User blog:PullingoffMasks/Mental Health and the Mythos

(Please note this has been largely copy/pasted over from the series bible. I have cut out the writings from other folks, edited my bits up a bit, and...yeah. Have a read if you haven't already) 

''NB: This is likely going to be a longish post. It is also not aimed at anyone particular, but if the Mythos continues to grow, it is likely we will run into more and more issues with people taking the Hollywood approach to anything Mental Health related.''

First- basic definitions, why you need to take care, and language you should use

First: neurotypical, allistic, neurodiverse, and crazy.

Neurotypical is defined as mental ‘normalcy,’ eg. the lack of any disorder as defined by the DSM or ICD. It is a very culturally bound term, but gets lobbed around to mean ‘normal’ in a more specific way.

Neurodiverse is define as any form of deviation from the assumptive mental norm. Thus, I can say, with my official dx of anxiety, that I am neurodiverse.

Allistic is anyone who is not autistic, but may or may not be otherwise neurodiverse. So my friend with bipolar/manic-depressive disorder is allistic, because she is neurodiverse, but not autistic.

Crazy is ableist slur, but can be used in character to define mental state divergent from character norm.

There’s other language, outside of defining mental state, so let’s go with what the hell the DSM and ICD are.

The DSM is the major diagnostic tool used in the US- DSM stands for Diagnostic and Statistics Manual of Mental Disorders.

It uses Axises to define the larger course of the disorder. The one that is of most note for the Fear Blogging community is Axis 1 (‘clinical disorders’- includes mood disorders (depression/mania/manic-depression), Autism Spectrum Disorders (ASD), and substance abuse)

It is currently in its 5th edition (seen often as DSM-V), but most of the stuff in the post uses the previous DSM (DSM-IV-TR) given it was written whilst it was still valid.

The rest of the world uses the WHO’s ICD (International Statistical Classification of Diseases and Related Health Problems).

It is currently in its 10th edition (ICD-10) and is up for change sometime next year.

Why does this matter? Well, simply, it provides for how a disorder is defined, how it is diagnosed, and what therapy is suggested by the psychologist (or psychiatrist).

Please note that neither manual is a perfect tool. They have issues- see the DSM-I through DSM-III defining homosexuality as a mental disorder, current issues with gender dysphoria, autism’s definition has changed through time- but they are the BEST tool you can have for defining a characters disorder/dysfunction.

Also note: A psychologist is trained to observe and offer a diagnosis, but they cannot sign on any prescriptions or offer any psychoactive drugs. A psychiatrist can observe, offer diagnosis, AND can write prescriptions/sign off on suggested psychoactive drugs.

For the rest of the talk about diagnosis, etc, assume I’m using the DSM-IV-TR. It’s the manual I’m most familiar with and it has some of the clearest language of any manual I’ve ever browsed.

Now onto the more ‘fun stuff.’

Disorders such as schizophrenia, autism/Asperger’s, any mood disorder, etc are exactly that, they are disorders and/or dysfunctions. They are NOT diseases. PLEASE make sure you’re aware of this. The language here is important, as disease indicates, often times, that it can be cured.

As you’re likely aware, there’s not solid cure for any big mental disorder, only pharmacological stop gaps (which aren’t magic bullets, more on that later), therapies, and a whole lot of shitty fake treatments/cures.

The language that people used to talk about disorders also is a BIG thing in a lot of discourse, both fictional and via news.

SO:

'''Insanity is NOT a diagnosis. It is a LEGAL term defined by the courts''', which decides (in the US at least) whether or not a person can stand trial. A person who is ruled to be insane (or mentally incompetent to stand trial) cannot be tried, legally under US law, as the court psychologist has prove that the defendant is not fit.

Contrary to popular belief, it is a bitch to get a legal ruling of insanity, as the process is a complicated one, and includes a set of questions that essentially boil down to ‘can you, more often than not, tell what you did wrong, why it was wrong, and given same situation would you repeat your error?’

Sanity, like insanity, is a legal term.

Never call a character insane or sane, unless they have a history with the law.

Person first language.

Essentially, putting the ‘proper person’ before their disorder. There’s talk about it in a lot of mental health/disability communities (especially in the autistic community) about how it can devalue a person by separating them from something that may be an integral part of who they are. This is, though, highly variant on the person, and your best bet is to, as a writer, decide who your character is going to be before slapping labels upon them.

