So You Want To Talk About Multiple Personalities?

I’ve gotten a few requests over my blogging time to talk about multiple personality disorder. I’ve (half) jokingly told friends that this post would garner me a great deal of upset commenters but here it is. 

Important Note: My opinions on the scientific validity of this disorder DO NOT reflect any belief that identified ‘multiples’ or sufferers of DID aren’t suffering, don’t deserve to be treated, or should be in any way, shape or form ridiculed, belittled, or treated poorly. Full stop.

So, I totally spoiled it with the disclaimer, but here it goes.

I don’t think Dissociative Identity Disorder/Multiple Personality Disorder is scientifically valid as a diagnosis.

…and since this is a fairly prevalent feeling in the psych community, I’m less worried about the Internet is Forever ™ problem.

Sybil: a book, a movie, and a tale of really unethical psychology.

DID?

While there’s some reports of people exhibiting something like multiple personalities as early as the 17th century, but the diagnosis didn’t take off in popularity until the 20th century. It’s entry into pop culture is strongly linked to Sybil, a book about one (real) woman who appeared to have sixteen personalities. It was a popular book, run in newspapers, and cited as one of the main factors in the sudden upswing of DID/MPD diagnoses. Sybil and her therapist are no longer alive, but much  criticism surrounds it. (See below)

DID/MPD was called Hysterical Neurosis, Dissociative type in the second iteration of the DSM. By DSM III it was Multiple Personality Disorder, and DSM IV made both significant changes to the criteria and the name, creating Dissociative Identity Disorder (DID).  However, because of the prevalence of MPD in current literature/horror movies/culture, I’ll use DID/MPD.

In general, DID/MPD is characterized as having multiple distinct personalities or identities (this is the second required criteria for diagnosis). These are called ‘alters’. Usually, though not always, there’s a central personality that’s often treated as the “real” one. That identity is usually depressed or anxious.

 

So. Sybil.

Sybil is the pseudonym for Shirely Mason, the client of psychoanalyst Cornelia Wilbur.  Mason didn’t come to her therapist because she had DID/MPD–her presenting problems were anxiety and memory loss. Then, after seeing Wilbur, suddenly, BAM, she had sixteen personalities.

Do I sound suspicious? I am.

Though the client files are sealed, multiple analyses of the taped sessions have said that Wilbur herself encouraged Mason to develop alters…and offered her money for talking about her different personalities. How did those personalities appear? Wilbur, who gave many drugs to her clients (including some very highly addictive psychotropics), gave Mason sodium thiopental and heard her mention other identities under the drug’s influence.

Sketchy? Most definitely. If that wasn’t damning enough, Mason wrote later that she had made the alters up.

Relevant reading: Remnants: The Last Stand of the Satanic Ritual Abuse Movement.

Who gets diagnosed? Who is diagnosing?

Of course, Sybil/Shirely Mason being a the result of unethical practice doesn’t negate that multiple personalities could exist. So what else do we know?

Those with DID/MPD diagnoses are often reported as having severe trauma in childhood. Data on this isn’t actually very clear, because many of the psychologists to originally diagnose MPD/DID believed in repressed memories and used really unscientific techniques to ‘retrieve’ them (This was around the time of the satanic abuse cases). Current research doesn’t support the idea of this sort of trauma repression.

DID/MPD patients also score very highly in measures of ‘hypnotizabilty’–a specific measure of being suggestible…and anywhere between ‘many’ and ‘most’ practitioners who diagnose DID/MPD use hypnosis to determine if their clients have multiple personalities. Hypnosis: not a methodologically sound form of diagnosis.

And those practitioners? They’re a specific subset of  psychologists, and they appear to get a statistically improbable number of clients who turn out to have DID/MPD. Of course, this could be a result of skeptic practitioners under diagnosing, right? Absolutely.

However as many as 70% of those with MPD/DID diagnoses appear to have borderline personality disorder (BPD). That’s high enough to suggest something more than simple co-occurence, which has lead to suggestions that professionals are using the idea of multiple personalities to explain the impulsivity and rapid emotional changes of BPD. Further, when the diagnosis of schizophrenia was introduced, there was a sudden crossover from those with MPD/DID to schizophrenia. Is it possible that those who believe in the DID/MPD diagnosis are just more likely to categorize BPD or schizophrenia as multiple personalities?

Relevant Reading: Dissociative Identity Disorder: A Controversial Diagnosis

The North America Problem. Is this a cultural diagnosis?

North America has the highest rates of DID/MPD diagnoses in the world. It’s also the place where multiple personalities are most familiar to the population at large. While this doesn’t mean the diagnosis is invalid, it casts, shall we say…aspersions. Secondly, when DID/MPD became a popular diagnosis in the 80’s, we also saw a sudden increase in the average number of alters, from 2-3 to an average of approximately 15. Hmmm.

Memory crossover in alters.

We’ve learned a lot about memory in the years since MPD/DID gained traction.We know, for instance, that repeated exposure to neutral (or even nonsense) words will result in faster recognition of those words.

(This can be tested by giving participants a series of possible categories for nonsense words and letting them learn by trial-and-error which word matches which category. For instance, in Trial One, James may match word Njdhsuf to Category A. When the result is NO, he is unlikely to try Category A for word Njdhsuf in Trial Two. By Trial Three, he may know that word Njdhsuf goes with Category C. If he is retested a short time later, James will sort the familiar nonsense words into their correct categories at higher rate than random chance, even if he feels as though he is guessing.)

