Here's a site which has a good selection of free personality questionnaires:
http://similarminds.com/personality_tests.html
I find that questionnaires of this type rarely give any novel information that you wouldn't know about yourself already, and be able to describe in a short self-descriptive paragraph. Many such questionnaires are actually copyrighted, and one needs to pay a fee just to have a copy. I've always had a bit of a problem with this, as I think it exaggerates the importance of what is usually a simple set of questions, which in my opinion should usually be in the public domain. It is annoying to read a journal article about questionnaires (which are often referred to, in a somewhat aggrandizing way, as "instruments," as though we are talking about some kind of highly sophisticated engineering technology), where the copyrighted questionnaire is referred to in the article, but you can't actually see the questions!
But spending some time with these things can have a few positives:
1) a framework for reflection -- sometimes questionnaires can deal with questions or phenomena which are relevant, but rarely thought about or discussed. The questions can be a cue or a framework to contemplate issues. Some of these issues could be addressed in a therapeutic discussion.
2) entertainment -- it can be an interesting or possibly enjoyable activity to fill out questionnaires, and compare your results with others in the population.
It would be important to resist any tendency to be self-critical about your results; everyone will have a unique set of responses, some of which may change over time, or be mood-dependent, as well. Questionnaires are an imperfect way to measure any sort of characteristic anyway. But in any case, a questionnaire is a bit like a lens or a camera--it produces data which can be informative. Sometimes the information can be unique or interesting, like a clever snapshot of yourself from a camera; but other times the information may not be very unique or interesting at all (like a poorly-lit or blurry snapshot of yourself). Even if you may have issues with the way a particular questionnaire is constructed, it can be interesting to see how your responses compare on a percentile basis with others. You may find certain phenomena about yourself that you previously thought were quite extreme, are in fact really quite close to the population average. Or you might discover there are other phenomena which are farther from the mean. Any of these findings might be a subject of future therapeutic dialog.
Showing posts with label Diagnostic Information. Show all posts
Showing posts with label Diagnostic Information. Show all posts
Wednesday, September 15, 2010
Thursday, January 22, 2009
Antisocial Personality
Many people use the term "antisocial" in daily language to describe a feeling of not wanting to socialize, or of reclusiveness.
In DSM terminology, "antisocial personality" refers basically to a history of criminal behaviour.
So it is important to clarify what is meant by "antisocial" if it comes up in conversation.
I suppose, like all other judgmental categories characteristic of the DSM, one ought to question carefully what is considered "criminal", and whether this assessment is a product of cultural bias, prejudice, etc.
For example, a protestor advocating for civil rights in some tyrannical regime might be arrested
and labeled a criminal by some, a hero by others. These assessments might also change with the passage of time--the next generation might view the same events quite differently than we do today.
A soldier who has killed dozens of people in a battle might be considered a hero by some, a criminal by others. Depends on whose side you're on, I guess. And it depends upon one's sense of morality or fairness, regardless of whether you're on a "side" or not.
However, I do believe that there are types of behaviour, present in any population (whether the population is at peace, in a war, in states of wealth or poverty, etc.), which could be considered "antisocial".
The main "antisocial" problem in an individual that concerns me is a history of recurrent cruel or violent behaviour towards other people.
There are many other types of criminal behaviour, involving stealing, fraud, dealing drugs, etc.
And there are types of behaviour that are not "against the law", but which often accompany other antisocial problems. For example, a pattern of lying frequently in order to attain social or material goals. Or, simply, acting with no regard for, or understanding of, another person's feelings or well-being.
Once again, I suppose these phenomena need to be considered in a cultural context. If a person is lying, stealing, or engaging in forgery in order to help a persecuted person escape from a tyrannical regime, then such acts could be considered among the highest forms of altruistic heroism. Yet, for some individuals, such behaviours have been part of a daily pattern, independent of other circumstances, ever since early or middle childhood.
Another so-called antisocial trait would be a recurrent failure to take responsibility, to feel or express remorse, for actions that have caused harm to others.
Often times, antisocial behaviour has developed in childhood, and persisted through adult life. An important contributing cause is a childhood environment in which there is a lot of antisocial behaviour in the home and in the community. A history of trauma, neglect, or abuse can be risk factors. There are genetic predispositions, probably best understood by indirect influences, such as inherited tendencies towards aggressiveness, irritability, impulsiveness, difficulties perceiving or being moved by others' emotional states, etc.
Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/16291212
Antisocial behaviour has a strong subcultural influence as well, for various reasons. First of all, if a person is aggressive, they are more likely to associate with other aggressive people. In this way, violence may become more of a norm within this subculture, or even a quality to emulate or to boast about, leading to some elevation of social status within the group.
The criminal justice system deals with a lot of antisocial behaviour through the prisons. While sending a violent person to prison may protect society during the prison term, it exposes that violent person to a subcultural milieu in which all of his (or her) neighbours have also committed criminal offenses. This may perpetuate that person's "antisociality".
In psychiatric practice, I find that antisocial behaviour is very difficult to address. The main issue for me is my own feeling of safety--if the therapist does not feel safe with someone, I don't think therapy is possible.
So, I think safety is an essential prerequisite for any sort of therapy. Court-mandated therapy in a safe setting (such as a prison) may well lead to improvements in symptoms for many people with antisocial behaviour (e.g. learning about anger management, treating irritable depression, etc.). However I think that externally-mandated therapy is always likely to be very limited.
Another big problem with so-called "antisocial personality" is that this style may be what is called "ego-syntonic". That is, the individual may have no wish to "change", or have no true perception that there is any sort of "problem" with them. They may attribute their episodes of violence, etc. or their prison terms, to other people having crossed them the wrong way, or to the bad luck of having been caught. Or they may simply engage in various apparently positive social tasks motivated only by a sense of immediate material gain (e.g. they may be friendly or charming with someone only to be able to build enough trust to rob them, or sleep with them later, etc.). For ego-syntonic problems of this type, I do not think psychotherapy can be effective at all. It may in fact be just one more game that the person plays, in this case with the therapist.
There was a movie a few years ago called The Corporation (written by BC law professor Joel Bakan) which argues that corporations (big business enterprises) in our society function as antisocial individuals (the law actually considers them "persons"), and that our current system of laws actually encourages or even mandates this as a norm. A core part of this argument was based on the fact that a corporation's primary motive is maximizing profit; well-being, empathy, ecological stewardship, etc. may well be considered, but only as instruments to maximize profit, not as primary motives. This is similar to understanding the behaviour of a person with "antisocial personality" as being motivated primarily by the plan of immediate individual gain. (incidentally, I found this movie to be good, and I agree with many of its ideas, but it would have been much more effective and convincing for more people had it presented its case in a more balanced manner -- it comes off as politically very left-wing partisan, somewhat dogmatic, presents only one side of various issues, and therefore will immediately alienate and disengage others with different political views, who are likely to reflexively dismiss it, rather than accept its ideas or engage in a productive dialog).
Getting back to so-called antisocial personality, I think that if therapy is to help at all, it would have to require, first, that the therapist feels safe, and second, that the person truly wishes to work, on some level, on building a sense of care, love, and altruism for others. Otherwise therapy might be quite limited, for example to offering some help reducing subjectively bothersome irritability (help which would hopefully reduce future episodes of violence, etc.).
In terms of medical records, I do think that noting a history of antisocial behaviour is relevant, for safety reasons. Persons with a history of recurrent violence, sexual assault, stealing, etc. may pose a risk to fellow patients or staff during a hospital stay.
The other means of dealing with antisocial personality involve structures other than psychiatry. The criminal justice system is currently the main other structure. I feel that reform of the prison system could be a powerful change, since I think it is harmful for dangerous individuals to be locked up among a group of other dangerous individuals, then released again into society.
I wonder if modern technology could be one example of a practical solution for some cases: for example, if a violent person such as an assaultive husband or sexual offender, is given a restraining order forbidding access to his wife, family, or ex-girlfriend, it may be much safer for society, and especially for the wife, family, ex, etc. if the offender has some kind of electronic monitoring (using GPS technology, for example) which would immediately alert the family and the police if the offender were to violate the conditions of the restraining order (e.g. by approaching within a 1 km radius). It would permit the victims to feel safe, while doing least harm to the offender (by not exposing him to the negative environment of prison). Such a strategy could be much more effective than sending the offender to prison, since everyone would be right back to square one--or worse-- the moment after the prison term ended. I think of how many tragic episodes of violence (numerous such examples from local media alone in the past few years) could have been prevented if such a system were in place.
In DSM terminology, "antisocial personality" refers basically to a history of criminal behaviour.
So it is important to clarify what is meant by "antisocial" if it comes up in conversation.
I suppose, like all other judgmental categories characteristic of the DSM, one ought to question carefully what is considered "criminal", and whether this assessment is a product of cultural bias, prejudice, etc.
For example, a protestor advocating for civil rights in some tyrannical regime might be arrested
and labeled a criminal by some, a hero by others. These assessments might also change with the passage of time--the next generation might view the same events quite differently than we do today.
