Bipolar 2 From Inside and Out

When You Don’t Realize You’re Mentally Ill

October 16, 2022

You’ve heard the stories: A homeless man who has been diagnosed as schizophrenic panhandles for change, though few people stop because of his bizarre behavior. He refuses help from a governmental or charitable organization. His family finds him, but he won’t let them do anything to help.

Or this one: A bipolar woman has manic psychosis. She is convinced that her coworkers and people on the street are reading her mind and planting thoughts in her head. She refuses to take her medications because she thinks she doesn’t need them.

Or, perhaps worst of all, this one: A teenager who has been struggling with undiagnosed schizophrenia is convinced his mother is trying to kill him. He threatens her with a knife. The police are called and they shoot the boy.

Extreme stories? Yes. But these tragedies occur nearly every day. Most of them don’t make headlines, but they still cause suffering and even death for countless individuals and families across the US and around the world.

What these three people – and many others – are suffering from is “anosognosia.” It literally means “lack of insight,” but anosognosia is much more than that. It means that a person has so little insight that they don’t even realize that they are mentally ill. They don’t know that their behavior and thoughts are part of an illness.

Anosognosia is not the same thing as denial. Denial is when someone avoids something that is unpleasant or distressing to them. They do realize that there is something wrong – they just don’t want to deal with it. A person with anosognosia doesn’t even realize that there is anything wrong at all. They don’t realize they are mentally ill. Their brains don’t let them see that their thoughts and perceptions are not in line with reality. They don’t realize that their functioning is impaired. They think that they are perfectly normal. If anything, they think that the people around them are clueless and deluded.

Anosognosia is the number one reason that people with schizophrenia or bipolar disorder do not seek treatment or take their necessary medications. By some estimates, it occurs in up to 98% of people with schizophrenia and 40% of people with bipolar disorder. It’s also common in people with Alzheimer’s or dementia. People with anosognosia don’t get the help they need. Their condition doesn’t improve – in fact, it worsens.

So, what’s to be done? One solution may be a program that California Governor Gavin Newsom recently signed into law. It establishes CARE Courts – Community Assistance, Recovery, and Empowerment courts that make it easier for family members, first responders, outreach workers, and others to institute civil proceedings that make it possible to obtain up to two years of mental health services. The person being judged by the court will have access to a clinical team, lawyer, and “volunteer supporter.” Up to 12,000 of the most vulnerable people in California are expected to be helped by the CARE courts.

The program is controversial, however. Critics have said that the plan amounts essentially to forced treatment. Civil rights and disability groups are not in favor, though the program has been described as “voluntary.” In theory, a person would still be able to refuse treatment. And if the person has anosognosia, that might well be the case. The CARE courts plan is similar to another potential solution recommended by some clinicians – Assisted Outpatient Treatment (AOT). It’s not clear where the state would find people qualified and willing to monitor patients’ treatment and medication compliance. In Santa Clara County, AOT treatment consists of “intensive individual and group clinical services, peer support, intensive case management, housing assistance, 24/7 clinical crisis support, and medical evaluation.”

One of the most frustrating things about trying to get help for someone with anosognosia is the lack of appropriate treatment facilities, mental health workers, and other services. With many of the sickest patients being held in overcrowded emergency rooms or held for only 72 hours in a hospital ward, the situation is extremely complicated and not easy to solve. But if AOT or CARE courts keep mentally ill people out of jails and prisons, which typically provide either inadequate or no psychiatric treatment, that’s a good thing.

Most people with psychiatric disorders may hear about anosognosia and think, “Oh, that could never happen to me.” But the reality is that a person with anosognosia doesn’t realize when it is happening to them. It’s not an easy problem to solve, but educating people about anosognosia and developing plans for dealing with it are vital. It’s the most vulnerable members of society – and their families and friends – who are most affected by it. They need our help, even if they don’t realize it – or particularly when they don’t realize it.

This post first appeared on The Mighty.

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Three Days in the Life

October 9, 2022

What’s it like to have bipolar type 2? Here’s a look at three typical days.

It’s a day when I’m depressed. I wake up late and try to decide whether to get out of bed. I do so in order to take my meds, since I have to go to the bathroom anyway. If I have anticipated this depression, I will have left a box of Cocoa Puffs by my bedside, and these constitute my breakfast.

If I stay in bed all day, I am bored, because I can’t even focus enough to read. Everything I try to read means nothing to me. If I get up, I spend a large part of the day on the sofa, watching horrible reality shows that remind me that there are other people with crappy lives too. I skip lunch. I forget that I have an iPod with thousands of songs on it. I skip therapy appointments because I’m unable to get up and dressed and drive there. I feel numb and useless and pathetic. My brain reinforces this belief.

In the evening, I cry. I weep. I sob. Snot runs from my nose. I have circling thoughts about every stupid, embarrassing thing I’ve ever done. I try to wait till my husband’s asleep so he won’t hear me crying. I wake in the middle of the night, still crying.

I have anxiety attacks too, particularly when I’m in bed at night. I wake gasping. My husband holds me and strokes my hair until I fall asleep again. It’s really all he can do for me.

