TDD: Mood Disorder or Personality Trait?

There is an interesting article at Psychiatric Times on the temper dysregulation disorder (TDD) controversy. Particularly, it is noted that TDD is classified as a mood disorder rather than a state of disordered personality development:

In English, that asks whether we should put temper outbursts in with depression and other mood disorders (ie, in the clearly-defined cluster of genetically-determined
chemical imbalances of the brain, or should they be lumped with the personality disorders?). Is an impulsively aggressive person with a long record of assault, drug and alcohol abuse, poor work record, and unstable interpersonal relations suffering a formal mental illness (with all the forensic and social complications that would imply), or is he or she simply choosing to act this way, and is therefore responsible for his/her actions? This is not a trivial question, but it flows directly from the question of whether “such diverse symptoms as irritability, anger, agitation, aggression, distractibility, hyperactivity,
and conduct problems” are or are not of the same ontological nature as depression and hallucinations. For example, in Australia, which has universal welfare
and treatment, if these behavioral factors are held to be mental illness per se, then the “sufferer” is entitled to a pension for life, unlimited (world class) treatment, and an endlessly renewable excuse for all manner of antisocial conduct.

I wonder, actually, why it makes a difference. People who are personality disoredered, should in fact get treatment as much as, or even more than, those with a mental illness. In the Netherlands, in fact, people with personality disorders are entitled to the same welfare and treatment as those with an axis I disorder – which welfare and treatment are by no means universal, by the way.

Also, TDD is a proposed childhood disorder rather than a lifelong disorder, so why should one worry? I think that children with TDD warrant as much treatment as those with oppositional defiant disorder, who at least in the Netherlands do get treatment. Indeed, TDD was at one point proposed as a subtype of ODD, but this idea was thrown out for a reason.

Of course, it is important to decide whether children with TDD are presumed to choose their behaviors, not for the sake of excusing or whether they’re allowed treatment, but because of what treatment is chosen. I, in this light, support the classification of TDD as a mood disorder, especially because dysphoria is part of its currently proposed criteria. Children who are dysphoric (or depressed, as many TDD kids seem to be) need to have this mood recognized and treated with psychotherapy and, in severe cases, medication. Behavior modification alone isn’t going to help.

I have an interest in the matter, of course, in that I would’ve been diagnosed with TDD had it existed in DSM-IV. I was treated with harsh forms of informal behavior modification, and they didn’t work. It could be because I am autistic instead of TDD – and autism needs to be ruled out first before diagnosing TDD -, but it is likely many children currently diagnosed with Asperger’s/PDD and/or ADHD will later be diagnosed with TDD based on observations and the fact that TDD will be the new fashion disease. Now I have little against new fashion diseases – I do not think the children diagnosed with them, are just brats -, but at least these warrant proper, caring treatment.

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“Stop Whining!”: The Operant Approach to Pain Behavior

When reading my health psychology textbook, I came across something called the operant approach to treating pain. Well, more correctly, the operant approach treats pain behaviors. It utilizes a system of rewards and extinction (ignoring unwanted behavior) to lessen a patient’s pain behaviors, such as complaining of pain, refusing to perform physical activity, etc.

In some ways, I can see how the operant approach is useful, for example when someone’s pain behaviors interfere with physical rehabilitation. The example given in the textbook involved a young girl who refused to put on a splint by displaying pain behavior and was “rewarded” for this behavior by attention from the nurses. The refusing to put on a splint of course interfered with her recovery. In this sense, I can see how ignoring pain behaviors and rewarding appropriate behavior, such as putting on the splint, can be helpful.

However, the operant approach has a risk that wasn’t mentioned in my textbook, in that pain behavior has a function other than getting secondary gains such as attention or getting out of unpleasant activities. Pain behavior, especially in people who have limited abilities – the patient in the example was three-years-old -, can signal to other people that the expectations set for them are too high. After all, initially at least, someone exhibits pain behavior because they are, oh duh, in pain, not because they want to get out of unpleasant activities or get attention. And, unlike cognitive or other behavioral approaches such as relaxation, it was not said that the operant approach actually reduces pain, which may however be assumed if the person stops communicating that they are in pain.

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Depersonalization Disorder in DSM-V

According to the current proposal for DSM-V, derealization – the feeling tht one’s surroundings are unreal -, will be classified as a specific dissociative disorder. That is, depersonalization disorder will be expanded to include derealization only as a possibility, and will be renamed depersonalization/drealization disorder. In DSM-IV, if someone has derealization only, they must be diagnosed with dissociative disorder NOS. It is good that derealization is recognized as a specific symptom, because then it can be more easily treated than if it were put under the umbrella of DDNOS.