A soldier who has killed dozens of people in a battle might be considered a hero by some, a criminal by others. Depends on whose side you're on, I guess. And it depends upon one's sense of morality or fairness, regardless of whether you're on a "side" or not.
However, I do believe that there are types of behaviour, present in any population (whether the population is at peace, in a war, in states of wealth or poverty, etc.), which could be considered "antisocial".
The main "antisocial" problem in an individual that concerns me is a history of recurrent cruel or violent behaviour towards other people.
There are many other types of criminal behaviour, involving stealing, fraud, dealing drugs, etc.
And there are types of behaviour that are not "against the law", but which often accompany other antisocial problems. For example, a pattern of lying frequently in order to attain social or material goals. Or, simply, acting with no regard for, or understanding of, another person's feelings or well-being.
Once again, I suppose these phenomena need to be considered in a cultural context. If a person is lying, stealing, or engaging in forgery in order to help a persecuted person escape from a tyrannical regime, then such acts could be considered among the highest forms of altruistic heroism. Yet, for some individuals, such behaviours have been part of a daily pattern, independent of other circumstances, ever since early or middle childhood.
Another so-called antisocial trait would be a recurrent failure to take responsibility, to feel or express remorse, for actions that have caused harm to others.
Often times, antisocial behaviour has developed in childhood, and persisted through adult life. An important contributing cause is a childhood environment in which there is a lot of antisocial behaviour in the home and in the community. A history of trauma, neglect, or abuse can be risk factors. There are genetic predispositions, probably best understood by indirect influences, such as inherited tendencies towards aggressiveness, irritability, impulsiveness, difficulties perceiving or being moved by others' emotional states, etc.
Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/16291212
Antisocial behaviour has a strong subcultural influence as well, for various reasons. First of all, if a person is aggressive, they are more likely to associate with other aggressive people. In this way, violence may become more of a norm within this subculture, or even a quality to emulate or to boast about, leading to some elevation of social status within the group.
The criminal justice system deals with a lot of antisocial behaviour through the prisons. While sending a violent person to prison may protect society during the prison term, it exposes that violent person to a subcultural milieu in which all of his (or her) neighbours have also committed criminal offenses. This may perpetuate that person's "antisociality".
In psychiatric practice, I find that antisocial behaviour is very difficult to address. The main issue for me is my own feeling of safety--if the therapist does not feel safe with someone, I don't think therapy is possible.
So, I think safety is an essential prerequisite for any sort of therapy. Court-mandated therapy in a safe setting (such as a prison) may well lead to improvements in symptoms for many people with antisocial behaviour (e.g. learning about anger management, treating irritable depression, etc.). However I think that externally-mandated therapy is always likely to be very limited.
Another big problem with so-called "antisocial personality" is that this style may be what is called "ego-syntonic". That is, the individual may have no wish to "change", or have no true perception that there is any sort of "problem" with them. They may attribute their episodes of violence, etc. or their prison terms, to other people having crossed them the wrong way, or to the bad luck of having been caught. Or they may simply engage in various apparently positive social tasks motivated only by a sense of immediate material gain (e.g. they may be friendly or charming with someone only to be able to build enough trust to rob them, or sleep with them later, etc.). For ego-syntonic problems of this type, I do not think psychotherapy can be effective at all. It may in fact be just one more game that the person plays, in this case with the therapist.
There was a movie a few years ago called The Corporation (written by BC law professor Joel Bakan) which argues that corporations (big business enterprises) in our society function as antisocial individuals (the law actually considers them "persons"), and that our current system of laws actually encourages or even mandates this as a norm. A core part of this argument was based on the fact that a corporation's primary motive is maximizing profit; well-being, empathy, ecological stewardship, etc. may well be considered, but only as instruments to maximize profit, not as primary motives. This is similar to understanding the behaviour of a person with "antisocial personality" as being motivated primarily by the plan of immediate individual gain. (incidentally, I found this movie to be good, and I agree with many of its ideas, but it would have been much more effective and convincing for more people had it presented its case in a more balanced manner -- it comes off as politically very left-wing partisan, somewhat dogmatic, presents only one side of various issues, and therefore will immediately alienate and disengage others with different political views, who are likely to reflexively dismiss it, rather than accept its ideas or engage in a productive dialog).
Getting back to so-called antisocial personality, I think that if therapy is to help at all, it would have to require, first, that the therapist feels safe, and second, that the person truly wishes to work, on some level, on building a sense of care, love, and altruism for others. Otherwise therapy might be quite limited, for example to offering some help reducing subjectively bothersome irritability (help which would hopefully reduce future episodes of violence, etc.).
In terms of medical records, I do think that noting a history of antisocial behaviour is relevant, for safety reasons. Persons with a history of recurrent violence, sexual assault, stealing, etc. may pose a risk to fellow patients or staff during a hospital stay.
The other means of dealing with antisocial personality involve structures other than psychiatry. The criminal justice system is currently the main other structure. I feel that reform of the prison system could be a powerful change, since I think it is harmful for dangerous individuals to be locked up among a group of other dangerous individuals, then released again into society.
I wonder if modern technology could be one example of a practical solution for some cases: for example, if a violent person such as an assaultive husband or sexual offender, is given a restraining order forbidding access to his wife, family, or ex-girlfriend, it may be much safer for society, and especially for the wife, family, ex, etc. if the offender has some kind of electronic monitoring (using GPS technology, for example) which would immediately alert the family and the police if the offender were to violate the conditions of the restraining order (e.g. by approaching within a 1 km radius). It would permit the victims to feel safe, while doing least harm to the offender (by not exposing him to the negative environment of prison). Such a strategy could be much more effective than sending the offender to prison, since everyone would be right back to square one--or worse-- the moment after the prison term ended. I think of how many tragic episodes of violence (numerous such examples from local media alone in the past few years) could have been prevented if such a system were in place.
Thursday, January 8, 2009
Borderline Personality, addendum:
I continue to feel this whole subject--of borderline personality-- is a dicey one to wade into, but I didn't want to be avoiding it either.
Part of a problem I've observed is that many extremely important and valid concerns or complaints can be dismissively pathologized as part of a "personality disorder trait".
For example, negative experiences of physicians or the hospital system need not be considered part of an individual's "pathology".
In fact, I think it is more uncommon than common for anyone to have a smooth journey through any medical care system--it tends to be laden with frustration, despite hopefully encountering some good people along the way.
Negative experiences of individual caregivers or relationships within a system need not be dismissed as so-called "splitting" (a "borderline" phenomenon)--they may be accurate and insightful accounts of having encountered a negative relationship.
The experiences may be a product of having encountered poor medical care, a poor medical system, or an unhealthy set of social structures which provide inadequate help. Sometimes an individual's complaints about these negative experiences may actually be a sign of courage, a character strength, rather than of a "borderline trait".
I think a larger view of so-called "borderline phenomena" has to do with group dynamics, as opposed to individual dynamics. If expressions of concern or frustration are met with hostile, judgmental, or inconsistent reactions, this may magnify the initial concerns or frustrations, leading to a vicious cycle. Each individual in such a dynamic may be behaving "healthily", but the relationship is not working. The relationship failure may be due to an inadequate structure, a lack of mutual understanding, communicative failure, a long history of relationship problems which biases the present point of view, tiredness or frustration on either side, or an insurmountable cultural gap. This reminds me of some of the conflicts between nations that go on today, in which each nation's "point of view" is understandable and valid, but the relationship fails, sometimes in a very destructive way, sometimes leading to an "arms race." Ironically, in psychiatry, such borderline relationship dynamics may occur involving the very individuals who are trying to be relationship mediators. My point here is that sometimes it is not the individual who has a "borderline personality disorder", but the relationship, or the system, which is suffering from "borderline dynamics".
An author on the subject of borderline personality I consider important is David Dawson. Title: Relationship Management of the Borderline Patient, Brunner/Mazel, 1993
I do find him wise and frank. He challenges some of the the professionally self-indulgent dogmas about psychotherapy, psychiatric hospitalization, and psychiatric medication, dogmas which may not apply to every situation, dogmas which may well, in some cases, aggrandize the "healing power" of the system or the therapeutic process, dogmas which deserve a generous dose of humility in order to more soundly be helpful. He describes numerous dramatic "case vignettes", with much needed attention given to the consideration of process and relationship dynamics. Many of his ideas about the vignettes I disagree with, but the book could open a forum for debate and discussion.
But-- I find his style at times too cynical and lacking in gentle warmth, to affirm it strongly. In fact, Dawson's ideas I think at times have been misapplied in the medical system, used as part of a tactic to prematurely discharge some patients from hospital or from other follow-up care. Yet, I think Dawson's views are important to hear, at least as the starting point for a debate.
Part of a problem I've observed is that many extremely important and valid concerns or complaints can be dismissively pathologized as part of a "personality disorder trait".
For example, negative experiences of physicians or the hospital system need not be considered part of an individual's "pathology".
In fact, I think it is more uncommon than common for anyone to have a smooth journey through any medical care system--it tends to be laden with frustration, despite hopefully encountering some good people along the way.
