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 People with cluster A disorders tend to be suspicious, paranoid, and/or withdrawn.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. 🙂

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 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.

Brave New Films: This is Crazy

In a previous post, I discussed my thoughts on Frontline’s New Asylums documentary, about the overcriminalization of the mentally ill. Millions of taxpayer dollars are being spent on housing the mentally ill in prisons, when they could be treated more affordably (and more humanely) by the community. Because that video (filmed in 2005) left me with a lot of questions, I looked up some more recent resources. Of the videos I watched, my favorite was a series created by Brave New Films.

Brave New Films: Why are we using prisons to treat mental illness?

The video begins by dramatically pointing out a problem: police and correctional officers are not trained to deal with mentally ill “offenders,” which results in unnecessary deaths. This is an issue that I’ve already been seething about in my home suburb here in Minnesota. There have been a few times in recent years when our police have killed mentally ill people that they have been called to help. For instance, an officer shot a knife-wielding suicidal teen after his family called the police for help. Because the police are untrained to deal with mentally ill, families are left in a quandary: they sometimes don’t feel safe around their mentally ill loved one, but they don’t want to call the police for fear that their loved one will either be killed or get tied up indefinitely in a revolving-door judicial system.

The video continues by describing the Crisis Intervention Training (CIT) program. In CIT, officers are trained to drop the authoritative attitude that they are supposed to use in non-crisis occasions. They are trained to use soothing and empathetic tones of voice to disarm the mentally ill. The video included a heartwarming interview with a mother of a schizophrenic man who is grateful for the CIT officers’ treatment of her son during a crisis – how the officers managed to defuse the situation without anyone getting hurt or being sent to jail.

CIT officers in San Antonio can now bring mentally ill people to treatment centers instead of emergency rooms. This change keeps ER and officer overtime costs down. (Officers must be paid overtime because they spend hours in the ER waiting for the “offenders” to get psych evaluations.) An officer on the video claims that in the past 5 years they’ve saved about $50 million of taxpayer money by utilizing CIT and treatment centers.

Watching this video made me feel optimistic about the future of mental health. There’s a lot of work to be done – a lot of training to do, a lot of lobbying to resistant politicians (and an unsympathetic public), a lot of treatment centers to be built – but there is a solution. New Asylums was a fantastic documentary, but it left me feeling hopeless. I’m happy I found the Brave New Films’ snippet.

I also watched this Brave New Films documentary:

Brave New Films: This is Crazy: Criminalizing Mental Health

This video begins in much the same way as Why are we using prisons to treat mental illness, providing different examples. It continues by discussing brutality within prisons, and the over-use of solitary confinement for mentally ill inmates. One mentally ill woman claims that of the 18 years she spent in prison, 4 of them were in solitary confinement. Each person in solitary confinement costs taxpayers $75,000 a year; compared to the $16,000 a year per person in supportive housing.

Finally, This is Crazy discusses the fate of prisoners once they are released from prison. As discussed in New Asylums, prison is like a revolving door for the mentally ill. Most of the homeless population are mentally ill. They break laws either because they are delusional or because they have basic needs. When they are arrested, they spend 3 to 4 times more jail time than “normal” inmates. They often get shuttled back and forth between stabilization hospitals and jail (where their psychiatric treatment, and their mental state, degenerates). When released, they are given 2 weeks’ worth of medication and are left out on the streets again – with nowhere to look for treatment. Despite the fact that community treatment would save taxpayer money, the first item on the political finance chopping block are treatment centers and institutions for mental illness.

The take-home point of these documentaries is that because police are not trained to deal with mentally ill people in crisis, many mentally ill people end up being abused, killed, or put in a revolving door prison system. Once a mentally ill person has a bad experience with cops, he is likely to be fearful and uncooperative in the future. I have seen this myself. I have a mentally ill friend who suffers from PTSD after being brutalized by police for a case of mistaken identity. Now whenever he sees a cop, even if the cop is completely uninterested in him, my friend goes into a blind panic. I strongly suspect that my friend wouldn’t have been brutalized by the cops if he hadn’t been mentally ill. Another important point is that outrageous amounts of taxpayer money would be saved, and deserving human beings would be treated with compassion, if only cities around the US would develop CIT programs and fund more treatment centers. If only the taxpayers and politicians would listen to reason.

