Repositioning symptomatology for mental health conditions post DSM-5
In the throes of madness, I have found some form of peace to hold on to like an anchor while discovering my innermost serenity. Only at the very end of my tormented nights was I unable to identify a technique to self-manage the chaos around me. At that point, I would not suggest self-managing the dysfunction around you; instead, I would recommend finding a safe space, a hospital or other service, that can help you sort out the extreme distress you are experiencing. This presentation is intended to arm readers with the tools necessary to self-manage their own frustration tolerance throttle. In plain English, this article will help people regulate their thinking and feelings while tuning into his or her own mental status and internal barometer for healthy living. Consumers should feel empowered to always live peacefully and independently, regardless of their chosen path to serenity and peace, even when the world before it becomes too chaotic to live without medical or psychiatric intervention.
There are a few additional caveats to remember. The first, when dealing with the interpersonal world, no level of calmness and serenity can prepare you for what someone will throw at you when they are in crisis and mishandling a situation. In cases like this, you may not have to dig deep into your psychological profile to unhinge your frustration; but instead, you can remind yourself that other people’s problems are their own. Feeling or thinking for them will only make their jobs more complicated and difficult to manage independently without you in the future. The second and last caveat: Sometimes you should be, or need to be, anxious. Our anxieties are signals that tell us we need to make changes in our lives. If you can’t locate the deep-seated issue, and you know something has to give, sometimes just going ahead without digging too deep into your subconscious or psychological wellspring might provide you with a fast and very much needed change to feel better in the next few moments. The most ornate and complex set and manifestations of symptoms exist in the schizophrenia and related psychosis family of mental health diagnoses.
Schizophrenia has both positive and negative symptoms. The symptoms are labelled differently to address and explain the experience of the symptomatic person. To identify which is a negative and which is a positive symptom, differentiate between an added feature to your presentation or an internal sensation or belief at work in your thought process. One example is thought broadcasting. This is a positive symptom in which a person believes his or her own personal thoughts are available to other people seemingly anywhere in the world. It differs from telepathy in that these thoughts are not transmissions per se but a vast web of shared knowledge amongst the people listening or accessing the information being broadcasted.
Without a lot of clinical jargon, this post targets reducing the impact of a specific symptom common to mental health issues: paranoia. Paranoia is disabling. It limits us by cutting off our world and making us feel too uncomfortable to explore and live our lives without fear. There is no reason to live with paranoia. Paranoia is fear, and fear stops us from celebrating every moment of our existence. So, how do we stop it? Eliminate it? The most important place to begin is with assessing what you are afraid of and categorizing it into three domains of fear. The categories include: 1) letting our small critical thoughts snowball into major fears; 2) eclipsing hopes and limiting our future-oriented thinking; 3) combining our fears or apocalyptic projections.
We are critical because we care. We want to manage our lives effectively and precisely. But these small critical thoughts can snowball into major crippling fears that stop us from getting out of bed or being social and making new friends. Why let that happen? Check in with yourself. Self-monitor and find an internal balance with your thoughts. Ever look forward to something? Future-oriented thinking keeps us motivated and happy about time elapsing, or in plain language, experiencing every moment of every day. Paranoia stops us from experiencing our days because we become so pained that we stop and detach; we do anything to stop the internal fear from strangling other aspects of our lives. The worst thing you can do to make paranoia worse is to combine fears. A hurricane is bad news, but flooding due to high winds and high water is even worse. See what I mean? Don’t do it!
First episode psychosis, delusional symptoms, and thought disorders
Delusions put the crazy in madness and mental health disorders. This means, simply, when we think he or she is “out there” and “nuts”, we are referring to the delusional systems within a person’s larger set of symptoms. Delusions carve out the imaginary and marry it with our orientation in various ways that complicate and distort our reality and sense of self. When we say someone is delusional, clinically we mean someone’s ideas and the beliefs they hold about their world are more than just unusual, they are a departure from reality: what is happening internally isn’t congruent with the external world. Usually, with most mental health disorders featuring psychosis, delusions are more abundant than one isolated, disordered thought. Delusional systems are either fixed or solvent. This means that no matter how a person’s recovery progresses and how much the external world changes, the delusion persists. This post targets how delusional systems are born and evolve in the person experiencing an altered realty and what the implications are for practice and treatment.
