The Serpent King, by Jeff Zentner

Dill is no stranger to hardship. He’s dirt poor, financially supporting his mother, and seems to have zero future prospects. His father, a snake-handling preacher, is in prison; many of his former parishioners blame Dill. Yet Dill has two things that keep him getting up in the morning – his friends Travis and Lydia. The three are strikingly different but are pushed together by their mutual status as social outcasts.

This is a story about friendship, futures, and fighting. It’s the first book in a long time that’s made me just start bawling – I generally avoid crying if I can, but this book deserved a good cry. It was that moving. I didn’t just feel for Dill and his friends, I felt with them – which is saying a lot since I personally have not experienced most of the hardships that Dill and his friends were going through.

The characterization and mood of this book were what made it amazing. The characters were real. They were flawed. They got angry for stupid reasons or were sometimes bossy and blind to the needs of others. Yet they were perfect. They were just what good friends should be. They knew how to love, how to inspire, how to live. The mood of the book was remarkably well-kept. It somehow mixed the darkness of hardship with the light of an amazing friendship.

Overall, I would recommend this book to anybody who likes gritty teen realism. Personally, I volunteer for a texting crisis hotline for teenagers, and I find reading books like these helps me to better relate to the teens that text in. I am currently collecting books that I think would either be good to recommend to troubled teens, or help others in the crisis center to empathize with teens in crisis. I consider this an important collection, and carefully think about each book that I include. This one is a definite yes. Issues that I consider important in this book – religious extremism (and how it impacts youths), family members in prison, bullying, grief, mental illness, and coping mechanisms.

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.

Borderline Personality Disorder

Borderline personality disorder (BPD) is in Cluster B, but I didn’t discuss it in my Cluster B post because I think BPD deserves a post of its own. People with BPD have high impulsivity, drastic mood swings, terror of abandonment, and extremely volatile relationships. Such individuals also have self-images that vary significantly from one moment to the next.

Relationships with people with BPD can be very difficult, since these individuals have intense fear of being abandoned. They also have black-and-white thinking. Their loved ones tend to be either placed on an ivory tower or (with only small provocation) viewed a hateful, evil person. This is often seen in relationships with therapists, parents, and significant others. A person with BPD may feel an intense attachment to her therapist, to the point of crossing personal boundaries, and then feel abandoned and hateful when the therapist tries to set clearer boundaries. People with BPD often respond to environmental stimulus in extreme ways, not understanding or caring what the repercussions of their responses might be. In the example of the therapist, a patient who feels abandoned might become violent, verbally abusing the therapist or attacking her physically.

People with BPD often self-harm, and make multiple attempts at suicide. Often, the attempts at suicide can be viewed as a manipulative attempt to get attention, though sometimes the suicide is completed. (After all, the more often someone attempts, the more likely it is that completion will eventually happen.) Patients with BPD can also experience psychotic or dissociative symptoms. They might have hallucinations or paranoia.

BPD often occurs with other disorders – bipolar disorder is very common. I imagine this has a lot to do with the mood swings, impulsivity, and psychotic and dissociative symptoms. As I’ve said in previous posts, I have been diagnosed with both bipolar disorder II and BPD. I am still very skeptical of the BPD diagnosis, because all of my symptoms that fit in the BPD category can be explained by my bipolar disorder – and I don’t have the characteristic difficulty with relationships and fear of abandonment which are so strongly associated with BPD.

Another disorder that often occurs with BPD is PTSD. This is most likely because people with BPD have often gone through traumatic experiences such as sexual, physical, or emotional abuse as a child.

In order to be diagnosed with BPD, an individual must have five or more of the following traits: 1) frantic efforts to avoid real or imagined abandonment; 2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation; 3) identity disturbance – markedly and persistently unstable self-image or sense of self; 4) impulsivity in at least two areas that are potentially self damaging – spending, sex, substance abuse, reckless driving, binge eating; 5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior; 6) Affective instability due to a marked reactivity of mood – intense dysphoria, irritability, or anxiety; 7) chronic feelings of emptiness; 8) inappropriate, intense anger or difficulty controlling anger; 9) transient, stress-related paranoid ideation or severe dissociative symptoms.

I have a former friend who has been diagnosed with BPD. She experienced most of these symptoms. One incident that really sticks out in my mind is that when we were going on a distance drive from city-to-city, we stopped at a truck stop along the way. She went into the bathroom, and I stepped into the book shop. When she found me she was frantic – she’d thought I’d abandoned her in the middle of nowhere and that she’d have no way of getting home. At the time I didn’t understand the symptoms of BPD, and I was shocked at her attack. I mean, why on earth would I abandon her in the middle of nowhere? Especially for no reason at all? I told this story to a BPD guest speaker for our class. She laughed and said that her best friend will hop behind an aisle while shopping and she’ll freak out and think he left her. Even though he’s done this many times, she still freaks out every time.