Negative experiences of individual caregivers or relationships within a system need not be dismissed as so-called "splitting" (a "borderline" phenomenon)--they may be accurate and insightful accounts of having encountered a negative relationship.
The experiences may be a product of having encountered poor medical care, a poor medical system, or an unhealthy set of social structures which provide inadequate help. Sometimes an individual's complaints about these negative experiences may actually be a sign of courage, a character strength, rather than of a "borderline trait".
I think a larger view of so-called "borderline phenomena" has to do with group dynamics, as opposed to individual dynamics. If expressions of concern or frustration are met with hostile, judgmental, or inconsistent reactions, this may magnify the initial concerns or frustrations, leading to a vicious cycle. Each individual in such a dynamic may be behaving "healthily", but the relationship is not working. The relationship failure may be due to an inadequate structure, a lack of mutual understanding, communicative failure, a long history of relationship problems which biases the present point of view, tiredness or frustration on either side, or an insurmountable cultural gap. This reminds me of some of the conflicts between nations that go on today, in which each nation's "point of view" is understandable and valid, but the relationship fails, sometimes in a very destructive way, sometimes leading to an "arms race." Ironically, in psychiatry, such borderline relationship dynamics may occur involving the very individuals who are trying to be relationship mediators. My point here is that sometimes it is not the individual who has a "borderline personality disorder", but the relationship, or the system, which is suffering from "borderline dynamics".
An author on the subject of borderline personality I consider important is David Dawson. Title: Relationship Management of the Borderline Patient, Brunner/Mazel, 1993
I do find him wise and frank. He challenges some of the the professionally self-indulgent dogmas about psychotherapy, psychiatric hospitalization, and psychiatric medication, dogmas which may not apply to every situation, dogmas which may well, in some cases, aggrandize the "healing power" of the system or the therapeutic process, dogmas which deserve a generous dose of humility in order to more soundly be helpful. He describes numerous dramatic "case vignettes", with much needed attention given to the consideration of process and relationship dynamics. Many of his ideas about the vignettes I disagree with, but the book could open a forum for debate and discussion.
But-- I find his style at times too cynical and lacking in gentle warmth, to affirm it strongly. In fact, Dawson's ideas I think at times have been misapplied in the medical system, used as part of a tactic to prematurely discharge some patients from hospital or from other follow-up care. Yet, I think Dawson's views are important to hear, at least as the starting point for a debate.
Wednesday, January 7, 2009
Borderline Personality
There are many patients I have seen who have had some mixture of the following symptoms or experiences:
1) sudden, intense shifts of mood, often towards extreme sadness, emptiness, or rage. Often times, these sudden shifts occur in the context of a relationship event (a disappointment with someone, a conflictual conversation, a breakup, etc.)
2) very chaotic interpersonal relationships -- lots of conflict, sometimes a lot of aggression, sometimes frequent break-ups, reconciliations, break-ups, reconciliations, etc. Sometimes this is a product of the person having chosen a partner with a chaotic relationship style, but sometimes this relationship chaos occurs even with a partner who is calm
3) prominent, longstanding thoughts about suicide, even when mood is better
4) frequent self-injurious behaviour (most frequently, cutting skin with a razor), which is often done to relieve extreme emotional tension. Sometimes self-injury or suicide attempts occur as a form of non-verbal interpersonal communication or protest.
5) prominent, longstanding self-hatred
6) symptoms which "seem psychotic", such as hallucinations, paranoia, or thought disorganization of various types, but which do not have the characteristic qualities or patterns found in psychotic illness such as schizophrenia
7) pronounced confusion about identity, often with respect to gender, sexuality, or "sense of self"
8) difficulty with relationship boundaries
9) a chaotic and often very negative set of experiences with doctors, the health care system, etc.
10) hospital stays in which symptoms got worse rather than better
I have seen many for whom these symptoms were their manifestation of depression, or part of a type of bipolar disorder, and for whom these issues improved following standard treatments for mood disorder.
For others, some of these symptoms are part of a post-traumatic syndrome.
I have seen many others for whom these symptoms seemed to be part of a developmental struggle, arising with adolescence or earlier, and resolving with time, support, work, development of purpose, meaning, community, autonomy, etc. Often a fairly short-term experience of therapy has helped.
For others, these symptoms become more lasting phenomena, and may in fact become more and more entrenched with time. It is as though the person has a chaotic relationship with time itself, which feeds the symptoms, rather than relieving them.
Some of the symptoms, such as self-injury, seem to have strong addictive components. Other types of addictive behaviours (such as substance abuse) are common in this population as well.
For many of my patients, there is so much overlap between "depression" and so-called "borderline personality traits" that I don't find that there is much point being concerned with "labeling" at all, since the same things help with both.
Here are some things that I have found to be helpful in all cases (in addition my standard advice about a healthy, happy lifestyle):
1) gentle, supportive, compassionate, friendly, consistent care in a setting with clear but non-rigid boundaries
2) treatment of specific symptoms pharmacologically (e.g. antidepressants may help with mood; anticonvulsants or antipsychotics may help with anxiety, irritability, insomnia, and lability; stimulants may help with inattention, hyperactivity, or distractability)
3) avoidance of harm (e.g. I would tend to avoid prescribing potentially addictive medications, or medications that are particularly dangerous in overdose; also some types of overly confrontational, reactive, over-medicalized, suggestive, dogmatic, or "digging into the past" styles of psychotherapy can probably be overtly harmful for some people, especially if the therapy style is engaged in without the patient's full understanding or consent).
4) gentle attention to the same kind of dynamics happening in the therapy as what happens in other relationships (e.g. intense conflicts, feelings of abandonment, "chaos"), and an attempt to gently work it out rather than let the symptoms threaten the relationship
5) cognitive-therapy techniques of various types can be particularly helpful; specifically Linehan's "Dialectical Behavioural Therapy" which is a type of cognitive therapy enriched by ideas from Buddhist mindfulness. Also Linehan's ideas emphasize the idea of "validation" which I consider extremely important -- symptoms need to be calmly understood, empathized with, rather than discounted or dismissed
6) long-term dynamically-oriented psychotherapy, 1-on-1 or group (or both). There is an expanding strong evidence base that this helps a lot
7) trying neither to over-react (e.g. push for an immediate hospital visit), nor to under-react (e.g. ignore or dismiss), regarding suicidal thoughts or self-injury; but to try to be understanding and helpful in any case
8) I do not tend to recommend hospitalization, especially through an emergency admission, as a cornerstone of therapy, except I do encourage people to use the emergency rooms if they cannot survive safely through the day and they do not feel they have other resources available. I believe it is much more therapeutic for people to choose themselves whether or not to use the emergency room.
9) a good day-program, if available, can be very helpful. These are harder to find nowadays
A few references:
http://www.ncbi.nlm.nih.gov/pubmed/16437534
(a Cochrane review of psychotherapy for borderline personality)
http://www.ncbi.nlm.nih.gov/pubmed/16437535
(a Cochrane review of medication for borderline personality; this shows, as I would expect, a modest and inconsistent evidence base, which I think supports the idea of being open-minded about using pharmacological therapies, but perhaps of having modest expectations of them, and being wary of relying too heavily on medication treatments alone)
http://www.ncbi.nlm.nih.gov/pubmed/17541052
(a randomized study showing broad, large effects from psychotherapy in patients having a borderline personality diagnosis, over a 1-year period)
http://www.ncbi.nlm.nih.gov/pubmed/18347003
(a study with an 8 year follow-up! --we need more such very long-term studies-- It shows that an intensive day program approach was very helpful)
http://www.ncbi.nlm.nih.gov/pubmed/17427099
(another longer-term study showing substantial benefits from psychotherapy)
It is important to note that many with so-called "borderline personality" may have depression or other problems at the same time, and each of these problems may improve with specific types of therapy. Many studies are not considering these "comorbid" conditions, and therefore underestimate the effectiveness of various types of therapy.
Here is a link to a dialectical-behavior therapy self-help site:
http://www.dbtselfhelp.com/index.html
1) sudden, intense shifts of mood, often towards extreme sadness, emptiness, or rage. Often times, these sudden shifts occur in the context of a relationship event (a disappointment with someone, a conflictual conversation, a breakup, etc.)
2) very chaotic interpersonal relationships -- lots of conflict, sometimes a lot of aggression, sometimes frequent break-ups, reconciliations, break-ups, reconciliations, etc. Sometimes this is a product of the person having chosen a partner with a chaotic relationship style, but sometimes this relationship chaos occurs even with a partner who is calm
3) prominent, longstanding thoughts about suicide, even when mood is better
4) frequent self-injurious behaviour (most frequently, cutting skin with a razor), which is often done to relieve extreme emotional tension. Sometimes self-injury or suicide attempts occur as a form of non-verbal interpersonal communication or protest.
5) prominent, longstanding self-hatred
6) symptoms which "seem psychotic", such as hallucinations, paranoia, or thought disorganization of various types, but which do not have the characteristic qualities or patterns found in psychotic illness such as schizophrenia
7) pronounced confusion about identity, often with respect to gender, sexuality, or "sense of self"
8) difficulty with relationship boundaries
9) a chaotic and often very negative set of experiences with doctors, the health care system, etc.
