Monday, October 21, 2019

#18 Underground DSM-IV - Full Version

Reprinted a few times over the years.  I didn't update it much this time.

Further slight editing 10/31/11.
Addition 11/22/16, next paragraph, and then far below

Someone at work requested that I print out the whole thing in 2011, and I have had a recent request to reprint this.  It is ten years old now.  I have edited it, primarily by removing some sentences I no longer think are that defensible.   The following is a collection of empirical observations about people with various diagnoses.  Some are a bit unfair, and I plan to attend to that when I improve it and add pieces to it.  Soon, I hope. 

Uses the phrase: “Head games”= Borderline PD
“Deep” depression Dependent Personality, or less often, Borderline or Histrionic.
  (“very, very” is also a bad sign. I spoke with a woman yesterday who used three "very's" a half-dozen times while describing her history. Her children are very, very, very, important to her.  Except operationally they aren't.) It is a bad sign in everyday conversation, also.  A close relative once posted on Facebook about some political cause that is largely a pose for him "This issue is very, very important to me."  I want to say "I'm sure you mean that it is very, very, very important to you."  But I didn't. As with the truth discussion below, too many intensifiers is a bad sign.

“…died in my arms.” = Antisocial Personality Disorder.   It’s amazing how often this is claimed, and how seldom it is true. Of political note: Jesse Jackson claims that MLK died in his arms.   He didn’t. So now we know Jesse’s diagnosis.
The wife or mother of the violent sociopath who says “I just want him to get help” is going to take him back (See “I need therapy,” next.)
“I need (undefined) therapy.” Means I feel bad and think I will feel better if other people listen to me endlessly. Our other offerings, including group therapy, DBT, skill-building, IMR, etc won’t be considered real therapy.  Real therapy might mean no homework and a person of the opposite sex to say “there, there.”    But even short of that, it means other people will just listen. Variations include “I haven’t gotten any therapy here.”

Identifying “low self-esteem” as your problem means you want someone else to fix it. Self-esteem (in the popular sense, not the older, precise sense) is entirely subjective.  Self-respect is based on actions. Seeking self-esteem is seeking to feel better without doing anything, and does you no good.   But no matter how far down you go, you can always do something to increase your self-respect. I think of that when public figures have screwed up. One can usually tell pretty quickly quickly whether they are protecting self-esteem or self-respect.

If you take an antisocial male on a ride near his home community he will keep claiming to see people that he knows, or their trucks or motorcycles. (“That’s Tiny’s Harley!”)

Not original to me:  Tattooing L-O-V-E on one fist and H-A-T-E on the other is a type of intimidation that Antisocial Personality Disorders are fond of.  It's your fault if they have to hit you, y'see, because they are basically peace-loving people who aren't looking for a fight.

When a patient claims that the hospital doesn’t know him, and therefore has no right or foundation for evaluating him, he means that the objective evidence should be ignored in favor of his rationalizations.  "That doctor only spent five minutes with me."  Dude, I had 90% made up my mind just reading the first page of your chart.

 Related:  To a person with Borderline Personality Disorder “No one is listening to me,” means “no one is agreeing with me.” This has been remarkably durable over my career.  The idea seems to be "If you were really listening to me you couldn't possibly disagree."  Countering with the statement "I hear what you are saying, but I don't agree with it" can actually provoke assaultive rage.  It must come near the core of problem.

 Pts. referring to length of time they have been in hospital as an argument for privileges or discharge means they still don’t get it. Similarly, arguing "But it's my daughter's birthday party this Saturday" or "I'm supposed to be at work today.  I could lose my job," mean much less after a suicide attempt.  What was your daughter going to do if you were dead? These are, sickeningly, often followed by "My children are everything to me."  Your actions say the opposite is true. But if that ever sinks in, you probably will commit suicide, so I don't say it out loud.

Gazing intently slightly upward -- choosing among several things to say (Lots of people do this.)
 The further up the gaze, the more possible responses - usually not a healthy sign.
Gazing at ceiling: = Choosing among a multitude of things to say, i.e. lying.
Turning back to interviewer, spinning in chair:  Antisocial PD

Commenting that there are a lot of people in the interview room.   = Borderline PD.
(Thinking it or acknowledging it doesn’t count. Anyone might do that.) I don't know why.  There may be something around the insecurity of managing so many emotional dyads.

Shaking hands with more than one person = manic.   More handshakes, more mania. Today I had someone who wanted to high-5 everyone in the room.

