Suicide – An Overview

Suicide is a huge issue that is extremely stigmatized and ignored. It ranks among the 10 leading causes of death in most Western countries – and the number of suicides is likely higher than estimated since many deaths are ruled “accidental” rather than being given the stigmatized label of “suicide.”

Suicide is a huge tragedy. Many people label it as “selfish” – but those people don’t understand that when someone is in the state of mind in which they would commit suicide, they are severely mentally ill; they think life is hopeless and see no way out; they often think that people will be happier and more successful without the burden of knowing the suicidal individual. Another tragedy is that many “survivors of suicide” – that is the families, friends, and even acquaintances of suicide victims – are often traumatized and blame themselves for not noticing the signs; not being there when they were needed the most.

Although in the past people who attempted / completed suicide were between the ages of 25 and 45, there is an appalling trend of teenagers and elderly men who are now killing themselves. Women are more likely to attempt suicide, and men are more likely to complete suicide. This is because, at least up until now, women tend to use “less messy” or “romantic” – and therefore less dangerous – ways to kill themselves. Men, on the other hand, generally choose guns. However, from reading the news, I personally believe that the number of women who use guns in suicide attempts are dramatically increasing.

At this time, the highest rate of suicide completion is elderly males who are widowed or divorced or have terminal illnesses. This may be because men of that era were taught to hold in their emotions rather than express them. Thus, they are less likely to seek help when suicidal thoughts arise.

As much as 90% of individuals who attempt/complete suicide are mentally ill at the time. Major depression is the highest predictor of suicidal ideation, but people with impulsivity disorders – such as borderline personality disorder or bipolar disorder – have a higher rate of attempt/completion.

The rate of suicide attempt/completion for people between the ages of 15-24 has tripled between the 1950s and 1980s. Suicide is the third most common cause of death (after accidents and homicide) of people between the ages of 15-19. It is unclear why the rates of suicide has increased in teens and young adults, but it may be because of increased drug and alcohol use, and perhaps use of antidepressants which often increase suicidal ideation in teens. Young adults in college seem particularly susceptible – this seems to be due to academic pressure, though those who commit suicide are generally doing quite well academically; therefore it is thought that the anxiety of perfectionism or fear of disappointment may be a leading cause. Teen suicide hotlines have become increasingly popular in the past years. I volunteer at one called TXT4LIFE, in which a teen or young adult can text the word “LIFE” to 61222 and have a text conversation with someone who will hopefully deescalate them. There are also websites, including this one, that provide further suicide hotlines for teens.

Many people who commit suicide are ambivalent about wanting to die – this is likely why they call suicide hotlines. Although, I must admit, even indirectly insinuating that a texter might feel ambivalent in my volunteer work only encourages them to say how much they really want to kill themselves.

There are three basic ideation types that occur in people who attempt suicide. Most people are ambivalent. These are often women or teens who are attempting to send a message about their state of mind. These people generally use a non-lethal means of suicide attempt – such as ingesting a small amount of pills, a bottle of not-so-dangerous pills, or minor cutting. It is thought that Sylvia Plath, who died by sticking her head in the oven, had expected a friend to stop by the house shortly after she attempted suicide; thus saving her from an actual death. A small minority of individuals seem to have no ambivalence at all, and tend to use “messy” paths to suicide, such as guns or jumping. The third group leaves it up to fate. The figure “If I die, I’m meant to die. If I live, I’m meant to live. These people generally use more dangerous means to suicide like ingestion of large doses of pills or major cutting.

There is a myth that people generally do not leave hints that they are having ideation before attempting suicide. And there’s another unfortunate myth that people who threaten suicide seldom actually attempt. Both of these myths are false. Studies show that of people who committed suicide 40% made direct comments about suicide and 30% made comments about dying in the months leading up to suicide. Only 15 to 25% of people leave suicide notes, and they are often unclear as to what the reasons for suicide were.

Suicidal ideation is generally treated with mood stabilizing or antidepressant medications, therapy, and a large number of crisis hotlines. Unfortunately, there is little research to show whether these hotlines actually decrease the number of suicides. In his bestselling book Noonday Demon, Andrew Solomon even suggests that talking about suicide with the callers might increase the likelihood of suicide because it makes it seem like a viable option.

Most suicide hotlines are staffed by unprofessionals (like myself) who assess the gravity of the situation and either deescalate the individual or intervene by calling the police. I’d very much like to think these suicide hotlines are helpful. I know, at the very least, that they are help make the callers/texters feel better on an immediate basis, which makes them seem worthwhile to me.

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 7: Mood Disorders and Suicide. Abnormal Psychology, sixteenth edition (pp. 212-262). Pearson Education Inc.

Dialectical Behavioral Therapy

To supplement my post about borderline personality disorder (BPD), I’ll comment on a highly effective therapy developed especially for BPD. I, myself, have been through DBT and can attest to its wonderful results. DBT is a modified form of cognitive behavioral therapy (CBT). CBT focuses on addressing cognitive distortions (thoughts that assume negative reasons for a potentially neutral situation) and practicing changing the way you think about the situation. DBT focuses on accepting the way you think, but changing the way you react to the thoughts.

DBT was created by Marsha Linehan for patients with BPD, but is now used for many other disordered patients who suffer from suicidal ideation and self-harm. DBT teaches skills that a person can use to react healthily to difficult emotions.

