Category Archives: Diagnosis

Psychopharmacology

Medication against mental illness has always been an iffy topic full of taboo. Many believe we are being over-medicated, that mental illness should be treated mentally through therapy and not physically through medication, and so on and so forth. I tend to fall more towards the “no medication” than the “yes medication” end of the discussion. But I also think it is unwise to refuse medication entirely. I realize that my feelings on the matter are just feelings, not actual facts, and ultimately irrational.

I’ve never been a fan of antidepressants and am even less inclined to like antipsychotics. A big part of it is an irrational fear that the drugs will turn me into a completely different person somehow. Like the drugs will make me think and feel different than I normally do. But you could also say that my disorder makes me think and feel differently than I normally would. When you’re sick for so long, it can be difficult to discern where you end and the illness or disorder begins. Am I me or am I just the drugs?

Another big part of my reluctance to take any medication is, I’m embarrassed to take them. Especially when I visit my dad on the weekends. I don’t want him to see me take any pills. It’s a stupid, stupid reason not to take medication, I know. Even so, when I was on antidepressants, I often found myself “forgetting” to bring the pills or forgetting to take them when I did bring them. When I finally took them, I’d always covertly swallow them while no one was looking.

Because of my own stance on medication and the fact my symptoms have always been relatively mild as far as I can tell, my experience with medication is very limited. I’ve been on mild antidepressants twice in my life. Both times I abruptly stopped taking the medication. I’ve never been on antipsychotics. Why would I want antipsychotics when I’m not psychotic? Although, perhaps the classification is a little misleading. Perhaps it’s more helpful to think of them as thought-regulating medication? On second thought, that might actually be worse… It’s silly to get hung up on names and specification, I know but what can you do? My brain’s just full of excuses.

I’ve heard some medication can help with excessive thoughts. I considered something like that, but my thoughts feel more slow and rusty than excessive and I was afraid the medication would somehow slow my thinking to a crawl or even stop completely. I should probably have talked more about this with my psychologist at OPUS. Probably he would have been able to clarify what sort of medication does what and what might be a better fit for me. But I didn’t.

My biggest hang-up against psychopharmacology is perhaps the side effects. Sometimes, the side effects of some medication can be quite severe and it can feel a bit like cutting off a leg to save the arm. It’s a different kind of debility but still one way or the other, you’re still not whole. There are other medications you can take to treat some of the worse side effects, which is good. But at the end of the day, it’s just more pills to take and that can get a little exhausting just to think about.

The first time I took antidepressants, I was 18 and living at home in Nuuk, Greenland. I was diagnosed with mild depression and a visiting psychiatrist (meaning he worked there for a short time before returning to Denmark) prescribed me with Citalopram, I believe. It worked great for a couple of months. Then it stopped working. So I stopped taking them. I didn’t like my psychologist at the time either and when she failed to make a new appointment one session, I simply stopped coming. Instead of ineffective medication and useless psychologists, I decided to treat my own depression by making a point of exaggerating the enjoyment of the few things I still enjoyed. It worked well enough for a while. Focusing on the good things in life is helpful short-term, but if you don’t treat whatever’s making you miserable, eventually all those bottled up emotions are going to come crashing down. It may take years, but it’ll happen sooner or later.

The second time, I started taking basically the same drug, but a different brand because I felt mildly depressed while I was at OPUS and I had a lot of trouble sleeping. This time, I felt no difference at all from the drug after taking it for about a month. Rather, I suffered the unfortunate but very common side effect of being unable to orgasm or taking ages and ages to get there, without the actual intended benefit of the drug. And so, when I forgot to pick up my new prescription just before Christmas the year before last, I simply stopped taking the pills when I ran out. This turned out to be a very reckless move. As it turns out, going cold turkey on antidepressants can have some pretty uncomfortable side effects. Like dizzy spells. At first I thought it was simply lack of sleep that caused the dizziness, but after talking to my psychologist, I realized it was probably the drug. Thankfully, I didn’t suffer any worse side effects and the dizzy spells disappeared on their own.

I’ve heard a few other horror stories about medication, like the schizophrenic patient who spent her time drugged into a stupor and her medication messed with her hormones making her obese and grow unsightly facial hair that she hated so much she would escape into another world where she wasn’t sick and had a successful life with a career and family. Sometimes, I dream about being able to just park my body in some institution and disappear into my own head and live in my own dream world where everything is exactly how I want it. I feel like I’d be happier that way. But I’m much too proud to allow myself to live out my days like some institutionalized drugged-out potato.

