When it's not OK not to be OK #MentalhealthAwareness

It's a great thing, the openness around mental health issues and all the initiatives out there to make it 'OK not to be OK'.

It's beneficial to understand more about depression and what may or may not be useful in finding a way through it, about dopamine, serotonin, endorphins, CBT and all the rest of it, and many people are being helped with the symptoms of their deep pain. People want to make people better. Of course, it means improved in wellbeing, physical or mental, but maybe getting better is loaded with being better. Which is what we should be. Feeling better, better at coping, better at being, better at living. Better in every way. To get or be better is not to accept where you are, which is laudable, if you can change. But there are some people for whom at sometimes, 'I can't' is very real. However much as it would be great for them, for the people who know them, and for society as a whole, it could be that they are not giving up, giving in, copping out or whatever but, for the time being at least, really, truly, just 'can't'. In the film 'Richard Jewell', about the security guard falsely accused of the Centennial Olympic Park bombing in Atlanta in 1996, there's a scene where the FBI is turning over his and his mother's home in the search for evidence. His lawyer tells him repeatedly how and how not to behave in front of them. Richard says,'You can do that because you are that sort of man. But I am not' or words to that effect. It struck a chord. However much others might wish to help us, offering solutions and telling us that we can do whatever it is that would make us better, normalise us, if we feel we can't, are temporarily imprisoned by that can't, like it or not, we can't. Maybe, for the time being, acceptance is as good as it's going to get. But people that 'can't', and on some level maybe never could in any 'normal' sense, may try to make it look as if they 'can', using whatever tools they have. Like a seedling in the dark, they might shoot up towards a crack of light, too far, too fast — no time to make a sound root system or side shoots. When the reality of drought or dark days come along, they collapse, suddenly realising they had adapted, yes, but it was a maladaptation, a mutation. No blame, it's just life trying to survive however it can.

A friend told me she'd seen a programme about chimps. A group of youngsters were given an iPad set to selfie mode. Most of them had a look, pushed some other buttons, played with the thing for a while then went off to do something else, maybe something that seemed more relevant, more real, more fun, who knows. But one little chimp didn't; he just sat and stared at himself, stared and stared. Was this an abandoned or orphaned baby chimp? I have no idea, but the image seemed so sad. A little baby chimp, the selfie setting the reflective techno-pond of the modern Narcissus. Not vain, self-centred, selfish Narcissus, but a poor, lonely one, so desperate to prove his existence to himself, so fascinated by what this could mean that he couldn't look away, or run off with the others, join in and play. 'So busy looking in the bathroom mirror he wasn't there when souls were given out', I read somewhere online describing the traits of a narcissist, the psycho bête noire of bête noires.

'It's OK not to be OK' up to and probably including bipolar disorder, which was my diagnosis when I was 22. But when you venture on along the spectrum of mental health issues into the murkier waters of 'personality disorders', I think that perhaps it feels less OK not to be OK for the sufferer and the people who love them. Depression is hard enough. When your friend is suddenly a blank-faced, monosyllabic, unreachable shadow of the person you knew, for months on end, it would test the patience of a saint. But, whatever depression is telling the sufferer about its everlasting nature, it is, hopefully, temporary. It is, like bipolar, classified as a 'mood disorder' and therefore it will pass, presumably. It is not 'you' any more than any other physical complaint. It is to do with chemistry, that dopamine-serotonin thing and it can be put right. Especially if you get on board with your psychiatrist and medication and run, dance, meditate, sleep, volunteer, and do all the things you love (although as anyone with severe depression knows, there just aren't anything of those things as far as the eye can see, and beyond).