Substance Rehab excuses:
Meatloaf version: I would do anything for rehab (said Monday), but I won’t do that (said Tuesday.)
Goldilocks version: That Rehab is too far. That Rehab is too near. No rehab is just right.
 Wearing clothing with beer logos to your rehab interview suggests you aren’t serious.

Chronic pain really can make you look like a Borderline or Dependent Personality.  It’s harder than it looks.  Mania can also make you look like an antisocial.  Be slow on the blaming attitude with these.

Paranoids have an uncanny ability to make their worst fears come true.   Eventually, everyone is watching them.
Borderlines seeking cool alternative diagnoses have an uncanny ability to locate the only private therapists who can’t help them.
Manipulating staff or lying is a high-level skill indicating significant organization and readiness for discharge. Sicker patients try to manipulate staff but do it poorly. To the complaint “but she’s just telling you what you want to hear,” my response is “I’ve got a caseload full of people who would love to tell me what I want to hear, but can’t.”

Some staff consider that a patient enjoying anything is a bad sign. “She likes it here,” is synonymous with “she’s not sick, she’s malingering.”
People who have a “problem with women,” or “problem with men,” reveal behaviorally in about 24 hours that they don’t do well with the other sex either.   Ditto for “problems with authority:” those folks tend to also show “difficulty working independently” and “difficulty sharing responsibility.” What’s left?

Rescuing women often accept the reasoning from the violent men in their lives that those just need to “get their anger out" somehow.  Actually, these guys get their anger out just fine. It’s keeping it in we want them to work on. This seems terribly unhealthy to both the violent male and his rescuing female, who are puzzled that mental health professionals do not understand this very obvious psychological need to get anger out.   This particular bit of faulty reasoning is often paired with needing “therapy,” as above. No one understands them, it seems. (I hear this less now than I did early in my career.)

What I call Oppositional Treatment Design is remarkably accurate.  If you want to sleep, we want you to get up.  If you want to be up, we want you to sleep.  If you want meds, you probably shouldn’t have them, but if you don’t want them they are likely to be exactly what you need.  If you want to leave, we make you stay.  If you want to stay, we make you leave.  If you’re blaming yourself, you should stop that.  If you’re blaming others, you should start blaming yourself.  It’s not as stupid or mean as it sounds.  People usually come to the hospital because of a particular point of contention with the usual flow of life.  That inability or refusal to change is usually the central difficulty getting along in the world.  The patient will usually hand you the opening, though it’s wiser to use a Colombo indirect approach than a direct confrontation. “People say I’m getting manic, but they just don’t understand that I have a lot of energy.”  That may sometimes be true for folks getting along in life, going to work, paying bills.  Involuntary arrival at a psychiatric hospital is usually an indication that something has gone wrong, however.

The content of paranoia is often a function of what is floating about in the air at the time of the first breaks.  In the early 70’s it was the CIA.  During the era of the Godfather movies it was the mafia. Radio waves were big for a while.  Now it’s computers or satellites, and implanted chips are going to have a strong run this decade. Plus, there's always the old reliable "drug dealers are after me because I told the cops that Bennett and Preston are using drugs."  Dude, the cops know all about Bennett and Preston, it's proving it that's the problem.  People of religious leanings might have demonic or angelic interpretations to their voices.    Movies may figure prominently.   Trying to tease out other meanings provides lots of exercise for ego-analytic psychologists, but no objective help to the patient.
If one staff member moves to rescue a patient with Borderline Personality Disorder, someone else will lean toward punishment to an equal degree. “You’re giving her everything that she wants!”  In large groups the mathematics of balance is more complicated but the principle is the same: the group will balance its negative feelings.  Moving to the extremes just increases splitting: shift wars, team vs. line staff, community vs. hospital.  The longer the staff discussion is going on, the more likely it is that this patient has Cluster B traits.  Everyone wants the last word on those.

The Rorschach protocol measures the psychologist’s ability to consider alternative diagnoses.

The closer you are to the situation, the more you are convinced the other person is being bad on purpose.  The more distance you have, the more you are convinced that non-elective forces are driving the behavior.  Both are inaccurate. Choices are always mixed, driven by both will and external factors. This is not patient-nature, this is human-nature.
If it’s Friday afternoon and it’s a crisis, there’s a personality disorder behind it.  But 50-50 it’s a staff member who’s got the Cluster B traits that is sucking the fluoride out of your teeth.
You can’t reach much of anyone on a Friday afternoon, but those you do reach are usually pretty competent. The others left them in charge and snuck out the back way.
Punching the wall is not something to be congratulated for just because you wanted to hit a person instead. You are still rehearsing violence. In fact, you are ably demonstrating how unconcerned you are with your own pain, so long as you get to show how angry you are.  It’s an intimidation tactic.