Also, the criteria that say that the symptoms do not occur exclusively as a consequence of a medical condition, substance, or other mental disorder, have been slightly amended to allow for comorbid diagnoses if warranted. I like this move as well, because many people with DP/DR are untreated for these symptoms because psychiatrists believe they are part of, say, depression or anxiety, which are very common comirbid issues.

The DES-B (part B of the Dissociative Experiences Scale?) is used to determine severity. I do not understand how severity is classified, however. The questionnaire asks you to rate how often symptoms happened to you in the past week – ie. not at all to more than once a day -, but it does not provide a scoring algorithm. Probably those experienced with the DES, which does not include me, will know how to score it, however.

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Weekly Linklove for 02/18/2011

A day early, because I will be leaving for a week-end at my boyfriend’s at 5:00 PM, here is this week’s Linklove.

s.e. smith at this ain’t livin’: Cuteifying Disability:

Cuteification of disability was once championed and pretty widely used, to get people to be more accepting of people with disabilities and to enlarge ideas about accommodation and needs. We aren’t disabled, we’re “special needs.” We aren’t handicapped, we’re “handicapable.” Etc. But I think it’s time to move
beyond cuteification of disability when it comes to neutral language used to refer to disability in general, because it has a chilling effect when it comes to talking about disability; cuteification is associated with “childishness” and as a result it tends to create the idea that children are the only disabled people (or the only ones worth caring about) and it contributes to the idea that it’s acceptable to talk down to and patronise people with disabilities of all ages, because we’re cute and defanged and nonthreatening.

William Peace at Bad Cripple: The Human Body: Can Disability Be Cool?:

When I think of my wheelchair I think of one thing: indispensible. I can assure you crawling is not an efficient means of locomotion. I cannot go far on the rare occasion when my wheelchair has a mechanical problem. I firmly believe wheelchairs need to be rugged in the extreme. When I get a wheelchair frame on the day it arrives I drop it out a third story window. If it survives the fall it is good to go. I have high end hubs and wheels. I have top notch upholstery.
I change all parts that experience wear and tear on a regular basis. When I travel or go out on an errand I always carry a spare tire, inner tube and pump. I am in fact entirely dependent upon my wheelchair for locomotion. This dependency does not bother me one iota. I am very attached to my wheelchair. I love that it empowers me. It makes my life go. I feel at home in my wheelchair and there is a bond that is hard to describe. I was thinking about this
bond as well as how frail the human body is this weekend. I am coming to the end of my journey with my wound. Within a few weeks or at most a month or two I will be up and around. I have found myself thinking that I want to in some way remember this time in my life. One way to remember is to modify your body. In a way I have already done that: I have grown a beard. I look like a paralyzed Santa Claus. My hair has little grey but my beard is white. But I was thinking of something more. Perhaps a tattoo or some other permanent mark. Perhaps some intense experience. I want to do something to remind me of this dark time. And if you think I am exaggerating I suggest you spend six months in bed in your own home.

Christy Matta at Dialectical Behavior Therapy Understood: Does Yoga Reduce Anxiety?: A Study on GABA Levels:

So many people who practice yoga expound on its virtues. I’ve heard many talk about the physical and emotional benefits of yoga. People say it makes them feel good, calm, peaceful. Since it’s a practice that’s been around for thousands of years and the people who practice it certainly tend to look healthy and relaxed, I was curious if there was research to back up the benefits I often hear about.

Sarah Mehta at Blog of Rights: Official Blog of the American Civil Liberties Union: At Guantánamo: Enough Already:

Yesterday morning, I watched Sudanese detainee Noor Uthman Muhammed plead guilty before a military commission in Guantánamo as part of a sealed plea deal capping his sentence at an undisclosed number of years. Noor Uthman Muhammed’s case is the only war crimes prosecution currently before the Gitmo military
commissions. He is accused of training recruits at the Khalden terrorist training camp in Afghanistan and providing additional logistical support to the camp’s operations between 1996 and 2002.

Margarita Tartakovsky at World of Psychology: The Birth of the Mental Asylum:

The first hospital in the U.S. opened its doors in 1753 in Philadelphia. While it treated a variety of patients, six of its first patients suffered from mental illness. In fact,
Pennsylvania Hospital would have a pivotal impact on psychiatry.