My psychiatrist and I keep trying different meds, but none of them does more than take the edge off a little. I still can’t function.

There is nothing I can do to change any of this. I can’t cheer up. I can’t even see a time when I won’t feel this way. This goes on every day for months. For years, even. I’d hope for an end to this, but I have given up on hope.

______________________________________________________

It’s a day when I’m hypomanic. I wake up early, not exactly refreshed, but with a more-than-usual alertness. I take my meds, then go downstairs and have a muffin and a container of yogurt for breakfast.

I go to my computer and start writing. I may have an assignment – typing or ghostwriting – or I may just work on new blog posts. The momentum of writing stays with me and presses me to keep going. I write lots, but badly. Maybe I forge ahead and write another blog post or volunteer for more typing. I forget that I need lunch.

I jump around from project to project. I scroll and scroll through Facebook. I check my email every few minutes. I go to clothing websites and order underwear and pajamas and blouses. I look at jewelry, too. I check my bank account at least four times.

I don’t read, because nothing holds my attention. I watch competition shows because of the excitement. I try to listen to music, but I can’t finish one song without flipping to another.

I may notice that I’m hypomanic and try to control it. This goes on for a week or so. I hope it ends soon.

______________________________________________________________

It’s a day when I’m stable. I wake up after nine hours of sleep and take my meds. I have a bowl of oatmeal and a cup of tea for breakfast. I check my calendar and see what I have scheduled for the next few days, such as an appointment with my therapist or finishing my writing or typing assignment. I have peanut butter and fruit for lunch.

I do my work. I reread what I wrote when I was hypomanic and immediately start revising it – if I haven’t already submitted it. I take on new assignments and try to space them out so they’re not overwhelming. Sometimes I even succeed. I keep a calendar on my computer with dates of appointments for both me and my husband, when assignments are due and when bills need to be paid, and which week is recycling week.

I meet with my therapist once a month via video chat and see my psychiatrist four times a year for medication updates. The only time I miss one of those is when my car is at the mechanic.

I’m very close to “normal.” I hope this goes on forever.

This post first appeared on The Mighty.

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Murder and Delusions of Grandeur

October 2, 2022

Sometimes when I’m hypomanic, I write. I think that my writing is terrific. This does not always prove to be the case.

I wrote a murder mystery for literally years on and off. I put heart, soul, and sweat into it. I kept revising. I had a bulletin board with index cards of plot points that I moved around, trying to find the best sequence and flow. At last, one day I declared it finished.

I sent a query and a sample to over 100 agents and publishers. I waited. I kept a list of everyone I contacted about my novel, and I marked them off the list when they rejected me. None of them bit except the you-pay-us types that I had accidentally included and scorned. My prospect list was long, so this went on for months.

No doubt I was hypomanic when I decided the novel was done, and when I sent those queries. I wasn’t even deflated when I started getting rejections back. Out of 100 queries, I thought, surely there would be some takers. Maybe there would even be a bidding war for the publishing rights. I started doing research for the sequel and even started writing it.

As I waited, I basked in thoughts of success. I would be a guest at mystery conventions. I would do a book tour. I even imagined that I would receive the Edgar Award (mystery’s Oscar) for Best First Novel. I pictured myself receiving the email telling me that I was nominated and the phone call informing me that I had won.

Of course, I eventually came down when one of the rejections actually told me why my manuscript was being rejected and what was wrong with it. Faced with that reality, I had to admit that I had deluded myself. I had needed to rework the novel a lot more before submitting it. I had needed to workshop it with fellow writers, preferably those who knew something about mysteries. (I had sent the first few chapters to some volunteer beta readers, but they had made comments only on small details, not the structure, pacing, or characters.) I realized at last that I had submitted a manuscript that had a great prologue, but that everything after that needed serious work. Despite the time and effort I had put into it, it just wasn’t good enough. And that was the reality.

That was the longest spell of hypomania I’ve ever had – about a year. Of course, I was doing other things while I wrote and while I waited. I had some depression and some mixed states, but not about my mystery novel. I was exhilarated with that.

What I had were delusions of grandeur. I imagined the success without putting in enough work to achieve it. Despite the evidence of all the rejections, I persisted in believing that I had produced something wonderful and worthy. I anticipated plaudits and acknowledgment of my writing prowess and remarkable achievement. My hypomania was giving me messages that I was great, just as my depression had always given me messages that I was nothing. And I was deluded. I believed the hypomanic messages.

I have abandoned that manuscript and taken up other projects. I have also abandoned my research and writing for a sequel. I still have problems recognizing the actual merits of my writing, or lack thereof. I try to keep my expectations in check. I have some successes and some failures, though none nearly as monumental as the mystery. I live with my limitations instead of flying with my fantasies. Have I lowered my horizons? Well, yes. But I like to think that now, at least most of the time, I view the horizon where it really is.

I did love the exuberant feelings that I experienced. They gave my life a sense of meaning. If I learned anything from the experience, it was that I couldn’t, or at least shouldn’t, pin my sense of personal worth on something that isn’t real.

Of course, when I’m in the grip of hypomania, it’s hard to realize that.