After so many months of depression and numerous different anti-depressants, I began to believe that there was more to my state of mind than could be 'explained' or fall under the definition of bipolar depression. Surely I should have bounced up into a high by now as had happened in the past? Why hadn't I? I turned in my despair to the internet to find something that seemed to chime with my experience. I didn't know very much about personality disorders; I still don't, but the name suggests something worse than mental illness (although they are listed as such in the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders 5th Revision). Instead, they are intractable and entrenched, something about you — about your personality— something which you can't medicate away because it is you. It runs right through you like lettering on a stick of rock. That's very scary. That just doesn't feel OK on any level. But what I was feeling didn't fit any definition. My God! Not one of these bundles of awful symptoms fits me, in the whole megastore of malfunction. What sort of a freak does that make me?

Labels have their uses. When well, you might not want one. When unwell, it's nice to know that someone, somewhere has experienced something akin to what you are going through. Some labels are easier to wear than others, ill or well. It's a double-edged sword along the lines of, thank God I'm not the only one/oh please God, I do not want to be this — this just cannot be what my life is. But how else to explain such a long depression? And how else to describe these behaviours? I'm sure it's very well-intentioned. It seems like an impossible task, unravelling all these symptoms and traits and rounding them up into 'disorders' and then clusters. Clusters? WTF? Haven't we all felt some of this stuff, sometimes, if we're honest? I completed an online test and scored an average of 90% for every single 'PD'. I was suicidal at the time which might not have helped. Whatever, that's self-diagnosis for you. Below is an article from Psychology Today's website to help you get your head round the clusterfuck (dictionary definition:a disastrously mishandled situation or undertaking). My thoughts as I read it in black — both ink and mood.

'The study of human personality or "character" (from the Greek charaktêr, the mark impressed upon a coin) dates back at least to antiquity. In his Characters, Tyrtamus (371-287 B.C.) — nicknamed Theophrastus or "divinely speaking" by his contemporary Aristotle — divided the people of 4th century B.C. Athens into 30 different personality types, including "arrogance," "irony," and "boastfulness." Characters exerted a strong influence on subsequent studies of human personality, such as those of Thomas Overbury (1581-1613) in England and Jean de la Bruyère (1645-1696) in France.

The concept of personality disorder itself is much more recent and tentatively dates back to psychiatrist Philippe Pinel’s 1801 description of "manie" sans "délire", a condition which he characterised as outbursts of rage and violence (manie) in the absence of any symptoms of psychosis, such as delusions and hallucinations (délires).

Across the English Channel, physician JC Prichard (1786-1848) coined the term "moral insanity" in 1835 to refer to a larger group of people who were characterised by "morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions and natural impulses," but the term, probably considered too broad and non-specific, soon fell into disuse.

Some 60 years later, in 1896, psychiatrist Emil Kraepelin (1856-1926) described seven forms of antisocial behaviour under the umbrella of "psychopathic personality," a term later broadened by Kraepelin’s younger colleague Kurt Schneider (1887-1967) to include those who "suffer from their abnormality."

Schneider’s seminal volume of 1923, "Die psychopathischen Persönlichkeiten" (Psychopathic Personalities), still forms the basis of current classifications of personality disorders, such as those contained in the influential American classification of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders 5th Revision (DSM-5). That's it! I'm a frickin' psychopath! I knew it! God, my poor neighbours. I can see the News report now after being found dead, there being 'no suspicious circumstances': 'Our neighbour from hell — we always knew there was something odd about her etc, etc.'

According to DSM-5, a personality disorder can be diagnosed if there are significant impairments in self and interpersonal functioning together with one or more pathological personality traits. Yup. In addition, these features must be (1) relatively stable across time and consistent across situations, Ditto (2) not understood as normative for the individual’s developmental stage or socio-cultural environment, For sure and (3) not solely due to the direct effects of a substance or general medical condition. Unfortunately not.

The DSM-5 lists 10 personality disorders and allocates each to one of three groups or "clusters": A, B, or C.