Daniel Kennedy aat ZDNet: The Country of Facebook Recognizes Civil Unions:

The 600 million user social networking behemoth made a small change to its “Relationship Status” drop down box today, and in doing so recognized “In a civil
union” and “In a domestic partnership” as valid choices in the way one can report their personal relationship on the site.

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My Truth on Dissociation and Childhood Trauma

In my previous post, I discussed whether I’m exaggerating the effects of my traumatic experiences. This is a common theme for survivors of trauma. Often, we’re either told or think ourselves that we exaggerate or make stuff up. When dissociative identity disorder complicates the matter, this is even worse.

Some people deny that DID even exists, and believe it is created by unethical therapists. Other people diagnose it quite quickly or believe it’s significantly underdiagnosed. My opinion is somewhere in between, and I draw it from my own experience. I knew I was multiple for almost ten years before coming out to my current psychologist. I’d never seen a therapist when I realized I was multiple. I didn’t know I lost time, and, hence, didn’t believe I had DID, but I was told by my boyfriend that I couldn’t remember stuff when I switched some of the time back in 2009, before I’d come out. Consequently, I believe my multiplicity is real, whether it can be objectified or not

It is quite likely that an implicit memory test would reveal most, if not all, dissociators do know what their alters learned. In fact, there is research to this effect with a small group of DID sufferers. It is also possible – another research study that I forgot the reference to, claims this -, that time loss in DID is “simulated”, in that people score below chance level on a recognition task. I put “simulated” between scare quotes, because it is not a deliberate action, but possibly some kind of metacognitive problem.

All of this does not mean that DID is not real to the person who experiences it. And even if the multiplicity had been created by a bad therapist, that doesn’t mean the trauma memory has. Childhood trauma is very real and likely not recognized enough. Multiplicity is very real to the person who is multiple. Whether time loss can be objectified or not, it is real to the person who experiences it. Denying these things may look good for a legal psychologist like Willem Wagenaar – whom I otherwise hold in high esteem, by the way -, but it deeply affects survivors of childhood trauma, who’ve often lived their lives being told their truth is a lie.

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Psychological Report

Last week, I received a psychological report by someone from the Center for Consultation and Expertise, which gets involved when long-term care agencies can’t handle complex care needs, like apparently mine is. The consultant psychologist had spoken to me and my team, and had administered a few psychological questionnaires. She had also analyzed the information that the institution keeps on file about me, which has a summary of my history and parent perspective (from the parent interview part of my autism diagnosis in 2007). She would’ve wanted to speak to my parents – although she never asked me -, but neither I, nor my parents would likely feel like that.

The report said some things about me that I didn’t know or remember. In the summary of my history, for example, it said that I was sometimes physically aggressive towards my mother as a young teen. I thought I was only physically aggressive at a much younger age, and was verbally aggressive as an adolescent. Apparently not. Makes me feel quite guilty.

There are also pretty harsh words about the painful experiences I’ve gone through. I won’t quote them here as they’d reveal the nature of my experience, but they are much harsher than those I’d spontaneously use myself. I know where they came from – I said “yes” when questioned -, which makes me feel rather guilty as well. Is that survivor guilt or is it something else, like truly being ashamed of exaggerating? I sometimes feel that I’ve been dragged into this by suggestion. I have some vague memory of being questioned about sexually inappropriate behavior (which I didn’t go through apart from a few minor incidents at about age six and twelve, by the way) and other trauma way back in late 2009. I never told lies about what I’ve experienced, but maybe its consequences, like the DID and PTSD symptoms, are exaggerated.

That was also what the report talked about: PTSD. As I wrote last Sunday, I checked its criiteria in the DSM-IV and unfortunately may meet them. It was not assessed directly, but my team considers me to have its symptoms, and my personality profile and other scores on questionnaires are consistent with it. ON Tuesday, I realized that I sometimes lose time for when I have a flashback, so that could explain why I feel it’s pretty minor. By the way, my dissociation was hardly discussed, but that may be because its full reality didn’t come to my team’s mind until into the assessment process.

