Bipolar 2 From Inside and Out

Posts tagged ‘mental illness’

Are Holistic Approaches to Mental Health Useful?

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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Divisions in the Mental Health Community

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.

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

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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What If My Symptoms Come Back?

It’s inevitable. Once you’ve dealt with a mental illness, you’re afraid it will come roaring back, even if you’ve been stable for a long time. You wonder if your medications will stop working. You dread “breakthrough” episodes that will put you back in the same awful space you thought you had escaped from. You have flashbacks or dreams that take you to places you thought you had left far behind. You imagine you hear someone call your name and wonder if it’s a symptom. Sometimes, something you never thought of as a trigger will catch you by surprise and send you right back to the dark place, the anxious place, the out-of-control place.

Those fears are not unwarranted. All of those things could happen. For many people, they do. For most, the thoughts pop up at odd moments, even when you’re doing well. They’re unpredictable. That’s part of what makes them so scary – the knowledge that you have no control over these thoughts of recurrence.

It certainly happens to me. I obsess over my own thoughts. I fear dropping back into depression. I wonder if I’m exhibiting hypomanic behavior without realizing it. I overanalyze nearly every feeling I have if it has the slightest hint of a symptom of bipolar about it.

That’s when it’s good to have a strong support system – a person or persons you can talk to and check in with. Someone who recognizes your baseline behavior and when you start to depart from it. Someone who understands your disorder and what the symptoms might be.

I’m fortunate to have a support system in place, though it consists of only two or three people at this point – my therapist, my husband, and to some degree my prescribing psychiatrist. I see my psychiatrist only four times per year for med checks, but I can tell him when I think I’m experiencing symptoms and ask whether he thinks it’s something that warrants a change in meds.

I see my therapist approximately once a month, and she has a better handle on intrusive thoughts and whether they are irrational or not. She provides a “sanity check” for me. Most of the time, she reassures me that they’re normal (or nearly so). Sometimes, she tells me if I should bring them up with my psychiatrist the next time I see him. Mostly, she listens, which is what I think a good therapist does.

The mainstay of my support system, however, is my husband. He understands bipolar disorder from years of living with me and living through my mood swings. He knows my baseline level of behavior and when I begin to depart from it. For example, he can recognize when I am starting to get hypomanic and suggest to me that I might be beginning an episode. Or, if I feel like I might be getting manicky, I can ask him if he sees the symptoms in me or not. If I’m having delusions that other cars are swerving into my lane, he can suggest I take an anti-anxiety med.

Four former members of my support system are no longer there, two because they recognized my symptoms increasing and were not able to deal with them, and two lost to death. Even though my husband and my mental health providers help keep me on an even keel, I do miss the additional input. I need reassurance when I am doing well and help when I begin to veer off course.

This month, however, I am doing better. I just postponed my therapist appointment because I have no pressing issues that need addressing this month. May it stay that way.

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Mental Health and Awareness Campaigns

There certainly are a lot of mental health campaigns going on. There’s one or more in every month. Most of these are “awareness” days, which is a little bit confusing. People who already have the assorted disorders are already aware of them, as are probably their families and perhaps their friends.

When it comes to awareness, though, most non-affected people (or people who don’t realize they are affected) find out about them through TV commercials – during Men’s Health Month, in ads for medications, or from organizations like the Wounded Warriors Project. There may be local events, too, but I haven’t seen any in my area. I don’t even see much of anything on my Facebook timeline, even though my friends list contains a lot of people with mental health concerns. I note that there isn’t a Women’s Mental Health Month, even though most people who receive treatment for mental illnesses are women. (There are many, many special days not related to mental health that I knew nothing of until I started to research this post, such as World Animal Road Accident Awareness Day (though I have some experience with this phenomenon), Insect Repellent Awareness Day, and even Spider-Man Day.)

Here’s what I did find.

