What Do I Mean When I Say Anxiety?

Yesterday, I made a Facebook post that included the word anxiety. When I made it, I was dealing with a fairly strong anxiety attack, and I mentioned my frustration at coping skills that weren’t working. A few people commented and joked or just treated it like I was talking about having too much energy. It wasn’t a big deal, but it did rub me the wrong way as I was trying to be open about something that was a fairly crappy experience for me and a lot of people completely misunderstood what I was saying.

A lot of the time, people don’t understand why mental illness advocates suggest that they don’t use words like “OCD”, “anorexia” or “depression” to mean things other than the actual diagnosable illnesses. This seems to me to be a good example. We have lots of words for things that aren’t clinical level anxiety: worry, fear, nervousness, a sense of impending doom. But we don’t really have any other words for the feeling of anxiety that comes with an anxiety disorder. So when I try to express that feeling, I have no way to say it except with a word that will inevitably be misunderstood by at least some of the people I’m speaking to.

That’s actually incredibly frustrating and can feel quite invalidating. If you had a broken leg and tried to tell someone, and their response was more along the lines of what you’d say to a stubbed toe, you’d be a little miffed. That’s what it feels like to try to talk about mental illness and get advice that applies to neurotypical brains. There’s fairly good evidence that invalidation is really bad for a person’s mental health, as it makes it hard for them to trust their own emotions. So while no one was intending to fuck with me last night, it certainly felt as though I was trying to ask for help or comfort or recognition, and instead got people completely ignoring what I was saying.

These are the kinds of small experiences that add up. If you have a mental illness you get them all the time, which means that you have to spend extra time and energy deciding how you want to explain yourself and your feelings to other people. It also means always feeling as if you have to convince other people of the seriousness of a given emotion or problem. When I say anxiety, I don’t mean I’m worried about something. I mean that my whole body feels like it’s going to rip apart, that I have so much energy I can’t keep still, that I alternately cry and do pushups, that my brain will not and cannot turn off, that I am desperate to escape whatever situation is bothering me. These differences are important. We need a word to talk about the intense anxiety. It’s hard enough to talk about it without having the language itself obscure your meaning.

For those who don’t have to learn how to express their emotions in a language separate from the one everyone else does, it might seem like no big deal. But if you’re trying to be honest and open with others and not seem overly dramatic, it’s really important to be able to use the accurate terms without them being misunderstood.

Treating Depression Is Not Medicalizing Sadness

One of the criticisms I often see leveled at therapy and medication is that it’s turning basic human emotion into an illness. There was a huge outcry of this when the DSM V took out the grief clause from the diagnosis of depression (previously one could not be diagnosed with depression 6 months after a major loss), people often throw this at ADD, and in this otherwise lovely article about chronic depression, one psychiatrist refers to diagnoses like dysthymia as follows: “The ‘thymias’ which the DSMs discover – cyclothymia, dysthymia – are helpful for private practitioners in the States. They provide another disorder to be diagnosed, treated and billed for.” The author follows this up with “We’ve reached a point where if you are not actively experiencing ‘happiness’ then you feel you are ill. And if your friends and family think you aren’t happy enough or making them happy enough, they advise a trip to the doctor. “

Now don’t get me wrong, I do think there are many ways that our society fetishizes happiness. Many people find ways to run away from any negative emotions, and those who do act down or angry or sad are generally encouraged to do whatever they can to change that. Those of us with fairly pessimistic temperaments are accused of self-sabotage, of choosing a bad attitude, of being debbie downers. No one really much wants to be around us and we are informed in no uncertain terms of that fact.

But where I do want to differ from these criticisms is that they seem to equate the treatment of depression, even low level depression, with our society’s inability to handle negative emotions. These are two very different things. There’s an odd perception from those who haven’t actually experienced therapy that it’s about getting rid of all the bad feelings and that the end goal is to create someone who is happy clappy skippy doo. At the very least, people who go to therapy are supposed to come out “well adjusted” which for some reason is often associated with a Stepfordish oddness or calmness. We imagine Chris Traeger bouncing around like a hyperactive puppy when we think of those who have overcome depression.