Those diagnosed with DID/MPD report distinct personalities and identities, almost always reporting autobiographical amnesia (alters report knowing nothing of other alters or of what was done when the client was in a different identity) between personalities, one. So in a test like the one described above or similar, you would expect to see that if James is one identity, when he became an alternate identity, he would show no memory of the nonsense words, and sort them into correct categories at rates that resembled random chance. That’s not been shown to happen*. (This study also showed that indirect measures of behavior and ERP–which could be grossly oversimplified as how your neurons fire–found recognition in one identity of neutral words learned in different identity.) This study tested emotionally loaded words and found the same.

Okay, so what about autobiographical information? Though patients may have a central organizing identity, most report their personalities know nothing of other personalities. Objective tests have utterly failed to validate this. Though I strongly encourage reading this entire study about autobiographical memory in those with MPD/DID, here’s some relevant sections  [bolding is mine]:

Consistent with previous studies, transfer between identities on the memory task occurred even for negative material, despite patients reporting amnesia for this material, learned in another identity state. Transfer across amnesic barriers in DID also occurs for conditioned emotional information. Testing DID participants, Huntjens et al. administered an evaluative conditioning procedure that confers a positive or negative connotation on neutral words. In a subsequent affective priming procedure, participants displayed transfer of this newly acquired emotional valence to the amnesic identity (i.e., transfer of emotional material between identities).

Our findings are consistent with the results of other studies involving objective laboratory tasks indicating intact inter-identity memory functioning in dissociative identity disorder. In most studies, researchers test memory within the same experimental session shortly after learning. In contrast, we tested memory after a 2-week delay, thus increasing the ecological validity of our study. However, the results do conflict with the reports of amnesia between identities, suggesting that the subjectively experienced absence of autobiographical knowledge about other identities is quite self-convincing.

These findings become particularly important in cases like these**.

So what about people who appear to be multiples***?

I don’t have a great answer to this. Right now, therapy for DID/MPD seems to focus on integration: bringing all facets together into a single identity. There’s some pushback from self-identified multiples on this idea, many of whom feel that they’re not sick or broken, and that therapy treats them as such. I don’t really disagree, if they feel that they’re coping well. Forcing someone into therapy rarely goes well, and except in instances of danger to self or others, I’m all about the hands-off approach.

In the long term? I think we need to remove Dissociative Identity Disorder from the DSM. Like other diagnoses (*cough* Transvestic Fetishism *cough*) it seems to be the theory of a small contingent of scientists with little support in the community. When this dies as a cultural meme, I believe we’ll see a similar decrease in diagnostic popularity and even symptomology.. (We’re also seeing a sharp decline in scientific interest.)

——–

A great deal of the links and understanding that were required for this blog would not have been possible without Ed Cara, who you can find on twitter and blogging at The Heresy Club.

*Upon reflection this isn’t quite accurate. A few case studies have suggested autobiographical amnesia. However, I’m going to go with the majority of evidence found in studies that used controls (and simulators–people pretending to have amnesia) and larger pools of participants.

**Though DID/MPD has been a staple of the horror genre and several sensational trials, please don’t make the mistake of thinking DID/MPD is linked to being violent.

***This seems to be the preferred term in my reading of multiples’ writings (another popular term is ‘systems’). I’ll take correction and change this if I’m wrong.

Psychometrics: Using and Abusing

Look, SkepTech already has my favorite talk up!

Stephanie talks about psychometry: the way we measure concepts in psychology. It’s the intersection of statistics and psych, and I dearly love it. I was particularly happy about her answers to questions about fMRI’s and [my question] what we should keep fixing in how we measure intelligence.

On Running Out of Feelings, and What to Do Next

Hello, internet.
This is where I come to spill my secrets, right?

Sometime between last week and this one, I went numb–ran out of feelings. I think it was somewhere after the third friend in forty-eight hours contacted me with questions about leaving abusive relationships, between finals and Steubenville and painful anniversaries and suddenly having a living situation that went from Absolutely Planned to Horrifyingly Tenuous. Oh, and it’s my last day of therapy this week.*

And that’s the simple stuff.

Add in friends who need a Social Kate who smiles and has opinions and wit and does not resemble a posed block of wood. Sprinkle in academics, and taking a quarter off to work at a small agency that expects a lot from me.  Roll it all in the stress of attending a competitive university where everyone Accomplishes Things that can be itemized on a resume–things that don’t contain scary words like atheist…and feeling anything outside Ron Weasley’s teaspoon involved too much work.

So I just started feeling numb.

It’s awful. I hate it and I go round and round between being irritated at not feeling anything, and getting angry about it…and then giving up because even anger feels muted and exhausting. It’s not terribly unusual–when you run out of emotional energy, that’s how it goes. It sucks, and I know I’m not the only one who gets this. So here’s how I minimize suckage. (The technical term, ya know.)

Lists

An idea stolen from someone–either the indomitable Captain Awkward or Keely. Each day gets two lists. List One: everything I have to accomplish that day in order to prevent the week from crashing and burning, and nothing more. Anything else you accomplish goes on List Two.

List Two starts out empty, and you have no obligation to fill it. It can be empty at the end of the day, and you will still have survived and accomplished important things and can sleep easily. If there is anything on List Two, you get to feel proud of it. You have gone above and beyond. Congratulations! Well done, you.