Cluster A (Odd, bizarre, eccentric)

Paranoid PD

Schizoid PD

Schizotypal PD

Cluster B (Dramatic, erratic)

Antisocial PD

Borderline PD

Histrionic PD

Narcissistic PD

Cluster C (Anxious, fearful)

Avoidant PD

Dependent PD

Obsessive-compulsive PD

Before going on to characterise these 10 personality disorders, it should be emphasised that they are more the product of historical observation than of scientific study, and thus that they are rather vague and imprecise constructs. As a result, they rarely present in their classic "textbook" form, but instead tend to blur into one another. You're not kidding. Their division into three clusters in DSM-5 is intended to reflect this tendency, with any given personality disorder most likely to blur with other personality disorders within its (nut)cluster. For instance, in cluster A, paranoid personality is most likely to blur with schizoid personality disorder and schizotypal personality disorder. Leaving the person where exactly?

The majority of people with a personality disorder never come into contact with mental health services (result), and those who do usually do so in the context of another mental disorder or at a time of crisis, commonly after self-harming or breaking the law. Nevertheless, personality disorders are important to health professionals, because they predispose to mental disorder and affect the presentation and management of existing mental disorders. OK...I think I get it...They also result in considerable distress and impairment, and so may need to be treated "in their own right." But how? Whether this ought to be the remit of the health professions is a matter of debate and controversy, especially with regard to those personality disorders which predispose to criminal activity, and which are often treated with the primary purpose of preventing crime. Ah, I see. The primary purpose is not to help the poor nutjob 'in their own right.'

1. Paranoid personality disorder

Cluster A is comprised of paranoid, schizoid, and schizotypal personality disorders. Paranoid personality disorder is characterised by a pervasive distrust of others, including even friends, family, and partners. ✓ Sometimes. As a result, this person is guarded, suspicious, and constantly on the lookout for clues or suggestions to validate his fears. It has been known. He also has a strong sense of personal rights: He is overly sensitive to setbacks and rebuffs, ✓✓ easily feels shame and humiliation, ✓✓ and persistently bears grudges. Not so much, no, because it's all my fault. Unsurprisingly, he tends to withdraw from others ✓✓ and to struggle with building close relationships. The principal ego defense in paranoid PD is projection, which involves attributing one’s unacceptable thoughts and feelings to other people. Sound familiar? A large, long-term twin study found that paranoid PD is modestly heritable, and that it shares a portion of its genetic and environmental risk factors with schizoid PD and schizotypal PD. Aha! No comment.

2. Schizoid personality disorder

The term "schizoid" designates a natural tendency to direct attention toward one’s inner life and away from the external world. A person with schizoid PD is detached and aloof and prone to introspection and fantasy. ✓ Second bit at least. He has no desire for social or sexual relationships , is indifferent to others and to social norms and conventions, and lacks emotional response. A competing theory about people with schizoid PD is that they are in fact highly sensitive with a rich inner life: Be nice to think so.They experience a deep longing for intimacy , but find initiating and maintaining close relationships too difficult or distressing, and so retreat into their inner world. ✓✓ People with schizoid PD rarely present to medical attention, because despite their reluctance to form close relationships, they are generally well functioning and quite untroubled by their apparent oddness. ✘ No. It's torture.

3. Schizotypal disorder

Schizotypal PD is characterised by oddities of appearance, behaviour, and speech, unusual perceptual experiences ✓✓, and anomalies of thinking similar to those seen in schizophrenia. These latter can include odd beliefs , magical thinking (for instance, thinking that speaking of the devil can make him appear), suspiciousness, and obsessive ruminations. ✓ If depressed, the devil frickin' well has appeared — in the goddamn mirror. People with schizotypal PD often fear social interaction and think of others as harmful. ✘ No. Others are perfectly functioning, lucky, normal bastards.This may lead them to develop so-called ideas of reference — that is, beliefs or intuitions that events and happenings are somehow related to them. ✓ Oh yes. My hideous energy is controlling everything out there. Donald Trump is my doing. So whereas people with schizotypal PD and people with schizoid PD both avoid social interaction, with the former it is because they fear others , whereas with the latter it is because they have no desire to interact with others or find interacting with others too difficult. People with schizotypal PD have a higher than average probability of developing schizophrenia, and the condition used to be called "latent schizophrenia." Great, got that to look forward to.

