Should Impusle Control Disorders and Conduct Disorders Be Classified Under the Same Category?

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.

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Study Blames Childhood Behavior Problems for Victimization to Abuse

Back in 2005 and 2006, before I was diagnosed with autism, I always used to wonder how my emotional and behavior problems related to the things I’d gone through as a child. I always assumed there was a reciprocal connection, but generally assumed, apparently correctly given my diagnosis, that my behavior problems were there first. That always made me feel guilty, because, if I didn’t have the problems I had, I would not only not have annoyed and hurt my family and peers by my behavior, but I would not have had to go through their reactions to the behavior.

Now, in the most recent issue of Child Maltreatment, I came across an interesting study. The study examines whether internalizing and/or externalizing behavior problems in children lead to increased victimization to sexual abuse, caregiver maltreatment, and peer abuse, independent of past victimization and adversity. The results are clear that mainly children with both internalizign and externalizing behaviors are at high risk of all three types of victimization. Elementary school children are especially vulnerable to bullying, while young adolescents are more vulnerable to sexual abuse. Children of all ages are extra vulnerable to caregiver maltreatment.

In itself, it is not a problem that a study aims to establish vulnerable populations to victimization. After all, if children at risk of victimizaiton can be identified, appropriate intervention can be provided in giving them the tools to protect themselves from abuse and to handle abuse once it occurs. If it were unethical to identify vulnerable populations, it would also be unethical to say that women are at strongly increased risk of rape and sexual assault, because it would sound like the women’s body type is being blamed for the assault. It does not surprise me if this is a known victim-blaming tactic, of course.

However, I have some problems with some of the language used in the article. For example:

Researchers have observed that some peer-victimized children exhibit “externalizing problems” such as disruptiveness, aggression, and argumentativeness (Olweus, 1978; Perry, Perry, & Kennedy, 1992). Such symptomatology is believed to irritate and provoke perpetrators and therefore contribute
to exposure to peer victimization. Child symptomatology may also arouse anger or aggressive impulses of caregivers because it is often associated with
undesirable behaviors such as being demanding, needy, or disobedient. (P. 133)

So, if a child were just less needy, demanding and disobedient, they would not have been physically abused or neglected by their caregiver. And if a child just stopped to be disruptive, aggressive and argumentative, the bullying would stop, too. Now I am not saying that aggression is acceptable if it comes from a victim of abuse. Aggression is unacceptable, period. I have somewhat more understanding, but not sympathy, for peer abusers, because they may not yet have the skills and/or knowledge to refrain from aggression, just as the victim who has externalizing behavior problems, may not have the tools to control their behavior. However, that does not diminish each person’s responsibility for their own behavior. Therefore, an appropriate response to bullying is not to have the bullies tell the teacher what the victim does to annoy them, as happened to me in early high school. The victim is responsible for their annoying behavior, of course, and it is good to teach them appropriate behavior, but they are not responsible for the subsequent bullying. And as to adult caregivers: it doesn’t matter that your child is “challenging”, that is no excuse for violence or neglect. Further, victims of sexual abuse have it blamed on their risk-taking behavior, their insecurity, and their poor self-concept, except when they are under twelve, as the study did not find an effect of behavior on victimization for this age group. In other words, adolescent girls (the victims were mostly female), be less slutty and less weak and the perps will stop targeting you. Oh, how pervasive victim-blaming for sexual assult has become!

Reference

Turner HA, Finkelhor D, Ormrod R (2010), Child Mental Health Problems as Risk Factors for Victimization. Child Maltreatment, 15(2):132-143. DOI: 10.1177/1077559509349450.

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What Shall We Do With Irritable Adults?

When searching PubMedCentral for articles relevant to the proposed diagnosis of temper dysregulation disorder with dysphoria, I came across an interesting paper discussing controveries in the current DSM diagnosis of irritability. Temper dysregulation disorder with dysphoria, or its alternative name, severe mood dysregulation, was not mentioned, but a number of interesting issues were discussed, especially for the diagnosis of adults.