10) hospital stays in which symptoms got worse rather than better
I have seen many for whom these symptoms were their manifestation of depression, or part of a type of bipolar disorder, and for whom these issues improved following standard treatments for mood disorder.
For others, some of these symptoms are part of a post-traumatic syndrome.
I have seen many others for whom these symptoms seemed to be part of a developmental struggle, arising with adolescence or earlier, and resolving with time, support, work, development of purpose, meaning, community, autonomy, etc. Often a fairly short-term experience of therapy has helped.
For others, these symptoms become more lasting phenomena, and may in fact become more and more entrenched with time. It is as though the person has a chaotic relationship with time itself, which feeds the symptoms, rather than relieving them.
Some of the symptoms, such as self-injury, seem to have strong addictive components. Other types of addictive behaviours (such as substance abuse) are common in this population as well.
For many of my patients, there is so much overlap between "depression" and so-called "borderline personality traits" that I don't find that there is much point being concerned with "labeling" at all, since the same things help with both.
Here are some things that I have found to be helpful in all cases (in addition my standard advice about a healthy, happy lifestyle):
1) gentle, supportive, compassionate, friendly, consistent care in a setting with clear but non-rigid boundaries
2) treatment of specific symptoms pharmacologically (e.g. antidepressants may help with mood; anticonvulsants or antipsychotics may help with anxiety, irritability, insomnia, and lability; stimulants may help with inattention, hyperactivity, or distractability)
3) avoidance of harm (e.g. I would tend to avoid prescribing potentially addictive medications, or medications that are particularly dangerous in overdose; also some types of overly confrontational, reactive, over-medicalized, suggestive, dogmatic, or "digging into the past" styles of psychotherapy can probably be overtly harmful for some people, especially if the therapy style is engaged in without the patient's full understanding or consent).
4) gentle attention to the same kind of dynamics happening in the therapy as what happens in other relationships (e.g. intense conflicts, feelings of abandonment, "chaos"), and an attempt to gently work it out rather than let the symptoms threaten the relationship
5) cognitive-therapy techniques of various types can be particularly helpful; specifically Linehan's "Dialectical Behavioural Therapy" which is a type of cognitive therapy enriched by ideas from Buddhist mindfulness. Also Linehan's ideas emphasize the idea of "validation" which I consider extremely important -- symptoms need to be calmly understood, empathized with, rather than discounted or dismissed
6) long-term dynamically-oriented psychotherapy, 1-on-1 or group (or both). There is an expanding strong evidence base that this helps a lot
7) trying neither to over-react (e.g. push for an immediate hospital visit), nor to under-react (e.g. ignore or dismiss), regarding suicidal thoughts or self-injury; but to try to be understanding and helpful in any case
8) I do not tend to recommend hospitalization, especially through an emergency admission, as a cornerstone of therapy, except I do encourage people to use the emergency rooms if they cannot survive safely through the day and they do not feel they have other resources available. I believe it is much more therapeutic for people to choose themselves whether or not to use the emergency room.
9) a good day-program, if available, can be very helpful. These are harder to find nowadays
A few references:
http://www.ncbi.nlm.nih.gov/pubmed/16437534
(a Cochrane review of psychotherapy for borderline personality)
http://www.ncbi.nlm.nih.gov/pubmed/16437535
(a Cochrane review of medication for borderline personality; this shows, as I would expect, a modest and inconsistent evidence base, which I think supports the idea of being open-minded about using pharmacological therapies, but perhaps of having modest expectations of them, and being wary of relying too heavily on medication treatments alone)
http://www.ncbi.nlm.nih.gov/pubmed/17541052
(a randomized study showing broad, large effects from psychotherapy in patients having a borderline personality diagnosis, over a 1-year period)
http://www.ncbi.nlm.nih.gov/pubmed/18347003
(a study with an 8 year follow-up! --we need more such very long-term studies-- It shows that an intensive day program approach was very helpful)
http://www.ncbi.nlm.nih.gov/pubmed/17427099
(another longer-term study showing substantial benefits from psychotherapy)
It is important to note that many with so-called "borderline personality" may have depression or other problems at the same time, and each of these problems may improve with specific types of therapy. Many studies are not considering these "comorbid" conditions, and therefore underestimate the effectiveness of various types of therapy.
Here is a link to a dialectical-behavior therapy self-help site:
http://www.dbtselfhelp.com/index.html
Personality Disorders
The area of personality disorders is a sensitive one. Many people find this type of diagnostic labeling pejorative, judgmental, or insulting. And there are examples I have seen where professionals have applied such labels to patients in a pejorative, judgmental, or insulting manner.
Some of the professional literature on this subject is almost impossibly pedantic or arcane.
Yet on the other hand, personality disorder categories do describe the experiences of life many people have been through, or are continuing to go through.
Some of my patients readily accept the idea of having a "personality disorder", and have worked earnestly and successfully with their symptoms, using this type of diagnostic framework.
I am cautious myself about using "personality disorder" terminology. Yet I acknowledge that sometimes understanding, and speaking frankly about, these issues, permits opportunities for things to get better more efficiently and quickly.
In general I would say that "personality disorders" could be understood as collections of chronic symptoms and behaviours which have had strong, recurrent, entrenched feedback cycles involving a person's experience of relationships with other people, with society, with work, and with lifestyle. The intersection of symptoms with these relationships tends to lead to negative results, then tends to perpetuate the pattern. And this dynamic persists irrespective of whether there are prominent mood or anxiety symptoms.
In chronic psychological conditions of any type, whether it be depression, anxiety, psychosis, etc., there are similar intersections between symptoms and relationships, but my sense of the dynamic in personality disorders is that the relationship and lifestyle disruption persists independent of other psychological symptoms.
In some cases, chronic primary symptoms such as anxiety, depression, irritability, or mood lability, could cause "personality disorders" to arise, particularly if such symptoms have been present since early childhood.
Another frequently-observed or theorized cause for "personality disorder" phenomena is childhood adversity or trauma. The adversities or traumas may differ, but in most cases recurrent or ongoing trauma is most strongly associated. Different types of adversity may affect people with different inherited temperaments in different ways -- the same type of trauma may severely affect one person, while causing few lasting symptoms in another.
It is clear that, just as with most any other set of psychiatric symptoms or diagnoses, there is a significant inherited predisposition to have a "personality disorder" diagnosis. Heritability estimates are typically in the 40-50% range. To some degree these types of findings have always seemed obvious to me, it confirms that most anything that happens in life is jointly a product of genes and environment, and the proportional split of causality is often about 50/50.
Advancing understanding of this issue has led to a conceptual shift: "personality disorders" need not be considered lifelong ailments or "defects of character". It is clear that all types of psychological symptoms may change or improve with time, under the right conditions.
There are numerous categories of "personality disorder" as described in the DSM-IV and other diagnostic schemes, and in future posts I would like to discuss each of them in turn. Also there are different theoretical schemes about what "personality" even means--and I think the best research in this area shows that personality itself is better-described using categories quite different from those in the DSM-IV. Yet, I find the DSM-IV categories do describe a common variety of problems and experiences which many of my patients have been through, and so I do think that they have relevance and validity.
Some of the professional literature on this subject is almost impossibly pedantic or arcane.
Yet on the other hand, personality disorder categories do describe the experiences of life many people have been through, or are continuing to go through.
Some of my patients readily accept the idea of having a "personality disorder", and have worked earnestly and successfully with their symptoms, using this type of diagnostic framework.
I am cautious myself about using "personality disorder" terminology. Yet I acknowledge that sometimes understanding, and speaking frankly about, these issues, permits opportunities for things to get better more efficiently and quickly.
In general I would say that "personality disorders" could be understood as collections of chronic symptoms and behaviours which have had strong, recurrent, entrenched feedback cycles involving a person's experience of relationships with other people, with society, with work, and with lifestyle. The intersection of symptoms with these relationships tends to lead to negative results, then tends to perpetuate the pattern. And this dynamic persists irrespective of whether there are prominent mood or anxiety symptoms.
In chronic psychological conditions of any type, whether it be depression, anxiety, psychosis, etc., there are similar intersections between symptoms and relationships, but my sense of the dynamic in personality disorders is that the relationship and lifestyle disruption persists independent of other psychological symptoms.
In some cases, chronic primary symptoms such as anxiety, depression, irritability, or mood lability, could cause "personality disorders" to arise, particularly if such symptoms have been present since early childhood.
Another frequently-observed or theorized cause for "personality disorder" phenomena is childhood adversity or trauma. The adversities or traumas may differ, but in most cases recurrent or ongoing trauma is most strongly associated. Different types of adversity may affect people with different inherited temperaments in different ways -- the same type of trauma may severely affect one person, while causing few lasting symptoms in another.