Lastly and most annoyingly but least surprisingly, the consultant questioned my autism diagnosis in favor of believing my social problems are due to my blindness. That is at least what I read between the lines – but I’m known to read things between the lines that aren’t there. Her expertise is in blindness, so it is not surprising that she’d attribute social problems to blindness. She had some things about my hsitory wrong and incorrectly assumed I’d been living mostly in a sighted world, while I’ve been in special education for half my school life. However, the assumption that I’m unable to read non-verbal communication, is of course correct. I would assume that this possibility has been considered at my 2007 diagnosis, and at least I explained about it to the psychologist back then. So did my parents probably, being that they assume that all that is wrong with me, is blindness. All tests she administered – AQ-test (again!), Dewey Story Test (measures social insight) and some semi-structured interview -, indicated I’m on the autism spectrum. I scored higher on the AQ-test than back in 2007, which I attribute to my reduced social contact. It is also apparent that I’m easily overwhelmed and have trouble organizing stuff. So the consultant concludes that I’m on the spectrum after all, and my nurses reassured me that no-one is going to take away my diagnosis. Would be a problem if they did, since then I wouldn’t be able to go to the workhome. By the way, the consultant also briefly mentioned adaptive problems, but I’m not sure whether these are attributable to my autism, blindness or both.

The recommendations are pretty vague. Go on with treatment for my difficult experiences, and work on my self-acceptance, or something. I’m also supposed to need “intensive care”, due to the complexity of my problems. What this means, is not clarified, and, in the Dutch system, this could mean a lot of things. However, the head nurse is pretty confident that I can remain in my current care class – two classes higher than the one I was in in 2009 – when my funding needs to be renewed at the end of this year. One is supposed to work on my independence, but without me losing support in the areas that I need it. This seems obvious, but, according to the report, I’ve been overburdened a lot in the past, and I am clearly afraid of losing needed services.

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It’s Okay to Be Questioning

Questioning is in a sense a sexual orientation, although it may also not be one, since someone who is questioning is, for whatever reason, unsure of what gender(s) they are attracted to, if any. It can also mean being unsure of whether one is asexual or sexual. Being questioning is developmentally typical in early adolescence, although most people assume they’re straight and sexual because it’s the “default” sexual orientation. Being “bi-curious” and similar things are forms of being questioning, but they are not really inclusive.

There is much stigma associated with being questioning. Most people assume that you must somehow know your sexual orienttion, but are either afraid of coming out (if you are presumed to be queer), or “it’s just a phase” (if you’re assumed to be straight). In my own case, I was told that I only identified as first lesbian, then pansexual, and finally as questioning, because I wanted to be different in a way other than blindness.

I want to make this really clear: it’s okay to be questioning. It doesn’t even mean you’ll ever find otu your sexual orientation – you may not. If you do ever find out your sexual orientation, it doesn’t mean that you were “faking” when you were questioning. Being questioning also doesn’t mean that, if you’re in a relationship, you do not love your partner. Sexual orientation, after all, has to do with what gender(s) you are generally attracted to, rather than the gender of your current partner – which may not have been relevant in why you fell in love with them.

I identify as questioning. I am aware that I possess some straight privilege due to being in an opposite-sex relationship, but I do encounter a lot of the stigma I described above when trying to come out as questioning. I have internalized some of this, but I am learning that, as I said, it’s totally fine not to know your sexual orientation.

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Blogging as Advocacy

I recently participated in a research project on blogging and autistic self-adovcates. That got me thinking whether blogging is a form of advocacy. I write about autism, mental health, and disability, but does that constitute a way of advocating, either for myself or for others?

There are some obvious examples of advocacy on my blog. For example, the times I raised awareness of individual cases of abuse of disabled persons, or called on people to contact their representatives in order to get some law passed or defeated. But these kinds of posts make up a minority of my posts. The majority are informative, simply opinionated, or personal journal articles.

It is possible that even these posts constitute a form of (self-)advocacy, as in the idea that one advocates by simply existing in the world as a person with disabilities. The personal is political, as they say in the feminist community, in this case. I try to educate people about mental health and disability. Meanwhile, I’ve been told that my writing about my institutionalization demystifies the mental institution.

In another respect, I use my blog to communicate with people offline and online, to express myself. I find communicating via the Internet one of the easiest ways of communicating, and this has helped me get my perspective across to people in the mental health system, for example. In this way, blogging is a form of self-advocacy through self-expression.

Nonetheless, I never considered myself a (self-)advocate, despite being called one by people all over the Internet. Maybe, in my opinion, advocacy requires some form of being successful in daily life. This is inherently disablist, and in other people, I see (self-)advocacy regardless of accomplishment, but I am not sure whether I can call myself a (self-)advocate simply by expressing myself through a blog.