As the author states, there is no current DSM diagnosis for adults who show frequent anger or irritability but no aggressive behaviors. The two possibly relevant diagnoses, antisocial personality disorder and intermittent explosive disorder, after all, both require that the person has displayed acts of destruction or assault. I begin to believe that my (former, I might hope) diagnosis of impulse control disorder NOS, back in 2008, was an awkward attempt at categorizing my irritability somewhere. Of course, in my case, it wasn’t all that necessary, if my doctor had looked beyond the surface of the DSM-IV criteria for autism, but that’s not the point. The author, namely, contends it as a problem that irritability is spread out over so many non-specific diagnoses in adults, when in fact it is not a core feature of any of these diagnoses. For example, it is said to be a possible defining characteristic of a manic episode, when in reality most people in a manic phase are not primarily irritable. It is also a descriptor of generalized anxiety disorder, posttraumatic stress disorder, and pathological gambling, among others, all of which would not be diagnosable if the person were merely irritable. Lastly, it is a non-core feature of a huge number of disorders, such as ADHD, intellectual disability and dementia. It is not in the DSM criteria of any of these conditions, but it is very commonly seen in patients diagnosed with them.

There are several solutions proposed for this nonspecificity of irritability. One of them is to expand the category of mood disorders to include dysfunctional anger and anxiety. The author prefers dysfunctional anger over irritability, but I did not really understand why. The inclusion of a separate mood category for anger, however, could, in my opinion, be somewhat confusing, given that the author also proposes a number of changes that reflect the idea that adults can have behavioral disorders with irritability, too. How is one going to distinguish irritable moods from irritable behavior disorders?

The author proposes to expand the diagnosis of oppositional definant disorder to adults, and to move the diagnosis of intermittent explosive disorder into a new category of social behavior disorders. The reasoning behind the latter is rather weird: IED is currently listed as an impulse control disorder, but, since none of the other specific impulse control disorders are truly impulsive, IED has to move. Why does this fact suddenly make IED not an impulse control disorder but a behavior disorder?

The other proposal, to expand the diagnosis of ODD to adults, makes little sense to me, too. The reason is not that adults cannot possibly display inappropriate anger, or kind of egocentric reasoning like the fact that I don’t want to be labeled with a “behavior disorder”, but the context in which ODD is set. That is, ODD is clearly presumed to be a disorder of obedience to authority, while in reality the vast majority of people of all ages who are irritable, do not have the purpose of defying authority. This is one of my major problems with the diagnosis of ODD in general: if a child is often irritable, it is readily assumed that they are so on purpose, and that the specific purpose is to defy the power dynamics in which they live. It is already probleematic for children, but it is even more problematic for adults, because, in most real-life contexts, they are not supposed to be obeying someone else at all times. Of course, there are power structures in adult life, too – at college or work, with the police, etc. -, but they are not as clearly present as the conventional parent-child power dynamic. On the other hand, however, as soon as a person of any age enters the healthcare system, especially psychiatry, they enter a power dynamic. If ODD is expanded to include adults, will it not be abused to merely describe the “non-compliant” patient?

I do think a diagnostic category is warranted to describe severe irritability in people of all ages, but I already have a problem with the artificial distinction between irritable moods and irritable behaviors. If a patient is neither depressed nor manic, how can a clinician tell whether they are having an irritable mood or displaying “oppositional” behavior? In children, ODD and mood disorders often coincide – and they did before the large-scalde overdiagnosis of “pediatric bipolar”, I might say. This does not mean that all these children have classic depression: in fact, many display the irritable variant of current major depressive or dysthymic disorders. If irritability is included as a descripptor of mood disorders in people of all ages, or even as a separate mood disorder category, the water gets even muddier: will pretty much every adult with irritability then receive a comorbid diagnosis of ODD and a mood disorder with irritability? For children, the proposed TDD diagnosis might solve this – if it is not used as an excuse to label even more children not in need of labels at all -, but this disorder doesn’t apply to adults. So, what will we do with the irritable adult?: diagnose them with a “behavior disorder” regardless of their mood, diagnose even more people with mood disorders, diagnose them with both a “behavior disorder” and a mood disorder, eventually expand TDD to include adults – with all possible consequences not yet foreseeable -, or what? So far, it doesn’t seem like DSM-V is going to come up with a useful solution.