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Body and Brain: Self-Image

September 25, 2022

I’m fat. I admit it. I haven’t been fat all my life, so this came as something of a surprise to me, but I’m dealing with it. I don’t know whether it’s my eating habits or my medication or some genetic thing that has caused me to gain weight, but there you have it. It could be any or all of those.

I’m not trying extreme diets or grueling workouts, though I admit that some exercise would be good for my mental condition as well as my body. I’m living with and acknowledging the fact that I am fat.

The thing is, when I think about myself, I don’t think of myself as fat. Perhaps I’m in denial about it. But I do know how much I weigh and that it’s over what I should, according to all the height vs. weight and BMI Index charts. And I don’t think of myself as thin. I just feel as though I’m still in my 30s and weigh what I weighed then, despite my body’s very clear rejection of those notions. I know I’m really in my 60s and have trouble getting up off the floor if I fall, in part because of what I weigh.

I’ve heard that everyone gets stuck in their head at a certain age and always remains that same age in their mind. It’s not quite like having an inner child of four or ten (or in my case, more like 15). I used to think I didn’t have an inner child until I remembered how much I still love chocolate milk, plush animals, and naps. And I do have that inner teen that wants to make up for all the things I missed when I was a depressed teen, like mad crushes and experimenting with fingernail polish and fake nails. But having an inner weight is different somehow. It’s like my brain and my body are clashing in some way.

At least I don’t have Body Dysmorphic Disorder. That’s when you see tiny, imperceptible flaws in yourself and magnify them until you think that’s all people see when they look at you. Technically, it’s not the same as anorexia because, in anorexia, you focus only on your weight even if you are thin. Anorexia is an eating disorder that you have as a reaction to your flawed perception of your body size. Dysmorphic Disorder is more about smaller perceived flaws such as balding or the size of your nose. (The Mayo Clinic does say that Body Dysmorphic Disorder can cause or be associated with eating disorders, low self-esteem, mood disorders, obsessive-compulsive disorder, and substance abuse. The DSM-5 does not classify Body Dysmorphia as an eating disorder. It’s confusing.)

One of the dangers of Body Dysmorphic Disorder is overuse of plastic surgery, which can be somewhat of an addiction in itself. Just watch a few episodes of the TV series Botched and you’ll see what I mean. There are always horror stories like the one in which a young man wanted to look like Michael Jackson and as a result of repeated surgery suffered the same health problems and conditions that the singer did.

If I had Body Dysmorphic Disorder instead of the ones that I do have, I might be undergoing multiple treatments of liposuction, “cool sculpting,” tummy tucks, gastric bypass, extreme fad diets, weight-loss pills, and other procedures. I don’t and won’t. I’m aware that those are only temporary fixes and leave you open to disappointment, infection, scarring, and other bad effects and complications that can be worse than your original condition and stay with you for life.

So, where does that leave me? Besides fat, I mean. I try to be body-positive about people who don’t conform to societal messages about weight, including myself. It’s a difficult thing to get over. The messages are relentless. I have found myself in the past thinking that fat is unappealing and in the present thinking that extreme thinness is dangerous. But that’s only in the abstract. Any number of men I’ve been attracted to have been anywhere from pudgy to fat, including my husband.

I realize that I may get a lot of pushback from people telling me of all the medical reasons I should lose weight. I’m not saying they’re wrong. I’m just saying that if I’m comfortable with being fat, they could at least be okay with my fatness as well. In other words, I already struggle with my mind. I don’t want to struggle with my body too.

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Are Holistic Approaches to Mental Health Useful?

September 18, 2022

Well, first of all, the answer to that question depends on what you mean by “holistic.” If you mean treatment that considers the mind, body, and soul, I certainly have to say yes. All three are inextricably intertwined and healing one tends to heal the others as well.

Certainly, the mind is involved – that’s implicit in the word “mental.” To many, this means the brain as the location of the mind. Increasingly, this also means thinking of and referring to mental illnesses as brain illnesses. And the competing theories of what causes depression and bipolar disorder, for example, have had something to do with the brain. Perhaps neurotransmitters in the brain are not behaving the way they are supposed to, or processing traumatic events causes brain illnesses (certainly true in PTSD), or genetics is responsible. whichever it is, the brain is involved.

It’s not controversial to say that the body and the mind are linked in the most profound ways. What affects one affects the other. Mental illness has demonstrable effects on the body, all the way from not being able to care for oneself physically to having a shortened life span. Treatment programs for mental illness often include an exercise component, which causes physical changes in the body and brain. Depression in particular is known to be alleviated by even small amounts of exercise. The exercise partially relieves the depression, which makes it more likely that the depressed person will be able to exercise. It’s a cycle that benefits both the body and the mind.

As far as the soul goes, I don’t feel theologically competent to make any definitive statements. I do know, however, that many people find that spiritual practices such as prayer help them cope with the effects of brain illnesses. It may be subjective, but what works, works. I personally don’t believe that prayer cures mental illness, but even if it just makes the sufferer feel more at peace and more comforted, that’s a component of healing that’s important.

Holistic healing that recognizes the interconnectedness of these three aspects of the person is, in my opinion, more likely to be more effective than any one of them alone.