Frontline: New Asylums

New Asylums (2005) is a Frontline documentary that delves into the problem of housing the mentally ill in prison systems. Believe it or not, the world’s three largest asylums for mentally ill are the Cook County Jail in Chicago, the Twin Towers of the Los Angeles County Jail, and Riker’s Island in New York. This problem has been escalating ever since the mid 1900’s when deinstitutionalization of mentally ill and intellectually challenged became a popular movement to encourage “humane” treatment of mentally ill and to reduce state expenditures on medical care.

The original plan, as described by the Community Mental Health Act of 1963, was to fund community mental health centers in which the mentally ill could be treated while working and living at home. However, most of the proposed centers were never built, and few of those built were fully funded. As deinstitutionalization accelerated, hundreds of thousands of mentally ill patients were released without a place to go and without adequate access to mental health care. A lot of them ended up on the streets. And on the streets, their mental illnesses flared up, leading to law-breaking. Many of the laws broken were for basic living purposes – theft of food, break-ins to get a place to sleep, stealing blankets out of a car – and many were violent crimes fueled by a desperate situation combined with psychosis. And this is how jails and prisons became the new asylums.

The documentary New Asylums focuses on the Ohio state prison system, which has a relatively well-developed system for dealing with the mentally ill. In 2005, when the documentary was filmed, there were nearly 500,000 mentally ill people housed in America’s prison systems – 10 times more than the 50,000 housed in mental institutions.

The documentary begins with a disturbing scene of “group therapy” in which inmates are locked inside tiny cages, with just enough room to sit in a chair. In this warm, inviting environment, the inmates are encouraged to share their problems with their fellow inmates. I think it is fantastic that group therapy is provided for inmates, but how helpful is it really, in this environment? Can an inmate really share his fears and heartbreaking secrets with other inmates? Wouldn’t rumors get around quickly among the inmates and less sympathetic officers in prison? How much help can group therapy really do these inmates, especially since they are locked in a tiny cage; which probably doesn’t encourage openness?

A while back, I told my therapist that I thought Dialectic Behavioral Therapy (DBT), which I was currently undergoing, would be a world of help to many people in prison. She agreed. But now that I see this video, I realize the limitations of such therapy. Prison does not provide a safe environment to let those feelings out. But what to do? Do we just not provide the inmates with therapy because of these limitations? Clearly, the problem needs to be solved before the mentally ill people are imprisoned, but I don’t know how to solve that problem, other than reinstitutionalization.

The documentary only became more horrifying after that. There were scenes in which a naked, frightened, screaming man was resisting being handcuffed. Eventually, a group of 5 men who were dressed like a SWAT team and carrying a riot shield burst into the cell, pinned the man down, and carried him kicking and screaming away. One officer tells the camera “A lot of the mentally ill inmates in here, you gotta use more…I mean, you do have to use force on them.”

Having seen the footage, I understand why the officers feel that they need to use a lot of force. I mean, how else would they get the naked, psychotic, screaming man down to solitary? But don’t you think that the strict and unforgiving culture of prisons is part of the reason these inmates are acting out? Isn’t the fear of solitary, which would certainly exacerbate psychotic symptoms, part of why they’re acting out? Most of them would certainly be better behaved in a healthier, more caring environment. And then force wouldn’t have to be used.

I can see two solutions (both of which I think should be implemented): the number of mentally ill patients housed in mental institutions should be increased, thus decreasing the prison population. And people in prison should be treated with more kindness – providing a rehabilitative instead of punitive justice system.

The documentary continued by describing Oakwood Correctional Facility, which is a temporary housing unit for mentally ill inmates who need to be stabilized. The culture and environment seems so much more caring and open – it appears that inmates who were dangerously psychotic in the general prison are stable and well-behaved at Oakwood. There’s a heartbreaking scene in which one of the inmates is being told by a panel of mental health workers that he’s stabilized and ready to go back to the general prison population. The inmate practically begs to stay at Oakwood. The panel is at first kind, but they become more and more firm. They show a depressing lack of empathy. The tragedy is that they have to. They have to send the inmate back to the general population, because they don’t have enough beds to house all the thousands of mentally ill inmates in the Ohio state prison system.