 (not me)

In reality, this is exactly the opposite of the experience that I have had with therapy, and I suspect that many other people have had to delve into some extremely unpleasant emotions as a result of therapy. One of the main elements of therapy for me has been learning that negative emotions are necessary, provide information, and can be tolerated. I have learned tools to be able to feel bad and not immediately spring to fix whatever is wrong (which oftentimes is nothing).  My therapists have repeatedly told me that they want to find the appropriate place for all of the elements that make me up, including such winners as ennui, existential angst, and an overactive sense of guilt.

Here’s the clear and defining line between depression and normal, healthy sadness: depression affects your ability to function in your life. Whether that’s because it’s major depressive disorder and you have reached a point where you can’t shower in the mornings or whether that’s because it’s pervasive depressive disorder and you’ve felt low level emptiness your entire life and you just can’t handle it anymore, what makes something a problem is when it starts to interfere with someone’s life in a negative way. Now this isn’t as clear and defining of a line as we would like, but there it is and most individuals would be able to tell you if they feel like their emotions are getting in the way of their life.

Treating depression, whether with medication or with therapy, is about allowing an individual to function again. A functional human being feels painful feelings sometimes. One of the most obvious examples of the ways in which treatment of depression is actually antithetical to happiness obsessions is in mindfulness practices, particularly DBT. These ask an individual to simply notice their feelings without judgment, letting them happen without trying to change them.

One of the many reasons that people often end up in therapy or on medication is because they have been too afraid to honestly look at their negative emotions, feel them, and let them go. Of course there are some therapists and clinics that may go too far and end up treating any negative emotions as problematic, but overall the profession’s aim is to help people who are struggling.

The other piece of the puzzle is medication, which many people view as a “quick fix” for those who refuse to deal with their problems and just want to be happy all the time. Now I haven’t been on every medication ever so I can’t speak to all experiences, but that really is not how medication works most of the time. I have never had medication actually lift my mood, it simply has held back some of the negative so that I have space to work towards positive for myself. It allows me to go about my daily life in a relatively normal manner so that I can find ways to be effective long term. Again, it’s about keeping depression from drastically impacting my life.

Perhaps the reason that so many people point towards the prevalence of therapy and medication in our society as evidence that we refuse to be happy is because of a basic misunderstanding of what those treatments do. If someone’s emotions are keeping them from achieving their goals in life, from having relationships, from effectively doing their jobs, then the aim of treating those emotions is to help that person live their life. That doesn’t require happiness, but it does require the ability to cope with negative emotions.

I do think that it’s important to address our societal phobia of sadness, grief, and pain. But the way to do that is not to throw the mentally ill under the bus by implying they are running from their negative emotions when they seek out treatment. A diagnosis of depression does not say “this person is too sad”. It says “this person can’t function the way they would like to because their emotions are consistently out of control”. There is a world of difference between those two statements.

Ok, maybe I’m a little bit Chris Traeger.

Falling Through the Cracks: When the DSM Can’t Find You

This week in my DBT group, we were talking about what Borderline Personality Disorder is and how it’s diagnosed (DBT was originally formulated for BPD). Essentially, there are nine traits that are used to diagnose BPD. If your diagnosing therapist sees five or more of them in you, then you are diagnosed with BPD. If you have less than five, but still have some, you are diagnosed with what’s called BPD Traits. I had never heard of BPD Traits before, and I don’t think most people have. Insurance is far less likely to cover something that sounds subclinical like that, and it’s far less likely to be understood by the general public. It simply sounds less severe, right?

 

Unfortunately, this system has a few major flaws, and it seems to me that these flaws are indicative of many of the problems with the DSM as a diagnostic manual. The main problem with this system of diagnosis is that many of the traits of BPD are things that everyone has to some extent or another (things like anger issue, or efforts to keep people from leaving you), and so they only become diagnosable when they seem to be excessive or problematic. This leaves a great deal up to the discretion of the diagnosing therapist. It also means that that therapist has to draw a hard line about what counts as problematic and what doesn’t, when in reality these traits exist on a spectrum. So you could be just over the line and counted as having the trait, or you could be so far over the line you can barely function on a day to day basis, and in the eyes of the diagnosis, you have the same trait.