So, do I believe psychopharmacology’s all bad and should be avoided at all costs? No. I do believe drugs can be helpful, even necessary. For all the horror stories, there are many more happy stories where drugs bring relief from internal torment and allow for a relatively normal life. I know someone who takes medication for her anxiety and it relieved her of the terrible stomach pains she suffered from due to the anxiety. I know of a family friend who takes antidepressants because he simply can’t function without them. I don’t think medication is the ultimate solution, but it can bring relief where it’s needed. Recognizing that need is an important step towards recovery.

If your own brain torments you so badly you can’t be in your own skin, if your anxiety is so bad it causes physical pain and leaves you trapped in your own head, if you feel so awful death seems the only escape? Then perhaps trading off happy-fun times with your favorite sex toy doesn’t feel like such a bad deal. And perhaps it won’t have to be for the rest of your life, but just until you’re in a better place overall. The important thing is, you get to a point where you can live well.

inappropriate or constricted affect

What on earth does that even mean?

A quick Google search describes constricted affect as a restriction in the range or intensity of display of feelings. While inappropriate affect is the display of feelings inappropriate for the situation.

I’ve already talked some about the restriction in the range or intensity of display of feelings in Symptom: Emotionally Inexpressive.

Inappropriate affect however, I haven’t talked about at all. It’s fairly easy for me to find examples of this in my own life.

Two memories in particular stand out to me:

The first, I was younger than 15 at least. Maybe 13-14 or a couple years younger? I was in an indoor swimming pool with my dad, his girlfriend and my youngest half brother. I knew the girlfriend could swim. She would jump into the deep end and dog-paddle around. Then, suddenly she began calling for help while splashing around in the deep end of the pool. Maybe she had suffered a panic attack and forgotten how to swim. She wasn’t a very good swimmer to begin with. I didn’t understand any of this. All I saw was that this woman, who I knew could swim, was splashing around as if she didn’t and people were starting to look concerned. It was so funny to me, I couldn’t help but laugh. Being the one closest to her, I simply swam over and pushed her to the shallow end of the pool where she could reach the bottom and get out of the pool herself. Chuckling all the way. It was an indoor pool. Where was the danger? The harm? Of course, I was reprimanded by the attending life guard for laughing. She could have drowned! But she knew how to swim! I know now, that being able to swim is not the same as being unable to drown.

Looking back now, I can see how inappropriate my laughter was. But I still remember how absurd the whole situation was to me. The way she splashed around looked really funny. I just didn’t understand the gravity of the situation.

The second memory is somewhat similar. This one was in high school. The high school I attended had a proud history with not a single suicide among its students. This is significant, given the high suicide rate in Greenland. That record was broken when the school was hit with a suicide epidemic in my second or third year. 3 students killed themselves that year. Including one of my classmates.

After every suicide, the school would gather all the students and hold a memorial. 1 minute’s silence for the poor sod, every single time. By the third time, it went from horribly tragic to downright absurd. Students started asking each other: “Who’s next?” As if there was some invisible serial killer going around offing random people.

At the last memorial, I stood at the back, chuckling to myself. Laughing in the face of tragedy. This time I was well aware of how inappropriate that was. It was no laughing matter. But it still struck me as funny. 3 people, who’d suffered were dead by their own hands and all the rest of us could offer was a speech and a minute’s silence. It was so goddamn sad it was funny.

But yeah, laughing at a memorial is hardly appropriate behavior.

We tend to do odd things when we don’t know what to do. Some lash out and become violent. Others are paralyzed and overcome with their own inadequacies. Some, like me develop a warped sense of humor and laugh at tragedy.

Behavior that is inexplicable or inappropriate when looking from the outside, usually makes sense when seen from the inside. Our behavior, no matter how insane are bound by their own internal logic. Even if we can’t quite explain it, it makes sense to us. It feels natural. I couldn’t not laugh.

Reacting to horrible things by smiling or laughing isn’t actually as out there as it might sound. Laughter and smiles are mechanisms deeply ingrained in humans. They have a relaxing, calming effect. Even disarming. After all, people will like someone who’s smiling better than someone who’s frowning. It’s an excellent coping and defense mechanism. For example, we automatically laugh when we get tickled. I don’t know about you, but I don’t particularly enjoy being tickled, even though it does feel good to laugh.

So, do I laugh at horrible things because I’m a horrible person who lacks empathy? I don’t think that’s the case at all. But it’s very easy to make that assumption. If tragedy makes you laugh, you’re assumed to be horrible, if comedy makes you cry, you’re assumed to be overly sensitive and if you get angry at nothing at all, you’re an excellent target for bullying.

So, I think inappropriate affect is an expression of a divide between what goes on on the inside and what goes on on the outside. Either due to the outside stuff being interpreted incorrectly inside your head, like putting 2 and 2 together and getting chicken pot pie, or because you’re reacting to something going on inside your mind that doesn’t necessarily have anything to do with the outside world. I find that spending too much time with your own thoughts tends to dull awareness of what’s actually going on around you. My point is, the inappropriate behavior has meaning and logic behind it. Just not meaning or logic that’s obvious when seen from the outside.