Excuses ahead of time are your friend.

Because the socially appropriate answer to a concerned “How are you feeling?” is almost never “My brain is being awful and I can’t feel anything and also everything fell apart last week.”, stock phrases are your friend. Among my favorites:

I haven’t been sleeping quite right, thanks for asking!
Because this is true even if it means you’ve been sleeping constantly and your brain feels like fuzz.

Oh, you know, long week. [Tired smile.]
Where a “long week” is defined as any set of days where life was hard and not worth explaining.

I’m a little out of it right now. It’s probably [related thing that may or may not explain your actual problems.]
Poor finals. I’m constantly blaming them–this is my most used phrase. I actually rarely find exams overwhelming, but they’re a fabulous explanation for why I’ve developed the habits of your average hermit crab.

Sorry, I have a touch of a stomachache.
People with stomachaches tend to get all silent and huddle in the corner of any given gathering, trying to force their gastric juices to cooperate. I don’t particularly advocate lying, but if this gets you out of an nosy stranger’s headlights, I approve.

This terrible clip art is not the Feelings Police

This terrible clip art is not the Feelings Police

Numb is okay.
There are no Feelings Police. They will not come find you and lecture you into submission for not possessing the correct emotional range. Feeling numb is weird and uncomfortable and unpleasant, but it goes away and you can survive it. Give yourself permission to feel as bad as  you do, to nap as long as you need to, and to feel a little hollow.

Be greedy.

And along with that, be greedy. Will taking day off to paint your nails and consume only popcorn make you feel better? Do it. Will skipping that party to play videogames in your room feel better than pretending to feel social? You suddenly have new plans for the evening. Within the limits of your wallet and abilities, do whatever seems as though it could improve your day.

Hide in groups.
The thing about large groups of people is that you can get lost in them. Everyone else will jump about and make noise and try to figure out how to split the check when Susan ate half of the onion rings that Johnny ordered, David and Sarah split an entree, and Jacob only brought large bills.  And you can just sit there. Let everyone else have wild, sweeping feelings. There’s less pressure to say interesting things when everyone else is being exciting. You can tune out, drop in for the occasional murmur of agreement, and still be holding up your little corner of being social.

Update: Puzzles
Stephanie explains.

—-

So there it is. Ideally, these will work this time around, and I’ll kick the fuzzy-brain feels sometime before the end of my spring break.  What do you do?

* NU requires that I take the coming quarter off from classes to work Monday-Thursday, from 9-5. Therapy is only available Monday-Thursday, from 9-5. I’m sure there’s a witty name for the choice between skipping my lunch hour to get therapy and not having therapy for an eating disorder, but right now I can’t manage to find it.

Brain Self-Help: An Incomplete List of Resources

Yesterday Andy pointed out that a list of non-going-to-therapy resources would be useful. Insurance, time, frustration with therapeutic experiences, inability to tell parents, etc, can make seeing a therapist either impossible or unappealing. Here’s a (totally incomplete) list. Please please please add other suggestions in the comments! I’ll keep updating.

Relevant disclaimer: I’m not a therapist. Most of the linked blog posts are not written by therapists. (Though most of the books are written by someone with a psych degree.)

The below are first general resources, then sorted specifically by disorder, followed by some resources if you do decide to seek therapy. If I could pick three I endorse the most, I’d say Boggle, How To Keep Moving Forward, and Don’t Tell Me To Love My Body. All three are italicized in the list.

Miscellaneous/Multi-Disorder Help & Information

DBT Workbook
This is one of many, but it’s received very positive reception from the psych community and did get an award for being evidence based. DBT is an evidence-based therapy that focuses on mindfulness and combines many principles of Zen with therapeutic techniques.

Mindfulness Course
8-week course on mindfulness, suggested by commenter kabarett.

CBT Workbook
Again, one of many, but I’ve looked through this one, and liked the formatting and set up. I’ll amend this with critiques or other suggestions if you have them. CBT is an evidence-based therapy and works for many people, but not all.

What It’s Like in a Mental Hospital

Breakup Girl
Advice and relationships. Suggested by Keith David Smeltz

Dr. Nerdlove
“dispenser of valuable love and relationship advice to nerds, geeks and neo-maxie-zoom-dweebies.”

How To Keep Moving Forward Even When Your Brain Hates You

Books Which Received the Association for Behavioral and Cognitive Therapies Seal of Merit

The Bounce Back Book
Recommended by Miri–I’ve not had a chance to take a look at it.

Depression

Mood Gym

#450: How to tighten up your game at work when you’re depressed.

Boggle the Owl.
Boggle is an owl. And he is worried about you. Seriously, the best resource on this list.

The Secret Strength of Depression
A general self-help book, highly recommended to me.

Depression Subreddit, r/depression
Because nobody should be alone in a dark place.

I Don’t Want To Talk About It: Overcoming the Secret Legacy of Male Depression Have a close friend or partner who is a man with depression–or are one yourself? I don’t actually have either, but I’ve heard good reviews from friends who read this. And we really don’t examine depression in men nearly as well as we should. For instance, it often manifests in feelings of numbness, or unexplained rage–not things we normally associate with depression.

Anxiety

Boggle the Owl

The Take This Project
It’s dangerous to go alone. Designed by videogame developers, suggested by commenter michaeld.

