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Moved

As of August of 2013, I have moved my blog to Blogspot. Please check out my blog at Blogging Astrid. Thank you.

The DSM-V workgroup proposes to include impulse control disorders and conduct or disruptive behavior disorders in the same category. This implies, in my opinion, that there is something intrinsically similar among these conditions. Now I am personally strongly opposed to this connotation, as I was originally diagnosed with impulse control disorder NOS in 2008, and one of my major fears was being seen as merely behaviorally disordered. Now in the current DSM-V draft, only intermittent explosive disorder is listed along with conduct disorder, oppositional defiant disorder, dyssocial personality disorder (antisocial personality disorder) and disruptive behavior disorder not elsewhere classified. Trichotillomania, now called hair-pulling disorder, is reclassified under the obsessive-compulsive and related disorders. I have not yet seen what happed to kleptomania, pyromania and impulse control disorder NOS.

Now I can see why intermittent explosive disorder would be seen as a behavior disorder, in the sense that people do have an essential problem with aggression. However, etiologically speaking, there is quite a difference between willfully destroying property or attacking someone and doing so in an impulse. I know that for the victim it makes little difference, but that’s not my point. Treatment is also quite different if someone is malicious rather than impulsive.

Now the DSM should be focused on observable behavior, not on etiology. I am not sure, therefore, what I think yet. Is it merely my personal fear of being diagnosed with something seen as a behavior disorder again, or is it something else? As a side note, my current psychologist removed the diagnosis of impulse control disorder NOS from my file in 2010.

I’m writing from m.wordpress.com, because the regular WordPress site doesn’t work well with my adaptive technology since they implemented the new “fresh” look. A disadvantage is that the mobile site doesn’t automatically publish to Twitter and such, and that I have to type in the categories rather than select them. I also notice I’m having an extremely narrow text field, which kind of sucks. I hope there will come a way to reset the WP site to “classic” mode. Then maybe I’ll be back to blogging soon.

A few days ago, I read a sensationalist news article that said multiple personalities are not caused by trauma. The research suggesting this was published in Current Directions in Psychological Science, a not-too-well-known psychological journal, and was written by Lynn et al. (2012).

The authors first explain two models of dissociation: the post-traumatic model, which is the most conventional, and the sociocognitive model. The former is based on the idea that dissociation is a coping strategy for dealing with severe trauma, while the latter suggests that dissociation is a cognitive style influenced by suggestion from therapists, sensationalist media portrayals, and susceptibility to fantasy or hypnosis. The authors strongly favor the sociocognitive model, and present some evidence for this, such as the fact that dissociative amnesia cannot be objectified and, in fact, people with DID have a better memory for to-be-forgotten sexual words in a directed-forgetting task.

The authors do not say that there is absolutely no role for trauma in the origins of dissociation. In fact, they claim early trauma causes persons to be more fantasy0prone, which could predispose them to cued dissociation. They also state that sleep deprivation causes dissociation, and post-traumatic symptoms often impair sleep.

In my opinion, indeed, therapists should be careful not to suggest dissociation to clients, and I do not deny that some cases of DID have been created by untethical therapists. However, the authors go so far as to say that there is often no link between trauma and psychopathology when controlling for family history of mental illness. This is a nature-based view of psychopathology which I find rather unfulfilling. Besides, as a person who knew she had alters before ever having seen a therapist, I do not feel it is appropriate to say all cases of DID have been fabricated.

Besides, even if DID is a form of mass hysteria, this doesn’t make it less real. Women – and DID occurs mostly in women – still have a hard time in today’s society. Even if DID itself does not start when a girl is two-years-old and being sexually abused, this abuse, together with other, maybe less severe, acts of oppression, may cause her to develop a psychological coping mechanism that involves fantisizing and psychological traits usually seen as unstable. Mass hysteria is still hysteria, and hysteria is a real mental illness. I am not going to buy it that people with DID are naturally attenton-seekers who want to fabricate trauma in order to have a florious story to tell.

