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.

First, sorry for my almost three-month hiatus. I am back, anyway. A few days ago, I commented on someone in a YouTube video claiming that high-functioning autism and Asperger’s Syndrome are subtly different in other ways than language acquisition. I disagreed based on DSM-IV criteria. However, the DSM-IV can be criticized, and it remains an ongoing debate whether HFA and Asperger’s are distinct.

Yu et al. (2011) did a meta-analysis of neuroimaging studies on people with autism and Asperger’s Syndrome to determine grey matter volume differences. In each of the analyzed studies, Asperger’s or autistic individuals were compared to controls, so the two groups were not directly compared. Note that autism or Asperger’s diagnostic status was determined based on the absence or presence of language delay.

It was found that not only did autistic individuals’ brains differ more from controls’ brains than the Asperger’s brains differed from those of controls, but that different areas within the grey matter were affected. Specifically, the studies on HFA people showed lower volumes in the cerebellum, right uncus, dorsal hippocampus and middle temporal gyrus compared with controls and grey matter volumes greater than in controls in the bilateral caudate, prefrontal lobe and ventral temporal lobe. In Asperger’s Syndrome people, lower grey matter volumes were found in the bilateral amygdala/hippocampal gyrus and prefrontal lobe, left occipital gyrus, right cerebellum, putamen and precuneus. Grey matter volumes were greater in fewer areas than among HFA subjects, including in the bilateral inferior parietal lobule and the left fusiform gyrus. The areas that are dissimilarly affected in Asperger’s versus HFA are not only related to language acquisition. The authors discuss observed differences between Asperger’s and HFA in the light of neuroimaging. They go so far as to speculate that Asperger’s should be considered more similar to schizophrenia on a continuum of neuropsychopathology than should autism.

Reference

Yu KK, Cheung C, Chua SE, McAlonan GM (2011), Can Asperger Syndrome Be Distinguished from Autism?: An Anatomic Likelihood Meta-Analysis of MRI Studies. Journal of Psychiatry and Neuroscience, 36(6): 412-421. DOI: 10.1503/jpn.100138.

It is already September here in the Netherlands, and I forgot to post the link to the August Blog Carnival of Mental Health. OccasionalWallflower put together a nice collection of posts on the theme of personal journey. Check it out and get touched.

No-one stood up to host the September carnival, so I will be hosting it here at Astrid’s Journal. The theme will be treatment. Please get your submissions in, via E-mail or comment, by September 28, and I’ll post the carnival on September 30. I am also looking for volunteers to host the carnival from November (its one-year anniversary!) on. If you’re willing to host, please comment here or send me an E-mail.

I just found out that termper dysregulation disorder with dysphoria (TDD) is still included in the proposal for DSM-V, but under the category of depressive disorders. It is now named disruptive mood dysregulation disorder. This reflects the fact that the predonimant feature of this disorder is a mood problem rather than a behavior problem. The “disruptive” part does show that there is still consideration that this disorder is a behavior problem in essence, however.

The criteria are very strict, but unfortunately, bipolar disorder has to be ruled out first before a child can be diagnosed with this disorder. This makes it easier for doctors to diagnose pediatric bipolar disorder, while it seems the TDD idea was to correct the misdiagnosis of pediatric bipolar.

I still think that I would’ve been diagnosed with this had this disorder been present in DSM-IV. I used to meet all the criteria before I went on Abilify, except that a pervasive developmental disorder should be ruled out first.

The July Blog Carnival of Mental Health is up. Willfindhope put together a large collection of posts on the theme of stigma and discrimination in all kinds of areas of life. The August carnival will be hosted by OccasionalWallflower. She hasn’t yet posted an annoucnement, but she has told me her theme will be personal journey. More details later.

ETA: OccasionalWallflower has posted the announcement for the August carnival. As she says, the deadline for submissions is August 29.

Adjustment disorder has been a category of its own in DSM-IV. IN DSM-V, the workgroup is proposing that it be included in a category of trauma and stressor-related disorders. I agree to this, as there is a lot of resemblance with other trauma and stressor disorders. Further, the criteria are almost the same as those in DSM-IV. However, a few new subtypes are considered:

• With PTSD/ASD-like symptoms: if the person experiences symptoms similar to PTSD or acute stress disorder, but the full critieria for trauma or for the symptoms of PTSD/ASD are not met.


• Related to bereavement: when the stress reaction is related to the death of a close relative or friend, and the person experiences intense longing for the deceased that is in excess to what is normal.

The workgroup also proposes a new disorder for research purposes only: bereavement related disorder. In this condition, after the death of a close relative or friend, the person not only experiences intense longing for the deceased, but also a number of specific symptoms, including social or identity disturbances and reactive distress symptoms. This condition is very controversail, as it is generally believed that grief and distress are normal responses to death, and that even complicated greif is not a psychiatric disorder. I agree to this and feel that bereavement related disorder should not be included in DSM-V.