At this point I got into a discussion with a classmate about why these inmates aren’t all housed in such therapeutic environments as Oakwood. But where would Ohio state get the money to pay for those units to be built? How would they decide who is mentally ill enough to end up in such a facility? And is it ethical to treat some 16% of their inmate population so humanely and ignore the inhumane treatment of all the other prisoners? Do the “healthy” prisoners not matter just because they don’t have a serious mental illness? Once we start creating this humane prison system, where do we stop?

During most of the documentary, I was applauding Ohio state for at least trying to create a therapeutic environment for its mentally ill inmates. But there were a couple of comments which made me rethink. Reginald Wilkinson, the Director of the Ohio Department of Corrections said that he once had a judge mention to him: “Well, I hate to do this, but you know the person will get treated if we send the person to prison.” So judges are more likely to give a prison sentence because they feel there’s better mental health care there? My question was confirmed later in the documentary when it pointed out: “We shouldn’t devote ourselves to continually raising the level of mental health care in prisons because the better you make an institution that shouldn’t be used for the purpose you’re improving, the more you’re ensuring its use.”

It’s a catch-22. If you don’t work to take care of the mentally ill in prisons, they’ll get worse and you’ll have to stash them away in solitary or other “general population” punishment areas. If you do develop a system to care for the mentally ill, then you end up with even more mentally ill people dumped into your system, where they don’t belong. So tragic. I wish enough people cared about this highly stigmatized group so that money could be raised to properly care for both the imprisoned and the unimprisoned mentally ill.

4 snowflakes for interest level, research, approachableness, and subject

Abnormal Psychology in Contemporary Society

Our class only read part of chapter 17 of Butcher’s Abnormal Psychology: a section about inpatient mental health treatment in contemporary society and another about controversial legal issues and the mentally ill.

Mental health treatment in contemporary society

In the late 19th century, mental hospitals were filled with patients. Many of these patients lived in a horrific environment that was unhealthy both physically and mentally. In those hospitals that had humane treatment of patients, there was a concern that patients would get “institutional syndrome” – in which people lost their ability to socialize and live independently because they had been in a mental hospital for so long.

In the mid-to-late 20th century, a movement to deinstitutionalize the mentally ill gained momentum. It began in the 1950s and 60s, when antipsychotic drugs were developed. These medications made it possible for patients to leave hospitals and live independent lives. Later, a desire to rescue people from inhumane environments and to keep them from getting “institutional syndrome” accelerated the rate of deinstitutionalization. Another consideration in deinstitutionalization was the desire to decrease medical expenditures. As mentioned in my earlier post on Chapter 2, deinstitutionalization was detrimental to many mentally ill people. One third of the homeless population is comprised of mentally ill people, and a horrifying number of the mentally ill are incarcerated with little to no mental health treatment (which, by the way, means that society is still doling out the bucks to pay for the housing of mentally ill).

In contemporary American society, if a person is unable to care for himself, or if he is a danger to himself or others, he can be placed in a psychiatric hospital. Such a commitment can be voluntary, but if someone is considered a danger to himself or society and he refuses hospitalization, civil commitment procedures can be undertaken, and he can be confined involuntarily in a mental hospital.

Such hospitals generally combine traditional forms of therapy with a constructive social environment. A study in 1977 by Gordon L. Paul and Robert L. Lentz compared the relative effectiveness of three treatment approaches.

Milieu therapy, which focuses on providing the patient with a very clear idea of what the staff expectations are and providing feedback about compliance with those expectations, encouraging the patients to be active in their own treatment decisions, and providing social groups for support and “positive” peer pressure.

Social-learning, in which the patients learn socially acceptable behavior through a token economy (they get tokens when they behave well). With tokens, the patients can buy privileges.

Traditional treatments, with pharmacotherapy, occupational therapy, and individual group therapy. For instance, a friend of mine was recently released from a mental health ward which had psychological therapy, psychiatry, yoga, prayer meetings, knitting classes, and all sorts of social groups.

Paul and Lentz studied 28 schizophrenic patients for resocialization, learning new roles, and reducing bizarre behavior. From the social learning program, 90 percent of the patients remained in the community after release; compared to the 70 percent who’d had milieu therapy, and the less than 50 percent who’d had traditional therapy. I haven’t read it, but there’s a review of Paul and Lentz’s study available here.