Then there’s the other thing people often mean when they say “holistic healing.” To many, holistic healing means avenues of treatment beyond the scope of Western medicine. Herbal medicine, meditation, homeopathy, acupuncture, yoga, and crystal healing are among the avenues that have been explored.

There is certainly some validity to herbal medicine. It’s been practiced for thousands of years and the results are well-known, particularly by indigenous peoples who have passed that knowledge on throughout the years. Chamomile, lavender, passionflower, and saffron have been studied for mitigating anxiety or depression in cancer patients, with favorable risk-benefit profiles compared to standard treatments. Ginseng is another popular herb for relieving mental conditions. St. John’s wort has been used as a treatment for depression for hundreds of years, and so has valerian for anxiety. And there are many vitamins and supplements such as B vitamins and zinc that might have beneficial psychological effects.

Unfortunately, there hasn’t been a lot of rigorous scientific study of plant-based medicine. For people who gather herbs and plants from the wild, there’s no telling the potency or amount of the active substance that may be present. Even in herbal products sold at health food stores, there is little standardization, so you don’t always know what you may be getting in terms of dosage.

Meditation and yoga are popular adjuncts to talk therapy and/or medication for psychological problems. In fact, these days, they seem to be promoted as a panacea for mental health. They’re particularly popular recommendations in corporate settings, where they’re seen as a low-cost alternative to more expensive treatments that would affect the company’s health insurance costs.

Nonetheless, meditation and yoga do have beneficial effects on mood disorders such as anxiety and depression, and may be helpful for conditions such as PTSD as well. Any amount of exercise is commonly recommended for people with depression and bipolar disorder. The effects are cyclical. The more one exercises, the more one feels able to get going with exercise. Yoga, being low-impact, is something that can be tried by nearly everyone. I’d still say they are adjuncts to traditional treatments for mental illnesses rather than a first-line approach.

Then there are practitioners of alternative medicine. These therapies range from acupuncture to chi balancing to aromatherapy to biofeedback to reflexology to reiki. Let’s start with one that has some science to back it up.

Acupuncture and its cousin acupressure have solid adherents behind them. Johns Hopkins Medicine says that acupuncture is useful in treating anxiety, depression, insomnia, nervousness, and neurosis, though more studies need to be done. And who am I to argue with Johns Hopkins? If they say it’s effective or even promising, I’m willing to say it falls inside the spectrum of helpful approaches.

Reflexology, not so much. The idea that there are areas on the feet that correspond to body parts and can be helped by foot massage is not scientifically proven for health in any body parts, either anatomically or physiologically. (It hasn’t been disproven either, but you can’t prove a negative.) It’s based on the idea that “energy lines” throughout the body somehow combine in the feet (or hands) to produce a map of the body. It is recommended for anxiety and stress relief.

On the other hand, the massage practice of concentrating on muscles that are tensed is much more well-documented. The Mayo Clinic has said that it can reduce stress and anxiety, and even mentions it as a treatment for depression and seasonal affective disorder (SAD). The thing is, any practice that reduces stress is good for relieving anxiety. Whether or not massage has any effect on serious mental illness (SMI) is doubtful.

Relief from tension is, of course, possible when a person believes that a particular technique can reduce it. So if you believe in aromatherapy, for example, it may help you relax. It’s the placebo effect. I’d rather stick with massage.

Then there are approaches that simply don’t work. Homeopathy is supposed to work on the theory that if a substance is good for the body, introducing a single drop of it into water will be effective in the treatment of a disorder. Never mind the science (though there are rigorous studies that say homeopathy simply doesn’t work), the math doesn’t support this. Diluting a substance to the extent that there are minuscule, millionth amounts per glass of water – or even less – just isn’t sufficient to do anything. If there are larger concentrations of the substance, in which there can be alcohol or heavy metals like iron and lead, there may be drug interactions or serious side effects. In 2017, the FDA alerted consumers that some homeopathic teething tablets contained excessive amounts of the toxic substance belladonna. Belladonna is also said to be a treatment for bipolar disorder and schizophrenia.

Crystals are another way that alternative practitioners attempt to cure assorted diseases and conditions. Jasper and tiger’s eye are recommended for anxiety and lepidolite or citrine for depression. Smoky quartz is even said to relieve suicidal thoughts. I wouldn’t count on it. Again “energy fields” of the body and “vibrations” of the various stones, minerals, and crystals are supposed to combine to affect mental and physical health. I own and wear any number of crystals for their beauty, but have never felt any healing effects. The only benefit I see is if a stone is carried in the pocket as a “worry stone,” which the person can rub to induce a calming effect, an early version of the “fidget spinner,” as far as I can see.

Still, proponents of these alternatives to traditional Western medicine will continue to hope for beneficial effects. The National Center for Complementary and Integrative Health says that Americans spend over $30 billion annually on alternative health care. I say, “Let the buyer beware.”

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The 988 Hotline: How Is It Working?

September 11, 2022

The 988 hotline, designed to be like the 911 connections to emergency services, has been in operation now for a couple of months. What have been the reactions to it so far?