Reference

Safer DJ (2009), Irritable mood and the Diagnostic and Statistical Manual of Mental Disorders. Child and Adolescent Psychiatry and Mental Health, 3:35. Published online: October 24, 2009. doi: 10.1186/1753-2000-3-35. PMCID: PMC2773760

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Reasons Patients Act Up (Other Than Just Being Ill)

A few days ago, Cellar Door of “Not Another Nursing Student Blog…”
wrote about some personal frustrations, thereby reminding me that mental nurses feel bad, too. Of course, staff have to keep a professional distance, and therefore are unlikely to discuss their own personal problems with their patients. Doing so could leave a burden on the patients. Patients, also, might use private information against staff. Besides, by being on too much a convivial basis with patients, some staff may run the risk of taking aggression too personally. Therefore, I can see why some nurses would shy away from sharing anything about themselves with their patients.

However, this is not the reason why I have trouble remembering that staff can have a hard time, too. The main reason is that some nurses have a habit of treating a patient’s every undesirable behavior as a symptom of their mental illness. I won’t go into the fact that just because something is due to someone’s illness, doesn’t mean they can push the “normal” button if they want. What I want to point out in this post, is that there are many other reasons a patient might act up. Patients are human, too, after all. By the way, this pos tis not directed towards Cellar Door or any specific mental nurse.

• Just having a bad day: oh, duh! Everyone has their good days and their bad days, and something as simple as you having missed your morning coffee, might make the difference. There is no reason why patients, even those whose illness is well under control, should always be happy (but not too happy, of course!) and never have an off day.
• Significant stressors: would you feel alright if you’d just heard that a loved one is in the hospital, if you’d just received a huge tax bill, or if a friend just told you she doesn’t want to be friends anymore? All the things that would stress you out, will stress your patients out, too, and some of these things happen more frequently to mental patients (financiaal problems, friends leaving them, etc.).
• Frustration about genuine problems related to their hospitalization or treatment: how would you feel if you had to be on a locked, short-term ward for over a year and still had no idea when you’d be moving? Or if an unclear time-out program were imposed on you (while you’re a voluntary patient, but informed consent is a privilege)? I had one of my most frustrating staff interactions in late 2008, when a nurse commented about my “depression” (I have never been clinically depressed), when I had a huge meltdown over having been on the locked ward for so long with virtually no perspective (of course my negativity also concerned other topics, but this doesn’t mean it wasn’t influenced by the situation). OMG, where’s your empathy?! It may be that a patient is in the hospital for a good reason, or that their seclusion or restraint plans are (supposed to be) necessary, but that doesn’t mean it isn’t frustrating.
• Problems with other patients: of course, everyone is ill, so chances are patients will behave in ways that scare other patients. Of course it would be easiest if eveyrone else could just ignore a patient who is acting up, but this just isn’t realistic. Staff have been trained in psychiatry. Patients have not, and, besides, we have to be together 24/7.
• Physical illness: if you are down with the flu, you likely won’t be as cheerful as you would otherwise be. The only difference between you and your patients is that you will stay home and only bug your family, while your patients will stay in the hospital and bug you.
• Hormones: you know, good, old PMS. The idea that it is an illness is populated by Big Pharma and the alternative medicine industry, but premenstrual symptoms can certainly be distressing.

There are likely many other reasons why you would feel bad, and all these could be applicable to your patients, too. Of course, if someone is throwing furniture or attacking staff, it doesn’t matter what the reason is – safety first. However, I’ve often gotten responses from nurses that dismissed genuine reasons for distress, when I wasn’t in a meltdown, let alone violent, but merely irritable. You get irritable sometimes, too. I don’t believe any nurse who says they don’t.

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The Illogical Assumption about the Relation of Behavior to Mental State

I’ve probably written about this a million times, but I’ve been particularly frustrated by this over the last few days, so I’m going to rant again: good behavior does NOT alwyas mean you’re fine!

Of course, the equation wouldn’t be as bad as it is now if it ran both ways. If behavior were assumed to be a direct, unmediated response to one’s mental state, it would not be too strange to assume that good behavior means one is in a good mental state. Of course this assumption would also mean that said behavior is particularly hard to treat, but that is not the point. However, if you say that good behavior means a good mental state because one’s mental state is always reflected in one’s behavior, you also must say the reverse: bad behavior means the person exhibiting it is feeling bad. You might say: “Oh duh, who would be acting up when they were feeling good?” I have actually once had a staff member accuse me of misbehaving for fun – when I had a huge grin on my face, indicating excitement, but I myself felt overloaded anyway and it didn’t matter which emotion was causing that -, but the majority of responses are not of that type. Rather, I am told that I 1. feel somehow entitled to this behavior (“Person X has the right to [insert overstimulating activity].”), 2. don’t try my best to act appropriately, or 3. should control my “impulses” to act out.