All of these programs seem like a positive change from the early 20th century, but in order to voluntarily get into one of these hospitals, the patient must have both resources and mindfulness of illness. In order to get involuntarily committed, the patient must have an advocate willing to report his danger. Most of the homeless do not have such advocates, and thus they slip between the cracks.

Controversial legal issues and the mentally ill

In recent years news reports have sensationalized grizzly murders committed by sociopaths and psychotic people. In fact, one such grizzly murder was just discovered in the Twin Cities (where I live). It’s easy to say that if only the mental health system were better, we could prevent such tragedies. But how do you really know when someone is dangerous before they actually do anything? A mental health professional is authorized to make such a judgement call, though the dangerous person must first be seeing a mental health professional before any judgement can be made. And often a patient gives no hint of his violent thoughts.

If the patient does give a hint of violent thoughts, the mental health worker (or even a priest during confession), has the duty to report the dangerous individual to the authorities, and in some states to warn the individual who has been threatened.

One huge controversy about dangerous mentally ill people is the insanity defense (or not guilty by reason of insanity, NGRI). Someone can be successful with this plea if he is thought to not know right from wrong or if he was compelled irresistibly to perform the violent act. The defense attorney must obtain the testimony of a mental health professional who convincingly claims that the accused was insane at the time of the crime.

Because it is very difficult to be acquitted as NGRI some people plea “guilty but mentally ill (GBMI).” With success of this plea, the convicted would be found guilty but placed in a mental institution instead of a prison. Many hope that this plea will decrease the number of patients who are found not guilty by reason of insanity, are confined to a mental institution, soon judged to be in recovery, and are unconditionally released into society. When a person is found guilty but mentally ill, he remains for his entire sentence in the mental institution.

A third way that a mentally ill person can protect himself from unethical treatment is to claim incompetence to stand trial. If a person is charged with a crime but is unable to understand the proceedings due to mental health, he can postpone the trial until they have recovered sufficiently to understand. Such people can be hospitalized until they are deemed competent.

An interesting point that the authors brought up was about patients diagnosed with disassociative identity disorder, DID – formerly known as multiple personality disorder. If one personality commits a crime, is it ethical to punish all personalities? This is a question that first occurred to me several years ago while reading A Fractured Mind, by Robert B. Oxnam. Oxnam gave a few examples of when one personality did something “wrong,” and Oxnam implied that he, himself, was not guilty of those transgressions, because it was his other self that committed them. The two examples I remember are when one of his personalities cheated on his wife and when one of his personalities stole a bunch of stuff from a boating store. It peeved me that Oxnam thought it was ok to brush off those acts by saying “the other (bad) me did it.” But perhaps that is because I’m skeptical of true multiple personalities that are unaware of, and unable to control, the others’ actions. If it does exist, I’m sure it’s very, very rare.

On the other hand, I do know someone who has disassociative episodes and was caught doing something illicit during an episode. But my friend has never blamed the “other” guy – he seems quite willing to step up and take the blame. Somehow that willingness to accept the blame makes him seem less culpable, in my eyes, than Oxnam.

What do you think? Do you believe that people with DID can have completely separate identities that are unaware of, and unable to control, each others’ actions? Do you think the entire set of identities should be punished if one personality commits a crime?

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 17: Contemporary and Legal Issues in Abnormal Psychology. Abnormal Psychology, sixteenth edition (pp. 583-607). Pearson Education Inc.

A History of Abnormal Psychology

Chapter 2 of Butcher’s Abnormal Psychology is a bit harder to summarize than Chapter 1. It covered the reactions of people towards the mentally ill throughout history. There were lots of names mentioned, and trends galore. But I will try to focus on the ones that I found most interesting.

During the classical age of Greek and Roman philosophers, mental illness began to be viewed more as a physiological trait than as demonic possession, which was the common viewpoint before this time. Hippocrates, a Greek philosopher considered the father of modern medicine, believed that mental illnesses were due to brain pathology. He recognized heredity, predisposition, and head injuries as common causes of mental illness. The doctrine of the four humors was related to Hippocrates and later to the Roman physician Galen. These four fluids in the body could combine in different ways to regulate the personality of an individual. Hippocrates promoted healthy living as a remedy to mental illness.