Well, the number is shorter than the ten-digit former one for the National Suicide Prevention Lifeline (now known as the 988 Suicide & Crisis Lifeline); is for people experiencing any emotional distress, not solely a suicidal crisis; and can be reached via phone, text, or message app. A trained crisis worker in a center close to the caller will listen and then provide information about support and resources available in the area.

All that sounds – and is – laudable. Even so, the hotline’s existence has not been universally applauded. What are some of the perceived or reported problems?

Back when the hotline was still the National Suicide Prevention Lifeline, there were difficulties with wait times before speaking to a therapist. Many people who were on hold hung up. There is little reason to believe that this problem will go away – in Illinois, it’s been reported that 30% of callers hung up before reaching a counselor. The same company that ran the former hotline, Vibrant Emotional Health, is running the new hotline. And with all the publicity around the new number, there may be an even greater number of calls. (This might be optimistic, though, since a recent survey said over 75% of Americans had not heard of it by the end of June, just before the hotline went live. Federal funding may allow them to hire more of those trained crisis workers, but will that be enough?

That federal funding is another problem. Much is left up to the states, and there are a number that are not cooperating, neither funding nor publicizing the hotline. Only 20 states have done so. And let’s do the math. The federal funding totals $432 million, far more than was formerly spent on the mental health hotline, but it still means only an average of $8.6 million for each state. States can tap additional funding through sources including Medicare and opioid crisis money. But the lack of state involvement will certainly hinder the counselors in finding and recommending resources close to the callers – and callers in rural areas, for example, may not have any resources close by.

Another major concern that has gotten a lot of pushback from the mental health community – especially expressed on social media such as Twitter and Instagram (hundreds of thousands responded with likes) – is who will respond to calls that require serious intervention. Many are afraid that the local police will be notified of a suicidal person or other mental health crisis and respond to it with the aid of a crisis response team.

Specifically, they are upset because of the number of deaths that result when police who do not understand mental illness and its symptoms get involved. The officials that run the hotline say that police or EMTs are called only as a last resort effort for suicide situations. But many potential users are skeptical.

There have been rumors that the hotline can collect geolocation information about callers, but this seems to be limited to general location by phone number and area code, or IP address, which may be helpful in putting callers in touch with local resources, but also means that law enforcement can have this information if the hotline counselors do contact emergency services. Counselors are scheduled to receive training on when to call in law enforcement personnel and the dangers of it.

Of course, not all police involvement results in death. But there are other concerns when police and EMTs are involved. Among these are people being taken to hospital emergency rooms, where they receive slow or inadequate treatment, and involuntary treatment in psychiatric hospitals. (This is a particular concern for people in the LGBTQ+ and POC communities.) When there are so few options to treat the seriously mentally ill, the likelihood of the counselors providing useful advice for sufferers or families is not great.

Nonetheless, we should not let these potential problems overshadow all the good that the new 988 hotline will do. The more coordinated effort with the easily remembered number will help those who know about it in times of crisis. When the bugs are worked out, the states get on board, and the public becomes more aware of the service, it should prove a valuable resource for those not just with suicidal thoughts, but with everyone who suffers from a mental illness and who needs a listening ear, counseling, and resources.

Of course, no new public service endeavor gets off the ground without some rocky start-up time and a few glitches. Let’s keep an eye on the new hotline and see what it can do once it shakes out a bit.

 

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Divisions in the Mental Health Community

September 4, 2022

It’s sad when communities that ought to work together for the betterment of all are divided by strife. But that’s just what has been happening in the world of mental health.

Even saying “mental health community” is controversial. There are different segments of the population who say that “mental illness” is the more accurate term. Then there are those who advocate for the term “brain illness” while advocating for adequate supports and services.

Indeed, what to advocate for is another discussion. Many people are trying to root out the stigma that goes with having a mental illness. Others say that’s a waste of time – that what is really needed is advocacy for improved treatments and more accessible services. There is, of course, the possibility that one could advocate for both, but the issue seems to be that the stop-the-stigma people are pulling focus away from those who campaign for social and political (and financial) reform. The situation seems complicated by the fact that many “It’s okay to have difficulties” promos actually promote online therapy businesses.

Then there are the different “what causes bipolar disorder?” schools of thought. For years we attributed it to a chemical imbalance – neurotransmitters such as norepinephrine, serotonin, and dopamine not performing their job properly. Now many people think it’s caused, or at least exacerbated, by something else – heredity and genetics, environmental and lifestyle issues, or some combination of them all. Treatment with psychotropic medications, which is the most common for bipolar, tends to lend credence to the neurotransmitter theory, although it’s generally accepted that we don’t have any real idea of how they work.

The drugs used to treat bipolar and other disorders such as schizophrenia are controversial too. Many people credit them with saving their lives. Some others describe them as “neurotoxins.” One typical Facebook post said, “They are powerful, toxic drugs which can cause a chemical lobotomy and terrible adverse effects such as akathisia, dyskinesia, Parkinson’s, dystonia, and many other tortuous, real effects. Many people are left on these drugs for life.” This is one of the milder posts reacting to psychotropic meds. Many also speak of withdrawal symptoms and lives ruined. They also state that Big Pharma is partly to blame: “The sale of psychiatric drugs will continue to increase and force will still be part and parcel of psychiatry….If we have hearts we will not expect psychiatry with all its terrible past of fear, force, and fraud to understand any human being or society!”