A dialectic, in the DBT sense, can be represented as a see-saw of extremes, with a healthy center-point. For instance, two state-of-mind extremes include Emotion Mind and Rational Mind. Emotion Mind is when a person’s thoughts and actions are governed entirely by emotions. This could be good – such as when someone is in love – but it is often bad. Too much emotion can lead to inappropriate decisions, behaviors, and unhealthy thoughts.

On the other side of the see-saw, a person might be in Rational Mind. Although this sounds good (and can be good when you are performing highly rational tasks like solving puzzles), it is generally not good to think exclusively in rational mind because you miss emotional components of the situation. For instance, a person who is entirely in rational mind is unable to experience empathy or react appropriately to emotional situations (this is often a complaint made about people with Asperger’s syndrome).

You are somewhere between rational and emotional mind at all times. The middle of the see-saw is called Wise Mind. Here, you can express the right amount of emotion and rational thought to make a clear-headed decision. DBT recognizes that people are often at the extremes of this see-saw, and asks that you use “skills” to move yourself back into Wise Mind before making decisions (such as breaking up with your significant other or self-harming).

Almost every situation has a dialectic see-saw. And according to DBT, it is often best to keep yourself in the middle of the two extremes. The middle would be a compromise. Of course, sometimes compromise is the wrong decision to make (such as when you need to cut ties with an abusive relationship), but compromise is generally best.

Skills that DBT suggest are separated into categories of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.

Mindfulness includes: grounding yourself in a situation, for instance, recognizing where you are, what you are doing, and what is going on around you; being nonjudgmental, for instance, one of my employees assumes that when the nurses say “she is awful to work with” that they are talking about her. This is a judgmental thought. To be non-judgmental, she would have to say “well, maybe they’re not talking about me. Why am I assuming they are?”

Interpersonal effectiveness entails balancing your own needs with the needs of others, building relationships, and being in Wise Mind when approaching difficult situations.

Emotion regulation includes being mindful of what emotions you’re feeling; being aware of what you want to do – for instance isolating – and doing the opposite; doing things that make you feel good – like leisure activities – or work that makes you feel accomplished – like writing a blog post; coping ahead, for instance, if I know that I will be upset tomorrow because it’s the anniversary of my mother’s death, I can plan some distracting activities to keep myself from brooding.

Distress tolerance includes distracting yourself when you feel upset; self-soothing by taking a bath or rubbing a smooth stone; and accepting reality.

Yes, all this mindfulness stuff might sound cheesy to a lot of you, but being aware of your emotions and how you’re reacting to them is an amazing way of changing the way you behave – and changing the way you behave can eventually remove your dysfunctional thoughts, as well.

Crazy: A Father’s Search Through America’s Mental Health Madness, by Pete Earley

Crazy: A Father’s Search Through America’s Mental Health Madness,
by Pete Earley, Narrated by Michael Prichard

When Pete Earley’s son was diagnosed with schizophrenia Earley was devestated. His son’s potential career was on the line, he wasn’t willing to accept treatment, and he was generally unpredictable and very unsafe. When Earley tried to get his son into the hospital, his son was turned away because he didn’t want to be treated – and laws say that unless someone is an immediate threat to himself or others, he can not be treated involuntarily. Earley had to pretend his son was a threat to Earley’s well-being to get his son hospitalized. Then Earley went to a commitment hearing to make sure his son stayed in the hospital until he was better. Early was appalled by his son’s defense lawyer who did her best to defend Earley’s son despite his son’s clear mental illness. In her own defense, the lawyer said it was her job to defend the rights of someone who did not want to be committed. Earley’s son won the case and was released.

After this incident, Earley’s son broke into a house, peed on the carpet, turned over the all the photographs, and took a bubble bath. He was arrested and charges were filed against him by the family. Despite Earley’s pleading with the family that his son was not targeting them specifically, that he was sick, the mother felt threatened and continued to press felony charges. Earley knew that the charges would be an irremovable bar from his son’s career choice.

Because of the horrors of being unable to treat his son, and the unfairness of the charges, Earley decided to research the state of the mentally ill in the Miami jail system. There are, according to the staff psychiatrist, “a lot of people who think mentally ill people are going to get help if they are in jail. But the truth is, we don’t help many people here with their psychosis. We can’t. The first priority is making sure no one kills himself.” The psychiatrist said that the point of the prison was to dehumanize and humiliate a person. Such treatment is counter to improving anyone’s health.

The psychiatrist’s task was to try to convince the inmates to take antipsychotic medication so that they could be deemed stable enough to stand trial. Earley was shocked at the state of the prisoners. Most of them refused the medication, and were clearly psychotic. Some huddled down into corners, covered in their own body matter. Some stood motionless and unresponsive. Some harassed the guards as they walked by with strange and crude accusations. The prisoners who were on suicide watch were stuck alone in a cell with no blanket, mattress, or clothes.

Miami has high numbers of mentally ill homeless people because of the nice weather and the immigration from Cuba. It is rumored that when a law was passed allowing Cuban refugees to enter America, Fidel Castro released his mentally ill inmates and deported them all to America – they ended up in Miami.

Earley picked mentally ill inmates at “random” and decided to follow them throughout the next couple of years to watch their recidivism rate. Most people who were released were not given proper care after release. They were given some pills and sent away; not being given proper social services to help keep themselves off the streets and stable. Thus, these people ended up back in prison within months. Others were held indefinitely because they cycled from jail to a hospital, where they were stabilized and deemed ready for trial; back to the jail, where they destabilized; and then back to the hospital again.

