Daily Archives: May 28, 2015

Psychosis can happen out of the blue, to anyone, and no one knows why. Not even the best doctors on the planet. (Jeanine Garsee)

I like the following song a lot; it looks at perceptions during psychosis, in a calm, first person voice (also, sad boy with guitar, yey). Thanks for posting it, Annie. I’ve also added it to my manic depressong playlist.

Who are you calling psychotic?

Psychosis seems to fascinate almost everyone, although a lot of people think it means out of control batshit crazy behaviour and/or severely disturbed criminals. Those misperceptions are frequently totally devoid of malice, but of course they still hurt. I find myself saying experiencing psychosis far more than I ever say psychotic. Psychotic appears to provoke an almost visible frisson in the sort of person who dresses up in Einstein hair and a straitjacket at Halloween. Obviously we can thank the film Psycho and its repulsive iconic stabby shower scene and that fucking eee eee eee soundtrack for much of it; people apply it to psychotic and psychopath until those terms mix and muddy. I’m tired of insanity porn. Fuck off and dress up as an Ebola patient next Halloween. And if psychotic is used as an offensive term, would everyone be okay with me saying things like you cancerous little fuck? No. That’d be a cuntly thing to do, wouldn’t it? You peptic ulcer! Holy fuck but we are an extremely illogical species and we do love to victimise…

It holds a fascination of a different flavour if you experience it, or love somebody who does.

Part of the loss of reality then was an over-projection of meaning and exaggerated concentration on some aspect of reality that most of us, by consensus, choose to ignore.

A few reputable websites use the standard dictionary definition of psychosis to explain it, which makes less than no sense to me. Unless we’re hanging out with Norman Bates, please let’s use a medical dictionary? All it is really, is loss of contact with reality (hallucinations, delusions) and when we’re experiencing it, we either know it’s not real (this is known as insight), or we don’t. Different cultures tend to have different types of content in psychosis; the most negative seems to occur in Western developed countries and the theories I’ve read so far, cite the media and the individual-focused society as influencing factors. My psychiatrist tells me that, besides the emotional etc effect on the sufferer, the content of psychosis is absolutely irrelevant. If that fact was proven, a lot of hippies would be unhappy. *waits to be lynched by wind-chime wielding mobs*

When does a strong idea take on a pathological flavor? How does a metaphysical crisis morph into a medical one? At what point does our interpretation of the world become so fixed that it no longer matters “what almost everyone else believes” [part of the definition of ‘delusion’ in the DSM]? Even William James admitted that he struggled to distinguish a schizophrenic break from a mystical experience. (Aviv 2010: 37)

My trainee-psychiatrist therapist, on the other hand, seems intrigued by the content of mine. I blogged the memories I dredged up about my stuff as the memories surfaced, here’s the list so far.

I am the shit (of the bat)!

1996: my gecko tattoo attracting skinks, the skinks were real (on a path along a bay) the rest was delusion, it was a one off.
2000: being stuck in a video game, total sensory immersion, hallucination and delusion. It was a platform game and there was a lot of dusky blue around. I never remembered much afterwards, but slept for around 14hrs as a result, feeling as though I were uncomfortably drugged). I had 10 one day and felt totally fucked for days. They stuck around at various levels of frequency until 2009.
2007: the sea speaking to me, not sure how long it lasted – either days or weeks. It was purely auditory and extremely reassuring, I miss it.

2010: 7ft chrome praying mantis. Purely visual and delusion. He’d stand behind me, usually in an almost dark room, I’d be sitting on a dark, straight backed chair, at a dark table (the whole thing was a hallucination). He’d quietly use his chrome pincers to efficiently snip my spinal chord, and it was an utterly painless, peaceful and reassuring thing. He lasted about a year, was frequent, and I miss him. (And yes, after my dog goes, I’d welcome euthanasia by 7ft chrome mantis.)
2014: hearing music and footsteps, seeing lights in a wave and hearing music come from it. The music was quiet and seemed to come from various places where it most certainly wasn’t. The footsteps sounded like those above a flat my mother and I lived in once. The wave stuff was beautiful and sparkly and merry and I’d love more of it.
2015: a reef I know very well and have explored for years, suddenly looked as though it had had the top of it sliced off cleanly. I knew it wasn’t real, I tried so hard to get rid of it and couldn’t. Eventually I had to crawl off it and I’ve no idea how I got home.

Fully qualified psychiatrist reckons the presence of insight in my psychoses is a very positive sign.

I tried hard to change the ones I didn’t like, and never managed at all. The good ones felt too good to lose. I wonder why I’m discussing them all in the past tense. I’m interested in your psychoses almost as much as I am in my own (grin, it’s the truth), I’d love to hear about them. I don’t have any tidy conclusions to make, I am, as usual, simply reading, writing and thinking, in order to clarify things in my own febrile mind. And apparently I like doing it best while perched upon my own personal soapblog.

ba-DUM-tshhhhh!!