Multiple personalities usually add up to less than one.

New social workers want to intervene in everything at once: couples counseling, substance rehab, going on disability, finding a self-help group, etc. This is the human services equivalent of invading not only Afghanistan and Iraq, but North Korea, China, France, Mexico, and the Maldive Islands, all at once. Addendum: If you suggest this to social workers, they won’t understand the analogy, noting irrelevantly that they were against going into Iraq.   Note:  This is changing.  I am noticing a trend of social work interns wanting to change the agency, and its institutional racism and sexism.

Psychiatrist: Can you tell me something about what brought you to the hospital?

Patient: I wrote it down last night and want to read it to you. ( It's three pages long. And this goes triply if it's a poem.)

Diagnosis: Borderline Personality Disorder. (Though Narcissistic might be a go.)

Naming your daughter after an alcoholic beverage is a bad sign (Brandy, Margarita, Champagne, Martini).   Exception for Margarita if you are from a culture where the name is historically common.
In every generation there seem to be given names of children associated with a much higher proportion of pathology.   No recent DCYF worker will be naming her own daughter Crystal, for example. (Crystal is now passe.)  The mechanism for this is opaque to me.  Most Justins and Jasons are just regular people of course, but somehow an enormous number of pathological mothers decided that those were the best names for their sons.  This annoys the hell out of the regular Crystals, Justins, and Jasons, who usually sense that they share their name with a lot of delinquents pretty early.  Just ask them.  The delinquents themselves never pick up on it – it’s always a surprise. “Krystl, that is like so amazing!  My boyfriend last summer was like Justin, too, and he had to go to rehab too!” Amber, Brandon, and Sean were problem names earlier. (Update: Sean not so much now.)   Cheyenne and Dakota may be on the rise. (Update: I was right.) Raven. Cody.

People who work at developmental agencies are concrete and fearful of change, like their clients.  We don’t know who gets it from whom.

Seeking guardianship is a measure of staff frustration.

If an experienced social worker has arranged a placement with only a small window of availability, the patient automatically becomes clinically ready to go, and you’d damn well better agree.
Otherwise, the SW will bite your head off the next time you ask about discharging someone.
When line staff says, “He needs to be discharged,” they mean “I’m sick of him.”

When psychiatrists are finished with med changes, they conclude the patient is at baseline, independent of any data.

When anything changes, the psychologist will find a way to interpret it as progress.

The difficulty with being a MHW (psych tech) is the social and emotional battering they receive from both patients and ungrateful staff. Stress reduction classes make this worse. Encouragement might work, but no one’s ever tried it.

Intense borderlines tend to live near the hospital and interact with each other. When any one of them dies, or especially if one commits suicide, several others will have short memorial admissions to the hospital. I no longer think this is a bad thing. 

When a patient challenges your credentials, no credentials will be good enough. There will always be something you lack. “Oh, so you’re not a psychonutritionist.” I have come to understand that this applies to everyone, not just psychiatric patients and their families.  When someone challenges or asks for your credentials, their only intent is to tear them down. This may be strongest in the social sciences, where credentials can be kinda fuzzy and science not well-regarded to begin with.   I have found that this is true of everyone, not just psychiatric patients and the       

When a patient – and some providers – claims a “right to be angry,” there will be a sudden shift in the meaning of ordinary words. That one is entitled to ones own feelings and opinions will be made to equal “I am justified yelling at people. Or worse”

Bonus international political comment. France is a glamorous borderline personality disorder – the cause?  An abusive incestuous relationship with Germany.  Much of European politics suddenly becomes clear if you keep this in mind.  The rescuing Americans are the bad parent who didn’t rescue enough, and so get blamed more than the perpetrator, who she has now gone back to live with.

Russia tends to paranoid personality disorder, and about half of the Arab nations are narcissistic personality disorders. Societies which oppress women tend to raise entire generations of narcissistic males. It is not a healthy thing for a boy to pass his mother in cultural status, for nothing that he has earned, when he is still a complete twerp.

11/22/16 Bethany thinks it should be a whole book.  But really, I don't think I've got much more material.  However I have things to add today, and maybe I should just keep adding that into the larger post.