Earely wasn’t only out to castigate the Miami prison system, he also focused on what the system was trying to do to make the situation better for the prisoners. He discussed the CIT program, which is meant to train officers to respond with compassion to mentally ill people in crisis so that they are less likely to be shot or arrested. (This program is discussed in a previous post.) Earley also researched institutions that tried to keep the mentally ill off the streets by housing them.

The end of the book returns to his son. Luckily, after too many postponements, the family that was pressing felony charges against Earley’s son were unable to make it to the trial. Therefore, the sympathetic prosecutor and judge found him guilty of a misdemeanor and was he mandated to stay on his medications. His career was no longer at stake.

Earley encouraged society to end stigma about mental illness, and to change laws that inhibited proper treatment of unwilling mentally ill patients. Of course, this is easier said than done.

If you are interested, I also have a post discussing the state of the mentally ill in Ohio state prisons, with a Frontline documentary.

4.5 stars for excellent research, well- written narrative, and a fantastic, revealing topic

Stress and Your Body: An introduction

Great Courses: Stress and Your Body, by Professor Robert Saplosky,
narrated by Robert Saplosky

Robert Saplosky is a professor of biological sciences, neurology, and neurosurgery at Stanford University. His lab focuses on how stress affects the nervous system. He also has extensive field work, studying a particular population of wild baboons in East Africa – where he examines how social rank, personality, and sociality affect vulnerability to stress-related disease. He is a fantastic lecturer, and if you get the chance to watch a YouTube video of him lecturing, go for it.

Saplosky and The Teaching Company developed the course Stress and Your Body to teach us about the detrimental effects of stress on our health. The primary textbook is his own Why Don’t Zebras Get Ulcers? Which, as far as I can tell from chapter 1 versus lecture 1, is pretty much verbatim with his lectures.

Remember that time you were lying in bed, worrying about the big exam, presentation, or event that might make-or-break you the next day? You couldn’t sleep because you were ruminating about the fact that if you couldn’t sleep, you’d do terribly the next day. Then you noticed some minor symptom that’s been troubling you lately. Your head’s been aching. Oh no! You have a brain tumor! Now not only can you not sleep because of your event the next day, but you’re worried about your health.

This is the type of stress that often happens to humans. We worry about things that might happen in the future, rather than worrying about things that are happening now. Thus, our stress is generally long-lasting rather than immediate and acute.

Animals biologically respond to stressors in very similar ways to ourselves, but their reasons for being stressed vary significantly from ours. A zebra might be munching contentedly on grass until suddenly he spots a lion. His fight-or-flight response ramps up. A part of his autonomic nervous system (responsible for controlling unconscious bodily functions) called the sympathetic nervous system is activated. His body goes into energy saving mode: it turns off all the functions that are unnecessary for fight-or-flight, and turns on the ones that are.

He saves energy. That means his stomach stops digesting, he stops producing semen, his immune system – which requires a huge amount of energy – slows way down. Tissue repair – also another drain on energy – halts. The rate of his heart and glucose metabolism increases so that oxygen and energy flows to the limbs for fight or flight.

He runs.

This is a very helpful response to an immediate stressor like a lion. As soon as the zebra escapes the lion, the stress is gone and the zebra contentedly starts munching on the grass again. His parasympathetic nervous system activates, reversing all the bodily changes outlined above. He’s now in rest-and-digest mode.

When humans experience long-term stress, many of the same pathways as short-term stress are activated, leading to chronically increased blood pressure, poor digestion, dysfunctional glucose metabolism, and heightened susceptibility to infection (among many other things). Such effects on the body will be discussed in detail as we explore Saplosky’s course.

References:

Saplosky, Robert. (2004) Chapter 1: Why Don’t Zebras Get Ulcers? Why Don’t Zebras Get Ulcers? Third edition. (Nook ebook pp. 13-30). Holt, Henry & Company, Inc.

Saplosky, Robert. (2010) Lecture 1: Why Don’t Zebras get Ulcers? Why Do We? Stress and Your Body. The Teaching Company, The Great Courses.

The Biological Effects of Anxiety on the Body

Stress and anxiety can wreak havoc upon your body. It can lead to problems with childhood physical development, and affect the immune, endocrine, gastrointestinal, and cardiovascular systems. It can exacerbate diabetes. Stress affects the mind as well, a tragic example being PTSD, where an individual might relive a traumatic event over and over.

Stress can be either good or bad event – such as marriage or a divorce. Low levels of stress can actually be a good thing – for instance, a small amount of stress might help you prepare for an upcoming exam better than you otherwise would have. But sometimes stress becomes overwhelming, and biological systems in your body that would usually only slightly increase during “good stress,” go into overdrive – potentially on a long-term basis.

In order to understand why long-term stress can be bad, we need to understand what immediate effect stress has on our bodies. Under stress, the hypothalamus-pituitary-adrenal system (HPA axis) is activated. The hypothalamus releases corticotrophin-releasing-hormone (CRH). CRH stimulates the pituitary gland. The pituitary then secretes adrenocorticotrophic hormone (ACTH). The Adrenal cortex then produces the stress hormone cortisol in humans.