January

Mental Wellness Month

February

Children’s Mental Health Week

International Boost Self-Esteem Month

National School Counseling Week

National Eating Disorders Week

March

Self-Harm Awareness Month

Brain Injury Awareness Month

World Bipolar Day (which I had never heard of, despite being bipolar myself)

April

National Stress Awareness Month

National Counseling Awareness Month

May

Mental Health Awareness Month

National Maternal Depression Month

National Borderline Personality Disorder Awareness Month

Tourette Awareness Month (May into June)

Children’s Mental Health Awareness Week

June

PTSD Awareness Month

Men’s Mental Health Month

July

International Self-Care Day

BIPOC (or Minority) Mental Health Month

August

National Grief Awareness Day

September

World Suicide Prevention Day (and National Week and Month)

October

World Mental Health Day

National Depression and Mental Health Screening Month

ADHD Awareness Week

OCD Awareness Week

November

National Family Caregivers Month

International Stress Awareness Week

International Survivors of Suicide Day

December

International Day of Persons With Disabilities

National Stress-Free Family Holidays Month

So, how are people made aware of most of these various disorders? By people wearing different colors of ribbons that correspond to them. The idea, I guess, is to prompt people to ask, “What is that silver ribbon for?” and to be told, “It’s for Borderline Personality Disorder Awareness.” If the person inquires further, it’s a chance to educate them, but most people don’t ask at all or ask only what the color means.

There are only a couple of colored ribbons that everyone knows the meaning of – yellow and pink. The yellow ribbon campaign was started in 1979 to show support for persons held hostage in Iran, but now means support for the Armed Forces. The pink ribbon for the Breast Cancer Awareness campaign started in 1991 and is probably the most successful ribbon awareness symbol there is.

Here are the colors of various ribbons and what mental health concerns they are intended to promote awareness of.

Peach – Invisible Illness

Yellow – Suicide Prevention

Periwinkle blue – Anorexia Nervosa

Teal – Agoraphobia, Anxiety Disorders, Dissociative Identity Disorder, OCD, Tourette Syndrome, Stress Disorders, Social Anxiety Disorder, PTSD, Panic Disorder

Green – Mental Health, Bipolar Disorder, Major Depressive Disorder

Lime green – Mood Disorders, Psychosis, Depression, Mental Illness, Postpartum Depression, Childhood Depression, Maternal Mental Health

Purple – Binge Eating Disorder, Bulimia Nervosa, Eating Disorders, Caregiver Appreciation

Purple and Teal – Suicide, Survivors of Suicide, Family Members of Suicide

Gray – Personality Disorders

Orange – ADHD, ADD, Self-Harm

Silver – Borderline Personality Disorder

So now you know what color ribbon to wear and what month to wear it in. I hope that if you do, people will ask about it and allow you to expand on what it means. I don’t expect that, however. Almost no one has ever asked me about my semicolon tattoo for Suicide Prevention and Awareness. (I occasionally get to explain it if I point it out to them.) Probably the most effective reminders are t-shirts that identify the condition and maybe the awareness month date, but those are harder to come by, except for Break the Stigma and Mental Health Matters ones. (I do have a t-shirt and a hoodie for The Mighty, a website for mental illness and other chronic illnesses.)

Whatever you do to promote mental health and awareness of mental illnesses, though, keep trying. We need to get the word out!

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Dissociative Identity Disorder: The Basics

I had a friend, Hal, who had Dissociative Identity Disorder (DID). I never met any of his alters until once we went to the corner store. He giggled. He grabbed numerous bags of chips and other snacks. When we got home, I mentioned this to him, and he said, “You just met Julie. She’s a teenage girl.” Later, I met an alter known only as The Angry Man, which is part of why we’re no longer friends.

DID, as its name says, is a dissociative disorder, one of three different kinds – Dissociative Amnesia, Depersonalization Disorder, and Dissociative Identity Disorder. DID is the most severe of the three conditions. All involve symptoms such as memory loss, “out of body” experiences, emotional numbness, and lack of self-identity. DID is thought to be a reaction to the trauma of extreme physical, emotional, and sexual abuse that occurs usually before the age of six.

Some trace the history of DID to 1584, when the records of a French woman who was exorcised recounted symptoms that today would very likely be attributed to DID. It’s likely that more cases that were actually DID have over the years been attributed to demonic possession. Later, it was seen as a form of hysteria, another disorder with dissociative symptoms.