Treatment for various disorders, particularly schizophrenia, is widely debated as well. Some people are appalled by involuntary commitment or “forced hospitalization and drugging,” while others see it as a valid procedure for anosognosia (the inability to recognize that one has an illness), as this increases potential harm to self and others. “Assisted Outpatient Treatment” or AOT, a form of supervised drug administration for those who have been released from treatment facilities is gaining adherents. Lynn Nanos’s book Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry makes a strong argument for AOT.

In fact, psychiatry itself is a disputed issue, and not just by Scientologists who feel that all mental illnesses are caused by whatever it is that can supposedly be cured by their practices. (You can probably tell that I don’t give any credence to their beliefs.) But psychiatrist Dr. Thomas Szasz railed against psychiatry in books including Psychiatry: The Science of Lies and The Myth of Mental Illness. Here’s a quote from The Science of Lies:

Because there are no objective methods for detecting the presence or establishing the absence of mental diseases, and because psychiatric diagnoses are stigmatizing labels with the potential for causing far-reaching personal injury to the stigmatized person, the “mental patient’s” inability to prove his “psychiatric innocence” makes psychiatry one of the greatest dangers to liberty and responsibility in the modern world.

With divisions like these, it’s no wonder that mental illness diagnosis, treatment, and priorities are large contributors to the broken system in the United States. Is it a healthy debate? Are they irreconcilable differences? Is there something to be said on both sides? Does science back up any side or does passion prevail? And will any of these debates be resolved in the near future? I believe that until the community gets together on a lot of these issues, not much will get done that will truly help sufferers.

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Why Can’t I Sleep? Why Can’t I Wake Up?

August 28, 2022
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Often in the past, I went to bed at my usual time but woke up at 4:45 a.m. and couldn’t get back to sleep, no matter what. It was like I had a hamster on a wheel inside my brain.

Other nights I would go to bed early and couldn’t get to sleep for hours. I tried reading, but sometimes I read till 2:00 a.m. with no sleep in sight. (I know you’re not supposed to read when you want to get to sleep because it activates your brain, but it’s been my nighttime habit for decades. When I find that I am reading the same paragraph twice, I know it’s time to knock off and fire up the CPAP machine.)

Then again there are days when I feel the need to nap in the early afternoon. I try to resist, but if I give in, there are no refreshing catnaps for me. I’m down for two and a half hours typically. Then the whole sleep-wake cycle gets off course.

And when I’m in the middle of a depressive episode, I’ve been known to stay awake all night, obsessing and catastrophizing. There are also days I can’t get out of bed in the morning, or all day in some cases, though I don’t usually sleep well after them.

What is it with all the sleep disturbances? Well, I have bipolar 2, so that may have something to do with it. An article published by the National Institutes of Health (NIH) says, “Sleep disturbance is a core symptom of bipolar disorder. The diagnostic criteria indicate that during manic episodes there may be a reduced need for sleep and during episodes of depression, insomnia or hypersomnia can be experienced nearly every day.” They also note that insomnia and hypersomnia are early warning signs, or “prodromes,” of a bipolar episode occurring. In fact, sleep disturbance is the number one prodrome for mania, and is recognized by approximately 80% of those suffering from it as an indication of an impending episode.

Webmd discusses a number of ways that bipolar disorder is associated with poor sleep: either insomnia or hypersomnia (over-sleeping); decreased need for sleep; a circadian rhythm sleep disorder; REM sleep abnormalities which can affect dreaming; and co-ocurring sleep apnea (around a third of people with bipolar also have sleep apnea, which is associated with excessive daytime sleepiness and fatigue). Bipolar meds have also been known to affect sleep-wake patterns, as well as co-occurring substance abuse disorders.

What are the consequences? Sleep deprivation has demonstrated detrimental effects on cognitive functioning, particularly in teens and young adults. This has been observed in performing psychomotor vigilance tasks, working memory tasks, and cognitive processing tasks. No wonder a series of sleepless nights can result in a foggy or fuzzy-headed feeling!

Unfortunately, the advice given for how to counter the effects of sleep disturbance in bipolar disorder is almost indistinguishable from the advice given to the general population, such as incrementally moving bedtime and waking time until the desired period of sleep is reached; and not using electronics such as computers, cellphones, and TVs near bedtime. Some preventives that have worked with bipolar patients have included bright light therapy in the morning and the use at bedtime of supplements containing the naturally occurring hormone melatonin that the body releases in response to darkness.

My own experiences with sleep deprivation and bipolar disorder have been a mixed bag. For many years before I was diagnosed, I was subject to the difficulties caused by shift work, either third or second shift. (When I was on second shift, we sometimes extended our sleepless periods by playing cards or midnight miniature golf after the shift was over.) Third-shift work made me too tired to drive safely, especially if I was also working first shift the next day, which sometimes happened. My husband pitched in and picked me up on those days. My friends knew never to call me before noon.