Unfortunately I lost my friend who had BPD. As I said, at the time I didn’t understand BPD. She was having a particularly hard time with her mental illness at the same time that I was having a particularly hard time with my own. We got into fight after fight after fight. Then one day she invited me to a party. I refused – I was isolating because I was very depressed. She decided that I had decided to “friend dump” her and she friend dumped me first. I’ve made several attempts to rekindle the relationship, but it is unfortunately dead.

That brings me to a point that I think is very important. BPD is highly stigmatized in our society. It’s even highly stigmatized among mental health workers – many of whom won’t take more than one BPD patient at a time. There are people who’ll say you should never be friends with someone who had BPD. I think this stigma is tragic. Every person with BPD that I have met was a wonderful person despite their problems. By understanding the symptoms of BPD, and by talking to them about how we should respond when the affected person is in a “mood,” we can have a healthy and wonderful relationship with someone who has BPD.

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.

Dissociative Disorders

Dissociation is when an individual is able to go through complex cognitive processes without explicit knowledge of what they are doing. Someone might suddenly become self-aware while in a completely unfamiliar place without having any idea of how they got there. The DSM-5 recognizes several types of pathological dissociation: depersonalization/derealization disorder, dissociative amnesia, dissociative fugue, and dissociative identity disorder.

In depersonalization/derealization disorder, one loses track of oneself or environment. Depersonalization is when a person feels disconnected from himself – he might feel like he is floating elsewhere, looking down on his body, or he might feel like events are happening to someone else. In derealization, the individual feels like everything happening to them seems unreal. Everybody feels this way sometimes, for instance after sleep deprivation or during a panic attack, but to be diagnosed with this disorder the individual must lose his ability to function in daily life due to frequent or severe symptoms.

In dissociative amnesia a person forgets very specific events of her life, generally something that is traumatic. To share something very personal, I was raped by my first boyfriend, and I am wracked with self-doubt about what actually happened (and whether it happened) because the memory has become so foggy. (I admit this very personal and humiliating bit of information not because I feel the need to share such things with strangers, but because there is so much stigma attached to women who were raped that it has become necessary to say “this can happen to anyone, it’s wrong, and it’s destructive.”)

I know another person who, while in prison, was continuously attacked verbally and physically by one of the other inmates. At one point, my acquaintance grabbed the throat of her bully and began throttling her while screaming in her face. Afterwards, she left feeling that she had handled herself quite well, and that the argument had ended peacefully. She only discovered her behavior later, when other inmates told her what happened. These events can happen to everyone to some extent, but in order to be diagnosed with dissociative amnesia the symptoms must cause significant troubles in dealing with daily life.

A more serious condition is a dissociative fugue. This is a state in which a person completely dissociates from their consciousness and forgets pieces or all of his past. Days, weeks, or years later the person might find himself in an unfamiliar environment, working another job, or living a whole new life. I know someone who experiences a less extreme case of fugue in which he will lose awareness for hours at a time and suddenly become aware of himself in awkward situations (missing clothes, banged up car, etc.)

During a fugue state, the individual is generally unaware of the amnesia, but his memory of what has happened during the fugue state remains intact. Many times a fugue state will remit on its own, and the memories from before the fugue state return, while the memories of what happened during the fugue state disappear. Like people experiencing conversion disorder, the individual is generally escaping from a highly stressful situation, but in this case they remove themselves from the source of the stress.

Dissociative identity disorder (DID), formerly known as multiple personality disorder (MPD), is another mental illness that is popularized in books and movies – usually with rather trite effects. (I mean come on, how many murder mysteries need to have the murderer be someone’s other personality?) DID is the most extreme of the dissociative disorders. It is characterized by two or more distinct personalities that have different ways of thinking and behaving. They also might have different personal history, self-image, name, sex, handedness, sexual orientation, eyeglass prescription, language, or age. There is generally an identity which most often presents itself, called the “host identity,” which may or may not be the best adjusted of the identities.

One of the reasons the term “multiple personality disorder” was dropped was that it gives the impression that the affected person has separate identities making them more than one person. Actually, it is more like the affected person is fractured and is less than whole. People with DID might exhibit a slew of other symptoms such as depression, self-mutilation, suicidal behavior, headaches, hallucinations, and PTSD.

According to the posttraumatic theory, the cause of fracturing is due to a traumatic event, usually during childhood. DID may be a coping mechanism in which the child can forget that something horrible has happened, or believe that the horrible thing is happening to someone else. Another theory is the sociocognitive theory, in which therapists inadvertently convince highly suggestible, hypnotized, patients that they have more than one personality. One argument for the sociocogntive theory is that “normal” patients can adopt multiple personalities under hypnosis. Also, many patients diagnosed with DID did not show obvious signs of DID before diagnosis. I tend to be a proponent of the sociocognitive theory, though I believe that the posttraumatic theory is probably true for many cases.