DID really hit the big time in the 1950s through the 1970s, when the books The Three Faces of Eve and Sybil became best-sellers and were made into movies. The books, written by Corbett H. Thigpen and Flora Rheta Schreiber, respectively, were accounts from psychoanalysts about the diagnosis and treatment of DID, which was at the time called Multiple Personality Syndrome, since the disorder was notable for “alters,” or separate personalities that appeared while the primary personality was unaware that they existed. “Eve” had three alters, while “Sybil” had 16.

Since that time, both of those cases have been controversial, with exposes purporting to reveal that neither Eve nor Sybil really had multiple personalities. The theories were that either the subjects were faking the disorder, or that the doctors suggested to them via leading questions and hypnosis that they had multiple personalities. (This was related to the “repressed memory” controversy in the 1980s to 1990s, which raised many of the same issues. Healthline recently reported that “the majority of practicing psychologists, researchers, and other experts in the field question the whole concept of repressed memories. Even Freud later discovered many of the things his clients ‘remembered’ during psychoanalysis sessions weren’t real memories.”)

Still, DID is real enough to have made it into the DSM. (We should remember, though, that diagnoses of “illnesses” such as homosexuality were present in earlier editions but later removed.) There are therapists who treat it with Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), medications, Eye Movement Desensitization and Reprocessing (EMDR), and/or hypnosis, which started to be a treatment in the 1830s and is said to lead to a rapid recovery. Although hypnosis for diagnosis or treatment of DID is still controversial, it may be useful for reintegrating the alters back into the primary personality.

DID has also been used as a potential criminal defense in legal cases over the past several decades, in cases that range from drunk driving to murder. It has been used to support a plea of “Not Guilty by Reason of Insanity” (NGRI). This defense is used in less than 1% of felony cases and is successful in only a fraction of them. The theory that a crime was committed not by the primary personality but by one of the alters has not always proved persuasive. It’s difficult to prove, for one thing, and there are professional witnesses and psychologists who testify that either DID does not exist or that even if an alter committed the crime, the primary person is legally responsible for it. The DID defense did work in 1977 for Billy Milligan, who was said to have 24 separate personalities, two of whom were claimed to be responsible for his crimes of rape.

DID is subject to a number of myths or beliefs. For example, many people believe that DID is either nonexistent or an overdiagnosed “fad” seen only in North America. Some believe that it is caused by the doctors who treat it rather than by childhood trauma, or that it is in reality the same as Borderline Personality Disorder (BPD). However, there have been neuroanatomical changes recorded by MRI in cases of DID: “The neuroanatomical evidence for the existence of DID as a genuine disorder is growing and the structural differences seen in DID patients’ brains…contribute to that growth.” So, although DID is believed by some to be nonexistent, there are studies that back up its reality.

As for me, I have experienced a few mild instances of dissociation related to my bipolar disorder, but nothing even remotely like what occurs in DID. But then, I didn’t have the childhood trauma associated with it. (During the “repressed memory” days it was said that the only truthful answer to “Have you experienced extreme childhood trauma?” is “Not that I’m aware of.”) Nonetheless, I find the subject fascinating, as well as dissociation in general. (This is not intended to diminish the experiences of people who have a dissociative disorder.) But I look forward to learning more about DID, particularly the neuroanatomical changes when they become available.

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Self Image: Who Do I Think I Am?

Self-image is a problem shared by millions of people every day. Take women, for example. They are bombarded by relentless messages that they are too fat (or too thin); too plain; with inadequately full, shiny hair; or with un-perky, non-voluptuous breasts. (Men face messages too about their lack of muscles, excess paunch, thinning hair, or short stature – but nothing like the volume (in both senses) that women receive.)

Self-image is also a big problem for people – both women and men – who live with mental illness. It’s not always physical self-image. Sometimes we get messages about how we should think and feel from all the ads on TV and in magazines and on the internet that feature happy people interacting joyfully with their friends and families. The subliminal message is that if your life isn’t like that, the advertisers’ products will make it so that it is.