Substance Abuse/Addiction

SMART Recovery

Suicidal Feelings

What to Expect When You Call a Hotline
I
 really like knowing how things go before I try them. This lovely little guest post from someone on the other and of those phone lines tells you what to expect in terms of conversation (you don’t have to know what to say!) confidentiality, and experience.

Samaritans Help Services

IMAlive
Fabulous IM styled chat where all volunteers you work with are trained in suicide prevention. Strongly recommend for people who don’t do phonecalls well or find dialing for help hard.

Befrienders Worldwide Directory of Hotlines/Help Web-Chats

Hello Cruel World: 101 Alternatives to Suicide for Teens, Freaks and Other Outlaws
Written by Kate Borenstein, this book is not teen-specific, though it’s friendly to all ages. It operates on harm reduction, which is the philosophy that less-dangerous-but-still-risky behavior is always better than more-dangerous-and-risky behavior. I really like it, and do subscribe to harm reduction (it’s supported by evidence!). You also don’t have to read Hello Cruel World from end to end–it’s very easy to just open to a page and go from there.

Eating Disorders

Beyond Body Acceptance: This blog by Pervocracy is…therapeutic. Lovely. Beautiful.

Elyse at Skepchick: Don’t Tell Me To Love My Body

Science of Eating Disorders
I
n my pre-therapy days (also the worst times in terms of mental health, and when I did the most work to unlearn disordered habits) I often taught myself what not to do by learning all about my disorder. For instance, if most patients with anorexia ate Small Number X calories per day, I decided I was going to eat more than that every single day. To this day, I unlearn behaviors by starting from a research perspective. Also, lots of research focuses on what treatments work and which don’t do as well, which can give you some ideas for coping strategies.

Weightless
Not my flavor of help, maybe yours? I might just be picky.

If You Do Look For Therapy

Green Flags: What You Want in a Therapist

Braaaains! Being a Skeptical Mental Health Services Consumer
[
shameless plug]

Gaylesta: Find a member of the LGBTQ Psychotherapy Association in your area. (Your mileage may vary–I’ve not tested this IRL.)

A 2.7 Minute Post About Personality Disorders

[I am being excessively pedantic. The average adult reads at 250 words per minute. This post is 670 words long.] 

I talked a little about my feelings on personality disorders and PDs as a whole at Chicago Skepticamp (So. FUN.) and in the last post.  Then I realized that few people get as into psych as I do, and as personality disorders are far too marginalized as it is, y’all might be missing some background. So here it is!

Personality disorders are on Axis II of the DSM

The DSM classifies using a five axis system. In a “full-workup” a client would be analyzed in terms of all axes. The idea is to include all factors of how behavior could be manifesting. For instance, if the patient is displaying disordered eating behavior, but hyperthyroidism hasn’t been ruled out…maybe they don’t have an ED? If they’re exhibiting erratic behavior that’s not responding to therapy or meeting criteria for something like schizophrenia, have you ruled out a brain tumor?

This doesn’t always happen in practice–which is incredibly frustrating. In a perfect world, psychiatrists and psychologists would have time to do these things, and clients would be able to afford it.

Wishful thinking aside, these are the axes.

Axis I: All the stuff you probably think of in terms of mental illness. Mood disorders, anxiety disorders, eating disorders, all of that. Also autism, a categorization location I have some quibbles about.
Axis II: Personality disorders and mental retardation. Autism diagnoses used to be located here.
Axis III: Stuff that is non-mental medical issues. Could be having migraines, cancer, etc.
Axis IV: Pyschosocial factors. For instance, the client could be in an unstable family environment, suffering abuse, in foster care, unable to get regular sleep due to work, imprisoned etc. All of those can contribute to manifesting a more severe version of a disorder, or major mood changes.
Axis V: Global Assessment of Functioning. This actually just a number from 0-100, based on the rater’s impression of how well the client can cope with day to day life tasks. Further elaboration here.

There are three categories of personality disorders. And there’s probably more PDs than you’ve heard of.

Cluster A (odd or eccentric disorders. I’m serious, that’s what they’re called)
-Paranoid Personality Disorder
-Schizotypal Personality Disorder (This isn’t schizophrenia.)
-Schizoid Personality Disorder (This isn’t schizophrenia either.)

Cluster B (dramatic/emotional)
-Antisocial Personality Disorder (ASPD)
-Borderline Personality Disorder (BPD. Here’s one experience of BPD.)
-Histrionic Personality Disorder
-Narcissistic Personality Disorder.

Cluster C (fearful/avoidant)
-Obsessive Compulsive Personality Disorder (OCPD. This isn’t OCD–we just like to make things confusing for you.)
-Avoidant Personality Disorder
-Dependent Personality Disorder

And Then These Conditional Diagnoses: (Which may or may not get added to DSM-5)
-Depressive Personality Disorder
-Negativistic/Passive-Aggressive Personality Disorder

There’s really very little research on personality disorders

This, as far as I can tell, isn’t actually because researchers don’t want to study PDs. But firstly, few people go in for treatment of their personality–because few people are distressed by their own personality. So there’s a small pool to begin with, often of people who have been jabbed into getting treatment by family or friends. (Borderline seems to be the only regularly studied one, but that just could be because DBT was developed for BPD and I read a lot about DBT.)