 

This also means that the difference between BPD and BPD traits isn’t as clear cut as it might seem in the first place. For example, someone with BPD might be just over the line on five traits, but someone with BPD traits might be way, way over the line in four. Who’s to say which is more severe, or that one should receive a full diagnosis that allows them access to treatment, while the other receives a diagnosis that gets them almost nothing?

 

Overall, this illustrates something that is definitely wrong with the DSM: mental illness and mental traits all exist on spectrums. There is no on or off switch to depression, anxiety, paranoia, or any other problem that may be diagnosed as a mental illness (with the possible exception of hallucinations). However in order to diagnose someone (and particularly for that individual to gain coverage of treatment), symptoms are treated as present or not present. Occasionally we use modifiers like “severe” or “mild”, but more often than not it’s either there or it’s not.

 

This seems to be a recipe for disaster for people whose symptoms either don’t present as traditionally understood, who are barely subclinical, or who have an odd constellation of symptoms. I find that I often have this problem: I have lots of issues (oh LOTS and lots). I have bits of OCD, OCPD, ADD, BPD, depression, anxiety, bulimia, anorexia, and really probably a whole host of other things. But because many of them are subclinical, or I don’t have the right pairings to fit into a particular diagnosis, I have been left without any sort of personality disorder diagnosis, or larger diagnosis to fit it all together. Despite how severe my eating disorder was, I was lumped in the EDNOS category, which is far less often covered, and is often treated with less respect and as less severe than other eating disorders.

 

This is a serious problem if we want to provide proper services for those people suffering from mental health issues. We shouldn’t have to wait until a symptom is truly interfering with someone’s basic functions before we give them help. There are many problems with the DSM, and trying to posit a replacement for it is extremely difficult, but one element that really could use replacement is this all or nothing thinking. There is no “partially depressed” or “sort of ADD”. You either have it or you don’t. One improvement could be seeing mental health on a spectrum. We all have different traits, and many of those traits are spectrum style traits. Understanding that moving towards the extremes is always a problem is one great way to view mental health in a more understanding and helpful way, because it allows us to try to help everyone move towards a more balanced place, and could allow us to provide treatment for those who have not yet reached the critical zone.

 

Another issue with this system is the amount of discretion that it allows for the diagnosing clinician. Let’s look at a particular example. One of the criteria for diagnosing BPD is “inappropriate, intense anger or difficulty controlling anger”. This is fairly vague. What counts as inappropriate anger? How might things like race and gender fit into this (hint: black women will always be viewed as having inappropriate anger)? Shouldn’t there be specific examples of things that might constitute inappropriate anger, or the consequences in someone’s life for “difficulty controlling anger” or the number on an emotional scale of what constitutes “intense” anger? How often does one need to be intensely angry to get this trait? All of these things are left up to the discretion of the diagnosing clinician, and unfortunately this allows for a lot of bias.

 

There is a difficult balance here, because having that kind of specificity means that you could be very close to a diagnosis, but not quite reach the correct number of episodes, or the right “level” of anger to reach diagnosis. It seems to me that having these specific levels combined with a spectrum view of disorder would allow clinicians to have less individual discretion that can lead to variability in diagnosis, but would also allow more people to get the treatment that they need. It is widely recognized that we need some changes in the DSM, but these particular issues are ones that I have seen in action in myself and in people around me, and that seem as if they could be fixed without great difficulty. Get on that DSM.

Follow Up: Mandatory Mental Health

A couple of notes here: I’ve noticed that I’ve been posting a lot and then having more thoughts come to me immediately afterward I put something up. I think that what this means is that I need to spend more time with each post before I hit the publish button. I probably flood this blog anyway, so I’m going to cut down how much I’m posting so that I can devote more time and energy to editing and putting up quality rather than quantity. I will be posting a fair amount on Teen Skepchick this week, and I should have posts going up at The Fementalists and CFI On Campus as well, so never fear you will have your overdose of my writing. With that explanation, here is my single post for the day.