If you want more stuff on it, may I suggest Neurodivergent K’s blog. She’s an amazing disability rights/autistic blogger and she’s covered a lot of what I’m talking about in a LOT better way than I can/could.

[examples of person first language]

autistic – ‘person with autism’ ‘they have autism’ epileptic – ‘person with epilepsy’

etc.

Second- more in depth stuff on the four major disorders/dysfunctions I’ve seen used across the Slender and Fear Mythos (Any dissociative disorders (including dissociative identity disorder), schizophrenia, depression (or more correctly, non-specific mood disorders), and autism spectrum disorders)

Note, that any of these disorders have to cause ‘marked distress or disorder to normative function within society’ before diagnosis is considered proper and complete.

This is going to be a bit more dense, so hang with me.

Dissociative disorders

Axis 1 disorder.

Is the large umbrella that collects dissociative identity disorder, depersonalization disorder, and dissociative fugues (all of which have been used in many a Fear and Slender blog).

All disorders under this umbrella are marked by a period in time (be it continuous, periodic, or cyclical) where perception of reality is markably different, often with affects on memory and sensory.

Or, in more lay terms, ever had that feeling that you’re ‘out of your skin’ or reality has slid a little to the left? That’s depersonalization, and mild moments of it are very common. Severe and/or recurrent ones aren’t.

It is VERY different to a psychotic break.

It also is NOT schizophrenia.

The main treatment for any dissociative disorder is therapy, usually talk. In the case of DID, one of the aims of therapy is to ‘mainline’ or integrate all of the personalities back into one whole.

Mood Disorders

Axis 1

A very, very, VERY large umbrella term that catches mania, manic depression/bipolar disorder, depression, and a few other disorders

''Mania is defined as a extremely elevated (up) and/or irritable mood. '' Note that it is a big UP! It isn’t 2 cans of Red Bull, pack of candy, late at night up. It’s flying high, feeling incredibly invincible, NOBODY CAN STOP ME!, I can do no wrong, mildly psychotic UP!

Talking to the same allistic friend I mentioned earlier, said it’s a ‘happy mood’ when you’re in it, because often times you’re not self aware enough of the mania to go ‘hang a sec, I should probably think about the consequences of my actions.’

(There is also hypomania, which is a mood similar to mania, but a little more lower in ‘volume. (If full blown mania is the volume up to 11, hypomania is about a 9, and normal mood is about a 6)

Depression is defined as an extremely depressed (down) mood Like mania, depression isn’t the ‘oh I’ve missed an episode of my favorite show’ down. It’s deep sinking, all encompassing feeling of doom, dread, nononono down.

Often times, severe depression comes hand in hand with ahedonia (lack of pleasure/drive) and suicide.

Mild depression exists, and it’s likely that you have (or eventually will) experienced it at least once in your life.

Using the volume analogy again, if ‘normal’ mood is around a 6, mild depression sits at around 3-4 (depending on the person), and severe depression sits at a 1.

Manic depression, or bipolar disorder, is a disorder defined by a course of 6 or more months marked by 2 or more major manic or depressive episodes.

Contrary to popular belief, manic depression is NOT commonly rapid cycling. There is a form of it which does rapid cycle- which adds the complication of mixed moods into the equation.

Mood disorders are often times treated with a mix of psychoactive drugs (which there are a lot of) and talk therapy.

A note on the psychoactive drugs for manic depression. You can treat mania with anti-psychotics. You can treat depression with antidepressants. You cannot treat both of the poles with one drug.

(Also, lithium is a last resort drug. It causes severe damage to the human body, at the cost of regulating mood, so it’s one of those ones that does not get used straight out. Used to tho’)

This is something, that if you want your character to have the disorder, you WILL NEED TO DO YOUR RESEARCH!

Schizophrenia is a group of disorders that are marked by psychotic episodes, a break down in thought process, and poor/misplaced emotional responses

It is NOT dissociative identity disorder.

Schizophrenia has two classes of symptoms. Positive and negative.

Positive symptoms add stuff that ‘isn’t there.’ So, hallucinations (hearing voices, seeing things that aren’t there, tasting stuff that isn’t there, etc), delusions, and disorganized speech/behaviour patterns.