It is clear that, just as with most any other set of psychiatric symptoms or diagnoses, there is a significant inherited predisposition to have a "personality disorder" diagnosis. Heritability estimates are typically in the 40-50% range. To some degree these types of findings have always seemed obvious to me, it confirms that most anything that happens in life is jointly a product of genes and environment, and the proportional split of causality is often about 50/50.
Advancing understanding of this issue has led to a conceptual shift: "personality disorders" need not be considered lifelong ailments or "defects of character". It is clear that all types of psychological symptoms may change or improve with time, under the right conditions.
There are numerous categories of "personality disorder" as described in the DSM-IV and other diagnostic schemes, and in future posts I would like to discuss each of them in turn. Also there are different theoretical schemes about what "personality" even means--and I think the best research in this area shows that personality itself is better-described using categories quite different from those in the DSM-IV. Yet, I find the DSM-IV categories do describe a common variety of problems and experiences which many of my patients have been through, and so I do think that they have relevance and validity.
Tuesday, October 14, 2008
Insomnia
Sleep problems can be frustrating and exhausting. Sometimes a person can have trouble sleeping for no apparent reason, and with no other associated symptoms.
More commonly insomnia is a symptom associated with another medical or psychiatric problem. Here are some of the causes of insomnia:
A) Physical Medical Problems
Here's a partial list:
More commonly insomnia is a symptom associated with another medical or psychiatric problem. Here are some of the causes of insomnia:
A) Physical Medical Problems
Here's a partial list:
- any painful condition
- infectious diseases (anything from a common cold to any more severe disease)
- endocrine disorders (e.g. hyperthyroidism)
- respiratory diseases
- bladder or kidney problems (e.g. causing a need to use the bathroom in the night)
- heart disease (e.g. in heart failure it may be very uncomfortable to lie flat)
B) Psychiatric Problems
- depression
- anxiety
- psychotic disorders
- mania
- situational stress
- substance use disorders
- specific sleep-related disorders such as sleep apnea or narcolepsy
- post-traumatic stress disorder (e.g. in which the past trauma occurred at night)
C) Environmental Problems
- uncomfortable bed, bedding, or pillow
- noisy bedroom at night
- too much light in the bedroom (e.g. street lights shining through a window)
- too hot, too cold, poor air quality, etc.
- sleeping next to someone who snores loudly or moves around a lot during sleep
In the management of insomnia, it is important to consider all of the above categories. A medical check-up to rule out or start treatment for physical diseases will be important. All possible improvements to the bedroom environment should be made. Evaluation and treatment of other psychiatric symptoms or conditions is important. If there is any question of breathing problems during sleep, or of a specific sleep disorder such as narcolepsy, then other tests may need to be done, such as an overnight sleep study.
For some people with allergies, I have found at times that a simple measure--such as starting a nasal spray at night which allows for easier breathing, or starting an antihistamine--can be a remarkably effective relief for insomnia and resulting mood/energy problems.
Beyond this, there are specific ways to manage sleep problems:
1) Careful documentation of exactly what is happening with sleep:
A sleep log can be very useful. In the sleep log, you can keep the following records for each day:
a) what time you went to bed
b) what times you were actually asleep
c) what time you got out of bed
d) what times you spent in bed or asleep during the daytime
e) your assessment of how good the quality of your sleep was
You can keep your log in the form of a chart, with sleep times indicated by a solid bar going across the chart, and times spent awake represented by interruptions in that solid bar. Here are some examples of a sleep log:
https://www.healthatoz.com/ppdocs/us/cns/content/atoz/tl/misc/sleeplog.pdf
http://www.snoozeorlose.com/index.php?id=40
2) Behavioural treatments:
- maintaining a constant wake time: it may be impossible to control when you fall asleep, but it is possible (even if difficult) to control when you wake up and get out of bed. If you are out of bed at the same time every morning, you will be more sleep-deprived after a night of insomnia, and will therefore have an easier time sleeping the next night. If you allow yourself to sleep in after a night of insomnia, you will not be as sleepy, and will have a harder time sleeping the next night.
- If you have a hard time waking and getting out of bed at the same time every morning, external stimuli can help, such as a timer circuit which turns on a bright light next to your bed in the morning, or even an automated coffee machine which starts at the same early time.
- leaving the bedroom if you are having a hard time sleeping. Otherwise there is a conditioning effect in which your brain associates your bed with being awake. Go back to your bed when you feel more sleepy.
- avoiding wakeful activities in the bed, such as watching TV or reading. Do these things in another place.
- avoid or minimize napping. If you must nap, keep it earlier in the afternoon if possible, and as brief as possible.
- sleep restriction: for example, if you are in bed for 9 hours per night, but are only asleep for 5 of those 9 hours, then you can try going to bed exactly 5 hours before your planned wake time. This strategy is intended to cause you to become more sleepy before you go to bed, to have deeper sleep while you are in bed, and to spend less time lying awake in bed. If this strategy works, a next step can be to gradually start going to bed earlier in order to extend the total number of sleep hours. It is harder to adjust to an earlier bedtime, so this process has to be very slow, perhaps trying a bedtime 15 minutes earlier than your previous bedtime, then sticking with it for a week or so, before adjusting again.
- morning exercise -- here's a link to a study showing this: (http://www.ncbi.nlm.nih.gov/pubmed/14655916)
3) Cognitive Treatments
- There are many thoughts which occur in the midst of insomnia; some of these thoughts can perpetuate the insomnia, or be part of a vicious cycle. For example, as you lie awake you might think:
- - "oh, no, not again! I'm still awake! I'll never be able to function tomorrow!"
- -"It's 3:21. I've been awake for 57 minutes. I have only 3 hours and 39 minutes before I have to get up."
- -"I can't slow down my thoughts! I'll never fall asleep!"
- -"No matter what I do, I still can't sleep."
- In working on insomnia cognitively, it is important to "talk back" to all of these thoughts in a way which is brief, without becoming an inner intellectual debate (this would be another example of a cognitive process which would keep you awake). Much of the "talking back" might involve reassuring yourself, accepting the thoughts and then letting them go, letting go of the need to control your thoughts, and accepting that sleep will happen on its own without your intellectual input, or regardless of whether your thoughts are active or not.
There is some solid evidence that cognitive-behavioural techniques are effective in treating insomnia. Here are some references:
http://jama.ama-assn.org/cgi/reprint/295/24/2851
http://jama.ama-assn.org/cgi/reprint/285/14/1856
http://archinte.ama-assn.org/cgi/reprint/164/17/1888
4) Other physical treatments
http://jama.ama-assn.org/cgi/reprint/295/24/2851
http://jama.ama-assn.org/cgi/reprint/285/14/1856
http://archinte.ama-assn.org/cgi/reprint/164/17/1888
4) Other physical treatments
- Light therapy: use of a 10 000 lux light box for 45 minutes in the morning can help with night-time insomnia. Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/15172210
- There is some evidence that using a light box in the EVENING can help "early morning awakening insomnia". In depressed states, waking too early in the morning is a frequent sleep disturbance. It could be an interesting and low-risk therapy for this to use evening bright light. Here's a reference: http://www.ncbi.nlm.nih.gov/pubmed/16171276
- There is a lot of evidence that sedative medications are effective short-term treatments for insomnia. Mind you, some of the evidence is not as robust as one might think it should be. Unfortunately, most of these sedatives tend to be habit-forming or addictive. And tolerance tends to develop to the sleep-promoting effects.
- Sedating antidepressants (e.g. trazodone, amitriptyline, doxepin, mirtazapine) could be useful in selected cases. Sedating antipsychotic medications in low dosages can also help sometimes (e.g. quetiapine). There is some current interest in very low-dose doxepin for treating insomnia, because it appears to have a very selective antihistamine effect at these doses; here's a link to an abstract about this-http://www.ingentaconnect.com/content/apl/eid/2007/00000016/00000008/art00014
- Melatonin: There is some modest evidence that melatonin can help with insomnia, with few side-effect problems. Here's a link to a study, in which they were looking at the effectiveness of 2 mg of prolonged-release melatonin: http://www.ncbi.nlm.nih.gov/pubmed/18036082
Tuesday, July 22, 2008
OCD
Obsessive-compulsive disorder (OCD) is a common anxiety disorder. It is characterized by recurrent, bothersome mental or behavioural habits. "Obsessions" are recurrent, unwelcome thoughts or images, and "compulsions" are habitual behaviours (physical actions or sequences of thoughts) which often relieve the anxiety induced by obsessions. The symptoms can arise at almost any time in life, but often begin during childhood or during young adulthood. The symptoms often wax and wane over time, sometimes changing slightly from one type to another, sometimes becoming worse during stressful situations.
There are certain types of symptoms that are most common:
1) obsessive concern about germs or dirt, leading to compulsive washing
-this pattern can become so extreme that hours of the day can be spent cleaning, hands getting badly chapped from overwashing; there can be a lot of avoidance of situations (e.g. crowds, public transit, washrooms, shaking hands with people) where there may be a perceived abundance of germs
2) obsessive doubt, leading to compulsive checking
-those with this symptom frequently feel that they have made a mistake--sometimes a catastrophic mistake such as having left the oven on, or having hit someone with their car--leading to a compulsive need to go back and check to make sure this hasn't happened. A lot of time can be wasted going back to check and re-check. Often times people with this symptom realize their behaviour is irrational or excessive, but the feelings are so strong that they can't stop the pattern.