Plato, also, supported the kind, empathetic treatment of mentally ill individuals. He suggested that mentally disturbed individuals were not responsible for criminal acts. However, Plato viewed mental illness, at least partly, as an effect of spirituality. Hippocrates’ and Plato’s support of humane treatments for mental illness influenced later Greek and Roman philosophers.

During the Middle Ages, the belief that mental illness had physiological origins almost disappeared in Europe. The texts of the Greeks and Romans survived in Islamic and Middle Eastern regions, but very few Europeans of this time were able to read Greek or Roman texts. The Middle Ages marked a regression in both scientific and philosophical thought. The Greek and Roman texts weren’t “rediscovered” until the Renaissance.

Supernatural explanations for mental illness gained popularity, and treatment was left mainly to the clergy. At least the treatment of the mentally ill by the clergy was mainly humane.

It is commonly thought that the mentally ill were often accused of being witches during the Middle Ages, and were thus cruelly executed. However, recent research suggests that witchcraft was not believed to be an effect of possession, as mental illness was. Usually the accused were ill-tempered, impoverished women.

Scientific explanations for mental illness reemerged in the late Middle Ages and Renaissance. Even some of the clergy were falling away from possession as the cause of mental illness. Saint Vincent de Paul declared “Mental disease is no different than bodily disease and Christianity demands of the humane and powerful to protect, and the skillful to relieve the one as well as the other.”

Despite the resurgence in the belief of physiological explanations for mental illness during the Renaissance, inhumane asylums for the storage of individuals who could not care for themselves were on the rise.

In the late 1700s, humanitarians began to intervene on behalf of the mentally ill. Physicians began to experiment with more humane treatment of individuals. The French physician Philippe Pinel demonstrated that the removal of chains, and introduction of healthy living in an asylum had extraordinary effects on the recovery of mentally ill individuals. English Quaker William Tuke later established a pleasant retreat for mentally ill patients, with similar positive results.

The success of Pinel and Tuke led to a period of humanitarian reform and the use of moral management. This movement promoted the rehabilitation of moral and spiritual character, as well as manual labor. Moral management was highly effective. Recovery and discharge rates increased dramatically.

Unfortunately, moral management made way to the mental hygiene movement, which emphasized the physical (rather than spiritual) treatment of institutionalized patients. Although hygiene and the belief in physiological as well as spiritual causes of mental illness were important, improving the hygiene of the patients alone was not successful, and recovery rates plummeted. However, the mental hygiene movement was meant to create a more humane environment for the institutionalized – so in that way it was progress.

The number of institutionalized patients increased throughout the 19th and 20th centuries, but during the late 20th century humanitarians began to support deinstitutionalization of the mentally ill. Popular culture seems to believe deinstitutionalization to be a good thing – and for many, it was. Reintroduction of the mentally ill and developmentally challenged to their supportive families was a huge success when that family had the resources to care for its loved one. However, deinstitutionalization occurred too quickly, leaving many people without shelter, and of those who had shelter, many families didn’t have the resources to care for the patients. Many of the shelterless people became homeless, and others were quickly shunted off into prisons.

During the 19th and 20th centuries, four major themes in psychology developed: 1) biological discoveries, 2) classification system for mental disorders, 3) the emergence of psychological causations and views 4) experimental and research psychology.

The first major breakthrough in biological treatment of mental illness was the discovery that a form of paresis was caused by syphilis. This discovery boded well for the discovery of more biological treatments for other illnesses. Later discoveries showed deterioration of the brain led to senility and that some disorders could be caused by exposure to toxic substances. Biological treatments also had some mishaps – such as surgical removal of body parts including tonsils, part of the colon, gonads, and the frontal lobe of the brain.

Emil Kraepelin, a German psychiatrist, pioneered classification of mental illnesses, and his system became the forerunner to the DSM.

The Nancy school began a movement exploring psychological causations of mental illness. Two scientists in Nancy, France, discovered that some of the traits observed in hysteria – psychological paralysis, blindness, deafness, and pain – could be introduced in healthy patients through hypnosis. These symptoms could also be removed by hypnosis. Therefore, the Nancy school believed that hysteria, and later other disorders, were a form of self-hypnosis. Jean Charcot, a French neurologist, disagreed with the Nancy School. His research suggested that mental disorders were caused by brain degeneration. Toward the end of the 19th century, it was accepted that mental disorders could have a psychological basis, biological basis, or both.