When a delusional system is born, it isn’t yet complex. In fact, it may be as simple and benign as a newly formed idea or routinely repeated habit executed internally by a person trying to complete their ADL’s or go to school or work. For example, a person might be cleaning wax from their ears when a switch flips in the brain and slowly, seemingly organically, the thought transforms. Suddenly, and conversely over time, the person cleaning the ear is no longer purposefully removing wax, he or she is doing something much different and likely more malignant in design than when the idea was first executed by the brain. In my own experience, when I first experienced the birth of a delusion it was my relationship status with a friend and, ultimately, my marital status. At one moment I knew myself as single, then over time and yet suddenly, I knew of myself as married with a kid on its way, depending on the health of my friend’s womb and a piece of fruit on my windowsill that I connected to the health of her uterus. This is an example of how one distorted thought can evolve into a complex system with both fixed and solvent features.
The manner in which a delusional system forms directly informs how it is to be devolved and taken apart by clinicians treating the person with altered realities. Since delusional systems develop over time and are realized suddenly by the person experiencing the change in their external world, the clinician must identify where and when the “break” or shift occurred and what that meant for the person experiencing the shift in reality. For example, if a person, over time, thinks there is a microchip implanted in his or her brain, the clinician must identify when the break originally occurred for the person and what it means to experience the symptom. This means, similar to performing a math equation, that charting the clinical picture’s distance from the shift in reality in terms of each aspect of their mental status (e.g. time, place, judgement, insight etc.) is the first step in unwinding the delusional system’s content and breaking fixed-thought structures into less toxic and maladjusted patterns.
I’ve experienced this symptom first hand during my final days in the community before I was hospitalized for full onset of first episode psychosis. This symptom is not so much scary as it is confusing and disorienting to experience. I was driving down a major interstate when I first heard my thoughts and believed they were being listened to by friends and family, who were hundreds of miles from me in reality. However, when experiencing the symptom first-hand, I felt as if my family could personally hear my thoughts immediately and without regard to space or time and the even the beginning of their response to my transmission if my imagination or subconscious really had a choice about things. In this sense, voices and delusions collide together to make this feature of psychosis even more difficult to experience without breaking from reality. The break is not a sharp departure in orientation but, rather, noise and interference of thoughts; the addition of these positive symptoms and the space needed to hold on to these overly complex delusional system takes time to process information effectively as it occurs. This is why very psychotic people speak slowly, and their reaction time is longer; there is so much more to process to maintain even basic life functions. So much is happening or not happening in the person’s speech and language centres in the brain that the person experiencing the symptom must sort out the overabundance of stimuli in order to stay connected to the world without getting lost in internal preoccupation.
In order to broadcast thoughts, the person transmitting must be listening. Since thought broadcasting is a symptom and not existent under normal circumstances, the person must acknowledge that it’s happening as it is happening. Thought patterns that are too involved and overly complex are even more diffused and difficult to decipher as either real or a symptom of illness. This is why, as this symptom progresses, people get increasingly lost in internal preoccupation and are unable to come out of their heads per se and spend their time just listening to or even responding to his or her internal thoughts externally or aloud. This is when you typically hear of people responding to their voices. When this happens, it becomes extremely problematic to not attract attention or appear bizarre to others. Since this also occurs late in the progression of the diagnosis, people experiencing the symptom are usually already in the hospital. Without experiencing this symptom, it is hard to believe it can happen to a person. I thought I had extra powers from a government experiment and needed to use them in order to solve the mysteries already at work from a growing delusional system. In my case I was driving. You may be walking the dog. Just be safe in any event and remember safety is first and foremost the goal when you begin experiencing something so otherworldly and yet so personal that it breaks the very conventions of time, space and communication between people subject to physics and human anatomy.
The final night I was hospitalized in the Community Hospital, I heard screaming all night long from my neighbour’s room on the unit. She was carrying on like a child. The screams resembled those of a baby’s cries. I kept pressing the button next to my bed to summon the staff, but nobody arrived until the next morning. Given the sleep deprivation and my compromised mental status, I was delirious at this point. By the time the staff from the unit was in my room addressing the situation, I was feeling so nauseous from the noise all night that I leaned over and vomited on the social worker and lunged towards the psychiatrist for help. I was immediately placed in the Quiet Room to be monitored and assessed for safety every 15 minutes until I was stabilised. About an hour later, the doctor came into my room and advised me that I would be transferred to another hospital and that I would be staying there for a very long time. We all have limitations. Some of them are more visible to the naked eye; others are more covert and hidden away from the public but still an internal struggle we battle every day. As a therapist, I have the opportunity to listen to other practitioners talk about their patients and their ideas on how to help them in their treatment.