3) obsessive or compulsive symmetry: a need to assess the symmetry of things, or to make things symmetric. Sometimes there may be a need to do an activity (e.g. brushing teeth, or tying shoes) in a very particular way, and if something interrupts the behaviour, the symptom makes the person want to go back and start again from the beginning. A related symptom is a feeling of needing to count things in multiples, or do things a certain number of times (e.g. things have to be in threes).
4) obsessional thoughts: often these are thoughts about doing something forbidden or inappropriate; they often have a violent or sexual nature, and can be hard for people to talk about (people can be embarrassed or ashamed at having the thoughts). Symptomatic people often will interpret their thoughts as evidence that they are not safe or that they are losing their mind. The symptom can lead to avoidance of many situations (e.g. if the obsessional thought is about doing something aggressive, it may lead to avoidance of being around other people).
There are many other varieties of obsessions & compulsions, and it can be helpful to read an educational book on the subject. The OCD Workbook by Bruce Hyman is a good example.
There are two types of therapy that help most with OCD:
Cognitive-behavioural therapy is extremely important and has been shown to work. The main principles here are to educate oneself about OCD, to be able to recognize and pronounce the symptoms as they occur (i.e. to recognize in one's mind that "this is an OCD symptom, not a sign of insanity or dangerousness"), to stop oneself from doing the compulsive behaviours, and to practice exposure to situations that induce the symptoms (e.g. for the germ phobic person, the exposure therapy may be spending time with bare hands scooping soil in a garden).
Antidepressant medications which act on the serotonin system in the brain also reduce OCD symptoms.
Typically, any treatment for OCD reduces symptoms by about 30%. For some people the treatments work much better. Often times, combinations of therapy techniques, continued for longer periods of time, are needed to tame the symptoms more completely.
There are certain types of symptoms that are most common:
1) obsessive concern about germs or dirt, leading to compulsive washing
-this pattern can become so extreme that hours of the day can be spent cleaning, hands getting badly chapped from overwashing; there can be a lot of avoidance of situations (e.g. crowds, public transit, washrooms, shaking hands with people) where there may be a perceived abundance of germs
2) obsessive doubt, leading to compulsive checking
-those with this symptom frequently feel that they have made a mistake--sometimes a catastrophic mistake such as having left the oven on, or having hit someone with their car--leading to a compulsive need to go back and check to make sure this hasn't happened. A lot of time can be wasted going back to check and re-check. Often times people with this symptom realize their behaviour is irrational or excessive, but the feelings are so strong that they can't stop the pattern.
3) obsessive or compulsive symmetry: a need to assess the symmetry of things, or to make things symmetric. Sometimes there may be a need to do an activity (e.g. brushing teeth, or tying shoes) in a very particular way, and if something interrupts the behaviour, the symptom makes the person want to go back and start again from the beginning. A related symptom is a feeling of needing to count things in multiples, or do things a certain number of times (e.g. things have to be in threes).
4) obsessional thoughts: often these are thoughts about doing something forbidden or inappropriate; they often have a violent or sexual nature, and can be hard for people to talk about (people can be embarrassed or ashamed at having the thoughts). Symptomatic people often will interpret their thoughts as evidence that they are not safe or that they are losing their mind. The symptom can lead to avoidance of many situations (e.g. if the obsessional thought is about doing something aggressive, it may lead to avoidance of being around other people).
There are many other varieties of obsessions & compulsions, and it can be helpful to read an educational book on the subject. The OCD Workbook by Bruce Hyman is a good example.
There are two types of therapy that help most with OCD:
Cognitive-behavioural therapy is extremely important and has been shown to work. The main principles here are to educate oneself about OCD, to be able to recognize and pronounce the symptoms as they occur (i.e. to recognize in one's mind that "this is an OCD symptom, not a sign of insanity or dangerousness"), to stop oneself from doing the compulsive behaviours, and to practice exposure to situations that induce the symptoms (e.g. for the germ phobic person, the exposure therapy may be spending time with bare hands scooping soil in a garden).
Antidepressant medications which act on the serotonin system in the brain also reduce OCD symptoms.
Typically, any treatment for OCD reduces symptoms by about 30%. For some people the treatments work much better. Often times, combinations of therapy techniques, continued for longer periods of time, are needed to tame the symptoms more completely.
Thursday, July 17, 2008
Addictions
The area of addiction and substance abuse is challenging for me.
One simple definition of addiction is "continuing a behaviour despite harm".
In this sense, I suppose a broad range of human activities could be considered addictions.
The more obvious examples of addiction include more specific symptoms:
-developing tolerance (one has to do more and more of the addictive behaviour to get the same effect from it)
-withdrawal symptoms (discomfort--physical or emotional--if the behaviour is stopped)
-feeling psychologically or physically dependent upon the addictive behaviour
-wanting or trying to stop or cut down, but feeling powerless or unable to do so
One core aspect of addiction in my opinion involves a relationship analogy. The addictive behaviour is a relationship. An addictive relationship is one in which other relationships become less and less important or enjoyable, while the addictive relationship consumes more and more time, energy, commitment, and money. In severe addiction, all of the person's other relationships (with people, work, hobbies, other pleasures, and with self) atrophy, while the addictive behaviour monopolizes. Associated relationships may foster the addiction (e.g. the addict's only social supports may eventually only be fellow addicts). An addictive behaviour often starts off being pleasurable, but eventually the pleasure usually fades. It is a trap. Once inside the trap, it is hard to get out. One of the most powerful, exquisitely difficult aspects of the addictive trap can be that the person entangled in it might not be aware of being in the trap; or so much identity or will may be bound in the addictive relationship, that the person might not want to take any steps to escape, and may angrily reject offers of help.
I have often felt that various symptoms of depression and other mental illnesses have addictive features: in depression, for example, there can be behavioural habits, or habits of thought, that can monopolize a person's life, sapping energy that could otherwise be directed in healthier directions. Like other addictions, these habits can be very hard to change without external help.
In chemical addictions (alcohol or drug), the addictive trap can have an overtly pharmacological aspect, which may need to be treated medically. For example, severe alcohol withdrawal can cause death if it is not treated medically.
Aside from treating withdrawal symptoms, pharmacological treatments for addiction have been less successful or useful, although there are some new medications that are showing some modest benefit.
In heroin addiction, one of the most effective treatments of all is not to "escape the trap" at all, but to provide a continuous supply of the addictive agent or analog (e.g. methadone), so that the addict does not have to live a life of desperation, constantly battling with withdrawal symptoms, or needing to engage in dangerous behaviours to seek the daily supply of heroin.
Treatments for addiction need to address a variety of factors:
-the behaviour itself needs to either stop or be reduced substantially (abstinence)
-or the addictive need has to be provided continuously ("harm reduction")
-Once these changes have taken place, the relationships outside of the addiction need to be rebuilt -- if there are no such external relationships left, then an addicted person is isolated, and understandably drawn quickly back into the familiarity of the addictive behaviour.
One common resource for addictions is a "12-step group". I think the greatest strength of such groups is the mutual understanding among members, and the daily community support. Addictive behaviours have a magnetic allure, that often draws a person back into the addiction on an hourly or daily basis, and so a therapeutic resource that is available on an hourly or daily basis can be extremely important and necessary. A problem with 12-step groups can be that they may be quite dogmatic, they have a specific belief system not unlike a religion, and the views may conflict with other resources (e.g. some groups may be strongly opposed to the use of psychiatric medication).
Yet, in approaching addictive problems, I encourage people to give 12-step groups a try, to try repeatedly, perhaps to try several different groups to find one that suits them best.
There are other resources out there as well, and once again I think that finding good primary medical care (a gp) is an excellent first step. In severe chemical addictions, a detox centre may be needed to discontinue the addiction in a medically safe setting.
A day away from an addictive behaviour is a powerful start. A week away is a path away from the trap of withdrawal symptoms. A month away is the start of rebuilding healthy relationships. And a year away seems to be a qualitatively powerful and significant period of abstinence; rates of successful long-term abstinence are much higher for those who can be abstinent for a year. But a single day at a time is a good place to start. And you may need help to get through that day, don't be afraid to seek it. Here is a link to the Vancouver AA meeting schedule:
http://www.vancouveraa.ca/directory.pdf
One simple definition of addiction is "continuing a behaviour despite harm".
In this sense, I suppose a broad range of human activities could be considered addictions.