4. Antisocial personality disorder

Cluster B is comprised of antisocial, borderline, histrionic, and narcissistic personality disorders. Until psychiatrist Kurt Schneider (1887-1967) broadened the concept of personality disorder to include those who "suffer from their abnormality," personality disorder was more or less synonymous with antisocial personality disorder. Antisocial PD is much more common in men than in women and is characterised by a callous unconcern for the feelings of others. ✓ though callous is too strong, I sincerely hope. The person disregards social rules and obligations , is irritable and aggressive , acts impulsively , lacks guilt ✘✘✘ , and fails to learn from experience.✓ Ouch. In many cases, he has no difficulty finding relationships — and can even appear superficially charming (the so-called "charming psychopath") — but these relationships are usually fiery, turbulent, and short-lived. I can't lie, I have been that and I have had those. As antisocial PD is the mental disorder most closely correlated with crime, he is likely to have a criminal record or a history of being in and out of prison. Woo-hoo! Managed to avoid that. Does sectioning and hospitalisation count?

5. Borderline personality disorder

In borderline PD (or emotionally unstable PD), the person essentially lacks a sense of self and, as a result, experiences feelings of emptiness and fears of abandonment. ✓✓✓ There is a pattern of intense but unstable relationships , emotional instability , outbursts of anger and violence (especially in response to criticism), and impulsive behaviour. ✓✓ Violence — no, might well have felt like it though. Suicidal threats ✓not so much threats as incessant thoughts of and acts of self-harm are common, for which reason many people with borderline PD frequently come to medical attention. (Read: get locked up.) Borderline PD was so called, because it was thought to lie on the "borderline" between neurotic (anxiety) disorders and psychotic disorders, such as schizophrenia and bipolar disorder. It has been suggested that borderline personality disorder often results from childhood sexual abuse, and that it is more common in women, in part because women are more likely to suffer sexual abuse. However, feminists have argued that borderline PD is more common in women, because women presenting with angry and promiscuous behaviour tend to be labeled with it, whereas men presenting with similar behaviour tend instead to be labeled with antisocial PD. Sauce for the goose etc.

6. Histrionic personality disorder

People with histrionic PD lack a sense of self-worth and depend on attracting the attention and approval of others for their wellbeing. They often seem to be dramatising or "playing a part" in a bid to be heard and seen. Indeed, "histrionic" derives from the Latin histrionicus, "pertaining to the actor." Really? I thought it was about hysterics from hysterika meaning uterus i.e. wombs, women and their wayward wildness. Easy mistake to make, learn something every day. People with histrionic PD may take great care of their appearance ✘ couldn't care less and behave in a manner that is overly charming or inappropriately seductive. ✓ Oh yeah, you should have seen me work that baby, back in the day... As they crave excitement and act on impulse or suggestion , they can place themselves at risk of accident or exploitation. ✓ It's quite amazing I survived this long. Their dealings with others often seem insincere or superficial you'd have to ask them, which in the longer term can adversely impact their social and romantic relationships. To put it mildly. This is especially distressing to them, as they are sensitive to criticism and rejection and react badly to loss or failure.✓✓✓ A vicious circle may take hold in which the more rejected they feel, the more histrionic they become — and the more histrionic they become, the more rejected they feel. It can be argued that a vicious circle of some kind is at the heart of every personality disorder and, indeed, every mental disorder. And vicious is the word.