Reference

Lynn SJ, Lilienfeld SO, Merckelbach H, Giesbrecht T, and Van der Kloet D (2012), Dissociation and Dissociative Disorders: Challenging Conventional Wisdom. Current Directions in Psychological Science, 21(1):48-53, DOI: 10.1177/0963721411429457.

On Tumblr earlier today, I posted a short piece against health insurance coverage for birth control. Mind you, I was not opposing birth control as such, or the idea of women who can’t afford it, getting birth control paid for. What I was saying, was that birth control is not a health issue, and therefore should not be covered through health insurance.

So why is it not a health issue? I acknowledge that it is, in some cases. For example, some women use birth control to prevent premenstrual symptoms or to lessen the risk of ovarian cysts. However, most women use birth control for its intended purpose, which is contraception. And while the right to prvent pregnancy, is a women’s right, it is not a health issue.

So what is it? It’s a matter of reproductive justice and of sexual liberty. Women (and men and people of all genders for that matter) have a right to consensual sex however they please, and this is the reason most people use birth control, and have every right to do so. Making sexual rights about health, however, distracts people from the real point of the discussion, which is that people of all genders have a right to do sexually as they wish as long as they obtain consent from the other people involved. Too often, liberals and feminists, indeed, use tragic examples of the health uses of birth control to draw attention to the need for coverage, but these needs can easily be met without having to admit that every woman has a right to birth control.

Then there is the thing that contraception should not be covered by insurance. The reason behind this is more based on what insurance is for, which is to cover the costs of unforeseen risk. Birth control is, however, there to deal with in most cases a calculated risk. (I know that in cases of rape and incest, this is not true, but these make up the minority of birth control uses.) Women know whether they want to get pregnant, so when they purchase health insurance, their need for birth control is known to them. Besides, we have insurance systems to cover relatively small risks, while in the case of birth control, 99% of all American women have used it in their lifetime, if we have to believe Sen. Gillibrand, which I do. That’s such a substantial number that it’s not something insureable.

On my Tumblr, people commented that men get Viagra paid for through the health insurance industry, too. I at first found this a valid argument, but my husband, with whom I discussed my Tumblr post and its responses, reasoned otherwise. He said that erectile dysfunction is not natural, while getting pregnant after unprotected sex is. I am not sure I agree with this logic, which is based in what it’s meant to be a functioning human.

However,the Viagra comparsion goes awry in one respect, which is what I mentioned above: erectile dysfunction is much less common, and much less calculable, than pregnancy after unprotected sex. Therefore, even if you reason that it’s not a medical problem and therefore doesn’t need health insurance coverage, it could still fulfill the other principles insurance is based on, and people may for example opt to buy additional coverage for this purpose.

Note, again, that I never said that women should have to pay for birth control out-of-pocket just because it’s not an insureable risk or a health matter. My husband proposed, and I agree with this, that there should come some kind of low-income fund, which would pay for birth control for women who can’t afford it otherwise. After all, I am totally for birth control to be affordable to all women.

In a recent TV show in which he appeared, Dutch cabaret perfomrer Vincent Bijlo apparently showed a dislike for use of the white cane. On Twitter, people are debating whether this has to do with him accepting or not accepting his blindness. At first, I commented that I, too, have an issue with the white cane which is somewhat related to trouble accepting blindness, but that I didn’t want to judge Bijlo’s reasons for not using a cane.

Someone pointed out that Bijlo is making himself rather vulnerable by talking about his blindness in his performances, so it is hard to find evidence that he doesn’t accept his blindness. This is true: you may like his shows or not – I for one have gotten used to them by now -, but he is rather open about his blindness.

Also, there may be other reasons for not using the white cane as often or as properly as should. I for one find it very hard to use the cane properly, and, while I do use it off institution grounds and don’t have a problem with this, I do prefer to walk sighted guide. This has nothing to do with my not wanting to look blind. In fact, I’m well aware that, as I walk sighted guide, I look more stereotypically blind than if I learned to use the white cane properly. But so what? I don’t need to look like the superblind person I am not.