The more obvious examples of addiction include more specific symptoms:
-developing tolerance (one has to do more and more of the addictive behaviour to get the same effect from it)
-withdrawal symptoms (discomfort--physical or emotional--if the behaviour is stopped)
-feeling psychologically or physically dependent upon the addictive behaviour
-wanting or trying to stop or cut down, but feeling powerless or unable to do so
One core aspect of addiction in my opinion involves a relationship analogy. The addictive behaviour is a relationship. An addictive relationship is one in which other relationships become less and less important or enjoyable, while the addictive relationship consumes more and more time, energy, commitment, and money. In severe addiction, all of the person's other relationships (with people, work, hobbies, other pleasures, and with self) atrophy, while the addictive behaviour monopolizes. Associated relationships may foster the addiction (e.g. the addict's only social supports may eventually only be fellow addicts). An addictive behaviour often starts off being pleasurable, but eventually the pleasure usually fades. It is a trap. Once inside the trap, it is hard to get out. One of the most powerful, exquisitely difficult aspects of the addictive trap can be that the person entangled in it might not be aware of being in the trap; or so much identity or will may be bound in the addictive relationship, that the person might not want to take any steps to escape, and may angrily reject offers of help.
I have often felt that various symptoms of depression and other mental illnesses have addictive features: in depression, for example, there can be behavioural habits, or habits of thought, that can monopolize a person's life, sapping energy that could otherwise be directed in healthier directions. Like other addictions, these habits can be very hard to change without external help.
In chemical addictions (alcohol or drug), the addictive trap can have an overtly pharmacological aspect, which may need to be treated medically. For example, severe alcohol withdrawal can cause death if it is not treated medically.
Aside from treating withdrawal symptoms, pharmacological treatments for addiction have been less successful or useful, although there are some new medications that are showing some modest benefit.
In heroin addiction, one of the most effective treatments of all is not to "escape the trap" at all, but to provide a continuous supply of the addictive agent or analog (e.g. methadone), so that the addict does not have to live a life of desperation, constantly battling with withdrawal symptoms, or needing to engage in dangerous behaviours to seek the daily supply of heroin.
Treatments for addiction need to address a variety of factors:
-the behaviour itself needs to either stop or be reduced substantially (abstinence)
-or the addictive need has to be provided continuously ("harm reduction")
-Once these changes have taken place, the relationships outside of the addiction need to be rebuilt -- if there are no such external relationships left, then an addicted person is isolated, and understandably drawn quickly back into the familiarity of the addictive behaviour.
One common resource for addictions is a "12-step group". I think the greatest strength of such groups is the mutual understanding among members, and the daily community support. Addictive behaviours have a magnetic allure, that often draws a person back into the addiction on an hourly or daily basis, and so a therapeutic resource that is available on an hourly or daily basis can be extremely important and necessary. A problem with 12-step groups can be that they may be quite dogmatic, they have a specific belief system not unlike a religion, and the views may conflict with other resources (e.g. some groups may be strongly opposed to the use of psychiatric medication).
Yet, in approaching addictive problems, I encourage people to give 12-step groups a try, to try repeatedly, perhaps to try several different groups to find one that suits them best.
There are other resources out there as well, and once again I think that finding good primary medical care (a gp) is an excellent first step. In severe chemical addictions, a detox centre may be needed to discontinue the addiction in a medically safe setting.
A day away from an addictive behaviour is a powerful start. A week away is a path away from the trap of withdrawal symptoms. A month away is the start of rebuilding healthy relationships. And a year away seems to be a qualitatively powerful and significant period of abstinence; rates of successful long-term abstinence are much higher for those who can be abstinent for a year. But a single day at a time is a good place to start. And you may need help to get through that day, don't be afraid to seek it. Here is a link to the Vancouver AA meeting schedule:
http://www.vancouveraa.ca/directory.pdf
Wednesday, July 16, 2008
Bipolar Disorder
I have neglected so far to discuss a very important diagnostic category: bipolar disorder.
In bipolar disorder, there can be episodes of severe depression, in fact this may be the presenting or initial problem. Bipolar disorder is strongly heritable (it runs in families), even more strongly than other types of mental illness. Yet there are cases in which bipolar disorder can arise in an individual without an obvious family history.
The other "pole" in bipolar disorder is mania: this is a state in which mood is abnormally elevated or irritable, with a variety of other accompanying symptoms-
-increased energy (in its extreme form, severe uncontrollable physical agitation)
-decreased need for sleep (in its extreme form, no sleep at all despite high energy)
-racing thoughts or speech (in its extreme form, leading to incomprehensible speech)
-elevated self-esteem (in its extreme form, delusions of grandeur such as believing oneself to have supernatural powers)
-reckless and uncharacteristic behaviour (such as driving dangerously, taking other unusual risks such as substance use or gambling)
-uncharacteristic increase or change in social behaviour (e.g. promiscuity, socializing freely with strangers)
-increased spending (sometimes this leads to financial catastrophe, giving away one's savings, buying new cars, etc.)
-there may be psychotic symptoms such as hallucinations, paranoia, or severely disorganized thinking
-increased "goal-directed activity": many new plans, ideas, and actions, but often these are disorganized and chaotic
-usually these symptoms last for weeks or months at a time. For some people their symptoms fluctuate much more rapidly, sometimes between depressed symptoms and manic symptoms, or some combination simultaneously. This is so-called "rapid cycling".
A manic state can be very severe, leading to the police needing to bring the afflicted person to the hospital. There can be catastrophic life consequences, affecting relationships, finances, or physical health.
In other cases, though, a manic state can be quite mild (a so-called "hypomanic" state), and may even be quite a pleasant and productive period of time.
For any person seeking treatment for depression, it is extremely important to examine closely whether there have been any manic symptoms in the past--even mild ones--or if there is a family history of bipolar disorder. One important reason for this is that antidepressants can provoke manic episodes in persons with bipolar disorder. Treating depression in bipolar disorder requires extra care to prevent a manic episode from arising. This can involve a so-called "mood-stabilizer" drug such as lithium carbonate. Or, it can involve choosing a different type of treatment for the depression, such as a newer drug called lamotrigine, which can help with bipolar depression without causing mania.
In bipolar disorder, there can be episodes of severe depression, in fact this may be the presenting or initial problem. Bipolar disorder is strongly heritable (it runs in families), even more strongly than other types of mental illness. Yet there are cases in which bipolar disorder can arise in an individual without an obvious family history.
The other "pole" in bipolar disorder is mania: this is a state in which mood is abnormally elevated or irritable, with a variety of other accompanying symptoms-
-increased energy (in its extreme form, severe uncontrollable physical agitation)
-decreased need for sleep (in its extreme form, no sleep at all despite high energy)
-racing thoughts or speech (in its extreme form, leading to incomprehensible speech)
-elevated self-esteem (in its extreme form, delusions of grandeur such as believing oneself to have supernatural powers)
-reckless and uncharacteristic behaviour (such as driving dangerously, taking other unusual risks such as substance use or gambling)
-uncharacteristic increase or change in social behaviour (e.g. promiscuity, socializing freely with strangers)
-increased spending (sometimes this leads to financial catastrophe, giving away one's savings, buying new cars, etc.)
-there may be psychotic symptoms such as hallucinations, paranoia, or severely disorganized thinking
-increased "goal-directed activity": many new plans, ideas, and actions, but often these are disorganized and chaotic
-usually these symptoms last for weeks or months at a time. For some people their symptoms fluctuate much more rapidly, sometimes between depressed symptoms and manic symptoms, or some combination simultaneously. This is so-called "rapid cycling".
A manic state can be very severe, leading to the police needing to bring the afflicted person to the hospital. There can be catastrophic life consequences, affecting relationships, finances, or physical health.
In other cases, though, a manic state can be quite mild (a so-called "hypomanic" state), and may even be quite a pleasant and productive period of time.
For any person seeking treatment for depression, it is extremely important to examine closely whether there have been any manic symptoms in the past--even mild ones--or if there is a family history of bipolar disorder. One important reason for this is that antidepressants can provoke manic episodes in persons with bipolar disorder. Treating depression in bipolar disorder requires extra care to prevent a manic episode from arising. This can involve a so-called "mood-stabilizer" drug such as lithium carbonate. Or, it can involve choosing a different type of treatment for the depression, such as a newer drug called lamotrigine, which can help with bipolar depression without causing mania.
Tuesday, July 8, 2008
Causes of Depression & other mental illnesses
When we discuss causation, it is important to consider that every individual has his or her own story, perhaps his or her own unique causation. It is like the life of a tree, in which many individual and unique factors from the tree's history have caused the tree to grow as it did (e.g. what species of tree it was, what soil the seed was planted on, the climate conditions over time, fires or insect problems at certain times, other trees protecting the tree from wind damage, or competing with the tree for sunlight, etc.) Yet despite the unique stories of causation for every creature, we can study common factors that tend to influence the present state.
One of the risk factors for mental illness is a family history. It is clear, from an abundance of careful research, that the tendency to develop specific mental illnesses is inherited. Yet, we also know that the "heritability" is never 100% (often it is about 50%); thus, many people with a strong family history will never develop depression. And some people with no family history will develop depression.
My analogy with the biology of trees would be to comment on "tendency to die in a forest fire". Clearly this type of event, for a tree, depends on an external contingency (lightning strikes, or other causes for forest fires starting). But suppose the inherited quality is the thickness of heat-resistant bark. Trees with the thicker bark will less frequently die in forest fires. Likewise, there may be inherited factors for various types of resilience or sensitivity in the mind, such that some individuals may be able to tolerate more or less environmental life adversity, with different consequences to their mental health.