When someone says anything about honesty -
Can I be honest?
Not gonna lie
I'm just being honest
I truly think
I'm not sh---- you here
I really, really want
 - they usually mean something else.  Sometimes they mean candor, or bluntness.  Sometimes it's a feeling that they have no supporting evidence for. Sometimes they are saying true things, but leaving out other information that is important.  Sometimes it's just lying.  People who are speaking the truth generally don't reference "hey, did I mention that this is the truth?" They certainly don't make repeated references to how truthful and honest they are being.  In a side note, any political or religious organisation that uses the word "truth" in its name should be watched with the closest scrutiny.

This may be connected to the Biblical admonition of "Let your yea be yea and your nay be nay." (James)

Perhaps relatedly, many statements in mental health bureaucracies don't mean what their content would suggest, and I suspect there are parallels in your industry as well.  "I just want what's best for the patient," or "Look, we all want what's best for the patient here" usually means "Let's do what's best for my agency," or even, horribly, "we don't want to put in much effort to fix this and you're stuck with him, so we don't much mind if the patient is not being served."

Oh, oh, that reminds me.  When the hospital is discharging a patient over the objections of the family*- and this is often a risky proposition that we are wincing at and crossing our fingers over - I breathe a sigh of relief when someone shouts into my phone "If you discharge him today, I guarantee you he will be dead before midnight."  Whew.  So this is just a family that postures in overdramatic fashion, and the patient is cut from the same cloth, so their cat-and-mouse about suicide is mere drama. Good to know. The few actual suicides usually take us more by surprise.

And speaking of suicide, remember that there is a suicide rate for people leaving banks, people leaving schools, people leaving work, and people leaving hotels. The suicide rate for people leaving psychiatric hospitals over the next 30 days is only marginally higher.  It's just that ours make the newspapers and people think we should have done...something.

*this happens all the time and often really does suck for the family, who are up against it and have legitimate gripes, and a hospital is at least a safe and treatment-oriented environment for their brother, daughter, whatever. It's brutal to have a mental illness, and sometimes it's brutal to even be close to it.


Dubbahdee said...

Wow. So much ground to plow. So little time. It took me a bit to figure out many of the acronyms. A few still escape me. BPAD?
My three favorites
Self-esteem vs. Self Respect - You nailed this one in an especially succinct and articulate way. I have nothing to add. I just want to say yeah.
Keeping In Anger - it strikes me that modern pop psych views anger rather in the same way that catholics seem to view sin. It is rather like a substance that must be purged. Protestants view sin in one of several ways. (1.As a legal state which God removes through some sort of shuffling of the cosmic beaureaucracy: Jesus pays the fine and you're free to go with a new suit and 20 bucks in your pocket. 2)A spiritual/mental Illness to be cured by the Great Psychiatrist. 3)Bad choices or bad judgement that makes God sad.) In the catholic view sin is like a sticky nasty smelly gunk that must be burned away through suffering. It has a tendency to keep accruing and if you don't keep up on it through regular service calls, it'll totally clog your spirit. Pop psych view of anger seems similar except that it's not about removing the gunk. It's about releasing the pressure. The concept self discipline, of forgiveness, of a robust (as opposed to brittle or overly sensitive) ego is generally overlooked. I see the theme of personal responsibility running through your whole post, and this is perhaps the best example of it.

Names -- are you familiar with "News of the Weird?" Chuck Shepherd makes a fascinating anecdotal correlation between criminal tendencies and the name Wayne. Observe this quote from the NOTW website:
...escaped murderer Michael Wayne Thompson was recaptured in July near Farmersburg, Ind. And a few days later, Danny Wayne Owens, 38, was arrested in Birmingham, Ala., for allegedly murdering a neighbor. (Among other prominent middle-name Waynes: serial killers John Wayne Gacy of Illinois and Elmer Wayne Henley of Texas; recently executed Arizona murderer Jimmy Wayne Jeffers; sadistic Louisiana murderer Robert Wayne Sawyer; the Ohio Aryan Nations member caught last year with freeze-dried bubonic plague bacteria, Larry Wayne Harris; the Oklahoma rapist recently sentenced to 21,000 years in prison, Allan Wayne McLaurin; and of course John Wayne Bobbitt.)

Assistant Village Idiot said...

Bipolar Affective Disorder. What used to be called Manic-Depressive.

Woody said...

When I'm getting information to prepare someone's tax return and I ask them how many miles they drove for business, it's amazing how many times the answer is on the ceiling, because that's where they look before they respond.

Assistant Village Idiot said...

Remember that the lie-scale is a function of height. Looking up slightly is zoning out to choose between two possibilities. A little higher, three possibilities. The ceiling = a world of possibilities.