And it is quite common knowledge that Bijlo is not superblind. Why should he be? Because he is a performer and sets an example for other blind people more than others do? Well, I have never felt that it is blind people’s responsibility to make sure sighted people don’t have stereotypes. And even if it were, it wouldn’t be our responsibility to defeat all stereotypes at once. In fact, it is known that this doesn’t work. And Bijlo, of course, does belong to the 25% of blind people who have a job. I don’t think he needs to bear the burden of defeating other stereotypes just because he is well-known. I do see that the sighted are seeing Bijlo as the poster puppet for blind people in the Netherlands, but as a blind community, we shouldn’t be reinforcing this.

Should DSM-V include a diagnostic category for people with major depressive disorder with subthreshold hypomania? This isthe question that is at the center of the paper I just read. My initial answer to this question was a resounding “No”,because of some of the challenges the authors discuss. However, having read the paper, I have come to the conclusion that there may be some use for subsyndromal hypomania as a separae diagnosis.

The authors start by evaluating the prevalence and possible misdiagnosis of unipolar depression vs. bipolar disorder. Previous research found that aproximately 40-50% of people with major depressive disorder have a lifetime history ofsubsyndromal hypomania, depending on the precise criteria used. Furthermore, individuals with such a history are much more likely than individuals without subthreshold hypomania to eventually be diagnosed with bipolar disorder, usually even bipolar I.

In addition, those with major depression and a history of sunthreshold hypomania generally have a worse outcome, more mood episodes, and more work impairment than depressed individuals without a history of subsyndromal hypomania. With regards to family history, people with major depression and subthreshold hypomania are more likely to have family members with mania or other bipolar disorders than those with only depressive symptoms. An early onset (before age 21) of depression and a presentation with atypical features are also characteristic of people with subthreshold hypomania.

For the above reasons, the authors recommend that subthreshold hypomania be included in DSM-V. There is some debate as to which criteria should be used, but they advise an emphasis on overactivy rather than just mood elevation and a duration of at least two days with at least three of seven hypomania symptoms met. The authors also recommend that subthreshold hypomania should be seen as in the middle between pure depression and bipolar II. They argue against the diagnosis of individuals with major depression and subthreshold hypomania as bipolar, because of the stigma this can create.

This stigma was one of my initial reasons to oppose the widening of the bipolar spectrum to include subsyndromalhypomania. The other reason, which the authors also address, is the potential overprescription of antipsychotics and moodstabilizers. There is no evidence that antidepressants would be bad for individuals with major depression who might havesubthreshold hypomania, and neither is there evidence that mood stabilizers or antipsychotics prevent a worsening fromsubsyndromal hypomania to full-blown (hypo)mania. Given the fact that antipsychotics and mood stabilizers have significantside effects, it is not recommended that they be used without merit.

However, the authros do argue for better psychosocial treatmetn of individuals with depression and subthresholdhypomania. They state that cognitive-behavioral therapy, psychoeducation and some other psychosocial interventions may betailored more effectively towards those with subthreshold hypomania if this is idenftified in people with major depression.This is also in light of the worse outcome usually seen in individuals wiht subtreshold hypomania. Psychotherapy,apparrently, might help people manage their hypomanic symptoms.

So, contrary to what I expected, the authors of this study are not Big Pharma puppets who advocate the widespread use ofthe newest and most expensive medications. They also, interestingly, do not seem to suggest that mood disorders as a wholeare underdiagnosed, or that in general more people should be seen as mentally ill. They rather try to pinpoint the symptomsof a subgroup of depressed individuals more precisely than could previously be done. This does not directly change myopinion on subthreshold bipolar yet, but it does give me some thought.

Reference

Nusslock R, Frank E (2011), Subthreshold Bipolarity: Diagnostic Issues and Challenges. Bipolar Disorders, 13:587-603. DOI: 10.1111/j.1399-5618.2011.00957.x.

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