Anatomy of hypothalamus-pituitary-adrenal system
Top left, the pituitary gland is red
Top right, the hypothalamus and pituitary glands are connected
Bottom left, the adrenal glands are bright red
Bottom right, the adrenal glands are the yellow cones on the kidneys

Cortisol activates the fight-or-flight response. The sympathetic nervous system shuts down anything that your body doesn’t need during a traumatic event where you might need to fight or run away from a threat. That means your stomach stops digesting, you stop producing semen / ovulating, your immune system – which requires a huge amount of energy – slows way down. Tissue repair – also another drain on energy – halts. Activation of the sympathetic nervous system leads to release of the adrenaline (epinephrine) and noradrenaline (norepinephrine). These hormones circulate through the body and increase rate of the heart and of glucose metabolism – that gets the oxygen and energy flowing so you can use your limbs for fight or flight.

Cortisol is the hormone that prepares the body for fight-or-flight; thus, it is a good hormone to have around in an immediate danger. However, if stress continues, and cortisol is not turned off, the long term effects of suppression of vital bodily functions is quite detrimental to the body. Usually, after immediate stress, the cortisol has a feedback inhibition mechanism, in which it signals to slow its own production. However, if the stress continues for too long, cortisol’s feedback inhibition loop can be deactivated; thus allowing the adrenal cortex to continue pumping out cortisol and keeping the physiological effects of the sympathetic nervous system still active.

Since the immune system is inhibited by the sympathetic nervous system, individuals experiencing long-term stress are susceptible to infection by viruses and bacteria.

The best known physical side effect of stress is cardiovascular problems. As mentioned earlier in this post, the sympathetic nervous system increases heart-rate so that blood pumps more quickly throughout the body. Not only can this increase blood pressure directly, but it can also lead to damage of the blood vessel walls. The high blood pressure leads to tiny tears in the blood vessel walls. These tears are susceptible to accumulating circulating “junk” such as particles of fat and cholesterol. This accumulation – pictured n yellow above – can decrease blood flow through the vessel, or completely block flow as seen above. When the heart doesn’t get enough oxygen, then a heart attack may occur. Another problem with decreased blood flow is that if the brain doesn’t get enough oxygen, this can cause a stroke.

As you can see, stress can have a huge impact on your health. Doesn’t that stress you out?

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 5: Stress and Physical and Mental Health. Abnormal Psychology, sixteenth edition (pp. 129-161). Pearson Education Inc.

Personality Disorders – Cluster A

As mentioned in my opening post about personality disorders, personality disorders are split into three clusters: A, B, and C. This post will discuss the cluster A personality disorders. Cluster A disorders are characterized by distrust, suspiciousness, and social detachment. Often, people with cluster A personality disorders are considered eccentric or odd.

The characteristic traits of paranoid personality disorder are suspiciousness and mistrust of others, tendency to see oneself as blameless, and tendency to be on guard for perceived attacks by others. The disorder develops in early adulthood. To be diagnosed, a person must exhibit 4 or more of 7 traits: 1) he suspects, without sufficient basis, that others are exploiting, harming, or deceiving him; 2) he is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates; 3) he is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him; 4) he reads hidden demeaning or threatening meanings into benign remarks or events; 5) he persistently bears grudges; 6) he perceives attacks on his character or reputation that are not apparent to others and is quick to react angrily 7) he has recurrent suspicions, without justification, regarding fidelity of spouse or partner.

Of course, I am unqualified to diagnose anyone with a personality disorder, but I think real-life stories are helpful.

When I worked in retail, there was a guy that I had a crush on. We had been “friends” for almost a year, and I figured it was ok to tell him I liked him. He freaked out and said that I’d betrayed him (because he wasn’t ready to date anyone due to a bad experience in the past).

He soon became incredibly paranoid. He accused me to the manager first of stalking him within the store, then of calling his phone number just to hear the sound of his voice (mind you, this guy never handed his phone number out to anyone, so he was basically accusing me of sneaking into the office and illicitly looking up his number), and finally, he accused me of placing a kilo of marijuana near his car. (Though he couldn’t produce said kilo for evidence.)

Looking back, I realized his behavior had been odd all along. He was huge on conspiracy theory; stockpiled guns; thought everyone was out to get him; didn’t tell anyone where he lived, what his phone number was, or any personal details about his past; and he accused me of being nasty and demeaning when I made a casual comment “Oh, you’ve already started Christmas shopping? Seems a bit early.” And boy could he hold a grudge.

Since then, I’ve wondered what happened to this guy. He was really a sweet, caring person. I worry about his health and safety, since his paranoia clearly had a huge negative impact on his life.

This is one of the personality disorders that would be abolished if the next DSM adopts a dimensional approach as discussed in my previous post. I wonder what category these traits would fall into then?

Schizoid personality disorder is characterized by impaired social relationships and low desire to form attachments to others. To be diagnosed with schizoid personality disorder, a patient must have 4 of the following 7 traits: 1) he neither desires nor enjoys close relationships, including being part of a family; 2) he almost always chooses solitary activities; 3) he has little, if any, interest in having sexual experiences with another person; 4) he takes pleasure in few, if any, activities; 5) he lacks close friends or confidants other than first-degree relatives; 6) he appears indifferent to the praise or criticism of others; 7) he shows emotional coldness, detachment, or flattened affectivity.

This is another personality disorder that would disappear with the dimensional approach.

People with schizotypal personality disorder are also loners. People with scizotypal personality disorder tend to have superstitious beliefs, and some experience psychotic symptoms like believing they have magical powers. They can also be paranoid, have distorted speech, or see special meaning in ordinary objects or events. Schizotypal personality disorder is thought to be related to schizophrenia – perhaps a less severe manifestation or a precursor to schizophrenia.