But then, if someone can control their behavior, it isn’t a direct reflection of their mental state, is it? So you can’t say that misbehavior indicates one is feeling bad and that’s the end of the story. Misbehavior is, after all, at least in part controllable. But then you must draw the conclusion that, if someone is not acting out, it may just as well mean that they are controlling their behavior as it may mean that they are feeling good. And wasn’t that exactly what you wanted, when you told the person to “control their ‘imulses’” or “try their best to act appropriately”?

But too many professionals want the best of two worlds, from their point of view: when the person has a meltdown, it is because they won’t control themselves, and when their behavior is good, it is because they are feeling alright. Of course, sometimes, this nonlogic may in fact be correct, because there may be times when a person is better able to control thesmelf than at other times. After all, if someone is quite able to control themself, and learns not to have a meltdown even when they’re feeling bad, it doesn’t mean that they are always feeling bad if they never have a meltdown: sometimes they may not need to keep themself in check, because they’re just feeling well enough that it isn’t necessary. In reverse, if a person’s behavior is generally a direct reflection of their mental state, some punishment might just scare them so much that they won’t exhibit the target behavior at least for a while, without the conclusion being correct that they are feeling good during that time. What is problematic, however, is the application of the nonlogic as a general rule that needs to be falsified with lots of evidence rather than as the nonlogic that may be correct some of the time: when I act out, people say that I “can’t behave like this” as if assuming I can take control, but when I’ve not acted out recently, these same people often even straight out disbelieve me when I tell them, in an appropriate way, that I’m feeling bad. This is, to use a huge understatement, not the preferred method to motivate me for behavioral change.

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“Attention-Seeking”: It’s Not Just Schizophrenia

I am currently reading an inspiring book by Norwegian psychologist Arnhild Lauveng, in which she writes about her experiences with and recovery from schizophrenia. Although in the Dutch media the book is touted as a curebie success story, this doesn’t seem to be the main theme really. Actually, Lauveng didn’t use chelation, high doses of vitamins, medications not at all meant to be used for schizophrenia, or whatever the schizo altie community is into these days, to recover from her illness. Rather, the theme that shines through her stories is her insight that her symptoms were not pure disease, but a manifestation of interactions between herself, her environment, and the changes her illness had caused to her thinking and perceptual abilities. She recovered through talk therapy and occupational therapy, which helped her see that her needs were not unreasonable and there were better ways of getting them met than through the symptoms of illness.

One of her stories highlights the functions of symptoms as a means of communication, when real communication through human language has been taken away. She illustrates this with the example that she would not get attention from the nurses if she went up to their room saying she was having a hard time. Generally, nurses at her crisis unit would be far too busy to talk with her about her feelings, so would just tell her to distract herself through a game of solitaire or a little reading. This solitary activity could generally not fill the void she was feeling, so she started cutting herself. This, of course, did draw the nurses’ attention, cause at the very least they’d need to clean up the pieces of glass and apply first aid. Arnhild did not think consciously about cutting herself so that she would get attention, and fought the allegation when made in her treatment plans, but unconsciously of course she was conditioned into cutting whenever she felt lonely, rather than going up to the nurse’s station.

The point here is not that she did it for attention, but that she was conditioned into a maladaptive behavior – a symptom of her illness -, through an interaction of her loneliness with her situation as a hospital patient, where nurses had no time to provide her with much-needed company. You see, as human beings, we constantly seek attention. If we are said to be healthy, we generally have family, friends or colleagues to seek attention from. We expect our friends to be there to do activities with, to comfort us when we’re sad or to share in our joy when we’ve made an important achievement, to hang around with when we’re bored, etc. Colleagues at work don’t spend all of their interaction time on work-relevant matters at all. Most people need attention most of the time, and most people get worried when someone around them becomes withdrawn. But in psych hospital, because it’s easiest – unless, of course, you’re expected to participate in group therapy -, it’s better if you just sit in your room quietly playing thousand games of solitaire, than if you seek attention at the nurse’s station. So what do you do if playing the pack of cards won’t give you company? You cut, and find out that this will draw human attention, and the response gets conditioned.