Of course, nowadays there are also ads that feature depressed or bipolar people, but they end the same way. Get online help or psychotropic meds and you’ll turn into one of those happy, joyful people living life to the fullest. For many of us, that’s not the way it is. There are treatment-resistant disorders, for example, and complex problems like OCD, PTSD, and schizophrenia that aren’t mentioned at all. (PTSD is sometimes addressed in the context of veterans helping one another, which is good, but the ads for this usually offer moral and financial support, rather than a more trauma-conscious solution.)

I’ve been through my own battles with self-image, and not all of them related to things I saw in the mirror. When I was a child, I endured bullying that made me feel unworthy and unable to fit in. As a teen, I saw myself as plain and unlovable. I even doubted my parents’ abundant love, thinking they loved me only because, as I was their daughter, they had to. Later, my self-image consisted of being a depressed person. That’s who I was and all I could see of myself.

When I was working, I saw myself as an imposter. I had a “respectable business lady disguise” that I could put on when desperately needed, but I knew it wasn’t accurate. Then, when I lost my job, I saw myself as a failure.

Still later, after my most severe breakdown, I defined myself as my husband’s “sick, crazy, crippled wife.” I know those are terms we’re not supposed to use, but that’s what my brain was telling me. (The “crippled” part was because I had mobility issues that necessitated two operations on my back, and thereafter used a cane.) I used it as an excuse not to go places, see people, or do things. Actually, my husband used it as an excuse too, though he didn’t phrase it that way. (Now he doesn’t.)

In short, my self-image was someone who was broken – and not “in the best way possible,” as Jenny Lawson says.

Years of therapy and medication have largely gotten me to the point where my negative self-images are no longer constantly haunting me. They still rear their ugly heads on occasion, but now they aren’t all-pervasive. My husband helps too. He says, based on photos, that I was cute when I was in high school and he would have dated me. (I still have my doubts about that.)

What I’m getting at is that a person’s self-image can and does change over time. I think I am more accurate now in thinking I am no longer cute, except maybe when I smile; still mobility-challenged but not so self-conscious about it; and, I would have to say, a “recovering” bipolar person.

We’re getting to the point where we don’t all or always think that what we see in the mirror reflects our worth or our true self. We’re learning not to believe our own or others’ negative messages about our appearance – though there is certainly still a long way to go.

What I’m not sure of is that we’re making much headway on redefining our self-images regarding our mental health or lack thereof. Despite all the positive affirmations we see and hear in so many memes and elsewhere, do they really sink in and change our thinking? Or is the only way to do that bound up in time, treatment, and the support of our family and friends? I’m just glad that it is possible to change, whatever the mechanism. My life is much more settled and happier now that I no longer see or define myself as I once did. That’s something I want to hang on to.

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How Do We Talk About Mental Illness?

Language matters. What we call things matters. Does language shape thought or does thought shape language? Either way, both are important when it comes to brains.

The latest discussion in the debates over language is what to call mental illness (which is what I’m used to saying). Many of the words and phrases that have been in use for years no longer seem quite accurate.

Take mental health, for example. When policymakers talk about subjects like mass violence, they often speak of “mental health issues” and what should be done about them. The thing is, if someone is mentally healthy, nothing really needs to be done about that. But mental illness is a term that doesn’t sound so easily addressed. Policymakers are notorious for using language that soft-pedals actual problems. Not to mention the fact that when they talk about mental health, they’re usually talking about addiction issues or homelessness (though they still aren’t particularly effective in addressing those either).

Mental health is still a better term than “behavioral health.” I remember when community treatment centers and insurance programs were called behavioral health plans. Again, there was a lot of lumping psychiatric illnesses and addiction together. It was also wildly inaccurate. It was not the behavior that was unhealthy (the way smoking is). Behavior may have looked like the problem, but it wasn’t the cause. Something to do with thought or the brain was. Also, there was no equivalent term “behavioral illness.” That wouldn’t even make sense.