I recently posted that I thought it could be beneficial to institute mandatory mental health education in schools. In my initial post, I didn’t flesh out some of the serious benefits that we could see from instituting this kind of policy, and I didn’t really explore how we could implement it either, but rather focused on the first flash of an idea. In order for this idea to have any kind of impact, it needs to have some feet under it. I need to identify who it will benefit, how it will show benefits, and what might stand in its way. That’s what I intend to do here.

There are many practical benefits to adding a new . The first chunk of these benefits falls under the heading of “preventative treatments”. As it stands today, it is extremely difficult to get any kind of mental health treatment unless you are already overwhelmed or in a non-functioning state. We don’t hand out diagnoses to people who are showing signs of something and want help to keep those signs under control: we hand them out to people whose symptoms have gotten out of control. Unfortunately, a DSM diagnosis is the only way for many people to get help. By the time they get to this point, they’re often already in a state of crisis.

To take a stark contrast, we spend a great deal of time thinking about preventative measures in our physical health: we tell our children to wash their hands, to stay home if they’re contagious, to eat healthy and exercise, and to get vaccines. For some reason this logic isn’t extended to mental health even though there is a great deal of evidence for the biosocial theory of mental illness: we start with some predisposition that makes us vulnerable to mental illness, but our environment can either tip us into it or help us away from it. The messages that we are sent about our emotions and our worth make a huge difference in determining the severity of our emotional difficulties. Adding education to schools can help send positive messages to kids about accepting their emotions and about how to handle emotions. It reduces the stress level of the environment, or at the very least provides kids with some tools to diminish the stress levels in their personal environments.

There are many people who could benefit from this kind of preventative care. First, those people who are vulnerable to mental illness need all the help they can get to build a healthy and safe environment for themselves. This NEEDS to start as a child. Much of the evidence about mental illness suggests that childhood is one of our most vulnerable times and it’s when we begin to develop our patterns and understandings of emotions. Providing some extra help to children could mean significantly fewer individuals who fall into diagnosable states as they grow older. While we can only do so much to provide kids with safe and happy family environments, schools do provide an ideal location to teach the skills to help handle less than ideal environments. Giving a vulnerable child the skills to not fall into the place of crisis that a diagnosis requires would be a huge improvement in quality of life.

In addition to those children who may at some point gain a diagnosis, or who need help to not fall into a diagnosis, there are also individuals who have serious struggles with their emotions and mental health but who will never have a DSM diagnosis. They’re hovering in the uncertain place where they’re not destroying themselves, but they’re certainly not healthy or happy. People with subclinical symptoms, or who might have a bad environment but higher tolerance. Oftentimes these individuals can’t afford therapy or simply don’t have very many resources to help them learn about emotional regulation. With some regular education and practice at emotional regulation, these kids could grow into much happier adults. They deserve help to flourish just as much as anyone else.

Finally, the general population of kids (and the adults that they become) could benefit from learning emotional skills. Obviously we all feel better when we can regulate our emotions and tolerate distress. But the most important section in my mind is learning about interpersonal relationships. If the bullying epidemic in this country tells us anything, it’s that we haven’t been stellar at teaching our kids about interpersonal relationships. We’re constantly talking about how to decrease bullying, and asking all children to learn how to get what they want and need in a more appropriate fashion can only help. In addition, as a recent college grad, I can promise you that 99% of the jobs that I’ve been looking at list “work well in a group” as one of their requirements. Our world is very much about connection right now: technology seems to be thriving on the concept of connecting. So giving our kids the skills to navigate the world of constant connection would be extremely helpful, both for their future work lives, and for their current personal lives.