Of coruse the solution is not what I, and no doubt many other psych patients, get subjected to: professionally being ignored even more, in order to decondition them. Deconditioning won’t work if the need is still there and there’s no other behavior that will get it met. And, again, we’re talking about a normal human need, not some extraordinary and peculiar desire that should be wiped out as much as possible. It’s about time psych people realize this and stop talking about attention-seeking without reflecting on the normalcy of this need.

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BADD Behavior: Disablism in Psychiary

Note: in the process of writing this BADD post, it has taken a different turn than I’d initially intended. As I reread it, I feel that it may come across like I’m targeting specific people, eg. my former social worker, with my criticism. This was not my original intention. Rather, I was meaning to write about the impact the institution environment and accompanying mindset among staff has on people with mental illness. In fact, the point that I was trying to get across is that even well-meaning people may unconsciously dehumanize people with mental illness in an effort to keep the peace and quiet in the hospital environment, and fail to differentiate between illness-related behavior and problematic behavior that is a perfectly normal response to the institutional structure.

Today, May 1, is Blogging Against Disablism Day. I didn’t participate last year, probably because I couldn’t be sure that I’d be home to actually publish my post, even though I’d picked a theme to write on a while before the day came up. The theme I’d picked would be a more personal follow-up to my 2007 contribution on stereotypes and counterstereotypes. I wanted to write about the experience I’d had in the psychiatric hospital of staff treating me entirely differently based on whether I was “good” – ie. not melting down, not showing my irritability at other patients’ behavior, not criticizing the staff, except for maybe a few cynical jokes, and not shoving my distress too much into the staff’s face -, vs. when I was “bad”. Despite the fact that patient rights apply unconditionally unless a court has ruled otherwise (eg. in cases of involuntary commitment or incompetency), it is actually very hard to stand up for your rights when you’re “bad”. One of the reasons is that the staff are not tyrants, and treat you well when you’re “good”, thereby making you believe that you really must be bad when they treat you badly. You’re the patient, after all.

The problem is, however, that being “good” is emphatically not the same as behaving how a healthy person would behave. Rather, being “good” involves doing what the staff want you to do for their convenience. It isn’t “sick” to become desperate after sixteen months on a locked ward, after all. All my “healthy” relatives say they would’ve really become crazy far sooner than that. Many also say that they would’ve become far angrier than I did if a social worker had decided for them which of their relatives are and are not important, had forced them to sign forms to have them move out of the area, and had even suggested that they go on financial management.

A few days ago, someone on a Dutch autism forum started a discussion on the Rosenhan experiment. In this experiment, several perfectly healthy people showed up at psychiatric hospitals pretending to hear voices. All were admitted, and all but one were diagnosed with schizophrenia, even though after their admission, they behaved exactly as they would otherwise have and said that they no longer had symptoms. Everything the pseudopatients did, however, was interpreted as a sign of illness. For example, when they took notes during therapy, they were referred to as “engaging in writing behavior”, and their accounts of their lives were psychopathologized. The conclusion was drawn that psychiatric diagnoses are strongly influenced by the patients’ environment, rather than by their internal characteristics.

Of course, unlike me, the people in the Rosenhan experiment had no mental health problems and had never had any. Even so, does this mean that the mental hospital environment wouldn’t have the same impact on people with genuine mental disabilities? I don’t think so. The problem is that people with mental disabilities do display “sick” behavior besides their institutionalization symptoms, and it may be harder to tell the difference.

However, Rosenhan’s experiment did suggest that one thing that makes it extremely difficult to tell mental illness and institutionalization apart, is the lack of unbiased observation: the pseudopatients were simply thought of as patients and their behavior as illness, without any regard for the individual. And I may be developmentally disabled, and that disability may be an essential part of who I am, but I am still a person, not a behavior modification robot.