In order to be diagnosed with schizotypal personality disorder, a patient must have five or more of the following traits: 1) he has ideas of reference (believing innocuous events or objects have strong personal meaning); 2) he almost always chooses solitary activities; 3) he has unusual perceptual experiences (mild hallucinations); 4) he has odd thinking and speech (e.g. vague, circumstantial, metaphorical, overelaborate, or stereotyped); 5) he exhibits suspiciousness or paranoid ideation; 6) he has inappropriate or constricted affect; 7) his behavior or appearance is odd or eccentric; 8) he has a lack of close friends or confidants other than first-degree relatives; 9) he has excessive social anxiety.

This is the only cluster A personality disorder that would not be lost if we switched to the dimensional approach of diagnosis.

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 10: Personality Disorders. Abnormal Psychology, sixteenth edition (pp. 328-366). Pearson Education Inc.

Personality Disorders – Clusters and Dimensions

Personality disorders are a difficult topic for me. For one thing, they are highly stigmatized. And I think the term “personality disorder” encourages that stigma by suggesting that there is something terribly wrong with a person’s identity, rather than implying that people with these disorders respond to the world in a highly ineffective manner that creates problems for themselves and others. In fact, Butcher describes “personality disorder” in his textbook Abnormal Psychology as: characterized by “chronic interpersonal difficulties and problems with one’s identity or sense of self.” This description is good as long as we accept that the “problem with one’s identity” is that one’s self-esteem and view of one’s relationships with others is unstable.

Everybody exhibits some dysfunctional beliefs and behaviors, but they should not be diagnosed with a personality disorder unless the behavior is pervasive and inflexible, and causes “clinically significant” distress or impairment in functioning. People with personality disorders generally cause just as many problems for others as they do in their own lives. Most do not recognize the dysfunction in their own thoughts or behaviors; therefore, it is often friends, family, or the law that force people with personality disorders to seek treatment.

Personality disorders are grouped into three clusters:

Cluster A includes paranoid, schizoid, and schizotypal personality disorders. People with cluster A disorders tend to be suspicious, paranoid, and/or withdrawn.

Cluster B includes histrionic, narcissistic, antisocial, and borderline personality disorders. People with these disorders have a tendency towards drama, emotionality, and erratic behavior.

Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. These people tend to experience anxiety and fear.

Most personality disorders are not caused by a few traumatic events, but by a build-up of many stressors throughout life – like childhood abuse, neglect, or criminal behavior in parents. A child’s natural temperament may also have a strong impact on the development of a personality disorder later in life.

Compared to the other mental illnesses, there is little research on personality disorders. This is because people with personality disorders often do not feel there is anything wrong with themselves, or if they realize there is something wrong, they have less-than-helpful personality characteristics (such as lack of empathy or withdrawn social interaction). Another difficulty in studying people with personality disorders is the large amount of misdiagnosing that occurs. The criteria for diagnosis are more influenced by a clinician’s judgement than are the criteria for other mental illnesses.

Due to these difficulties in diagnosis of personality disorders, much work has been done in developing dimensional systems as an alternative to the cluster model. A dimensional model would rate a person on a set of personality traits, thus providing an overall behavioral pattern. Such an analysis would theoretically be more empirical than the cluster model. Such changes were proposed for the DSM-5, but they were deemed too complex for rushed clinicians and were shunted off into the “Emerging Measures and Models” section.

One popular dimensional approach is the five-factor model. According to proponents of the Big Five, everyone’s personalities can be defined by our strengths and weaknesses in five traits: neuroticism, openness to experience, extraversion, agreeableness, and conscientiousness. Each of these traits are further separated into sub-traits.

Neuroticism: anxiety, anger/hostility, depression, self-consciousness, impulsiveness, and vulnerability.

Extraversion: warmth, assertiveness, gregariousness, activity, excitement seeking, and positive emotions.

Openness to experience: fantasy, aesthetics, feelings, actions, ideas, and values.

Agreeableness: trust, straightforwardness, altruism, compliance, modesty, and tender mindedness.

Conscientiousness: competence, order, dutifulness, achievement striving, self-discipline, and deliberation.

Using this model, when a patient comes in for analysis, she would be rated high or low for each of the factors. The overall pattern (combined with knowledge of whether the individual experiences clinically significant distress) can be used to diagnose a personality disorder. Using the five-factor model, only six of the personality disorders would remain: borderline, antisocial, schizotypal, narcissistic, obsessive-compulsive, and avoidant. The others (paranoid, schizoid, histrionic, and dependent personality disorders) would be dropped.

Hopefully much research will go into developing a more empirical approach to diagnosis of personality disorders, for I feel that patients would benefit greatly from treatments that target specific dysfunctional traits instead of a generalized “personality disorder.”

If you’re interested, there are quite a few Big Five tests on the internet. I just took the Truity test. If you take it, you don’t have to create an account. There’s a “skip” option. My scores were:

Open to experience: 80%

Conscientiousness: 85%

Extraversion: 57.5%

Agreeableness: 92.5%

Neuroticism: 52.5%

Apparently, a score of 50% is considered “average person.” This test was fun and gives you an idea of what types of questions might be asked with a dimensional approach to diagnosis; however, it was certainly too short and silly to accurately diagnose a personality disorder. I’m surprised I didn’t get a higher score on neuroticism because of my bipolar disorder. Hopefully the test developed by clinical psychologists is much more extensive and precise. 🙂

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 10: Personality Disorders. Abnormal Psychology, sixteenth edition (pp. 328-366). Pearson Education Inc.