Disorder or Personality Disorder?

When searching “schizotypal” around the net, you may have seen it referred to either as a personality disorder or simply a disorder.

Why is that, and what’s the difference?

I’ve dug through a few internet pages including APA’s (American Psychiatric Association) homepage and various danish sites on psychiatry and mental health information pages.

Far as I can tell, the main difference lies simply in the diagnostics system. There are two distinct, primary diagnostics systems used in psychiatry largely depending on where you live in the world: ICD (International Classification of Disease) and DSM (Diagnostic and Statistical Manual of Mental Disorders).

ICD is developed by WHO (World Health Organization). It is primarily used in Europe and various countries connected to WHO. It is the official diagnostics system used in Denmark, where I live. The newest iteration and currently used version is ICD-10. In this system, schizotypal is listed as a disorder. Here, it is loosely grouped with psychotic disorders such as Schizophrenia, paranoid delusions and acute or passing psychoses. This, I believe is due to the relationship and similarity to schizophrenia.

DSM is published by APA and is primarily used in USA, Canada and Australia. If memory serves correctly, it is also the system most commonly used in research papers. The newest iteration and current version in use is DSM-5. In this system, schizotypal is listed as a personality disorder. It is classed as a cluster A personality disorder, which is known as the “eccentric personality disorders” along with schizoid and paranoid personality disorders.

There are a total of 3 clusters of personality disorders in DSM-5.
B is the dramatic, emotional, irratic cluster, which consists of antisocial, histrionic, narcissistic and borderline personality disorders. cluster C is the fearful, anxious cluster and consists of avoidant, dependant and obsessive compulsive personality disorders.
So, what is a personality disorder? It is a type of disorder so deeply ingrained in a person’s behavior and way of thinking that it could be considered a distinct part of their personality. Roughly speaking. Symptoms typically become apparent during adolescence and cause long-term difficulties in personal relationships and function in society.

Essentially, Schizotypal Disorder and Schizotypal Personality Disorder are the same disorder, only classified differently, with slight variations. Symptoms are essentially the same. In DSM-5, the symptoms have to appear even without outside stressors, whereas ICD-10 is slightly more lenient in this. In practice, there’s hardly any difference that I could detect.

I might remember this wrong, but I believe the difference in classification comes from the structure of the diagnostics system. In ICD-10, disorders are largely classified on a spectrum or several, like autism spectrum disorders, whereas in DSM-5, they are largely categorical.

By calling it a personality disorder, DSM-5 focuses on the distinct pattern of thought and behavior in people with schizotypal personality disorder, which deviates from what is considered normal in society. Personality disorders affect the way one thinks of oneself, relates to other people, responds emotionally and controls one’s behavior. These problematic behaviors and thinking patterns persist over very long periods of time and treating a personality disorder can be a lengthy endeavor both with psychotherapy and if needed, medication. The fact that psychotic symptoms such as delusions and hallucinations are very limited or entirely non-existent probably also plays a role in this classification.

ICD-10 on the other hand seems to primarily consider the similarity of shizotypal disorder to schizophrenia. Research has shown a fairly strong familial relationship between schizophrenia and schizotypal disorder where families with cases of schizophrenia are more likely to also have cases of schizotypal disorder. Another reason for this classification might be the hierarchical nature of ICD-10, where disorders are ranked by numbers where the lower numbers take priority over lower numbers. So if someone has symptoms fitting into several different disorders, it is the disorder listed first in the system that takes priority. That way if I have enough symptoms to be diagnosed with both schizotypal disorder and bipolar disorder, depression or anxiety, it is the schizotypal disorder that is diagnosed first while any symptoms of the other disorders are treated as part of my schizotypal disorder. I’d guess this is to prevent over-long, messy diagnoses.

I am slightly more familiar with ICD-10, but I am by no means an expert in either diagnostics system, so there’s a good chance I got some things wrong. If you spot any mistakes, please correct me in the comments.

In this blog I use the term schizotypal disorder, because that is the term I am most familiar with.

TL;DR version: DSM-5 is American and calls it a personality disorder, ICD-10 is European and calls it a disorder related to schizophrenia.

Diagnosis, yay or nay?

Let’s talk diagnoses for a second. Unlike with physical illnesses, mental illnesses often carry a stigma and a sense of judgement. This can, for some, make certain diagnoses very hard to accept and creates conflict, which gets in the way of healing.