And this is exactly how some people in mental institutions seem to see us. Probably not consciously or intentionally, but it is how some behavior will come across. For instance, some people are committed involuntarily because their mental illness supposedly causes them to elicit violence from others, but their fellow patients in the institution are punished for even getting irritable with them, because their irritability is thought of as part of their own mental disorder. My frustration at the long-time hospital stay was also seen as part of my mental disorder, and so was my rage when the social worker forced me to sign Apeldoorn living facility forms, claiming that my boyfriend isn’t important since he’s never introduced himself to her. As I said, probably the staff didn’t intend to suggest that my every behavior is due to autism, but their actions suggest otherwise. One anger tantrum when the social worker forced me to sign the Apeldoorn forms, was a reason for her not to ask me for consent to contact my parents and other people important to me – except that my parents insisted that she obtain my consent before they would do anything. I still believe in this social worker’s good intentions, at least from her perspective: I am autistic and may have meltdowns when in a situation I can’t cope with. To prevent this, she probably tried to keep me away from the stress of having to hassle with living places, etc., that may have led to meltdowns. After all, this is the explanation she gave for not having obtained my consent.

Even if the assumption that any attempt to obtain informed consent would’ve led to a meltdown anyway had been true, is it really necessary to keep the peace and get the patient to do what you want them to do at the cost of patient rights? Healthy people argue, too, and often quite constructively. Healthy people won’t take it that anyone is taking away their right to decide for themselves how they want to live their lives. Some healthy people may even lose their tempers at some point, and on some occasions, they are thought of as on the right side of the matter. However, if the person arguing, or demanding that his civil rights be respected, or especially losing his temper, happens to have a mental health diagnosis and the other person happens to be a staff member, it is all too easy to dehumanize the mentally disabled person’s behavior and assume the “acting out” to be due to his illness. Well, maybe not so: people with psychiatric or developmental disabilities are disabled, yes, and that disability is an essential part of their being, but that doesn’t mean that they’ve lost their humanness and will take things that the healthy wouldn’t take.</p

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The Paradox of Psychiatric Hospitals and Tolerance for Non-Hamrful Quirks

A few days ago, I got in big trouble because I’d allegedly offended other patients by telling them to shut up when they kept talking to themselves (they’re psychotic so apparently can’t help this behavior). One other incident that I was at first reprimanded for was later found to be provoked when the nurse heard my side of the story (that the reporting nurse had not witnessed) – the other patient kept going on and on about how I can’t play a game because I’m blind, and then I told him to shut up (the nurse thought it was once again cause the guy talked to himself) -, but the ones that were indeed with me telling the patients to shut up because they talked to themselves, were found to be entirely my fault. Now I’m not going to blame other patients for behavior they cannot help due to their psychiatric illness, so I won’t say that the incidents were their fault, but I do find something interesting about these: we, psychiatric patients, are expected to put up with behavior that no-one else in society would put up with.

Of course, I’m all for tolerance, and I try not to pass judgment onto people in or out of hospitals who exhibit annoying behavior. I am in fact against the notion that some people should be committed involuntarily for non-harmful behavior that is “bringing other people’s aggression onto themselves with annoying behavior” – and yes, this is one of the examples of “danger” as used in involuntary commitment legislation here. On the other hand, there is only so much I can handle, and if I happen to be watching TV or in the middle of a meal, going to my room is not an option. I in fact have a lot more endurance for annoying behavior than my sister, who notices my fellow patients are “crazy” even when I consider them extremely “normal” (makes me wonder what she thinks of me when I consider myself “normal”). Obviously, tolerance gets better when you realize that behavior is not directed towards you personally, which I’ve learned quite a bit here. My patience with one of the psychotic guys who talks to himself became a lot better (unless the stories got really scary, when I did tell him to shut up, which I was reprimanded for) when I tried to remember that he was talking to his voices and not me. I have also watched a woman throw the entire set of coffee mugs to the ground several times without yelling at her, because I knew she was dissociative and probably didn’t realize what she was doing, and I’ve heard too many people wake the entire ward by screaming in the middle of the night to count. You can be sure that everyone here (except for me, as the nurse’s reprimanding sometimes came across) has a mental disorder that causes them to be unable to control some of their behavior. It is not willful behavior and therefore you cannot demand that they take total responsibility for it, and therefore you cannot react with anger or annoyance. I am not saying this is incorrect – as I said, I’m all for tolerance, and this post is not meant to defend my offensive comments -, but it does make me wonder.