There are other more immediate, medical causes, for depression and many other mental illnesses. Physical diseases of various types can cause emotional symptoms directly. For example, thyroid disease, neurological diseases, anemia, and many other illnesses, can cause symptoms in the mind, and many of the related symptoms of mental illnesses, such as fatigue, lethargy, poor concentration, trouble sleeping, etc. A thorough medical investigation is always warranted when assessing someone with psychiatric symptoms.
The adverse events of a person's life can have a very important role in causation, I think. Much of the psychiatric theory of the past 100 years has been devoted to attributing psychiatric symptoms and personality styles to the events of earlier life (often the events of childhood & infancy). I think it is extremely important, and often highly relevant, to explore an individual's personal life story; a life story is a very personal, intimate narrative. Yet it is important to know that the data on causation is actually quite weak, with respect to connecting particular past life events with current psychiatric symptoms. Much of the psychiatric theory about causation is, in my opinion, very dogmatic. Traumatic life events are an exception, in that trauma can clearly lead to symptoms later on.
The nuances of a personal history, though, I think are therapeutically important, as they can be an intimate framework to discuss the themes and symptoms of mental illness, to search for meaning. The process of recalling, creating and narrating a life story is a psychotherapeutic event, and telling the full story can be cathartic, poignant, painful, perhaps with kernels of joy, and perhaps with clues about how to write the future chapters of one's life story in the most meaningful and joyful way.
One of the risk factors for mental illness is a family history. It is clear, from an abundance of careful research, that the tendency to develop specific mental illnesses is inherited. Yet, we also know that the "heritability" is never 100% (often it is about 50%); thus, many people with a strong family history will never develop depression. And some people with no family history will develop depression.
My analogy with the biology of trees would be to comment on "tendency to die in a forest fire". Clearly this type of event, for a tree, depends on an external contingency (lightning strikes, or other causes for forest fires starting). But suppose the inherited quality is the thickness of heat-resistant bark. Trees with the thicker bark will less frequently die in forest fires. Likewise, there may be inherited factors for various types of resilience or sensitivity in the mind, such that some individuals may be able to tolerate more or less environmental life adversity, with different consequences to their mental health.
There are other more immediate, medical causes, for depression and many other mental illnesses. Physical diseases of various types can cause emotional symptoms directly. For example, thyroid disease, neurological diseases, anemia, and many other illnesses, can cause symptoms in the mind, and many of the related symptoms of mental illnesses, such as fatigue, lethargy, poor concentration, trouble sleeping, etc. A thorough medical investigation is always warranted when assessing someone with psychiatric symptoms.
The adverse events of a person's life can have a very important role in causation, I think. Much of the psychiatric theory of the past 100 years has been devoted to attributing psychiatric symptoms and personality styles to the events of earlier life (often the events of childhood & infancy). I think it is extremely important, and often highly relevant, to explore an individual's personal life story; a life story is a very personal, intimate narrative. Yet it is important to know that the data on causation is actually quite weak, with respect to connecting particular past life events with current psychiatric symptoms. Much of the psychiatric theory about causation is, in my opinion, very dogmatic. Traumatic life events are an exception, in that trauma can clearly lead to symptoms later on.
The nuances of a personal history, though, I think are therapeutically important, as they can be an intimate framework to discuss the themes and symptoms of mental illness, to search for meaning. The process of recalling, creating and narrating a life story is a psychotherapeutic event, and telling the full story can be cathartic, poignant, painful, perhaps with kernels of joy, and perhaps with clues about how to write the future chapters of one's life story in the most meaningful and joyful way.
Monday, July 7, 2008
What is Depression?
In my experience, everyone I've seen has a unique and individual experience of depression, in terms of their associated thoughts, and the impact of the depression on their life & behaviour.
Yet there are common factors, and the "DSM-IV" style symptom lists can be useful to review:
1) Depressed mood. This can vary from a continuous low mood, which might be coloured with sadness, tearfulness, anxiety, irritability, sometimes numbness or emotionlessness. Sometimes all of the above. Sometimes the mood is continuous, sometimes the feelings come in waves lasting minutes or hours. Sometimes the mood dips in reaction to external events (a daily frustration or stress), but sometimes the mood changes seem random. Some people can have other patterns, of good days & bad days, good months & bad months, good seasons & bad seasons. Some can display a cheerful mood for brief periods of time, while crashing immediately afterwards, or perhaps always feeling unhappy inside despite appearing cheerful. One common phenomenon is of a depressed mood that is consistently worst in the early morning.
2) Lack of interest or pleasure. Previous life joys feel boring, uninteresting, or unpleasant. A lack of drive to do pleasurable things (e.g. socializing, recreational activities, sex).
3) Sleep disturbance. Inability to sleep (difficulty falling or staying asleep, or waking too early in the morning). Or sleeping excessively. Sometimes both insomnia and excess sleep, at once, in which a person has fragmented, unrefreshing sleep, yet spends long periods of time in the day drifting in and out of sleep.
4) Appetite disturbance. Not wanting to eat, leading to weight loss. Or eating too much.
5) Lack of energy. Fatigue, lethargy, poor motivation.
6) Behaving in an agitated way, or in a very sluggish, slowed-down way.
7) Guilty thoughts. Blaming oneself for past events.
8) Indecisiveness. Trouble making small or large life decisions.
9) Trouble concentrating.
10) Thoughts about suicide.
11) Paranoid or delusional thoughts: for example, beliefs that there is a conspiracy going on, or that some terrible event is imminent.
12) Hallucinations: sometimes negative or derogatory voices can be part of a depressive episode.
13) "Low self-esteem": examples include thinking poorly of oneself most of the time, to self-hatred, self-loathing, feeling worthless. Often this is accompanied by so-called "negative self talk", in which one's own thoughts are critical or insulting to oneself.
14) Feeling helpless or powerless to effect any sort of change in self or circumstances
15) Somatic symptoms: many people have overt symptoms of physical pain, discomfort, reduced function, or other medical symptoms as part of their presentation of depression; this can lead to the person becoming worried about having a major medical disease such as cancer.
16) Frequently in depression there are also "comorbid" symptoms, especially anxiety symptoms such as severe worrying, panic attacks, and rumination (inability to stop thinking about a particular thing).
People can have different symptoms among this list at different times during their periods of depression, though quite often a similar pattern of symptoms repeats itself for a given person.
Yet there are common factors, and the "DSM-IV" style symptom lists can be useful to review:
1) Depressed mood. This can vary from a continuous low mood, which might be coloured with sadness, tearfulness, anxiety, irritability, sometimes numbness or emotionlessness. Sometimes all of the above. Sometimes the mood is continuous, sometimes the feelings come in waves lasting minutes or hours. Sometimes the mood dips in reaction to external events (a daily frustration or stress), but sometimes the mood changes seem random. Some people can have other patterns, of good days & bad days, good months & bad months, good seasons & bad seasons. Some can display a cheerful mood for brief periods of time, while crashing immediately afterwards, or perhaps always feeling unhappy inside despite appearing cheerful. One common phenomenon is of a depressed mood that is consistently worst in the early morning.
2) Lack of interest or pleasure. Previous life joys feel boring, uninteresting, or unpleasant. A lack of drive to do pleasurable things (e.g. socializing, recreational activities, sex).
3) Sleep disturbance. Inability to sleep (difficulty falling or staying asleep, or waking too early in the morning). Or sleeping excessively. Sometimes both insomnia and excess sleep, at once, in which a person has fragmented, unrefreshing sleep, yet spends long periods of time in the day drifting in and out of sleep.
4) Appetite disturbance. Not wanting to eat, leading to weight loss. Or eating too much.
5) Lack of energy. Fatigue, lethargy, poor motivation.
6) Behaving in an agitated way, or in a very sluggish, slowed-down way.
7) Guilty thoughts. Blaming oneself for past events.
8) Indecisiveness. Trouble making small or large life decisions.
9) Trouble concentrating.
10) Thoughts about suicide.
11) Paranoid or delusional thoughts: for example, beliefs that there is a conspiracy going on, or that some terrible event is imminent.
12) Hallucinations: sometimes negative or derogatory voices can be part of a depressive episode.
13) "Low self-esteem": examples include thinking poorly of oneself most of the time, to self-hatred, self-loathing, feeling worthless. Often this is accompanied by so-called "negative self talk", in which one's own thoughts are critical or insulting to oneself.
14) Feeling helpless or powerless to effect any sort of change in self or circumstances
15) Somatic symptoms: many people have overt symptoms of physical pain, discomfort, reduced function, or other medical symptoms as part of their presentation of depression; this can lead to the person becoming worried about having a major medical disease such as cancer.
16) Frequently in depression there are also "comorbid" symptoms, especially anxiety symptoms such as severe worrying, panic attacks, and rumination (inability to stop thinking about a particular thing).
People can have different symptoms among this list at different times during their periods of depression, though quite often a similar pattern of symptoms repeats itself for a given person.
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