Secondly, research usually tries to use ‘clean’ patients, that is, people who have just one diagnosis. So, to avoid confounding data, research on OCPD is going to only want patients who have Obsessive Compulsive Personality Disorder and only Obsessive Compulsive Personality Disorder. Except…that doesn’t really happen all too often. PDs are, almost by definition, maladaptive to living in society, which results in increased stress, which can then up the risk of other disorders and suddenly….you don’t have lots of ‘clean’ patients wandering about. (Add in the complication of finding clean patients who live close enough to participate in your research and are interested and suddenly you have a very messy project on your hands. Probably better to make the psych undergraduates do Stroop tasks.)

 

Psych Nerdery: Cool Facts Edition

Random stuff about mental health I’m hoping you haven’t heard before! Relevant citations and further reading are located in the links on each number.  

1. You can’t be diagnosed with a personality disorder until you are 18 years of age. [use drop-down menu at link]

2. Capgras delusion: believing that a family member or friend has been replaced with an imposter. The delusion provides a fascinating inside view into ways in which our memory functions.

3. Children who will go on to develop schizophrenia are found to have specific cognitive deficits by ages 6-7. (In developmental psychopathology classes, I was told that children who developed schizophrenia were shown to have slower affect–expression of emotion, in non-psych lingo–when observers looked at home movies of said children, even at ages as young as four. However, I can’t find a citation on this, and no longer have the textbook, so add a grain of salt.)

4. Hallucinations don’t just come as things you see–there’s also auditory hallucinations, tactile hallucinations (commonly manifests as feeling things crawling on you) and olfactory hallucinations (which can be pleasant or nasty smells).

5. Because the psych profession just likes confusing you, there’s both Obsessive Compulsive Disorder and Obsessive Compulsive Personality Disorder. They’re not very similar at all.

6. People with one personality disorder often meet criteria for diagnosis with another personality disorder. This is one of many problems with the PD diagnoses–how can one have multiple personality disorders (Obvious multiple personality jokes are obvious). It may be that some of the problem is that people aren’t exactly likely to come in for treatment of a PD–how often to people describe their own personality as flawed?

7. And speaking of multiple personalities, even though Dissociative Identity Disorder (which used to be called Multiple Personality Disorder) remains in the DSM, there’s lots and lots of evidence that it’s mainly a cultural phenomenon, and not an actual disorder. [The attached link is easy to read and in depth--I recommend it]

8. In fact, Sybil, the case that spawned media interest in DID/MPD…was maybe a fraud created by an unethical psychiatrist and her poor client?

9. Marsha Linehan created Dialectal Behavioral Therapy (DBT) originally for work on those with Borderline Personality Disorder–though it’s now been shown to be effective for substance abuse, mood disorders, sexual trauma, and self-harm. It’s was groundbreaking treatment for clients who are often considered untreatable. In 2011, during a speech, Linehan told the world that she had suffered from BPD for her entire life, and developed the treatment around her own quest to survive. So basically, she’s my hero.

10.  Asking someone if they are feeling suicidal will not put the idea in their head–really, don’t be afraid to ask.

Have more? Add them in the comments!

Training Therapists: We’re Doing It Wrong.

Becoming a therapist should not take two degrees. If we want to create a program to train therapists, it needs to be one degree that actually intends to make good counselors. We need a vocational school styled approach, explicitly focused on licensing in four years or less.

Getting a grab bag of undergraduate psych experience–which may or may not relate to counseling people, and a year of graduate school before you start interning (read: doing therapy with supervision) is useless. It’s expensive, it limits who can become a therapist in the wrong ways, and lets people who should not be practicing slip through the cracks and emerge with a license.

So We Can Stop Making Therapy a Wealthy Person’s Privilege

Look, the cost of an undergraduate degree is really high. The average public university costs per year is $15,918 [source]. So you go there for four years, and you have a degree in psychology. That’s great, except you can’t do therapy with that.

So you need a graduate degree. That’s $6,000-$15,000 [source] per year in tuition again for two years (assuming a Masters program). Of course, you also have living expenses–even assuming that you don’t have kids or a partner or a car accident or a major illness–the majority of therapists start out in debt. So what they charge for services matters. They can’t afford to spend time giving away therapy sessions, because they need food on their table. It’s harder to do sliding scale sessions if that’s not how your repayment plan works. (Sliding scale is a pay-as-you-can model.) Therapists want to be on an insurer’s list, so they can get a stream of clients.

So therapy costs money, and cheap(er) therapy requires insurance. See the problem here?

Burnout/Weeding Bad Therapists Out:

Premise: Some people who want to be therapists will actually make terrible therapists.

Arguments? No? Okay.

Undergraduate psych isn’t a lot about actually working in psych services. It’s “Look at this cool brain thing! And what about this one?!” “Stroop tasks!” “Neurons!”

And I like all of those things. I like them a lot. But they don’t tell you about how much paperwork comes from being a counselor. Or what the hours look like (hint: it’s not a 9-5). You don’t spend hours practicing how to listen and think and avoid asking “Why?” questions* all at the same time. Not everybody can do this, and that’s fine. But maybe we shouldn’t make everybody figure that out on their own. A program that mirrors the practice of mental health care lets those who can’t do it drop out early (before they get a an expensive set of degrees, hate it, feel obligated to use their education, irritate and harm clients, and then burn out.)