Over the years, the prevalence of DID has increased dramatically. One reason for this is the 1973 release of Flora Rhea Schreiber’s Sybil, which depicted a woman with 16 separate personalities. The book, and subsequent movie, made a dramatic splash in popular culture as well as psychological circles. Highly suggestible patients began to wonder if they, themselves, had more than one personality, and these imaginings were encouraged under hypnosis by over-eager psychologists. The case of Sybil was since then discredited – for more information you can read Sybil Exposed, by Debbie Nathan – however, this discovery of fraud came too late for the MPD movement. It was about this time that the DSM-III recognized MPD as a mental illness. The DSM-III also tightened the criteria for schizophrenia so that people who had been previously diagnosed as schizophrenic were now diagnosed with MPD.

Some personalities in DID are aware of the other personalities, and know what they know, and some personalities are completely unaware of the other personalities and lack explicit knowledge of events that occurred to the others. However, these personalities that lack explicit knowledge actually have some implicit (unconscious) knowledge. For instance, if you teach word associations to one personality and then ask another personality to repeat the associations, that second personality will be unable to do so. But if given a word and asked to free-associate, the personality that lacks explicit memory of the pairs will often come up with the matching word.

There is a controversy about whether DID is real or faked. Because of episodes like Sybil, and because some people fake DID in order to get out of prison sentences, and because some over-eager therapists might be accidentally planting personalities into the mind of highly suggestible hypnotized patients, DID diagnoses are viewed with skepticism.

Another symptom that clinicians are skeptical of is retrieved memories of abuse. Patients do not remember the abuse before they are treated, but upon probing begin to remember abuse as a child. These memories are real in the mind of the patient, but they might not be grounded in truth. Memory is frighteningly suggestible. Something I was highly suspicious of when I was reading Sybil as a teenager is her recovered memories from the age of 2 and earlier. Really? She suddenly remembers forgotten things that had happened to her when she was 2? Although I hate to discount the horror of sexual abuse, I also hate to see innocent people falsely accused of atrocious acts.

I, myself, am skeptical of DID, as mentioned in an earlier post. It’s not that I don’t believe in DID hands down, only that I tend to think more cases are formed as described by the “sociocognitve theory.” However, due to the fact that part of my goal in this blog is to decrease stigma about mental illness, I now feel a little ashamed of my skepticism, despite the fact that some clinicians express the same skepticism. I think I might read a few books on the subject and reevaluate.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 8: Somatic Symptom and Dissociative Disorders. Abnormal Psychology, sixteenth edition (pp. 264-292). Pearson Education Inc.

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

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 B

As mentioned in my opening post about personality disorders, personality disorders are split into three clusters -A, B, and C. This post will discuss cluster B. People with these disorders tend to be dramatic, emotional, and erratic.

Patients with histrionic personality disorder are characterized by self-dramatization, over-concern with attractiveness, tendency to irritability, and temper outbursts if attention-seeking is frustrated. These patients often manipulate their partners with seductive behavior, but they are also tend to be very dependent on the partners’ attention. They are generally considered self-centered, vain, shallow, and insincere. These traits are much more commonly seen in women than in men – probably because many of the characteristics (like over-concern with appearance) tend to be “women’s traits.” In fact, some argue that histrionic personality disorder is just another form of anti-social personality disorder, which is much more prevalent in men.

In order to be diagnosed with histrionic personality disorder, the patient must have 5 or more of the following traits: 1) she is uncomfortable in situations in which she is not the center of attention; 2) her interactions with others are often characterized by inappropriate sexually seductive or provocative behaviors; 3) she displays rapidly shifting and shallow expression of emotions; 4) she consistently uses physical appearance to draw attention to herself; 5) she has a style of speech that is excessively impressionistic and lacking in detail; 6) she shows self-dramatization, theatricality, and exaggerated expression of emotion; 7) she is suggestible (i.e. easily influenced by others or circumstances); 8) she considers relationships to be more intimate than they actually are.

This is one of the personality disorders that will be dispensed with if the next DSM moves towards a dimensional model of diagnosis, as mentioned in my earlier post.

Narcissistic personality disorder is characterized by grandiosity, preoccupation with receiving attention, self-promoting, and lack of empathy. There are two types: grandiosity and vulnerable narcissism. In the former, the patient is convinced of their superiority; in the latter the patient expresses superiority defensively due to a low self-esteem. Narcissistic personality disorder is observed more often in men than in women.