The Noonday Demon, by Andrew Solomon

The Noonday Demon: An Atlas of Depression,
by Andrew Solomon, narrated by Barrett Whitener

Noonday Demon is Andrew Solomon’s amazing memoir / history of depression – it’s a must-read for anyone who wants to delve deeply into the causes and effects of depression. Solomon begins with his own journey through several severe depressive episodes. For a broader personal understanding of depression, he intermittently includes stories of “depressives” that he’s interviewed. In his research for this book, Solomon explored many standard therapies for depression (i.e. medicine, psychotherapy, cognitive behavioral therapy, electroconvulsive therapy, etc.); but he also explored some very atypical therapies such as an African ritual in which he lay naked and covered in goat blood while people danced around him with a dead chicken. (He actually found it very cathartic.)

He followed his personal journey with epidemiology, biological causes, and historical development of depression.

One subject that I found particularly interesting was when he discussed children of depressed mothers. Solomon claimed that such children are sadder, have lower IQ, more anxiety, and poor social skills. He said that it is often more beneficial to the child to treat the mother instead of the child.

Solomon made me cringe when he suggested that people who talk about suicide are more likely to commit suicide; therefore, crisis hotlines may actually be promoting suicide rather than preventing it. I’d rather not believe this, since I volunteer for a suicide hotline, though this information does match what Butcher’s Abnormal Psychology textbook claims in chapter 7: that research shows no evidence that crisis hotlines reduce the rate of suicide. However, I’m going to stubbornly continue my work at the crisis hotline, because I can’t possibly think that I’m doing any harm. And I know that most of the people I talk to feel better after the conversation.

Solomon shared a story about a suicidal octopus who was a retired circus performer. Apparently, this octopus kept trying to do its tricks, but was no longer receiving positive reinforcement. The octopus began to fade in color (a sign of stress) and stopped eating. After several months it performed its tricks one last time and then pecked itself to death. Although this was a moving anecdote suggesting that depression can occur in animals as well, I find it a little fishy. After all, anyone who was paying such close attention to the octopus to notice its change of color, appetite loss, and melodramatic last-show would certainly have tried to alleviate the octopus’ suffering.

Solomon’s history of depression was also quite fascinating. He pointed out that in the late 16th century it was in vogue to be melancholic, and that people would pretend to be depressed – loafing around on couches and saying melodramatic things – in order to appear intellectual.

Solomon suggested that depression might have evolved in hunter-gatherers in order to promote an appropriate social hierarchy. That early humans became depressed because they were at the bottom of the hierarchy – or after they had challenged the leader and lost. This depression helped them to stay where they belonged in the hierarchy and to discourage them from re-challenging the leader.

Depression may have had an evolutionary advantage at one time, but it has now lost that purpose. It now manifests for other, less suitable, reasons. Solomon suggests that one reason it is so prevalent these days is our increased choices. Hunter-gatherers didn’t have to stand in a grocery store looking at all the different types of food to eat. They ate whatever came their way. They didn’t have an uncountable number of potential mates, they had only a few. Thus they weren’t plagued by the notion that they may have chosen the wrongly.

Although the hierarchy-stress hypothesis fits well with Robert Sapolsky’s findings about baboons (I’m currently listening to a set of lectures by Sapolsky and will review soon), I feel a little bit of skepticism about the choice hypothesis. I think there are a lot of reasons we experience stress – choice might be one of them, but it’s not the main factor.

I found this book fascinating. Solomon did a great job of inserting little vignettes of his own story or stories of people he interviewed into his more intellectual portions of the book, so that the material never became dry despite its length. Solomon came up with so many interesting points that I was always interested in what he would say next. His own story was touching. His facts seemed very well-researched. In short, it was simply an amazing book.

4.5 stars for incredible research, ability to keep up interest,
and generally good writing style.

Depression – an overview

Depression is a surprisingly common mental health issue, affecting 17% of Americans at some point throughout their lifetimes. Depressions almost always are a result of a stressful life event, though not all of these depressions are severe enough or long enough in duration to be considered a mood disorder.

For instance, grief or bereavement often occurs when an individual has lost a loved one. Grievers tend to experience numbness and disbelief, yearning and searching for the lost person before acceptance that he is gone, disorganization and despair as realization is reached, and finally acceptance and reorganization of life. The DSM-IV had a bereavement exclusion for major depressive disorder (MDD): a person might not receive a diagnosis for MDD if he had experienced a major loss in the last two months. However, in a controversial move, this exclusion principle was left out of the DSM-5, allowing clinicians to diagnosis MDD soon after a major loss.

There are a surprising number of types of depression – many of them are well-known but not generally considered when we think about depression. For instance, postpartum depression is a negative mood response to the birth of a child. Feelings of changeable mood, crying easily, sadness, and irritability occur in 50 to 70 percent of women within 10 days of the birth. These symptoms generally subside on their own.

Another type of DSM-5 diagnosable depression is premenstrual dysphoric disorder. (That’s right. PMS.) In order to get this diagnosis, one of four symptoms must occur a week before onset of menses, and disappear within the first couple of days after onset. Those four symptoms are: mood swings, irritability or anger, depressed mood or self-deprecation, and anxiety or being “on edge.”

MDD is characterized by persistent symptoms that occur most of the day, every day for at least two weeks. The patient must either have a depressed mood or a loss of interest or pleasure (anhedonia). There is also a list of 7 symptoms, of which the patient must have 4: significant weight change, hypersomnia or insomnia, psychomotor agitation or retardation, fatigue, inability to concentrate, and recurrent thoughts of death. Untreated, these symptoms generally last 6 to 9 months.