In undergrad, psychology is an ‘easy’ major. Being a counselor is not easy. Let’s match the training to the reality.

Intersectionality & Real Life.

I learned a lot of things about brains and people and microskills and heuristics and biases and writing a concise abstract in my major. I like all these things–I don’t like psychology just because I want to be a therapist. I love statistics and reading research and neuroscience.

You know what I didn’t learn about, beyond a passing mention that they exist?`

Gender & sexuality minorities

Why most people return to abusive situations.

Harm reduction

What systemic poverty looks like

Incest

Rape

Child abuse

What the foster system looks like in practice

Chronic illness as it relates to mental health

Bullying

Suicide prevention

Psychopharmocology (Psych medication)

Asexuality

How to ask for preferred pronouns/getting used to gender neutral pronouns

Polyamory

…or how any of these can intersect.

I would have liked to.
I want budding counselors to begin their education by learning about ALL kinds of people and systems. I want to stop assuming that living in the world gives you enough life experience to counsel anyone. Because you know who can afford to go to college for two degrees, who are encouraged and supported in doing so? Mostly privileged people. Do you know who we’re really bad at providing mental health services for? The underprivileged.

What Psych Services Jobs Can You Do With A Psych Undergrad Degree?

Seriously. Somebody.

You can work at a crisis center or hotline or be a research assistant or or or…yup, I’ve got nothing.

Tracked Classes Are Better Than Pick ‘N Choose

Psychology majors usually have a basket system for major completion. This isn’t a terrible idea, and it’s how most humanities majors work. You get some intro level classes, some intermediate classes, a handful of special seminars, and a few required things like statistics  and Writing a Paper a Specific Way That Will Be Quickly Outdated (aka Research Methods. Yes, I’m bitter). You don’t really have to get them in any order, except you might need Intro Psych first, and research seminars might need you to understand statistics and paper writing. Other than that, you take what you want, in whatever order works for you class schedule.

On the whole, this doesn’t seem unreasonable. You don’t really need to understand 200-level Social Psychology to understand 200-level Cognitive Psychology. I do, however, think you should take Developmental Psychology before you take Developmental Psychopathology. You should also take Psychopathology before you take Counseling, and you should know a little bit about neuroscience, developmental problems, and brain injuries before that too. You should definitely take more than one class about counseling people, and the second, third, and fourth classes should build on each other.

I want a program that plans classes, that puts them in the most useful order, that builds on knowledge to create a well rounded counselor by intention, not by accident.

Look, I’m going to get my two degrees and become a therapist. I would hope that I’ll be a good one. But we need to create a system that makes that the most common outcome, that doesn’t put potential therapists into debt, and that treats mental health work like a career with real requirements in terms of personality, skills, and devotion.

*With the exception of Rational Emotive Behavioral Therapy, therapists are highly discouraged from asking questions that begin with “Why…”, because they come across as implicitly judgmental, even if that’s not the intent. 

The Myth of ‘Fight Back’

There’s an unfortunate habit of journalists to treat stories of mental illness as triumphs of will.

She fought an eating disorder and won! Now she’s happy with her body and wears whatever she wants!

He battled depression, and now he is this Super Famous Person I Don’t Recognize!

I don’t want to knock this idea on the personal level. I’m quite sure that for some, the metaphor is useful. Maybe even the most helpful way of envisioning recovery. That’s spectacular. I’ll promote any method of recovery. Imagining tapdancing bananas? Go for it.

My concern is for how the media elects to find one narrative–a story that automatically excludes perhaps even a majority of those with mental illness, and what that means for our understanding. “Fighting” doesn’t mean miraculously getting well for everyone, sometimes fighting means just staying here.

There’s exactly three dresses on hangers in my closet. Not because I own three dresses–I almost never wear pants–but because everything else is crumpled on the floor, the bed, the desk. I’ve tried on eight outfits. Maybe ten. And right now? I’m curled up in the corner in the same shorts and shirt I started in.

I’m going to put on nice clothes and go out at some point, because it’s one of my best friend’s birthdays, and you don’t get to do otherwise. Because I want to, and because isolation when clothes make me anxious seems like failing.

But first I have to breathe. The world has to stop closing in. The music is too loud and I can feel every inch of my skin. It’s not the romance novel kind, right before the heroine lands on 6,000 count Egyptian cotton sheets–it’s raw nerves and sandpaper air. It’s been weeks since this happened, and and and…

Breathe in.

The thing about clothes is that you have to wear them. You cannot show up to an interview, to class, to any function, without clothes. So I’ll find something to wear. Eventually.

Don’t you dare tell us to fight back.

We fight to be the awkward guy with at the edge of the conversation, to show up to parties and turn in homework. We fight embarrassment when we can’t drink punch at your party, when your ‘OCD’ means you cleaned your room, and ours means obsessions and compulsions. We fight to meet deadlines and call hotlines when things get bad.

Some of us fight just to be here.

 

 

 

The Weight Requirement, and Other Ways We Diagnose Anorexia

This is a post that’s been a long time in coming. Unfortunately, every time I start it, I get upset and then have to leave it alone. So here we have it: what’s wrong with how we diagnose anorexia. Now with less ragequitting!

Anorexia has a weight requirement.

Refusal to maintain body weight at or above a minimally normal weight for age and height, for example, weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.

PROBLEMATIC.