And another thing…

Here’s a quote I found fascinating, but couldn’t think of a way to include without offending and alienating my religious friends. Sorry guys, feel free to comment and tell me your thoughts.

When a ‘false belief’ is not ‘delusional’
For me, religion brings up much more complicated questions for the delusional, however. As Koenig (2009: 287) points out in an off-handed way: ‘Psychiatric patients with psychotic disorders may report bizarre religious delusions, some of which can be difficult to distinguish from so-called normal religious or cultural beliefs.’  Especially where there is a marked ‘religion gap’ between a patient population and psychiatrists — where psychological health care workers are much more likely to be agnostic or atheist than the people for whom they care — it can be difficult to decide when a ‘false belief’ is delusional and when it’s just, well, the normal kind of irrational (like believing that a person can expect others to read long blog posts).

It’s all so very meta round here innit.

I’ve been far too flippant.

I can joke; I’ve earned the right by living through things that, before I had them defined for me, frequently convinced me that I was genuinely losing my mind and that I’d lose myself entirely in the process. It taught me that the misconception that going nuts would be some kind of relief, an escape, is so far from the excruciatingly agonising truth, that to express that opinion is insulting at best. I’ve gone a joke too far today, perhaps. Psychosis is serious.

This is not comfortable viewing and it is not entertainment. Proceed with caution.

Sources, resources and interesting reading:

Slipping into psychosis: living in the prodrome. (a brilliant intro to psychosis, most of the quotes I used are from it, it contains stuff that’s rather wtf too.)
Delusions odd & common: living in the prodrome. (psychosis and culture)
Both of the above focus on SZ.

The prodrome is: the aura that precedes a psychotic break by up to two or three years. During this phase, people often have mild hallucinations—they might spot a nonexistent cat out of the corner of their eye or hear their name in the sound of the wind—yet they doubt that these sensations are real. They still have “insight”—a pivotal word in psychiatric literature, indicating that a patient can recognize an altered worldview as a sign of illness, not a revelation. 

Which way madness lies: Can psychosis be prevented? (download pdf)
Twitter can trigger psychosis (does what it says on the lid)
Crazy talk: we’re too quick to use “mental illness” as an explanation for violence. (those quotation marks make me very, very, very happy)
Bellwethers & Outliers Inc. (my sort of tongue in cheek take on people like us vs society) tl;dr the lunatics really are taking over the fucking asylum.

I think this is the third time I’ve blogged this video. I found it the day my psychiatrist casually informed me I’d experienced psychosis. I sent it to her and she now uses it as a resource. It’s completely reassuring. And I like badgers a lot.

A dream within a dream

Take this kiss upon the brow! 
And, in parting from you now,
Thus much let me avow-
You are not wrong, who deem
That my days have been a dream; 
Yet if hope has flown away
In a night, or in a day,
In a vision, or in none,
Is it therefore the less gone? 
All that we see or seem
Is but a dream within a dream.

I stand amid the roar
Of a surf-tormented shore,
And I hold within my hand
Grains of the golden sand-
How few! yet how they creep
Through my fingers to the deep,
While I weep- while I weep! 
O God! can I not grasp
Them with a tighter clasp? 
O God! can I not save
One from the pitiless wave? 
Is all that we see or seem
But a dream within a dream? 

Edgar Allan Poe, 1849

There’s so much outdated information and misinformation out there about bipolar that either ignores or misinterprets the changes from DSM IV to 5 (bizarre to change the numbering system of the whole thing too, innit?). The difference between bipolars 1 and 2 is the thing I find most vague and variable online, so I looked at the diagnostic criteria first.

||source|| (well worth reading)

I always need to break stuff like that info right down.

My simple understanding of the differences between Bipolar 1 and 2 from the above is as follows:
Bipolar I: mania, possible mixed episodes, 
Bipolar II: hypomania, no mania or mixed episodes.

And the commonalities:
Major Depression.
Mood symptoms not due to Schizoaffective Disorder, or part of other disorders such as Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder NOS.

The above helped me understand how and why I was diagnosed, as well as the reasons for the initial diagnosis being Bipolar II. I presented with Major Depression initially, as well as early signs of psychosis (low volume constant music auditory hallucinations). Once I’d worked out that I’d had previous psychosis stretching back to the late 90s at least, my psychiatrist updowngraded the diagnosis to Bipolar I. As the months went by, some more labels were slapped on. Rapid Cycling Bipolar I with Mixed and Psychotic Features.

Having received the first Bipolar II diagnosis while experiencing those early signs of psychosis, I was puzzled by all the info I found telling me that psychosis is a Bipolar I thing. So was early psychosis possible in Bipolar II, while full blown psychosis was Bipolar I, or what? Obviously I googled.