For many, being told you have a mental illness, such as schizotypal disorder, is like being told you’re a crazy person. Just hearing “schizo” might lead the mind to images of raving mad, paranoid lunatics babbling about some absurd conspiracy, or going on about voices only they can hear, telling them to do horrible things. It can be incredibly hard to see something like that in yourself or a loved one. Reality tends to look a lot different than in the movies. And sometimes reality described by one person can look very different for another. Maybe you went and read a quick description of the disorder and thought: “That doesn’t sound like me (or whoever), at all!” It can be a bit hard to interpret general descriptions into individual cases.

Most of us have an idea of what it means to be mentally ill. But when faced with it in reality, it becomes something different entirely and suddenly, we don’t know how to deal with it. Perhaps you’ve heard others say: “But you look/sound perfectly normal to me,” or “everybody gets a little X sometimes, doesn’t mean they’re sick,” or any such similar comment, which leaves you feeling misunderstood and dismissed. Maybe just imagining such reactions prevents you from talking about it at all. It’s such a difficult thing to come to terms with. If it’s not totally obvious, it’s far too easy to simply ignore.

Now then, the unthinkable’s happened: You’ve come home with/to a brand new mental illness. How do you take it? How should you take it?

There are several ways to view diagnoses, and depending on the perspective, the tone and feel of the word can change quite a bit. It can be a helpful tool, or a curse. If for one reason or another, you truly can’t accept your diagnosis, you don’t necessarily have to force yourself to. Just like with any medical diagnosis, there’s always the option of getting a second opinion from another professional, if you suspect the diagnosis doesn’t quite fit your problem. It is possible to receive a wrong diagnosis and if that is the case, it’s best to find the real problem as soon as possible.

Regardless of diagnosis, the important thing is that you receive the help you need. The aim is a better quality of life, not judgement. If that means adopting a certain label or accepting a certain diagnosis, perhaps it is better to focus on the opportunities offered rather than the constraints. The point of diagnosis is to identify the problem and establish a common ground for communication so the proper treatment can be found.

Just remember one thing: You are not your diagnosis! This way of thinking can, in some cases, be more harmful than good. There is a risk of becoming complacent in your illness.  It could be used as an excuse not to move beyond your comfort zone and thus prevent you from improving your life. i.e. “This is just who I am, so I don’t need to/can’t change”. Of course, that doesn’t mean you have to push yourself beyond your capabilities. Always know your limits.

So how do I view diagnoses, and how did I react to being diagnosed with Schizotypal Disorder?

To be honest, it was a relief. I felt validated somehow. Suddenly, I had proof that yeah, there actually was something wrong with me. And most importantly: there was a way to fix it, that there were people who could help me get me better. With the diagnosis came the treatment plan and others who lived with similar problems to mine. I was no longer quite so alone.

I like to see diagnoses as simply labels. Like on foods. When I say lasagna, we all know what I’m talking about. There’s the special pasta-sheets, the tomato sauce, bechamel sauce and cheese baked together into delicious, Italian goodness. In the same manner, Schizotypal disorder is simply a label with which to identify my personal set of mental problems. Like with lasagna, the specific ingredients that make up the individual case might vary, but there are enough similarities to justify the common label. Both lasagna bolognese and lasagna al forno fit under the label lasagna, even though they have inredients that set them apart.

(Edit: It occurred to me that lasagna is actually a terrible comparison and probably doesn’t make a whole lot of sense. Feel free to completely disregard the entire paragraph above. I apologize for the confusion, and the possible lasagna-craving.)

If I wanted, I could name each ingredient or symptom individually; but in most cases, simply using the label is more convenient. It’s not perfect, but it works well enough for me.

In between writing and editing this entry, I had an interesting conversation that made me rethink this whole topic. I found out someone I know could possibly have a schizoid personality disorder and my reaction upon hearing that was: That guy? Nooo, really? But he has a girlfriend and everything? I mean, isn’t someone with a schizoid personality disorder like a total misanthrope who wants nothing to do with other people at all? And that’s when I realized, I’ve still got so much to learn!

Labels aren’t just labels, they usually come with a certain understanding or preconception, maybe you’ll have some experience with a label, sometimes you don’t. But the thing to remember is: First judgement doesn’t have to be the final judgement. Taking an immediate dislike to a diagnosis is perfectly understandable. We judge things all the time. Sometimes we’re right, sometimes we’re wrong. I’ve had very negative first impressions of plenty of things I’ve ended up changing my mind on. Acceptance comes with understanding. The best thing we can do, is keep learning.

Perhaps I’ll write a bit about schizoid and other personality disorders as well once I know a little more about them.

 

TL;DR version:

Mental illness is hard to understand and unfair judgement sucks.

Reality is different from movies. Also, reality is sometimes different from reality.

If you don’t like the name, maybe just change it. The important thing is, you receive the help you need.

Your opinion and feelings do matter.

It’s okay to get something wrong, you can always change your mind. Seriously.