For a while I took a prescribed sleep aid, but sometime during the last year realized that as my sleep-wake cycle was regulating to a more “normal” pattern, and that the sleep I got without the meds was more refreshing and conducive to clear thought in the morning. So I quit taking it, with the approval of my psychiatrist. Even though I work at home and make my own hours, my work schedule has become predictable as well. Now I wake around 6:00 or 7:00 a.m., check my emails and timeline, have some breakfast and start my work (when I have some). I break for lunch, then resume work in the early afternoon. (And pray I don’t get any more work that day, as sometimes happens.)

As for getting to sleep, it’s usually not a problem (except when it is). Any more, I take my nighttime meds, read for about 30 minutes, and drift off to sleep normally. I usually only need a nap if extra work requires that I stay up late in the evening or get up very early in the morning.

So, does “Sleep, that knits up the ravelled sleave of care,” as Shakespeare described it, exist for people with bipolar disorder? I’d say, not for everyone, but when it does, it’s always welcome. We all have our various sorts of “ravelled sleaves” that need tending to.

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Was My Anger Really Grief?

August 21, 2022

I had a right to be angry. I had been gaslighted. I had suffered emotional and verbal abuse.

He told me that when I couldn’t answer his accusations, he wanted to kick me. He made up an obscene song as a “tribute” to me and gleefully sang it to his friends. He said that when I wanted to use the bathroom with the door closed, it was a sign that I wasn’t “open enough.” Once he left me to sleep in the car on the streets of Buffalo while he went to a party. He asked me what I would have done if he were not “supporting” me. When I made a mistake with some guests, he said I had “besmirched his honor.” When I told him the singers I listened to were popular, he replied, “Eat shit. Twenty million flies can’t be wrong.” He started an affair with my best friend and invited her into our bed.

When I got him to go to couples counseling, he asked me if I was sure I wanted to, because he and the therapist could have me hospitalized. I retreated into self-harm and self-medication with alcohol.

I lived with this for a year with no way of escape except to a separate room in the house, which I began to pay him rent for. My parents came to town for my college graduation and refused to come into his house.

He never hit me. I always swore I would never stay with a man who hit me, no second chances. But he didn’t, so I stayed. When I finally left, while he was at work, he threatened to call the police on me in case I stole any of his belongings.

When I left, I swore I didn’t feel any anger. Denial and numbness were my reactions at that point. A little later, when my feelings started to return, I had minor, ineffectual revenge fantasies, none of which I ever carried out. I started reading about battered women, learned helplessness, and even brainwashing, trying to get a handle on what had happened and why I had stayed as long as I did.

I was clinically depressed, of course (not yet diagnosed as bipolar). And this was back in the days when the standard definition of depression was “anger turned inward.” So, in effect, the mental health community was blaming me for my own anger and depression. I didn’t know enough to be angry about that, either.

I’ve carried that anger with me ever since, for decades. I’ve gotten past most parts of it, but it still haunts me from time to time. I have dreams and flashbacks, which led one therapist to say that I had PTSD. I didn’t believe it at the time, but now I wonder.

Recently, I’ve done some reading on bipolar anger. Among the ways that it affects you, I learned, are friends avoiding you, family not wanting to have meaningful discussions with you, and receiving reprimands at work. I’ve experienced all of those. The sources say that bipolar anger can manifest as anything from irritability to rage. I’ve experienced those too. My rage came when I finally realized that the abuse never should have happened, and that my abuser would never feel a speck of remorse for what he’d done.

A lot of the anger was kept brewing inside me. I’d like to think that I didn’t let it show, but I know I did. It would come out unexpectedly as sarcastic comments that drove people away, for example, and when I was in one of my longest and deepest depressive episodes, as irrational anger at my husband. I remember one particular time when I yelled at him and called him a racist, which he certainly isn’t.

Most of what I’ve read to do about bipolar anger boils down to anger management: avoid your triggers, take your meds, keep stress in check, and talk with a therapist. I’ve never gone through anger management therapy, but I’m not sure if it would work under my particular circumstances. I’ve taken all those steps just dealing with my bipolar disorder, anyway.

Then recently, I saw a meme on Facebook credited to Minds Journal that said, “I sat with my anger long enough, until she told me her real name was grief.” That started me thinking. What if my anger was really grief? I had lived so long with the anger. Was I unable to recognize its true nature?

Examining what happened and my reactions, I have to say that it’s likely. I actually have plenty of reasons for grief – that I was so naive, that my first really significant love relationship was so abusive, that it took me so long to realize it, that it had affected my relationship with my parents, and that the relationship I had been so invested in was based on nothing.

Psychiatrist Elisabeth Kubler-Ross is deservedly famous for her paradigm of the Five Stages of Grief – denial, anger, bargaining, depression, and acceptance. I’ve sat with denial, anger, and depression for a long time. If I’m honest, there was probably some bargaining in there too, which I understand stems from guilt and shame. If only I’d been a better judge of people; if only I’d gotten out sooner; if only I’d never done any of the things I did, from hooking up with him in the first place to letting him control both my feelings and behavior. (And yes, I gave him control. I didn’t stand up for myself. At the time, I didn’t know how, or even that I should.)