A sudden onset of mostly positive symptoms is something that can be called a psychotic break or ‘a break in reality.’

Negative symptoms remove stuff from ‘normal function.’ So, poverty of speech, flat affect/facial expressions, lack of motivation, ahedonia, lack of wish/drive to be social, etc.

Negative symptoms actually can do more harm than positive symptoms, as they have a tendency to be low level and continual, as opposed to ‘moments of.’

Any drugs that are given to alleviate the symptoms of schizophrenia only effect the positive ones. Negative symptoms are unable to be ‘treated’ and can, actually (depending on the drug), be made worse with psychopharmacy.

There are a LOT of drugs out there, mostly anti-psychotics which are used to ‘treat’ schizophrenia. Note, there is often times poor compliance with drug courses, as typical anti-psychotics have a whole slew of nasty side effects. (And most of the side effects for atypical anti-psychotics are just heavy drowsiness)

As a side note, if anyone fancies playing with comorbidities- an autistic adult is less likely to be caught as schizophrenic until the disorder has progressed out of it’s prodermal (early) stages, as a lot of the most noticed negative symptoms are part/parcel of ‘classical’ autism.

Autism Spectrum Disorders (including Asperger’s Syndrome, Rhett’s Syndrome, Persuasive Developmental Delay, etc) are a set of disorders which are characterized by sensory processing dysfunction, social deficit, normal IQ, communication issues, and special interests.

It is not a savant syndrome.

It is not caused by vaccines.

There is no cure. It is not a disease.

It does not ‘look’ a certain way.

And all the stereotypes you have are wrong.

Reciprocal language development usually is delayed until 3rd-5th year in classical autism, where as it develops ‘normally’ in someone with Asperger’s.

The biggest thing for this is realizing that often times, you cannot tell a person is autistic in text. There’s a flourishing autistic community on Tumblr and everyone is amazingly eloquent.

When writing an autistic character, realize that the largest issues that are faced day to day are sensory. Read, hyperacute hearing is common, meaning shopping malls/markets are a headache because of overhead lighting + music + tannoy + everyone else talking…

Most of the ‘treatment’ for ASD is therapy, with some drugs being used to treat comorbid conditions such as depression, anxiety, and ADD/ADHD.

Part III- MORE STUFF!

More fun language

If you're familiar with disability community dialouge, the words ‘ableist’ or ‘ableism’ crop up A LOT when talking about derogatory language and actions towards disabled people.

It’s a term with pretty much the same weight as racism, but unlike racism, which is the act/actions/language referring to discrimination of skin tone and culture…abelism is act/actions/language referring to discrimination of mental health status, physical ability, and often times any deviation from stated physical-mental norm.

'Retard is ableist language. It is a slur which still carries a lot of heavy nasty weight to it. Don’t use it in casual language when you think something is mind-numbingly stupid. There are LOTS of other words you can use. (It’s also a good marker on age and education level of the character who is speaking/narrating)'

Crazy is abelist language.

Psycho/psychopath is ableist language  (see below as to why)

Use of insanity/sanity outside of the situation of the courts can be considered ableist language.

On that note, I think it’s best we discuss:

Psychosis/psychotic, psychopathy, sociopathy, and anti-social personality disorder.

Know the difference.

Anti social personality disorder is defined by the DSM-IV-TR as “…a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.”

It’s is an Axis Two disorder (personality disorder).

It is not a lack of emotion, more a lack of a realization that ‘others’ are valid humans in their own right.

It is colloquially (and incorrectly) referred to as sociopathy (not a valid condition, but a personality type) or psychopathy (old, out of date language, also considered ableist).

Not all people with anti social personality disorder are crime committing mass murderers, but there is enough correlation that the public view of the disorder is incredibly negative.

''Psychosis is defined, rather unhelpfully, as a ‘lack of connect with reality.’ A person experiencing psychosis can said to be psychotic. Any other use of psychotic is not good.''

A psychotic break can include hallucinations, delusions, catatonia (a more motor related movement/lack of movement/bizarre movement), and thought disorder (word-salad being a good example of this).

It is part and parcel of schizophrenia, but can occur just by itself, or in conjunction with manic-depression/bipolar disorder.

Clinical Language

Not going to go into it too much here, as it’s hellishly complicated.