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Post-Traumatic Stress Disorder: DSM-IV and DSM-V

I have very recently been labeled with PTSD. I am not sure that I agree with this sort-of diagnosis – I’m not sure whether it’s an official diagnosis or not. I checked the DSM-IV criteria and unfortunately do seem to meet them. I was particularly reluctant to believe I avoid stimuli associated with the trauma, since most triggering things are also particularly fascinating to me. However, in DSM-IV, avoidance and numbing of emotions are categorized together into one criterion, and I do meet that criterion, because I have enough symptoms of detachment, expecting to have a limited future, etc.

In DSM-V, however, avoidance is its own criterion. One must either avoid internal or external stimuli associated with the trauma. I’m not sure I do that. Further, negative alterations in cognition and mood are collected in their own criterion. I do definitely meet that criterion even in DSM-V, where a higher threshold for a diagnosis is required than in DSM-IV. This is still under consideration though. The other two symptom criteria – reliving the trauma and hightened arousal – are pretty much retained as in DSM-IV.

The definition of trauma, most notably, has been made much more strict in the proposal for DSM-V than it currently is. First of all, threat to physical integrity (DSM-IV) had been renamed actual or threatened sexual violation. Whether this is significant remains to be seen. Secondly, however, witnessing violence through electronic media is explicitly excluded from the definition of trauma, unless it is work-related (such as for police officers). I can sort of see where the DSM-V workgroup is coming from there, but I’m not sure I agree. Lastly, death of a relative must be violent or accidental in order to meet the definition of trauma, except in children, where it is considered that death of an attachment figure can count. Again, I can see where the workgroup is coming from, but I’m not sure I agree.

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Weekly Linklove for 02/12/2011

Nicholoas Hakalar at The New York Times: On Evolution, Biology Teachers Stray from Lesson Plan:

Researchers found that only 28 percent of biology teachers consistently follow the recommendations of the National Research Council to describe straightforwardly the evidence for evolution and explain the ways in which it is a unifying theme in all of biology. At the other extreme, 13 percent explicitly advocate creationism, and spend at least an hour of class time presenting it in a positive light.

Shannon LC Cate at BlogHer: Top Ten Must-Read Books for White Parents of Black Children:

As an adoptive mother of two African American children (one Black, on biracial Black/white), I am often asked what I think white people who are considering transracial adoption* should do/think/know/read. As with most parenting questions, I think there are just about as many answers as there are families. That said, there are some issues unique to Black/white interracial families — especially when the parents and white and the children are African American — that can be addressed in a way that is useful to most if not all of them.

Suzanne Reisman at BlogHer: Rape Is a Victimless Crime According to Some Lawmakers:

There’s a lot happening these days that is raising my feminist dander. One of the most egregious of the issues is the attempts by various GOP members to undermine the criminality of rape.

Christopher Azalone at Informed Comment: The Muslim Brotherhood Myth:

Since the start of mass popular protests by Egyptians against their country’s autocratic government, headed by the aging president Hosni Mubarak and his new vice president, Omar Suleiman, a great deal of attention has been paid to Egypt’s Muslim Brotherhood (al-Ikhwan al-Muslimun). Attention on the opposition
movement has been particularly heavy and skewed in the United States where pundits from both the left and the right breathlessly claim that the Brotherhood is poised to take over Egypt in a repeat of what happened in 1979-1980 in Iran and erroneously tie the Egyptian movement to Usama Bin Laden’s Al-Qaeda Central. Much of this analysis is based on fallacies and conjecture rather than fact.

Rachel at Our Bodies Our Blog: Hearings Held on Anti-Choice Bills HR3 and HR 358:

Yesterday and today House committees are holding hearings on two controversial pieces of proposed legislation, HR3, and HR358, both of which attempt to reduce access to abortion.

Kim Milla at Autism Speaks Official Blog: Putting Self Advocacy to Work:

Sometimes it’s easier to just do a task yourself or make a decision for someone else, especially for those who are unable to speak and act for themselves. However, I think it’s important not to take the easy way out. I think its better in the long run to have conversations with individuals and explain things to them, even if it doesn’t appear that they understand everything you are talking about. If you simplify your wording, rearrange sentences and words as needed, while maintaining a clear solid voice, you can often get your point across and increase their opportunity to be included in a choice.

IP at Modus Dopens: Personal Xare and Sustainability:

The talking heads are always telling us that in Scotland, personal care is free to people over 65. The talking heads also tell us that this is not sustainable. In the last few weeks, I have grown to hate the talking heads, with a passion I did not know that I possessed.

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