In order to be diagnosed with narcissistic personality disorder, the patient must meet five or more of the following traits: 1) he has a grandiose sense of self-importance (exaggerates achievements and talents, expects to be recognized as superior); 2) he is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love; 3) he believes that he is “special” and unique and can only be understood by, or should associate with, other special people; 4) he requires excessive admiration; 5) he has a sense of entitlement; 6) he is interpersonally exploitative; 7) he lacks empathy and is unwilling to recognize or identify with the feelings or needs of others; 8) he is often envious of others or believes that others are envious of him; 9) he shows arrogant, haughty behaviors.

Now, I doubt my ex-boyfriend had a personality disorder, but he did have quite a few of these traits – possibly exacerbated by a lifetime of alcoholism which he had only recently given up when I’d met him. In fact, at one point in our relationship, he went to a neurologist to be checked for long-term side-effects of a past concussion, and he returned with a psychological assessment which said he had “narcissistic personality traits.” At the time, I had laughed it off, but later I began to see it.

This guy thought that he was incredibly smart, good looking, and absolutely amazing at his job. He was always bragging about the quality of his work; however, I saw some of his work a couple of times and found it lacking (which I didn’t say, of course). He was always talking about the future – how he had so many offers for jobs (he was unemployed) and how he’d be making well over $300,0000 a year in no time. He surrounded himself with people that he saw as superior (yes, that includes myself – he was always bragging to everyone about how smart and beautiful I was. It was rather embarrassing and over-the-top.) He also showed a surprising lack of empathy – he felt that anxiety was a sign of weakness in others, but when he had anxiety attacks he felt it was uncontrollable rather than a weakness.

Narcissistic personality disorder is one of the disorders that would be dropped if the diagnosis switched to a dimensional rather than cluster approach.

Because there is a lot of public interest in borderline personality disorder and antisocial / psychopathy, I will mention those Cluster B disorders in another post.

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.

The Biology of Desire, by Marc Lewis

The Biology of Desire, by Marc Lewis, narrated by Don Hagen

Neuroscientist and former addict Marc Lewis writes an engaging study of the biological changes that occur in an addicted brain, complete with personal stories about himself and several addicts that he interviewed. Lewis points out that there are two major models for addiction – the disease model and the choice model – and argues why he believes the disease model has outlived its use and is now harming rather than helping addicts.

The disease model of addiction is highly accepted by clinicians, psychologists, and insurance companies right now. It posits that the more an addict uses a substance, the more his brain changes, and the more he needs the drug. Furthermore, some people have a biological preinclination for addiction – it doesn’t mean that they will become addicts, but the genetic preinclination raises their chance of becoming an addict under the right environmental stimulus. The combination of genetic factors and changes in the brain suggest to clinicians that addiction is a disease. A lot of money, therapy, and medication currently goes into treating addiction as a disease – often successfully.

Lewis argues, though, that changes in the brain and genetic preinclination do-not-a-disease-make. After all, every experience changes your brain – and some events, like falling in love, change your brain in much the same way addiction changes it. Furthermore, much as people have a preinclination for addiction, they also have a preinclination to temperament. For instance, an introverted, agreeable parent is more likely to have an introverted, agreeable child. Despite this heritability, temperament is not considered a disease. So why do we pick-and-choose which heritable brain-changing habits are a disease?

My answer is that addiction is considered a disease whereas in-love and temperament are not considered diseases because in-love and temperament do not generally cause clinically significant impairment in an individual’s ability to function in the workplace and social interactions. And when they do inhibit the individual’s ability to function, then they are considered a disease.

Instead of the disease model, Lewis supports the “choice” model. People choose to abuse substances in the first place, and continue to make that choice. And when they give up the substance abuse, it is generally because they have chosen that now is the right time to give it up.

Lewis spends the great part of this book describing why he feels viewing addiction as a disease is harmful to addicts as well as unhelpful for treatment. When an addict views his problem as a disease, then he might feel helpless to make his situation better. Whereas if he views it as a choice, he recognizes that he has power over this problem. You might notice that this is in stark contrast to the first step of AA in which the addict accepts that he is powerless over his addiction. In fact, in the stories of Lewis’ interviewees, none of them mentioned AA or NA as a helpful tool for stopping their addiction.

Lewis also points out that although medication and therapy generally help the individual to give up alcohol to begin with, there is a very high relapse rate. And that is because although the individual doesn’t want the negative effects of his addiction, he has not yet accepted the choice to give up the drug.

Lewis claims that many people view the choice model and the disease model as mutually exclusive, but he believes that they are not. I would tend to agree with him on this. I don’t see the harm in viewing addiction as a disease – in fact, I think this model would be very helpful to a certain subset of addicts – it provides them a reason to say “this is not my fault, I have a disease, and I need to live as healthy a life as I can in order to not let it ruin my life.” But I also think the choice model is helpful to another subset of addicts – it provides them the ability to say “I have the power to choose not to use. I am not powerless.”

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.