back. It has a way of enduring.

As it turns out, I have a way of enduring too.


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Where I Am and Where I’ve Been

I Still Feel Anxious About Communication Every Day

I get asked a lot about how I set boundaries or communicate my feelings or do anything else in that constellation of terrifying interpersonal tasks.

Sometimes people are looking for concrete suggestions or scripts because they’re simply unsure how to put their thoughts into words. But more often, especially these days, they already know how to do that. So there’s usually something tacked onto their request, almost as an afterthought, although it’s really the main thing on their minds: “How do you set boundaries…without hurting their feelings?” “How do you tell someone they’ve upset you…without having an anxious breakdown about it?”

These are the questions I can’t really answer. I guess there’s strategies, ways you can make it easier for yourself and the other person. But you can’t control how other people feel, and often you can’t control how you feel either.

So how do you make myself vulnerable and communicate what you really feel without being anxious about it?

Maybe you can’t.

Here’s a confession: despite the fact that many people identify me as a role model when it comes to communication skills, I am not free of anxiety when it comes to communication.

Sure, it’s better than it used to be. I find that the more I cultivate relationships in which everyone intentionally and honestly shares their inner experiences–so that it’s not just me blabbing about my feelings all the time–the easier it gets. As I build up histories with people who are gentle with my vulnerability and who let themselves be vulnerable too, I gain trust that that vulnerability won’t implode, and that eases the anxiety a bit.

But I can’t tell you how to set boundaries and share your feelings “without anxiety.” I don’t do it without anxiety. I do it with anxiety, every single time.

Every time I set a boundary, I feel afraid that the person will lash out or abandon me. Every time I share negative feelings, especially negative feelings about someone’s actions, I worry that this time it’ll be too much, it’ll be the straw that broke the camel’s back, and they’ll decide that dealing with me and my feelings isn’t worth it anymore. Every time I am honest about my depression and anxiety–which often means letting them out into the open rather than suppressing their symptoms–I fear that people will recoil and withdraw.

I hate telling people they’ve hurt me. There’s no satisfaction or schadenfreude in that for me. I hate knowing that they might feel like bad friends/partners and that their guilt will be painful. Every time, I wish I could keep it to myself and get over it so that we wouldn’t have to talk about it and I wouldn’t have to take that risk. But I have to, or else those relationships will rot from the inside out.

I hate telling people I can’t make time or space for them in the way they’d like. I hate knowing that they might worry that I dislike them, and I hate that, honestly, sometimes I DO dislike them because I can’t like everyone. I hate that a lot of the time, giving them a reason would turn this into the kind of honesty that’s no longer kind or helpful. What’s someone supposed to do with the knowledge that I think they talk about their trauma too much and it exhausts me, or that they talk too loud and fast, or I don’t find them interesting because we don’t really care about any of the same things?

In my communities, we tend to cheer people on in their boundary-setting and emoting, applauding dramatic demolitions and disclosures in the hopes of helping each other feel better about being vulnerable. I’ve been praised for it and heaped praise onto others, relishing someone’s crisp shut-down of an online troll or a thoughtful post about their emotional needs.

But for the most part, real communication isn’t an Upworthy moment. It isn’t You Wouldn’t BELIEVE What Miri Did When Her Partner Accidentally Made Her Feel Like A Piece Of Shit. It’s more like, I’m crying and I hate myself for crying and I hate myself for saying that I hate myself because I’m not supposed to say that anymore and I’m trying to tell you that I hurt.

I suppose I should feel somewhat hypocritical for advising people to be honest about their feelings even though I have panic breakdowns about being honest about my feelings, but I don’t, because it’s not hypocritical. I never said it was easy; I only said it had to be done if you want better relationships than your parents had, or at least ones that don’t look like a TV sitcom.

The good news is that your communication skills aren’t measured by whether or not you can implement them without panicking, crying, or stumbling over your words. They aren’t really measured by anything at all, but if they were, it would be by your willingness to approach that scary swamp and wade around in it, and maybe even get stuck in it sometimes.

Nobody ever said you have to feel good about it.

You just have to do it.

And I can promise that it’ll get easier, and I can also promise that it probably won’t get easy.

I’m coming around to the conclusion that those feelings I described–the fear of abandonment, the guilt, the panic–are, like their cousin awkwardness, just the price of admission to being human. They certainly make it a lot harder to communicate openly, but they don’t make it impossible.

Those feelings are there because they speak to real possibilities. Sometimes you ask someone to stop hurting you and they decide that they’d rather not bother with you at all. Sometimes you try to set a boundary and the person would rather argue about it than respect it and move on. Sometimes you express your feelings as kindly as you can and people still take it personally, feel attacked, and blame you.

The only way to not have any anxiety about communicating is to do it falsely, or to stop caring if you lose people you aren’t ready to lose. Neither of those options appeals to me at all.

So if you could know–and accept–that you’re going to feel anxious and uncomfortable about speaking your truth no matter what, and if you could release yourself from the responsibility of controlling or preventing those feelings, what would you do instead?