Comorbidity!

Mental health is ‘fun.’ Rarely do you see one disorder come along by itself, as often times you get a knock on effect of one thing leading to another.

Any coexisting conditions that rest alongside any bigger diagnoses are called comorbid.

Very common comorbid mental health conditions include: ~ Any ASD with anxiety and depression ~ Epilepsy with anxiety ~ Schizophrenia with depersonalization disorder, anxiety, and depression ~ Antisocial personality disorder with depersonalization disorder

Essentially, if ability to function ‘normally’ within society is changed/limited/damaged, you will commonly see anxiety and depression hop along for a ride.

Part IV- PTSD and your character (Note, I’m lumping PTSD (which is severe) alongside it’s less severe cousin post-traumatic stress)

First things first, what is PTSD?

PTSD, also known as shell shock, stands for Post-Traumatic Stress Disorder. It’s an anxiety based condition, meaning it sits upon Axis 2.

DSM-IV-TR defines the criteria for PTSD as such:

~One has to have been exposed to a traumatic event. Note here that the definition of trauma has to fulfil the following: It has to have caused risk of serious injury/death to yourself/others (which you observed or were participant in). I would like to make the comment here that there are those who would make the comment that bullying and emotional abuse can invoke the stress response that leads to PTSD…but on a whole, that is classed as post traumatic stress, rather than full blown PTSD by shrinks.

~ “Persistent re-experiencing,” or in our lay terms “flashbacks.” Note flashbacks can take the guise of what Hollywood presents them as, re experiencing ‘in dreams,’ or any moment which evokes a negative reaction.

~ Avoidance and numbing. You don’t talk about it, because it leads to you being triggered, suppression of memories, bizarre affect, etc. This aspect is what can bring a dependency to alcohol or drugs into the overall picture. (Because alcohol is a depressant and, for most people, a damned good soporific)

~ Persistent arousal not present before occurrence of PTSD. No, not that sort of arousal, but mood. Hyper vigilance, paranoia, etc.

~ Symptoms above HAVE to have been present for a period longer than 30 days. If not, no luck, you’ve got another mental health issue…which can migrate into PTSD territory if it continues.

(And like always, it must form a serious malfunction with a person’s ability to interact with society.)

As for treatment: talk therapy to combat the interpersonal aspects and antidepressants/SSRIs to combat the somatic symptoms.

At this point, I will make comment.

Triggers and flashbacks.

Triggers are items/instances/phrases which can induce a flashback.

So, let’s take an example of a fairly nasty car crash. In that situation you’ve got several potential triggers: cars (and this can just be general, or down to a specific model), specific seating in car, fire, smell of petrol, sound of breaking glass, enclosed spaces, blood, etc.

Not all flashbacks are like Hollywood portrays them as. For every person with PTSD out there who will re-experience and re-enact the scene of most stress, there are just as many who will ‘shut down’ (a bit like a silent meltdown to those of you familiar with ASD topics), there are just as many people who will just “BLOW UP,” or will sit and have a panic attack.

So, car crash, with a trigger of the smell of petrol. Hypothetical person is filling their car up, and a bit of gas leaks. They are triggered by that and experience a flashback.

PTSD/Acute Stress Disorder/Post Traumatic Stress are all comorbid with:

Depression, ocassionally mania, and alcohol/drug dependency.

Panic attacks

Okay, sorry if this post goes off into ramble territory. I have a hard time writing about panic attacks, because I’ve discovered discussing them can occasionally cause me to induce one. Which is a right bitch and a half…and thankfully this was a discovery I made by myself, in solitude, not in public.

A panic attack is a response to stress. They can come with something triggering them (read, linked in with PTSD) or can occur ‘out of the blue.’ (Which, from personal experience, is even scarier than knowing that something you’ve bumped into will tick you from ‘oh stressed’ to ‘FUCKSTRESSEDPANIC!!!!!’)

Sometimes, like migranes, panic attacks can come with ‘pre-symptoms’ before the proper panic attack.

What do they look/feel like?

Short response, depends on the person.

Long response, because a panic attack is a somatic reaction to a mental state/condition (read, it’s a psychosomatic response) it has a varied expression.

The general response is that they’re fucking terrifying and because they can vary from time to time there’s no real ‘getting used to them.’