The disturbance in adjustment disorder must last for no longer than six months after the stressor or its consequences have stopped. An exception is made for the bereavement-related type, where the adjustment problems must last for at least twelve months. I consider that a reasonable timeframe, if bereavement is going to be seen as a disorder at all, but I do not agree to the six months cut-off for the other types, that is also present in DSM-IV. After all, an adjustment problem can last for more than six months, and it is strange that a person must then be diagnosed with another mental illness which they may not have. In my own case, I was diagnosed with impulse control disorder NOS after my six months with adjustment disorder, and this diagnosis was not only incorrect, but failed to reflect the fact that my behavior was in large part a reaction to an unstable situation.

It’s the end of the month again, so here is the June edition of the Blog Carnival of Mental Health, on the theme of hope and despair. Pandora nicely put together the largest carnival we’ve ever had so far.

For the month of July, Willfindhope will be hosting the carnival, on the theme of stigma and discrimination. Please submit your posts via a comment or E-mail by July 28 and watch out for the carnival before the end of the month. Please realize that Willfindhope lives in Australia, so your post likely needs to get in early on July 28 for her to receive it at night.

Remember that I’m still looking for volunteers to host the Blog Carnival of Mental Health from August on (except for September). If you have a blog that is at least partly about mental health, and you are willing to host the carnival, please leave a comment here or send me an E-mail. Hosts get to choose the theme for their carnival edition, of course.

There are many strange disorders being proposed by outside parties or by the American Psychiatric Association for inclusion in DSM-V. Oddly enough, however, complex PTSD is not among them. C-PTSD is not just gradually different from regulat PTSD, but encompasses other features such as those seen in personality disorders. It is a disorder caused by captivity or other situations of long-term, severe trauma.

Of course, the subtype of chronic PTSD is included in DSM-IV as well as DSM-V, but this is merely regular PTSD that lasts for more than six months, without the additional features of impaired self-concept, trust, and emotion regulation, among others. In my opinion, complex PTSD is more warranted as a specific disorder than such things as parental alienation syndrome and body integrity identity disorder, both of which are proposed by outside parties.

There are many people who would meet the criteria for complex PTSD but not the full criteria for regular PTSD. What do they end up being diagnosed with, if anything at all? Do they fall within a treatment loophole, getting no counseling because they don’t have a legitimate mental condition? Or do they end up with stimgatizing and incorrect diagnoses that don’t reflect the fact that they are trauma victims?

Today, June 27, is PTSD Awareness Day. Let’s stand up for the rights of victims of long-term, severe child abuse, war camps, or other states of captivity, to get the recognition and treatment they deserve.

Last week, I heard on an E-mail list that the DSM-V workgroup is considering adding parental alienation disorder to DSM-V. It was only looking for feedback, so my hope is that enough people have campaigned against this diagnosis that it will not be included.

Parental alienation disorder is a specific set of symptoms, where a child chronically denigrates one parent, usually in the context of custody battles. The child may belittle, accuse or otherwise detach themself from one parent. The assumption is that the disorder is caused by unconscious or conscious indoctrination by one parent against the other, as well as the child’s on personality. Included in parental alienation disorder are false accusations of abuse.

In my opinion, if this were a real concept at all rather than a fantasy to cover up actual child abuse, this should be a psychological concept rather than a psychiatric one. Parental alienation disorder, if it exists, is the manifestation of a dynamic between parents and children, rather than a mental disorder on the part of the child. So, for that reason, it does not belong in a psychiatric handbook like the DSM.

I, personally, do not believe in parental alienation enough to consider it an actual condition at all. Sure, it may happen on occasion, but not on the large scale that proponents assume it occurs.

Besides, even if a child denigrates a parent without reason, this does not mean it has to occur in the context of custody battles or that it is the other parent’s ffault. It may be that a child has an attachment issue, which in the DSM can only be caused in the context of pathological care, but which, in my opinion, can be caused by a number of factors. Also, it may be that a child has a problem with irritability, such as oppositional defiant disorder, and is acting it out specifically towards the less assertive parent.

I do not deny that indoctrination in the context of custody battles happens, but if it does, it is not something the child is responsible for, and therefore does again not reflect a disorder of the child. Rather, if indoctrination is present, the parent doing it has a serious psychological problem, though not a mental disorder. So, rather than concluding that parental alienation is a disorder, look at the broader picture of whether the child may have other issues causing them to act out against one parent, whether either parent has a psychological problem, etc. And please don’t pathologize problematic but non-medical behavior.