There are several types of MDD. The specifiers are: “with melancholic features,” “with psychotic features,” “with atypical features,” “with catatonic features,” and “with seasonal pattern.”

The melancholic patient awakens early in the morning, has depression that is worse in the morning, exhibits psychomotor agitation or retardation, loss of appetite, and/or excessive guilt.

Psychotic features are delusions or hallucinations that are “mood congruent” (in other words, they tend to be a very depressing psychotic experiences). One example is the belief that one’s internal organs have completely deteriorated, leading to the depression. Patients with psychotic features generally experience extreme guilt and feelings that they deserve depression as punishment.

Atypical features include more mood fluctuations than a person with MDD would usually experience. The patient’s spirits might temporarily lift at a positive event. Other atypical features are increase in appetite, hypersomnia, arms and legs feel as heavy as lead, and being acutely sensitive to interpersonal reaction.

I find the description of atypical features to be interesting because in the times that I have experienced severe depression, I have experienced all of these symptoms. But apparently people with bipolar disorder tend to have atypical features to their depressive episodes. In fact, a person should not be diagnosed with MDD if they have ever experienced a manic or hypomanic episode, as I have. Another interesting difference between MDD and bipolar disorder is that those with bipolar tend to have much deeper depression than those with “unipolar” depression.

Catatonic depressives experience extreme psychomotor retardation often to the point of complete immobility. They often stop talking as well. I have an aunt who experienced these symptoms for weeks at a time during her teenage years. Apparently, she would just sit at the kitchen table all day, every day. Not moving, not talking, just staring. I’ve asked my dad “didn’t she eat or go to the bathroom or to bed?” He just answers “I don’t know. I never saw her doing those things.”

In order to be diagnosed with a seasonal pattern, you must have experienced two or more depressive episodes in the past two years that occurred at the same time of year, usually fall or winter, with a full remission at the same time of year, usually spring or summer. Sometimes the seasons can be switched – these patients tend not to get as much sympathy as those who get depressed in the winter. To get this diagnosis, non-seasonal depression must not have occurred in this 2 year period.

When depression occurs almost every day for most of the day for more than two years, the patient is generally diagnosed with persistent depressive disorder. “Normal” moods may occur, but they generally only last for a few days. This depression contains many of the same characteristics of MDD, though they are not as severe. Persistent depressive disorder generally lasts for 4-5 years, but can last longer than 20 years. It often starts during adolescence. This disorder is quite common, occurring with a lifetime prevalence of 2.5-6% in Americans.

Depression has been attributed to many biological causes. There is a genetic factor – people with family members who have MDD are more likely to develop MDD themselves. The serotonin-transporter gene, which is responsible for the uptake of serotonin in the brain, has a heritable mutation which makes depression much more likely. An imbalance of the neurotransmitters norepinephrine or serotonin is strongly associated with depression, and most anti-depressant medications target these neurotransmitters.

Another biological cause can be a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. In response to a perceived threat, norepinephrine signals the hypothalamus to release a signal which eventually leads to release of the stress hormone cortisol from the adrenal gland. Cortisol is not harmful for short periods of time, but long-term it can promote hypertension, heart disease, and obesity. It is hypothesized that during MDD, the signal stimulating cortisol release is continuously present in the system, or the feedback inhibition mechanism, which tells the adrenal gland that it should stop releasing cortisol, is not functional. The HPA axis is related to the stress response, which explains the onset of depression after stressful life events, and also explains the concurrence of depression with anxiety.

There are several theories about psychological causes of depression. In 1967, Aaron Beck proposed the cognitive theory of depression – which led to the development of cognitive behavioral therapy (discussed in my post Contemporary viewpoints on treating mental illness – psychology). Beck proposed that before experiencing depression, a person experienced dysfunctional thinking – these thoughts could be about oneself, about the world, or about one’s future. Dysfunctional thinking may include: 1) all-or-none thinking, for example someone thinks he must get 100% on a test or he is a complete loser; 2) selective abstraction, which includes a tendency to focus on one negative event even if surrounded by positive events; and 3) arbitrary inference in which the individual jumps to a conclusion based on little to no evidence. (Examples of these are given in my previous post.) Although research shows that this dysfunctional thinking occurs during depression, research leaves it unclear whether dysfunctional thinking occurs prior to depression, suggesting that such thinking might not be the cause of depression, as theorized by Beck.

There are also the hopelessness and helplessness theories of the psychological causes of depression. In these, the individual might feel incredibly pessimistic about the future, or incapable of having any impact on himself or his environment. A final theory is the ruminative theory, in which a person’s tendency to roll negative thoughts over-and-over in her head leads to depression. Women tend to ruminate more than men, and they also are more likely to experience depression than men. But when a study controls for rumination, the sex difference disappears, suggesting that rumination has a strong impact on depression.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 7: Mood Disorders and Suicide. Abnormal Psychology, sixteenth edition (pp. 212-262). Pearson Education Inc.

Post Traumatic Stress Syndrome – the Basics

I think we all have some idea of what we think PTSD is, but it turns out PTSD isn’t as clear-cut as I thought.

Apparently, when PTSD was first introduced into the DSM, the diagnostic criteria required a traumatic event “outside the range of usual human experience” that would cause “significant symptoms of distress in almost anyone.” That fits pretty well with my own perception of PTSD. Rape, war, torture, violent experiences…these all fit into that description. PTSD is a normal response to an abnormal stressor.