Part 1: Bipolar with Psychosis
Bipolar disorder is an illness that affects a person’s ability to regulate their moods. The two main mood swings are mania and depression and most people familiar with the illness have at least a basic understanding of these two symptoms. But when it comes to bipolar psychosis, knowledge can be limited and this very complex and very normal part of bipolar disorder is often underreported or missed until it’s too late. One reason for this is that there are still many people who don’t know that psychosis is common for people with Bipolar I (one) during manic and depressive episodes and is often present in Bipolar II (two) depression as well. But the main problem is that the general public has such a distorted view of bipolar psychosis, it’s difficult to find real and helpful information regarding this fascinating and often very destructive symptom of bipolar disorder.
||source||

For those who desire the srs bsns side of it, this is for you.

But there’s a ton of info that says that psychosis is only present in Bipolar I, so wtf is the reality? I googled for results within the past year and found more precise explanations, which confirmed and expanded upon the above. For example (there are many more) …

Psychotic symptoms are often present in the mania of Bipolar I disorder. The symptoms can also occur during depression and in many other disorders. The presence of psychosis automatically rules out a diagnosis of hypomania. Thus, people with both Bipolar 1 and Bipolar 2 can experience psychosis, but in Bipolar 2 they only appear during depressive episodes.
||source||

*Oprah voice* Eeeeeeeverybody’s getting psychosis!!!

(O joy, o rapture etc.)

Anyway, I thought I’d hunt down another sensible analysis of it all. One site did well until it included Bipolar NOS, which was one of the changes, there were other sites that did far better, but I thought a more academic approach might be the way to go, so here’s what the International Journal of Bipolar Disorders has to say, and it’s by a Swiss dude with the best name for his field ever – click the link for the full article. One thing I like about it, is that it points out some shortfalls in the Disturbing Specifications Manual.

From Bipolar disorders in DSM-5: strengths, problems and perspectives, by Jules Angst.

The main lines of the DSM-5 definition of major depressive episodes (MDE), basic to the diagnoses of both bipolar I and bipolar II disorders, are similar to those of DSM-IV: presence of five of nine diagnostic symptoms with a minimum duration of 2 weeks and a change from previous functioning. However, it is now possible to specify both depressive disorders and bipolar disorders with mixed features.

The definition of both manic and hypomanic episodes have been radically revised, which will impact on both bipolar diagnoses. The main changes are three: (1) a problematic change concerning the gate questions (criterion A), (2) a welcome reduction in the number of exclusion criteria and (3) a vigorous effort to operationalize bipolar subthreshold syndromes, hitherto unified under the NOS heading.

Gate questions for mania and hypomania

Where DSM-IV required, as criterion A, the presence of one of the two mood symptoms (elation/euphoric or irritable mood), in DSM-5, ‘the mood change must be accompanied by persistently increased activity or energy levels’. This new rule is, of course, more restrictive and excludes all individuals who report only one of the three entry symptoms and those with both elated and irritable mood. Thus, for no apparent reason, DSM-5 classifies some patients as having subthreshold bipolar disorders who would formerly have been diagnosed with manic episodes or bipolar I or II disorders. This strict new rule is not based on data, indeed it contradicts available evidence. As the international Bridge Study of 5,635 patients seeking treatment for major depressive episodes demonstrated clearly, any of those three gate questions is valid on its own, according to the criteria established by Robins and Guze (1970) and Angst et al. (2012).

Exclusion criteria

One important and amply justified change in DSM-5 concerns the diagnosis of bipolar II disorder. In DSM-IV, the change of major depression into hypomania under antidepressant treatments (ADs) was in principle an exclusion criterion. In DSM-5, that change – provided it persists at fully syndromal level beyond the physiological effect of the treatment – is explicitly a criterion for bipolar II disorder. DSM-5, like DSM-IV, allows some scope for clinical judgment as to causality. In addition, DSM-5 provides new formal criteria for substance/medication-induced bipolar and related disorder.

On the basis of the Bridge Study data (Angst et al. 2012), we can estimate that DSM-5 bipolar II disorder will be diagnosed about twice as often as heretofore and have a prevalence approaching that of bipolar I.

A more frequent diagnosis of bipolar II disorder is both justified and logical: a milder condition (in this case hypomania) is usually more prevalent than a severe one (mania). Over the long-term course of their illness, bipolar patients spend much more time in milder conditions, mainly minor depression, than in major syndromes (Phillips and Kupfer 2013).

Two exclusion criteria survive in DSM-5, namely ‘substance/medication-induced bipolar and related disorder’ and ‘bipolar and related disorder due to another medical condition’. Both clearly rely on questionable causal attributions based on partial co-occurrence with substance or medication use or full co-occurrence with another medical condition.

Other specified bipolar and related disorder (DSM-5)

DSM-5 has fortunately replaced DSM-IV’s vague group NOS by defining MDE with several subthreshold conditions of bipolarity, for instance, allowing a duration of 2 to 3 days for hypomanic episodes, as suggested by child psychiatrists, or fewer than four symptoms of hypomania during 4 days, or, for cyclothymia, specifying shorter manifestations (more than 24 months). A further important step is the recognition that dysthymia can co-occur with hypomania which is considered as a co-morbid condition, but why – one might ask – is it not allocated to cyclothymic disorder?