So beyond helping our kids and future citizens be happier and healthier, what else do we get out of adding mental health education to our schools? I know that politics right now is about money, money, money, pragmatics, the economy…we can’t just go throwing money at things without some guarantee of a return on our dollar. But I have news: this will likely save us money. I don’t know if you’ve noticed, but mental healthcare is EXPENSIVE. My experience is primarily with eating disorder treatment, and I know that it’s come near to bankrupting a fair number of families. Most of the money for treatments is coming from insurers, and thus drives up the cost of insurance for everyone. Therapists are damn expensive, and once a mental illness becomes thoroughly entrenched it can take many, many years of therapy and work to get it under control. That’s a huge amount of expense both for individuals and for the community. If we can prevent some mental illnesses from ever occurring, we can save a great deal of money.

In addition to the cost of treatment, mental illness itself can be expensive, both individually and societally: individuals who are struggling can have a harder time getting and keeping work, or may spend money on things they don’t want (BPD can lead to excess shopping, addiction leads to money spend on substance of choice, BED means money on huge quantities of food). If someone is desperately fighting for their own mind, they’re likely not contributing as much to society as they could be (this is in no way meant to shame individuals with mental illness. Your job is to bring yourself back to health, not to contribute to society on a monetary level. If someone had a debilitating physical illness you wouldn’t shame them because they can’t work as many days. This is simply to say that when we’re very ill we’re not at our best). But if society wants its members to be as productive as possible, holding down jobs and putting money back into the economy, preventing mental illness is a really good way to do this.

But maybe money isn’t your thing. Maybe you’re more interested in the people than in the money. Well first of all go back and read the first few paragraphs about how we could make a lot of people happier and healthier. Still not enough? Ok, I’ve got another. The most immediate and concrete would likely be an improve in grades. Now I don’t know of any studies on the relationship between mental health treatment and grades, but I’m gonna go out on a limb here and say that when you’re fighting a mental illness or fighting to stay out of a mental illness, you’re more likely to struggle in school or at work. Now there are absolutely people who can keep up good grades while struggling. Some mental illnesses tend to push people towards perfectionism, and those individuals appear highly competent while in the throes of a mental illness. I myself managed to keep up above average grades through all of college while dealing with an eating disorder, depression, and generalized anxiety. But the worst grades of my life came at the time when my mental health was at its worst. This is not a coincidence. If we want our children to be well-educated and to be as successful as possible, we have to help them to be able to focus on school when they need to, and to have ways to deal with whatever else might be going on in their lives.

In addition, spending time with one’s own emotions can really help to create more empathy for others. Again, I am speaking from my own experience here, but I find that the more I learn about understanding where my own emotions come from, the more I find myself curious about why others are upset or struggling. If even half of the kids in these classes gained something, we would have a significantly more empathetic and supportive community for others who might still have difficulties. And if every child went through something very like therapy at a young age, we might be able to decrease some of the stigma against mental illness and against therapy.

Now obviously there would be a cost here. It’s not free to get a therapist into the schools, or to further educate our already over-burdened teachers to handle one more thing. But adding a single additional school therapist who did one hour of work per week with each classroom would not break the budget (possibly two for larger schools. Keeping therapy groups small is REALLY important), and it could lead to some serious improvements. Therapists are expensive, but if we get all of the benefits outlined above it seems that it would be well worthwhile.

The ideal way to do this seems to me to have one therapist who is entirely devoted to education and preventative work, who conducts classes with small groups of students to teach them different skills, check in about their week, and assign them a short piece of homework to practice an emotional skill during the week. This would be a highly demanding position for one therapist to build close relationships with a large number of kids, but if schools were capable they could add more therapists for more students. Even if it didn’t exactly mimic a traditional therapist/patient relationship, it could still be a useful way for kids to simply have a time to check in, learn how to talk about emotions, and get some emotional education. It absolutely seems to be a cost effective measure to improve grades across the board (because this seems to be a measure that would benefit all kinds of students, and engage those with some interest in psychology at an early age) and to prepare kids for jobs and life.

Now I am obviously not a school administrator or policy maker. I have never been in the position to create a budget for a school. So I would love to hear input from those people who might have more experience with these sorts of things: do you think it would be a cost effective measure? Could it help to lighten the load of some of the other school counselors to do some preventative measures? How could we try to push for this change to be made?