Please, someone define what a normal weight is. Because I know this totally isn’t controversial. Using BMI? It doesn’t account for muscle mass, so you’re leaving out  anyone who’s particularly athletic. Using clothing sizes? Ahahahahahahaha. 

Even supposing we had some accurate scale of normal height-to-weight ratios, should a diagnosis rest on a weight? If I’m restricting caloric intake, and I drop under 85%… Bingo, I have anorexia. Ding ding ding and all that. The next day, I enter treatment, or I eat a particularly large meal, or retain a little water, and suddenly I’m at 86%. Have I suddenly developed a disorder that is markedly distinguishable from what I had on Monday? I think not.

The emphasis on being excessively thin is also in the second criteria:

Intense fear of gaining weight or becoming fat, even though underweight.

Anorexia does not just happen one day, when you stop eating and magically, everyone can tell! This, like lots of the criteria, seem to be waiting to diagnose after the disease has progressed significantly.* That’s dangerous.

This is particularly true for people who start at an above-average weight. We fetishize the idea of heavy people losing weight through whatever means possible, up to and including unhealthy ones. (Biggest Loser, anyone?) It’s going to take an especially long time for family and friends to notice such severe weight loss–and of course, they’ll probably praise and reinforce it along the way–and all the while, the disorder will become more entrenched, wreaking havoc on the body it inhabits.

Amenhorrea

In postmenarcheal females, amenorrhea, i.e., the absence of at least 3 consecutive menstrual cycles. A woman having periods only while on hormone medication (e.g. estrogen) still qualifies as having amenorrhea.

Defined as non-menstruation for three cycles, this is competing with weight measurement for least helpful criteria. For one, it isn’t useful for anyone on hormonal birth control (withdrawal bleeding is not the same as getting your period). For two, it’s a fairly useless metric. Only cisgender women who can ovulate, are not pregnant, and who have reached puberty, but not menopause can use it. (Also, you qualify for this criteria automatically if you’re on birth control. Say what?) Further, there’s not a lot of research suggesting that amenhorrea occurs in a standardized way, or that it represents the severity of deprivation. Luckily, this is heading out with the publication of the DSM-5.

Waltzing between diagnoses.

In the span of six years, I met criteria for…

Anorexia nervosa (purging type)

Anorexia nervosa (non-purging type)

Binge Eating Disorder (BED)
Note: this is a proposed conditional diagnosis, given separate status from BN and AN. 

Bulimia Nervosa (non-purging type)

Eating Disorder Not Otherwise Specified (EDNOS)

…that would be all but two of the ways one can have an eating disorder. This suggests that we may just be quantifying eating disorders incorrectly. Those qualifying for anorexia diagnoses are automatically going to fall into EDNOS as they recover and gain weight (and consequently, no longer meet the first criteria for AN). Should we rename EDNOS as “Anorexia in Remission?” No, because then you leave out the others who were diagnosed as EDNOS for other reasons, such as not qualifying for a bulimia diagnosis. If EDNOS is made up of lots of people with very different manifestations of disordered eating, can we do any useful research about the diagnosis? Will we be able to draw any useful conclusions? Probably not.

And why does it all matter? After all, society recognizes that refusing to eat is bad, right? It matters because the research doesn’t look at “a population of women who have refused to eat at some point”. It looks at “300 female patients who had been diagnosed with anorexia in the last calendar year”. That means how we assess treatment, how we examine the genetic basis, how we study the disorder is a product of how we describe it.

And we’re doing it wrong.

*Also, the face of anorexia, besides being almost always a thin woman, is always white and upper class. Incorrect, and a scary myth to perpetuate.

Psychopathology Sum-Up: Bulimia Nervosa

[This is a guest post by Tetyana Pekar]

Tetyana is about to defend her MSc in Neuroscience at the University of Toronto. She is passionate about making eating disorder research more accessible to the public. She writes the Science of Eating Disorders blog where she aims to make sense of the latest findings in eating disorder research for lay audiences. She can be reached at [email protected]

What is bulimia nervosa?

Bulimia nervosa (BN) is a serious eating disorder (ED) characterized by cycles of bingeing and compensatory behaviors. The most common compensatory behaviour is self-induced vomiting, but others include laxatives, diuretics, fasting, and excessive exercise. It is a common misconception that all BN patients self-induce vomiting—not so, while most do, there is a sizeable minority that does not (Keski-Rahkonen et al, 2009).

Individuals with BN are typically normal weight or overweight. This isn’t by chance; it is almost by definition. If someone binges and purges but is underweight, they will most likely be diagnosed with anorexia nervosa (AN) binge/purge subtype. Importantly, these diagnostic categories are not static, distinct groups, as over 50% of those diagnosed with restricting type AN cross over to bingeing/purging type within 5 years of ED onset, and about one-third cross over to BN (Eddy et al. 2008). So, take these diagnostic categories with a grain of salt.

Prevalence & Mortality

EDs have a high mortality rate, but keep in mind that prevalence and mortality statistics always depend on the duration of the study, the study size, and the population studied (among other things). However, most studies converge on a lifetime prevalence of BN somewhere between 1-2% (0.9-1.5 among women and 0.1-0.5% among men) (Smink et al., 2012).

The standardized mortality ratio (bulimia patients/normal, age-controlled population) for BN varies from ~2-5 (Arcelus et al., 2011). In one study of 906 individuals with BN, 3.9% died in the mean follow-up of 19 years, with suicide accounting for 23% of those deaths (Crow et al., 2009).