Panic attack versus Meltdown versus shut down

Okay. Realized that I’ve used some terms that I haven’t defined.

A panic attack, see above. Prevelent in NT, allistic, and autistic folks.

Meltdown…autism spectrum related.

Essentially it’s the point at which most instilled coping methods (read stimming, avoidance, reduction of stimulus) fail and you just can’t cope!

They will continue until stimuli are removed, ‘normalcy’ has been obtained, and the body-brain realizes it is ‘safe’

They are, very nastily, often referred to as temper tantrums. They aren’t.

Temper tantrums invariably originate from a behaviour pattern or things ‘just not going the right way’ and are fairly short (2-5 mins) in duration.

Meltdowns much more resemble panic attack, both in origin and length.

Shutdown…sensory sensitivity related, more often observed in older ‘passing’ autistic folks

Exactly as it says on the tin. The brain has had enough, it’s going to hard reboot…a person experiencing a shutdown will often get very quiet, very still, and ‘zone out ish.’

It is distinct from a specific form of seizure, in levels of awareness.

Often times a person who’s shutdown will be present, but in the sort of ‘long lecture after lunch’ sort of way.

Best bet is to, for both meltdowns and shutdowns, remove/minimize offending stimuli and offer the person ‘an out’ (access to a sensory safe/safer zone)

Part V– Exclusionary conditions and mental health

What does this mean?

Well, it’s a fancy way of saying that some somatic (body, not including brain) conditions are highly influential upon what we see going on in headspace.

This, before I forget, can go the other way- depression, ADD/ADHD, and anxiety all can effect the somatic side of things.

Often times ‘proper medical’ tests will be ran before a mental health approach is taken. This is to eliminate the possibility that it has a cause that can be ‘fixed’ by the wonder of modern medicine. /sarcasm.

Why is this important?

Well, simply put, psychoactive meds do jackshit for diseases/disorders which are caused by something that’s physically wrong/off centre with the body. And ditto for treating a mental health condition as a physical condition.

There is overlap at times. You will often times be asked about previous health conditions when you go to a psychologists, as they can recommend (but not force) you to go to a GP/general doctor.

(And in some places of the world, such as the UK, to even access a psychologist, one has to be recommended by a GP to even access psychiatric care (unless you’re posing a danger to yourself). Which, on one hand, helps prevent situations where you’ve got somatic conditions being treated as mental health conditions….BUT on the other hand, it prevents access to later diagnoses of items such as ADHD/ADD and Autism.

Because, remember, the general attitude towards ADHD/ADD and Autism is that they are largely mental health conditions faced by white, middle upper class, male children. Which is fucking bullshit, but that’s a different conversation topic)

Make note that because of how the body works, there are somethings that are able to be minorly managed by tweaking physical stuff… I’m looking at the whole idea of exercise and ‘proper sleep schedules’ in helping manage low level anxiety. '''BUT, it DOES NOT WORK FOR EVERYTHING. And for some mental health issues (looking at eating disorders as the big ones here), it can actually exacerbate the pre-standing issue.)'''

I’m going to used the example of the thyroid and it’s basic physical medical conditions as an example.

So, the thyroid is a gland, located just on top of your Adam’s Apple, that produces the hormones that regulate appetite, metabolism, and some mood.

Too much of either of the thyroid hormones (collectively referred to as thyroxine) or thyroid stimulating hormone, will cause your body to experience such wonderful symptoms, including but not limited to: Generalized anxiety/worry, irritability, racing/erratic heartbeat, hyperactivity, insomnia, low tolerance to stressful situations, and uncontrollable weight loss.

What do those symptoms sound like if we’re looking at only the headspace side of things? Well, generalized anxiety disorder usually looks a lot like hyperthyroidism on four counts (anxiety/worry, insomnia, low stress tolerance, irritability) if you’re not paying too much attention/have low awareness of ‘non-normalacy’ in terms of body to the other somatic symptoms.

Too little of thyroxine or thyroid stimulating hormone and your body will swing the other way. Low mood, low energy levels, weight gain, low cold tolerance, and the general feeling of brain sludge (which is about the best way I can describe that terrible feeling of your brain both feeling like it’s been replaced with cotton wool and is lagging worse than a 10K modem).

Which lines up fairly neatly (low tolerance to cold aside) with low level depression.