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I Still Feel Anxious About Communication Every Day

(Self-)Care in the Age of Trump

Over the past few years, the social justice and nonprofit spheres have been gradually building an awareness of the necessity of self-care for anyone who engages in the (often unpaid) emotional and intellectual labor of activism. While plenty of us–including myself–have critiqued the way that self-care is co-opted by those who want to exploit us, we’ve also recognized the fact that without it, people burn out and quit, and change is impossible.

Unfortunately but unsurprisingly, the election of Trump seems to have reset a lot of that progress.

I’ve seen people seriously claiming that calls to engage in self-care are a tool of the neoliberal agenda. (If there’s any word that’s become uselessly vague these days, it’s “neoliberal.”) I’ve seen that horrible “don’t mourn, organize” quote over and over. (I’ll feel however the fuck I want, thank you.) I’ve seen people berating themselves (and sometimes others) for being too mentally ill to engage in certain forms of activism. I’ve seen people altering self-care memes to be about political activism instead, such as this one:

I don’t want to hate too much on this graphic, much less on the person who altered it, because it’s an important message. Yes, those of us who still care about basic things like justice should be actively trying to bring it about, and it’s useful to reflect on the concrete things you’ve done to make that happen rather than to just reassure yourself that the arc will magically bend on its own.

But I would’ve much rather seen this as a stand-alone message rather as a negation of something else–and no, the cute hashtag doesn’t make it any better. Actively doing things to make the world a better place is important, and reflecting on your happy memories is important. We shouldn’t be crossing out the latter to make room for the former.

I think a few things are going on here. One is that some progressives, noticing that corporate interests have co-opted concepts like self-care and mindfulness in order to extract more labor for less money, have decided that this somehow means that these concepts are now meaningless. While I put the bulk of the blame for this on those corporate interests, I also think that anyone who accepts their redefinition is unintentionally colluding with them. Whether or not your employer makes you attend vapid corporate trainings on self-care, you can still decide that you, personally, need real self-care and that real self-care is important for others. You’re not going to stick it to the man by running yourself ragged.

Second, there’s a lot of activistier-than-thou posturing going on right now. Just like college students brag about how little sleep they got the night before the final, some activists hope that by appearing superhuman and beyond such petty earthly concerns as letting yourself feel happy about the good things in your life, they can impress others–or themselves.

Third, some progressives think that self-care is only for times when political action is less urgent, less life-and-death. It’s for when oppression and injustice are at their usual levels, not for when we’ve elected a sexual predator who gets saluted by Nazis.

I can understand that. When considered out of context, it does seem a little weird to just sit there filling a jar with happy memories while our democracy collapses. If anything, though, now is when keeping yourself recharged is especially important. First of all, that’s the only way we can get anything done. If I burn out, the world loses my contributions, possibly forever. If I keep myself from burning out, I can keep contributing, possibly for the rest of my life. It’s because this is a marathon and not a sprint that self-care is so important right now.

Second, what we’re up against is a regime that wants us to feel like shit. Trump’s America is designed to be a place where women, LGBTQ folks, people of color, and other marginalized people feel terrified and unwanted. That was the basis of Trump’s campaign, and it was the motivation of many (if not all) of his voters. If you can somehow resist that, you are resisting Trump. Self-care in this context is resistance. It’s not a form of resistance that’s accessible to everyone, but if it is accessible to you, why not use it?

And speaking of resisting Trump, that brings me to another form of resistance that many progressives are discounting and ignoring. In a healthy community, self-care is accompanied by plain old care–people caring for each other, and not just for their romantic partners, either. To survive Trump, we will have to care for each other even more than we already do. We will have to check in with each other, support each other, comfort each other, entertain each other, energize each other, encourage each other, love each other. This is emotional labor, and it’s not easy, and you can’t always do as much of it as you want for everyone that you want (let alone everyone that wants it from you), but it’s vital work and it has to be done.

I see people asking each other how many congressional representatives they’ve called, how many protests they’ve attended, how many bigots they’ve yelled at, how many Republican family members they’ve argued with, how much money they’ve donated and to how many organizations–how about how many friends have you listened to? How many hands have you held? How many wounds have you treated?

I don’t necessarily think we should quantify it like that, by the way. But if we’re going to make it about numbers, we should be counting all of the things that matter. And we should be keeping in mind that these quieter, less flashy acts of resistance are the very same ones that are feminized, racialized, and too often discounted altogether.

Armies don’t fight wars without doctors, nurses, social workers, and chaplains. So why should we?

In the past, I saw more activists talking about this. People used to talk about how we’re not all social justice warriors; some of us are clerics, healers, and bards. Where are the clerics, healers, and bards in the fight against Trump?

One of them is right here, and is fucking tired of being told that care is a frivolity we can no longer afford.

Kindness to yourself and to others is neither hippy-dippy bullshit nor neoliberal propaganda, and anyone who tells you otherwise is trying either to manipulate you or to escape accountability for their own unkindness.


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(Self-)Care in the Age of Trump