Causes

As much as people like the point the finger at the media and ‘thin culture,’ this explanation cannot be the whole story. After all, we are all exposed to images of thin models, and yet only 1-2% of women experience BN at some point in their lives. What is it about this percentage of women that makes them susceptible to BN?

Certainly, genetics plays a role.

Family studies are useful for determining if a particular disorder aggregates in families, though they cannot decipher if that aggregation is due to genetic risk factors of shared environmental factors (such as an over-emphasis on weight and appearance). These studies have shown that first-degree relatives of BN patients have a 4.4-9.6 higher likelihood of having BN than relatives of healthy controls (Kassett et al., 1989; Stein et al., 1999; Strober et al., 2000; ).

Twin studies are another good way to delineate the effects of genes and environment. These studies have shown that between 54-83% of the variation we see in BN is accounted for by genetic effects (Bulik et al. 1998, 2010; Kortegaard et al. 2001; Wade et al. 1999). (Note, this DOES NOT mean genes cause 54-83% of the disorder.)

This does not mean there are genes for BN (genes code for proteins, after all). However, commonly occurring temperament and personality traits might account for some of the genetic risk factors. Traits such as perfectionism, obsessionality, sensitivity to reward and punishment, and impulsivity often occur before ED onset and persist following recovery for many patients (Kump et al., 2004).

In addition, neurotransmitter systems, such as serotonin and dopamine, appear to modulate a lot of the traits associated with eating disorders. Indeed, serotonin might play an important function in the development of BN (and, along with the effects of estrogen, might partly explain why females are much more likely to suffer from EDs than males.)

It is almost important to emphasize that EDs are not “Western” disorders that arise solely due to an overemphasis on thinness. To provide just a few examples, blind women are not immune to EDs, and Iranian women living in Tehran exhibit similar levels of disordered eating behaviours as their counterparts in Los Angeles.

Behaviour does not occur in a vacuum. Genetics and environment both play a role. (For more on causes, see this post.)

Comorbidities

Eating disorders are generally highly comorbid with depression and anxiety disorders (Blinder et al., 2006). As mentioned earlier, patients with eating disorder tend to score high on perfectionism, neuroticism, impulsivity (particularly for BN patients), harm avoidance and obsessive-compulsive disorder. Among BN patients, the most common personality disorder appears to be borderline personality disorder (Sansone et al., 2005).

Treatment & Outcomes

Treatment for BN can include outpatient, inpatient, and/or residential treatments, among other things. As readers of FtB are well aware, any hard to treat diseases and disorders always attract pseudoscientific treatments. So, what treatments are evidence-based?

SSRIs, interestingly enough, have been shown to be effective in reducing the frequency of bingeing and purging in BN patients compared to placebo, particularly fluoxetine/Prozac (reviewed in Flament et al., 2012 and Hay et al., 2012). Cognitive-behavioural therapy is also widely considered to be an evidence-based treatment for BN (though, I have my reservations) (Murphy et al., 2010). In the end, the most important thing is to have a strong therapeutic alliance between the patient and the treatment team/therapist, as well as motivation to change.

In terms of outcomes, the results depend on length of follow-up, duration of illness, and sample population (i.e., how sick are the patients?). However, one large review found that about 45% of BN patients fully recovered, 27% improved, and 23% had a chronic course (Steinhausen et al., 2009).

Problems with the DSM

Compared to the problems with anorexia nervosa (AN), there are not as many. However, here are two things that annoy me:

  • Arbitrary frequency and duration criteria (2x/week for 3 months) (This will be reduced to 1x/week in the DSM-V.)
  • Too focused on weight (“compensatory behavior in order to prevent weight gain” and “self-evaluation is unduly influenced by body shape and weight”). These can certainly be true, but they don’t have to be. Bingeing and purging can just be a tool to regulate emotions.

Common Myths

Here are some other common myths that I haven’t mentioned yet:

  • BN patients throw up everything they eat. No, but some do, sometimes. The frequency and extent of behaviours varies a lot.
  • BN patients should just eat 5-small meals a day. Well, yes, but the problem has got nothing to do with not knowing how to eat well in theory.
  • BN is on the increase. Actually, studies suggest is pretty stable or even decreasing.
  • It is an effective weight control method (i.e., it is safe). I suppose, if you are okay with the plethora of medical complications (including death).

And one that bothers me the most:

  • BN is just about vanity. Actually, for me, bingeing and purging is incredibly anxiety reducing, and I’m usually symptomatic when I’m stressed, overwhelmed, or feel like crap about myself (not productive enough, for example). A sense of calmness and tranquility often follows self-induced vomiting (and I’m not alone in feeling this way).

Hopefully I’ve covered the basics. If you want to know more about BN, feel free to ask me questions in the comments, send me an email or check out BN-related posts on my blog here.


Tetyana was diagnosed with restricting type anorexia when she was in grade 10, started bingeing and purging at the end of first year in university. Her eating disorder has been all over the place, and she enrolled in outpatient treatment in high-school. She will be attending Women in Secularism conference. (Where I finally get to meet her!) You can follow her on Twitter.

Previous Psychopathology-Sum Ups:

Specific Phobias
Bipolar Disorder
Types of Antidepressants