So. We have mental illness as the term currently most used, with SMI (Serious Mental Illness) often used for disorders like bipolar and schizophrenia. Lately, though, there has been a push to replace those terms with “brain illness.” (The companion term is “brain health.”) It hasn’t caught on yet with the general public, though it’s gaining some traction among practitioners, advocates, and those affected by assorted conditions. I’ve heard some people are frustrated that it hasn’t caught on more widely already. They feel the process is going too slowly.

Calling schizophrenia, bipolar, and other disorders “brain illnesses” certainly makes one sit up and take notice more than “behavioral health.” And it jibes with the notion that these mental disorders (there’s another term) are caused by something going wrong in the brain. This is not without controversy, however. There are those who think that referring to depression or bipolar disorder as “chemical imbalances” in the brain or faulty neurotransmitters (or their receptors) is inaccurate. There are various theories as to what causes these conditions, all the way from childhood trauma to gut bacteria. To me, the most likely scenario is that there’s a combination of brain-related factors and environmental influences at work here. Nature and nurture, in other words.

Brain illness is certainly an attention-getting term. That should make it more likely to catch on with policymakers, but I suspect it won’t. It’s not a comfortable concept and there are no easy-sounding solutions to it. I doubt that it will catch on with the general public either. We still haven’t gotten people to move away from crazy, insane, maniac, psycho, or even nuts and stop throwing them around indiscriminately. Hell, we haven’t even been able to convince people that psychiatric institutions don’t use straightjackets anymore.

Does “brain illness” make these conditions sound more treatable? Is it likely to increase compassion for those who have them? Is it likely to make any kind of a difference? I don’t think we’ll really know until it penetrates the consciousness of the person-on-the-street. And I have my doubts about when or if that might happen.

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Garden-Variety Jerks

I see a lot of questions of this kind: My neighbor/sister/friend does this [unpleasant behavior]. Is this caused by his/her bipolar disorder?

There certainly are behaviors of people with bipolar disorder that are unpleasant to those surrounding them. Not taking showers for a week when the person is depressed is one of them. Another, when the person is in the grip of mania, is having sex outside a relationship. Being unable to leave the house is a bipolar-related behavior. So is gambling away your savings. So is standing you up or ghosting you. And blaming themselves for everything. And taking on too many projects and finishing none of them. Talking too fast or too slowly.

Playing their music too loud or parking across your driveway is not a bipolar-related behavior. Neither is littering. Or insisting that you take the garbage out. Or yelling when they are angry. Or becoming huffy when you criticize them.

There are some behaviors that may or may not be bipolar-related – for example, talking about themselves too much. This could be an indication that the person is depressed and brooding (if the talk is about how worthless they are) or manic and aggrandizing (if the talk is about how great they are). Or it may just be that the person has low or high self-esteem that doesn’t rise to the level of pathology. Feeling that everyone is picking on them could go either way. So could taking offense at every little remark. It’s sometimes hard to tell, particularly if you’re not a psychologist.

It’s more than a little weird that people are willing to attribute all kinds of bad behavior to mental illness. But think of all the racist haters and killers that are assumed to be mentally ill. While some may be, it’s an automatic and often unwarranted assumption. It takes away from the attention that ought to be given to real mental disorders and it perpetuates the stigma associated with mental illness. Or it assumes that racism and hatred are mental illnesses. These are extreme cases, of course.

Sometimes bad behavior is not due to mental illness at all. Sometimes what you’re dealing with is a garden-variety jerk. To address the picture above, it’s not pathology to be messy and it’s not a sign of mental illness to be mad at a roommate for being messy.

There’s not a lot you can do if the behavior you object to is caused by mental illness. You may have to simply understand or let the annoyance go. The person may resent that you assume their behavior is a sign of mental illness, even if it is. And about all you can do in that case is help the person get help if you can.

When you’re dealing with a garden-variety jerk, there are other sorts of remedies you can apply. You can call the police on the neighbor with the loud stereo. You can ask the messy roommate to straighten up or leave. You can set boundaries of what you will and won’t put up with and enforce those boundaries firmly but fairly when they are violated.

Of course, there’s always the possibility that the person in question has a mental illness and is also a jerk. If you can figure out what to do in those cases, please let me know.