After all, who can be 100% certain that someone not in a psychiatric institution, who exhibits this same behavior, is having control over his actions? Perhaps it’s just that no psychiatrist has ever examined them yet and they would’ve been hospitalized for some form of “danger” (another dubious one is “social disintegration”) if one did. After all, this is the exact response I get when I try to put an action that gets me in time-out into perspective by claiming I’ve done that many times before I was hospitalized. Even so, without this knowledge, it is not going to get you in trouble to tell someone who keeps talking to himself when you’re watching TV to shut up – because the assumption is made that if the person does it because they’re psychotic, they should be hospitalized and if they do it because they want to, they’re assholes and can be bitched at. If it’s not okay for a fellow patient to offend someone for talking to himself (when she doesn’t even realize that it’s offensive), how can it be okay for healthy adults to do the same? The answer is it’s not. We all have only so much we can handle and can lose our tempers when annoyed, but we should all aim to have tolerance for non-harmful “craziness” whether it be in the hospital or out in the community.

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When They Say “Danger” and Mean “Inconvenience”

Quite often, I’ve heard doctors and nurses here use the words “safety” and “danger” when really they seemed to mean “quietness” and “inconvenience”. An example is when the doctor told me about the time-out policy and said she wanted to talk about safety. While there’d been one safety incident a few days before the policy was introduced – that I’d stood still in the middle of a road -, the reasons why nurses would segregate me, are things like my slamming doors. Well, what’s so dangerous about that?

It is understandable, given the behaviors that I have exhibited, that there’s a time-out policy in place for me. Not that time-out would’ve made any sense at any of the times when I exhibited dangerous behavior – simply because the danger had already passed when a nurse found out about the behavior or when we reached a time-out room -, but at least some of my behavior would’ve warranted time-out.

But there is something else, that involves the question how necessary time-out really is. The nurses say I haven’t freaked out since the policy was introduced. Well, I have, at least two times. The difference was that now they all need to send me to my room first before placing me in time-out, and it’s very rare that I am so unreachable that I cannot follow this command – it happens, and at that point, time-out is often an appropriate measure. Previously, some nurses would send me to my room, but some would not. Besides, the time-out policy was introduced after an incident in which I did freak out, but did exactly what the nurse told me to do, so there would’ve been no reason for time-out.

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Thoughts about Expressing Emotions

Since being on the psychiatric ward, I’ve been accused of throwing objects for fun, or being funny about serious issues such as suicidal ideation, because I had a smile on my face when coming to the nurse. And today, I laughed a short while after a fellow patient had told us he has cancer. In none of these cases did I feel happy or did I see any fun in what was happening or what I was thinking about. It gets me thinking about the way I express emotions.

It happens quite often that I express the “wrong” emotion, or that the expression on my face or in my voice does not agree with the expression that would be appropriate in that situation – and, in my opinion, not with the actual emotion I experience, either. A few years ago, I read somewhere – I think in one of Tony Attwood’s papers -, that this is common in people with Asperger’s Syndrome. An example that was mentioned was when a child giggles when in pain, while NT children would cry. This is the reason I’ve come to dislike the “for fun” statements made by nurses: just because the child giggles, doesn’t mean they like pain, does it? It just means that they have a different way of expressing emotions.

There is something else, that I wanted to write about after reading a forum discussion on a Dutch autism forum. It started with a man referring to himself as unconsciencious. The reason is that there might be a huge airplane crash with hundreds of deaths, but he would laugh because one of the dead man had such a funnily ugly watch. While I could understand that this would come across as unconsciencious, and I would consider the man this based on the other examples he gave (for instance, being able to stab someone to death without feeling any regret), there is another possible explanation: that of being so detail-oriented tha tone little funny thing can catch all the person’s attention to the point of losing the big picture of grave sadness. This was what happened yesterday with the fellow patient informing us of his cancer diagnosis: while I did realize the seriousness of the big picture – someone I knew had a life-threatening disease -, I laughed as another patient forgot one of the nurse’s names and called her by her (by the way insulting) nickname – that has become funny as patients used it in other contexts than the original one. Hence, I didn’t feel funny about the one patient’s cancer, but a detail within the situation, caused me to laugh.

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