Sigmund Freud was a student of Charcot, but later leant more towards the psychological causations mental illness. Freud discovered that if patients were encouraged to discuss their problems under hypnosis, they felt considerable emotional release. The patients, upon awakening, made no connection between their problems and their disorder. This led to the discovery of the unconscious mind. Freud also discovered that free-association and dream analysis had the same cathartic effect on his patients.

By the first decade of the 20th century clinical psychology labs, which performed experiments on causes and treatments of mental illness, were on the rise. Soon, the behavioral perspective developed. This perspective emphasized the role of learning in disorders. It began with Ivan Pavlov’s serendipitous discovery that he could condition dogs to salivate upon the ringing of a bell. Watson used Pavlov’s discovery to develop behaviorism – the belief that humans gain personalities through changes in their environments. Watson believed that he could train a child to become anyone he wanted the child to become simply by creating the right environment. (Stephen Pinker’s argument against this belief is discussed in my review of The Blank Slate.)

B. F. Skinner developed his own form of behaviorism in which consequences of behavior influenced subsequent behavior. This type of learning was named “operant conditioning.” For example, positive conditioning occurs when someone is rewarded for a behavior, such as when we give a treat to a potty-training child who has successfully used the toilet. Negative conditioning occurs when a child receives a shock when sticking his finger into an electrical outlet.

And thus abruptly ended Chapter 2 – after a long list of names and dates that the book thought were important for us to remember.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 2: Historical and Contemporary Views of Abnormal Behavior. Abnormal Psychology, sixteenth edition (pp. 29-53). Pearson Education Inc.

The Definition of Abnormal

Well, my first week of Abnormal Psychology is through. We’ve read chapters 1-2 of our textbook, Abnormal Psychology by James N Butcher.

Chapter 1 was mainly about defining “abnormal” in the sense of “abnormal psychology.” This is a lot more difficult than you might imagine.

You could try a statistical approach, for instance. If someone’s behavior is statistically rare, then that behavior is abnormal. But lots of people have behavior that is statistically rare. For instance, I went to the Minnesota Renaissance Festival just yesterday, and enjoyed some good people-watching. The Ren Fest has a variety of people – some are just pop-culture “nerds.” Some are people who love cosplay (where you dress up as a character – either made up by you or pre-created in popular culture – and act as if you are that person). And some people honestly believe they are wizards. Should we consider any of these statistically rare behaviors due to mental illness? Well, perhaps people who really believe they are wizards, but some of those people are pagans – and should we consider people of a rare religion to be mentally ill per se?

You could also try a societal norm approach. If someone behaves outside the behavioral norm, then they are abnormal. But this, in itself does not imply mental illness. Societal norms can change from culture to culture. As an example, in some tribal cultures, the men cut themselves over and over again to “beautify” themselves with scars; but in America teens who cut are generally diagnosed with depression. Norms can also change within one culture over time. For instance, a couple decades ago homosexuality was considered a mental illness, but now it is, for the most part, accepted as “normal” behavior for certain individuals.

There is also the maladaptive approach. If someone’s behavior is injurious to himself or to society, then he is abnormal. A person with OCD who washes her hands so much that they are cracked and bleeding is maladaptive. But this approach is not full-proof either. Not everyone who commits a crime is mentally ill. Likewise, should we consider someone who donates bone marrow, blood, or a kidney mentally ill?

Many people who are mentally ill suffer. But not all. The mania state of bipolar disorder is often pleasant to the patient, but he is considered mentally ill. Also, where do we draw the line of diagnosing mental illness for those who are suffering? If someone has just lost her home or a loved one, she is suffering from grief. But isn’t grief a natural and healthy response, within limits?

Another approach is irrationality and unpredictability, but teenagers and young adults often do irrational and unpredictable things for attention or just because they’re trying to impress a girl. Mental illness? Nah.

The last approach I will discuss is dangerous behavior. But yet again, that is not always indicative of mental illness. Many people jump out of planes, bungee jump, or fight in a war. These people are not considered “abnormal.”