I’m not saying that mental illness should be an excuse for bad behavior or absolve a person of the consequences of their actions. I am saying that it’s easy to assume that all bad behavior is due to mental illness, just as much as it’s easy to assume that all bad behavior comes from being a jerk, or worse.

In a lot of cases, you simply have to live with it.

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The Self-Esteem Dilemma

I’ve heard that narcissists (and multiple murderers) have too-high self-esteem. I’ve also heard that they have low self-esteem. Which assertion is right? Surely they can’t both be!

Self-esteem became a big topic of conversation in the 1980s. That’s when self-esteem programs for children were beginning to be taught in schools and preschools. There were many questions about them, some of which I asked when assigning a writer to a story about them. (I was an editor for a publication for childcare workers and daycare owners at the time.) Why do children need self-esteem programs? Doesn’t daily living foster self-esteem? What can self-esteem programs do that parents and teachers can’t or don’t? The writer seemed taken aback, but bravely tackled all those questions and wrote a fine article on the subject.

Later, the self-esteem movement came into disrepute and was the subject of much mocking and more authentic criticism. Chief among the things detractors made fun of were “participation trophies” given to every participant in a game or sport, spelling bee, or whatever other sort of competition. Complaints included that this negated the idea of competition altogether, falsely inflated children’s sense of accomplishment, shortchanged children who had truly excelled, and was a touchy-feely practice that had no place in the realm of sports or other competitive areas.

It was also thought that self-esteem programs were teaching the wrong lesson. Instead of learning that effort doesn’t always achieve the desired results, children were learning that everyone was as good as everyone else, which seemed like a mistake to some. Self-esteem programs were also said to lead children to the idea that the world was a kindly place where they would be rewarded just for existing. Instead, they should “toughen up” and learn that the world would deal them harsh blows at times and that they needed to be ready to cope with them. Debate continued about when and where such a lesson should be taught and even if it should be taught at all.

How does this relate to the aforementioned narcissists and toxic people? The two theories about their level of self-esteem seem contradictory and counterintuitive. Do they have low self-esteem? It doesn’t seem like it, the way they take control over others’ lives and manipulate them. Do they have high self-esteem? This sounds a little more plausible.

Reconciling the two theories is problematic. On the one hand, these people’s self-esteem seems to be too great, so they feel they are special and entitled to control other people who aren’t up to the same standard. On the other, their self-esteem might be too low, driving them to overcompensate for their lack by acting powerful and controlling others.

It seems unlikely that both of these mechanisms could apply to a single person. How could they feel genuinely powerful and compensate for being less powerful at the same time?

But, at its heart, true, healthy self-esteem isn’t about power. It’s about loving, accepting, and appreciating yourself for the good qualities that you do have. It’s about recognizing that your place in life is to be neither a doormat nor an idol. It’s about having confidence in yourself that you can face obstacles – though not conquering every obstacle – but knowing your limitations.

Does life teach self-esteem? It can, certainly, if a child is raised in a supportive, encouraging environment; if the child learns that both effort and accomplishment are possible; if the child has role models for self-esteem; and if good lessons about self-worth are taught in the home and at school.

Of course, we know that not all children are raised in such an ideal environment. Probably far too few are. Or children receive mixed messages about self-esteem from parents, schools, religion, and other places where they get training for life events: not to be unrealistically proud but to be proud of achievements; to be humble or to be confident; to be assertive or to obey authority; to share with others or to know what’s theirs and defend it; to cooperate or to take the lead.

Self-esteem is particularly difficult for those of us with brain illnesses or psychological disorders. We may feel broken, unsure of ourselves, and clueless about where we fit into society. In the grip of mania, we can feel ten feet tall and bulletproof. When we are depressed, we can feel worthless. In bipolar disorder, in particular, the two states can be encompassed in a single individual at different times.

But this is not to say that people with psychological challenges are all narcissists. Far from it. I would say that in every person, there are varying degrees of longing to have control and desire to relinquish control. It’s achieving a healthy balance of these two things that’s the real trick.

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