7. Narcissistic personality disorder

In narcissistic PD, the person has an extreme feeling of self-importance , a sense of entitlement , and a need to be admired. He is envious of others and expects them to be the same of him . Wince, cringe. He lacks empathy and readily lies and exploits others to achieve his aims. It's true, I have been completely unable to put on, let alone walk a mile in someone else's shoes and if exploitative means getting your way then yes, that too. To others, he may seem self-absorbed , controlling , intolerant , selfish , or insensitive.If he feels obstructed or ridiculed, he can fly into a fit of destructive anger and revenge. Phew, one ✘! Such a reaction is sometimes called "narcissistic rage" and can have disastrous consequences for all those involved. ✓ Just call me the Human Weapon of Mass Destruction.

8. Avoidant personality disorder

Cluster C is comprised of avoidant, dependent, and anankastic (New word to you too?) personality disorders. People with avoidant PD believe that they are socially inept , unappealing , or inferior , and constantly fear being embarrassed , criticised , or rejected. They avoid meeting others unless they are certain of being liked and are restrained even in their intimate relationships. Avoidant PD is strongly associated with anxiety disorders, and may also be associated with actual or felt rejection by parents (let's not go there now) or peers in childhood. Research suggests that people with avoidant PD excessively monitor internal reactions , both their own and those of others , which prevents them from engaging naturally or fluently in social situations ✓✓. A vicious circle takes hold in which the more they monitor their internal reactions, the more inept they feel; and the more inept they feel, the more they monitor their internal reactions. No wonder I'm so damn tired.

9. Dependent personality disorder

Dependent PD is characterised by a lack of self-confidence and an excessive need to be looked after. This person needs a lot of help in making everyday decisions and surrenders important life decisions to the care of others. He greatly fears abandonment and may go through considerable lengths to secure and maintain relationships. A person with dependent PD sees himself as inadequate and helpless , and so surrenders his personal responsibility and submits himself to one or more protective others. He imagines that he is at one with these protective other(s), whom he idealises as competent and powerful , and towards whom he behaves in a manner that is ingratiating and self-effacing. Or just really irritating. People with dependent PD often end up with people with a cluster B personality disorder, who feed on the unconditional high regard in which they are held. ...Interesting. Overall, people with dependent PD maintain a naïve and child-like perspective  and have limited insight into themselves and others. This entrenches their dependency, leaving them vulnerable to abuse and exploitation.

10. Anankastic (obsessive-compulsive) personality disorder

Anankastic What?PD is characterised by an excessive preoccupation with details , rules , lists , order , organisation , or schedules ; perfectionism so extreme that it prevents a task from being completed ; and devotion to work and productivity at the expense of leisure and relationships . A person with anankastic PD is typically doubting and cautious , rigid and controlling , humourless , and miserly. His underlying anxiety arises from a perceived lack of control over a world that eludes his understanding , and the more he tries to exert control, the more out of control he feels . As a consequence, he has little tolerance for complexity or nuance , and tends to simplify the world by seeing things as either all good or all bad ✓ Bit of a contradiction, but true. His relationships with colleagues, friends, and family are often strained by the unreasonable and inflexible demands that he makes upon them.

Closing remarks

While personality disorders may differ from mental disorders, like schizophrenia and bipolar disorder, they do, by definition, lead to significant impairment. QED. They are estimated to affect about 10 percent of people, although this figure ultimately depends on where clinicians draw the line between a "normal" personality and one that leads to significant impairment. Characterising the 10 personality disorders is difficult, but diagnosing them reliably is even more so. For instance, how far from the norm must personality traits deviate before they can be counted as disordered? How significant is "significant impairment"? And how is "impairment" to be defined? Yes, how! How the bloody hell how?

Whatever the answers to these questions, they are bound to include a large part of subjectivity. Personal dislike, prejudice, or a clash of values can all play a part in arriving at a diagnosis of personality disorder, and it has been argued that the diagnosis amounts to little more than a convenient label for undesirables and social deviants.'

Well, at least that's honest.

#clusterABC #personalitydisorders #depression #bipolar #labels #symptoms