Sometimes my head spins from the ideas circulated around the table; hopefully, now it will be clearer to practitioners what treatment fit means in the context of supporting people in their healing with functional impairments. Mania can seem like the best high in the world and must be undersold as an affective state impairment in functioning. Mania is all intoxicating. Mania can make you believe and buy into fantasies of all shapes, sizes and forms. During a manic episode, you can transcend historical points of reference and religious symbolism/iconography prescribed by your belief system and find yourself incorporated into it despite anachronistic markers, which should signal there is a problem with your perception. In this case, mania will, in fact, create a new reality, if only for the moment, and shift your guidance system into a space that will seem like anything is plausible when there is something very wrong with your affective regulation. I have experienced first-hand manic episodes in which I have been awake for weeks at a time without sleeping or need for rest. I have witnessed other people so dysregulated from mania that they would do somersaults across the floors of the psychiatric ward floors just to find out their bodies would later feel the shock of these poorly planned acrobatic theatrics. With certain diagnoses, manic symptoms become more difficult to identify. People carrying diagnoses that include psychotic symptoms should pay even closer attention to their moods because psychosis can worsen with extreme elevations of mood, which then further complicates a person’s insight into and judgment of their symptoms. For most generic mood disorders, extreme euphoria, decreased need for sleep, hyper-sexual arousal, and religious ideation are the usual suspects when manic symptoms present. Should these symptoms activate in a subclinical or mostly unproblematic manner in your life, you may be working with hypomania.
In terms of self-management and self-regulation, there are several options for reducing the harmfulness of a manic episode on your interpersonal life and your capacity to execute activities of daily living without incident. These strategies are dependent on the manner in which mania was activated and how severe your symptoms are. Stimulant and drug-induced mania is just as dangerous as organically driven manic episodes. Considering substance abuse treatment for cases like this will be an important step in managing your symptoms for the long haul. Like most people, even minor stimulant use from caffeine can trigger an episode. Living a chemical free lifestyle isn’t for everyone, but it can provide a baseline, at least temporarily, with which to gauge further consumption of foods and beverages that might trigger an episode. For non-chemically induced episodes, internal and external barometers are essential for knowing your affective state baseline. Listen to your friends and colleagues. Maybe there have been recent complaints about your behaviour. Or maybe you feel like it’s hard to maintain a balanced mood. Begin to create markers in your living environment and for your internal g There will be times when you have to live with unresolved symptoms. However, creating a plan for friends and family will greatly reduce the risk of potential harm from an episode. This means making friends and family aware of your symptoms and triggers so they can help you avoid the ups and downs of mood dysregulation and even help you make decisions if your judgment and insight are too impaired for rational decision making. I send emails to friends and family when I feel like my moods may be impaired or have impaired my decisions or, in the future, might harm others. Preparedness and attention to details are always essential when managing an illness. Surround yourself with supportive people and allies in your recovery. You should never feel embarrassed by your behaviour, but you always need to accept responsibility for it. That’s how recovery works: acknowledging that change is necessary and moving forward in the process of adapting our behaviour until it serves our purposes
Personality disorders, interpersonal distress and identity issues
Previous research suggests that the gathering of “grandiosity and defensiveness” in people typically carrying this diagnosis creates complications for people undergoing treatment with psychotherapy. I am now suggesting a new approach that realizes these so-called symptoms for narcissistic personality disorder (NPD) and understands them as strengths for therapists to capitalize upon for treatment of the disorder. Firstly, it must be said that, by and large, people don’t come in through the therapy office door requesting treatment for their NPD. NPD can contribute to other diagnoses as well as psychosocial and psychological problems for patients to manage on their own without treatment. For example, typically NPD patients present with depression or related anxiety because of various symptoms and unmet needs, which drive these patients into treatment.
Based on this assumption, I would hazard to say that the primary focus of psychotherapy should not be on treating the NPD symptom but, instead, on its manifestation in other psychiatric and psychological problems, such as depression, anxiety, and other affective state regulators which become corrupted when the NPD symptom becomes active. Thus, instead of reinventing the wheel in psychotherapy, practitioners can focus on treating the real problem with the same sophistication as any other disorder that fits the treatment approach. This can be done in group therapy, which has proven to be helpful for clients to gain the reflective lens necessary to cultivate personal insight into their interpersonal landscapes. With the exception of “lacking empathy”, most, if not all, of the so-called indicators for NPD can be mobilized into strengths for consumers of NPD treatment. I will use the example of grandiosity and requiring excessive admiration from others to illustrate how this “deficit” can be flipped into a strength, even an asset, to the person carrying this label.