The DSM-5 defines mental disorder as:

“a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

What the heck does that mean?

In the end, mental illness diagnoses are subjective to the clinician. For instance, I was diagnosed with bipolar disorder II. This means that I experience abnormal highs and lows (as well as other traits). I totally agree with this diagnosis. But another psychiatrist diagnosed me with borderline personality disorder. “What?!” I said. I don’t have an intense fear of abandonment, a pattern of intense interpersonal relationships characterized by alternating states of idealization and devaluation, paranoid ideation, or disassociative symptoms. Granted, I have more than 5 other traits, which makes me diagnosable with borderline. But all of those symptoms are traits that can be explained by bipolar disorder. So why the boderline personality disorder diagnosis?

What do you think? How would you define “abnormal”?

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 1: Abnormal Psychology: An Overview. Abnormal Psychology, sixteenth edition (pp. 2-27). Pearson Education Inc.

Vulnerability – My deepest fear

As usual this week I am combining my Life of a Blogger (by Novel Heartbeat) post with my Friendship Friday (by Create with Joy). This week’s topic is fears.

Some fears are easy to discuss, and some are harder to discuss. It depends a lot on what your fears are. For instance, I have a fear of making myself vulnerable. So stating my fears actually goes against one of my deepest fears. However, I’ve been working on this specific fear, so this post will be a good opportunity to test out my new mad skilz at being vulnerable.

The Scream
Artist: Edvard Munch
(who theoretically had bipolar)

One of the things that has been making me feel vulnerable lately is my recent diagnosis of bipolar disorder. For those of you who are unfamiliar with this diagnosis, it used to be called manic-depressive disorder. I’m diagnosed with type 2, which means I’ve only been “hypomanic” and not “fully manic.” Hypomania increased my irritability, irrationality, and impulsivity while (on a happier note) making me feel that I couldn’t be wrong, that I had the ability to climb the highest mountains and take on the world. I lost several people I considered friends during that period. And that still makes me feel abandoned and vulnerable. (Though, I have to admit, the online community is SO amazingly supportive, and I’m very thankful for you guys. You’re all rockstars!)

With the spirit of fighting my fears, I will admit that the reason my blog has been a bit quiet last week is because I was in the psych ward of the hospital. (My doctor was unfortunately not as handsome as the one above.) I was really angry at my psychiatric NP for putting me there, because I didn’t feel that I was in crisis at that time. But now that I’m out, I realize that he was trying to make sure I was stabilized and ready for my new job, which starts on the 2nd of September. He was being forward thinking, and I was very unappreciative. I guess I’ll have to thank him later.

I hadn’t originally planned on writing about my mental illness on this post – nor had I planned to mention that I’d been hospitalized in my upcoming weekly update. But when I was searching stock photos for a nice illustration of fear, I found the one above. It seemed fitting, somehow. Before I can change (and therefore master my new job), I need to admit to myself that I actually am in crisis. And to admit that, I need to make myself vulnerable.

The picture I wanted to choose for this post is the one above – with the spooky religious images. I’d already been having a bit of a faith crisis before I was diagnosed with bipolar, but the diagnosis put my faith into a tailspin. What if…I thought…what if all this time that I thought I was being inspired or called by God, all those feelings of “rightness” and euphoria were just figments of a hypomanic mind? That is the most terrifying feeling I’ve ever experienced. The foundation of my faith was no longer stable. I’d say on the Richter scale this faithquake was about a 6.5. Most of my faith is still there, but I’m walking around all wobbly. There were a lot of things I felt that God had called me to do – writing is among them. I started writing this blog because I felt that God wanted me to write, and a blog would be a good place to practice both writing and marketing. Now I wonder…what do I blog for? If I give up on my faith, do I stop blogging?

Anyway, putting my vulnerability and faith aside, my own diagnosis of mental illness is a fantastic segue to plug my upcoming Suicide and Mental Illness Theme Read. Don’t forget to stop by my blog in September and October to see what people are reading and watching for this event. I’ll also be having a couple of giveaways. You’re welcome to jump in and participate at any point in time…all you need to do is read or watch something that educates you on suicide or mental illness. It can even be something that’s an accurate portrayal of mental illness – just tell us why you think it’s not. 🙂 I have a list of suggestions for both books and movies.