So, am I now sitting with my grief? I can’t say that I’ve reached the stage of acceptance. But I’m willing to own my grief and let go of my anger. Maybe in time, I’ll get to acceptance.

This post originally appeared on The Mighty (themighty.com).

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John Oliver Takes on the U.S. Mental Health Crisis

August 14, 2022

You’ve no doubt heard that the mental health care system in the U.S. is broken. You’ve probably experienced that for yourself. But have you heard what John Oliver had to say about it? On August 1, on Oliver’s Last Week Tonight program, the comedian/commentator devoted a full 25 minutes to examining the flaws that plague mental health care.

During the broadcast, Oliver presented appalling statistics (some of which even I had never heard before) and clips of interviews with participants in the mental health system, including people who have been affected by it, practitioners, and insurance executives. With his trademark sardonic humor, exasperated outrage, and comic zingers, Oliver deftly skewered the insurance industry and remote mental health companies, among other targets. It was an enlightening and satisfying performance.

Here are some of the highlights.

Oliver started with a flashback from the 1950s of women entering a beauty parlor (!) to receive makeovers that were supposed to solve their mental problems. “I don’t know what’s more alarming there — nurses being forced to take on the skills of a Sephora brand ambassador or the fact that ‘can make-up cure sad?’” Then he tackled the PSA on mental illness stigma featuring Harrison Ford, which was designed to make discussions of mental health “cool and trendy” and dissed the gallbladder for some reason.

Next, he went through some stats on why such a PSA was necessary – the lack of access to mental health care, particularly since “for every ten clinicians entering work in mental health clinics there, 13 leave. And if we continue at that rate, one day, we’re going to wind up with negative therapists.”

Oliver noted that nearly 85% of all psychologists are white, and ran an interview with an African-American couple. The man said that he “couldn’t find a black man to save my life,” which Oliver said was “something you expect to hear about the crowd on January 6th, or all ten seasons of “Friends.” He also played a video of another man who couldn’t find treatment. His friends said, “Everything will be fine tomorrow. Suck it up, buttercup,” a response that to him meant “a 12-pack of something or a bottle of something.”

Oliver also reported on the fact that hospital ERs are overrun, with one interviewee suffering a stay of 27 days there, and then receiving advice to go from the ER to a doctor. Oliver noted that 27 days in an ER is “not calming” and that seeking help is serious, that “you can’t just put off mental healthcare indefinitely. It’s not a check engine light.”

Some of Oliver’s most biting comments were reserved for AI programs that claim to counsel users on mental health issues. One of the free services was Woebot – “Bot as in robot and ‘woe’ as in ‘Whoa, that’s a dumb name.'” Their mascot is a robot waving a wrench (“He’s going to fix my brain with that!”). And when questioned about anxiety and lack of sleep, which affect 18% of people, the AI responded, “I can’t wait to hop into my jammies later.” Oliver also reported that when Woebot was confronted by the BBC with a test case of a 12-year-old reporting sexual abuse, it replied with the comment that it “shows me how much you care about connection, and that’s really kind of beautiful.”

He did note that teletherapy is valuable and it can fill some the gaps in care. But Oliver also highlighted investigations of sites that were “pill mills,” one of which claimed that 95% percent of their users “should get a scrip.” Noting that it was not 100%, Oliver compared it to the saying, “It’s not arson if you only burn most of a building down.”

Regarding lack of accessibility and insurance parity despite laws requiring it, the program noted that the issue was complicated by finding a provider who will take your insurance. The Labor Department has investigated only 74 claims against insurance companies in the past year (but closed only 12 of the complaints) and has issued fines only 13 times since 2017.

And insurance payments are often based on their own opinions on when a treatment is “medically necessary.” Oliver likened it to an insurance company, saying, “Imagine an insurance company reversing their decision in the middle of any other serious treatment. ‘Hey, we love how this heart surgery is going, just popping in to say, it’s done. Yeah, it’s done now. Hit the showers, everyone, great job. Don’t bother closing anything up, that’s not medically necessary.’” California, Oliver noted, requires insurers to “base medical necessity determinations on current, generally accepted standards of mental health care, instead of just making up the criteria for themselves.”

Insurance companies also have “ghost networks” that offer patients providers who aren’t taking new patients or even practitioners who have died. Phone numbers can be wrong too, some of them reaching “jewelry stores and boutiques,” which Oliver admitted that, “to be fair, if you’re a woman in the 1950s, a boutique and a jewelry store is apparently the only mental health care you need.” 

The segment ended with the statement and plea, “It can’t be the case that, when people ask for help, our only option is to tell them to ‘suck it up, buttercup.’”

We can only hope that Last Week Tonight‘s take on the U.S. mental health care system will reach its literally millions of viewers with the news that something needs to be done – and soon. You can see the whole segment at https://www.youtube.com/watch?v=jtIZZs-GAOA or on John Oliver’s official website, https://iamjohnoliver.com/. It’s definitely worth a visit.

This post originally appeared on The Mighty (themighty.com).

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