In a previous article, I talked about a concept I term “Too Big to Fail”. In short, this means it is in the interest of people carrying a diagnosis to mobilize all of their resources and support to meet their day-to-day challenges and reduce the likelihood of their opportunities coming up short of their expectations and hopes. Simply put, there is never a reason not to be fully prepared for the day’s endeavours and to be ready for anything. In a world where the unlikely is possible and there is no definite, I can fully understand why people carrying this diagnosis are labelled as grandiose, when it is really about being mindful and articulate about your needs as a consumer and what it will take for you to be successful in life. Finally, it is not the therapist’s role to teach empathy unless that is the stuck point in the work that is keeping someone from realizing a missed opportunity for insight. Empathy, however, can be reframed and posited as a skill or technique for people to learn in psychotherapy to barter for their own goals without walking over the needs of others in his or her life. Through bartering, people carrying this diagnosis will be less inclined to feel envious because they are participating in a system that leaves room for greater currency and a greater exchange of ideas. Instead of placing limitations and teaching restraint, people with this diagnosis are taught to reach for the upper limits of their personal success.
The intersectionality of functionality and ableism within mental health
Depending on the functional impairment or limitation in completing self-directed tasks to maintain a standard of living and quality of life, certain practitioners put together plans to address the interfering symptoms. I am suggesting that, depending on the goals of the individual, the interfering symptoms should not be the focus of treatment in people carrying a diagnosis; instead, we need to be focusing on strengthening the weak points in functioning, regardless of the particular symptoms blocking the person’s ability to maintain their desired quality of living. Interfering or unresolved symptoms can be treated, but they certainly should not be the focus of treatment. Some people never experience relief from their symptoms due to extreme chronicity and untreatable impairments. Not every symptom is rooted in a diagnosis. Sometimes, flaws in our personalities govern the expression of our limitations. We need to refocus treatment to target and identify the weak points in a person’s functioning, whatever the symptoms are that block abilities and create impairments. I have seen first-hand clinicians and peers dwelling on unresolved and chronic symptoms as if strengthening a person’s weaknesses in functioning wouldn’t help them move forward in their healing.
Let’s be completely honest about healing. We can address our impairments, but sometimes the wounds don’t close and the scars don’t fade. They need daily, ongoing care. Like the emphysema patient on oxygen, sometimes daily maintenance and care is the only way to keep moving on in your healing and recovery. Being honest with yourself about your mental and physical status will go much further than waiting for the miracle cure or, even worse, ignoring the problem because it’s unmanageable. Well, if good health means healing, then feeling better will require us to have better self-management skills, moving forward. It isn’t the problem that is the important thing to always focus on resolving, it’s the solution. Accepting the solution for what it’s worth will require you to always sharpen your self-management skills to live the quality of life you want and choose for yourself. I have always been a guru when it comes to relaxation and recreation. It seems to be a special talent of mine to be able to find nothing to do when the world was lighting up with opportunities for me to insert myself and begin, when all I really was interested in doing was sitting down to a glass of iced tea and the newspaper. I’m sure my co-workers can vouch for this personal phenomenon and would endorse me for this do-nothing talent.
Ultimately, however, doing nothing is often what is required of people to remain goal-oriented and engaged in their lives. Conversely, sometimes a situation calls upon people to “right the ship” and be more authoritative and directive in their approach to self-managing their lives and particular situations. I suggest starting here to locate your internal barometer. This is a little more involved then tuning into your gut and doing what feels right. During a looming personal crisis, tuning in to your feelings is only the beginning. If a situation needs fixing, it should capture more than just your feelings on the subject. There should be some ethical or, at the very least, problem of energy flow, and the mechanics involved to complete the task should be jeopardized or require retooling for future projects. My point is, your “feeling” world and your “rationality” need to be interlinked if you are to truly tune into your moment and decipher or filter out a better way ahead. This is true for most situations, not just work projects or tasks you are involved with that require your attention and focus to complete without incident. Therefore, when managing agitation, be prepared to look at your entire situation before coming up with a new plan.