However, in the DSM-IV, the nature of the “traumatic event” broadened drastically, and a requisite response was “intense fear, helplessness, or horror.” So in the DSM-IV, PTSD was a pathological response to a potentially less extreme stressor. Someone could be diagnosed with PTSD if they experienced “intense horror or helplessness” after watching a scary TV show or upon being diagnosed with a terminal illness.

Although I don’t wish to undermine the intense stress that someone with pathological responses may feel, I think this definition undermines the intensely awful experience that someone with PTSD (in my mind) has encountered. The statistics agree with my assessment of these criteria: in a community survey, 89.6% of people reported that they had been exposed to a traumatic event and had responses that could potentially qualify them for a PTSD diagnosis.

Luckily, the DSM-5 tightened the traumatic event criteria again, and broadened the range of response to the traumatic event. Now, the traumatic event must occur directly to the subject, and they can exhibit other pathological responses besides “intense fear, helplessness, or horror.”

To be diagnosed with PTSD by DSM-5 standards, a person must be exposed to “actual or threatened death, serious injury, or sexual violence.” They must exhibit one of the following symptoms: intrusive distressing memories of the event, distressing dreams reliving the event, dissociative reactions, intense psychological distress at cues that remind the person of the event, or marked physiological reactions to cues that remind the person of the event. Additionally, the person must persistently avoid stimuli associated with the traumatic event, have negative alterations in cognitions and moods associated with the event (e.g. distorted cognitions about the cause or consequences of the event), and alterations in arousal and reactivity (e.g. hypervigilance or angry outbursts).

In general, people respond to trauma with decreasing pathological symptoms. In order to be diagnosed with PTSD, the patient must have experienced these negative responses for more than 1 month, otherwise they are experiencing “acute stress disorder.”

Despite the common association of PTSD with war veterans, PTSD is actually more common in women than in men – and the traumatic events are more often domestic violence or rape than war. However, a great deal of money and time has gone into research of PTSD in war veterans.

During WWI, symptoms of PTSD were called “shell shock,” and were thought to be caused by brain hemorrhages. However, this belief slowly subsided as doctors realized that the symptoms presented themselves regardless of injury. By WWII, traumatic reactions were known as “operational fatigue” and “war neuroses,” before the terminology finally settled on “combat fatigue” during the Korean and Vietnam wars. A rigorous longitudinal study of PTSD by Smith et. al. in 2008 found that 4.3% of military personnel deployed to Iraq or Afghanistan had PTSD. Of those, the rate was higher (7.8%) in those that had experienced combat compared to those who hadn’t (1.4%). An issue that is (rightfully!) getting much attention lately is the high rate of soldier suicide. Between 2005 and 2009, more than 1,100 soldiers took their own lives – generally with a gun.

There are several risk factors that increase the likelihood of PTSD – being female, lower social support, neuroticism, preexisting depression or anxiety, family history of depression, substance abuse, lower socioeconomic status, and race/ethnicity. (Apparently, compared to whites, African Americans and Hispanics who were evacuated from the World Trade Center in 2001 were more likely to get PTSD.) There is also a genetic factor that increases susceptibility to PTSD. Preliminary studies suggest that people with a particular form of the serotonin transporter gene may be more susceptible to PTSD than those with the “normal” form of this gene.

On the other hand, there is at least one factor that promotes resilience to traumatic events: intelligence. It’s possible that people with higher intelligence are better able to make “sense” of the event by viewing it as a larger whole. Or an intelligent person may be better able to recognize and buffer cognitive distortions such as “I deserved that,” “why should I have lived when they died?” and “If I had only done _______, this wouldn’t have happened.”

Researchers have come up with several ways to decrease likelihood of succumbing to PTSD after a traumatic event.

Stress-inoculation training has proved successful with members of the Armed Forces. Soldiers can be exposed, through virtual reality, to the types of stressors that might occur during deployment. Thus they are better able to deal with the trauma when exposed to the events in real life.

Debriefing after a traumatic event can also be helpful. This allows the victim to process the event in a safe environment, before the details become internalized.

Interestingly, one study showed that subjects who were exposed to a highly disturbing film were less likely to report flashbacks if they played Tetris for 10 minutes after the film than if they sat quietly for those 10 minutes. This team of researchers also showed that simply being distracted after the disturbing video was not enough to decrease flashbacks, and that doing a verbal task actually increased the number of flashbacks. So, apparently, visio-spacial tasks decrease the likelihood of intrusive flashbacks if performed immediately after the traumatic event. I’m not sure this information is particularly useful, but it’s interesting.

As of yet, there isn’t a highly successful way to “cure” people with PTSD. Cognitive behavioral therapy, which helps the victims recognize cognitive distortions (e.g. “I deserved that,” “why should I have lived when they died?” and “If I had only done _______, this wouldn’t have happened.”), can be helpful in reducing anxiety. Antidepressant medications can alleviate some of the depression and anxiety experienced by victims.

One up-and-coming treatment has shown promising results. Someone with PTSD can undergo prolonged exposure to the traumatic events. They can do this through repeatedly reliving the events out loud, or even by re-experiencing them through virtual reality. Unfortunately, many PTSD vitimcs drop out of such treatments because reliving the events is too difficult. However, this treatment method has proven very helpful to people who complete the process, and I hope that work in this area continues.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 5: Stress and Physical and Mental Health. Abnormal Psychology, sixteenth edition (pp. 129-161). Pearson Education Inc.