Anonymous said...

AVI, I've seen this post up and haven't had time until this morning to read it all. This sentence really hit home: "Wearing clothing with beer logos to your rehab interview suggests you aren’t serious." Lets add to that individuals who interview for a position in a substance abuse rehab facility coming to the interview in said shirt. Four or five in the last year alone and they really do not understand why thier interview didn't go well. GREAT post my friend.

RichardJohnson said...

AVI hits the nail on the head. Dale clavo,as they say. His cynicism, perhaps better called realism based on observation after observation year after year, has enabled him to last 4 decades in a tough profession.

While I was an undergrad, I worked a year as an aide in a psych hospital. When I woke up one morning and realized I didn't want to go to work- the first time I had ever felt like that- I concluded it was time to quit and handed in my two weeks' notice. Several years later, a peer interviewed at the same hospital for an aide job, seeing the job as a possible intro into a career of social work. The nurse who interviewed him told him that most aides quit after a year, thinking they are going crazy.

I knew a SDS member in college who was a Lenin-worshiper. With such a viewpoint, she could have been cannon fodder for the Weathermen/Weatherperson. Instead, she stepped back from the abyss and took her Psych degree to work as an aide in a state-run psych hospital for 5 years. She later got her Ph.D. and went into politics, turning into a tax-and-spend and lets-take-a-picture-of-me-with-a-pol-higher-up-in-the-food-chain sort of Democrat. Which is at least least better than being a Weatherman/Weatherperson.

In dealing with psych patients is difficult to determine what can and can't be done. Some realism- or cynicism- is needed. AVI's line about the social worker's plans that were like simultaneously invading 5 countries was spot-on.

AVI is to be congratulated for having the forbearance to last 40 years in a tough job.

RichardJohnson said...

The difficulty with being a MHW (psych tech) is the social and emotional battering they receive from both patients and ungrateful staff. Stress reduction classes make this worse. Encouragement might work, but no one’s ever tried it.

Agreed. The most salient memory I had of staff training sessions was that they got cancelled. The most useful training I got was the set of instructions one psychiatrist gave for writing up patient notes.
1)What did you observe?
2)What were the dynamics behind what you observed?
3)Intervention: What did you do?

This set of instructions was also useful in deciding how to respond to patients. Ironic that instructions on what to write on patients would also assist in how to deal with patients, but it worked.

When I started the job, I was an Aide. Some 6 months into the job, I became a Mental Health Worker.

What killed my liking for the job was getting transferred to first shift. When I worked second shift, my primary function was talkmate to patients. On first shift, I became a cop, enforcing the directives of all professional staff, most of whom weren't around on second shift.

While the pay wasn't good, my view now is that I had one of the most interesting jobs available for that pay scale.

The job experience had an influence on my political views. As this was a private psych hospital, we dealt constantly with insurance companies, which left me with the impression that in the psych field there were finite funds for infinite needs. I concluded the same was true for government.

I also became aware that while staff had all these plans for patients, the plans didn't necessarily work. Some of this was due to poor plans or incompetent staff, but much of this came from dealing with what are probably intractable problems. In any event, I was left with the impression that regardless of responsibility, having a plan for spending money didn't necessarily mean that the plan would succeed.

The psych hospital experience left me with a very skeptical view towards bigger-government types who would claim that with more government funding, they had Program A that could solve Problem B. You do? Tell me another one.

Sam L. said...

RJ said above. "...having a plan for spending money didn't necessarily mean that the plan would succeed." But I'll bet the money got spent.

AVI, I nominate this for the most interesting post of the internet's day, and I wonder how you've stayed sober and coherent. Clearly, a man among clear-headed men!
Someone may yet nominate you for addition to the first step toward sainthood. Not being Catholic, I'm disqualified.

Texan99 said...

Brilliant stuff. I confess after all these years I still don't know what's meant by "borderline personality." It seems to refer to what I think of as "flaky" or "easily knocked off balance." I'm off to look up "Cluster B" now.

jaed said...

The first step in sainthood is to be declared "Venerable", which may fit (and I like the phrase "The Venerable Assistant Village Idiot")... but unfortunately the candidate has to be dead first. ;-)

Assistant Village Idiot said...

From AVI's wife presently in Alaska. This is brilliant. Dubbadee The news of the weird is in the Hippo and I have read it for years. I was rather upset when a friend's daughter was using Wayne as a middle name. I tried to dissuade her and my friend didn't appreciate my advice. I don't know what cluster B is either.

Texan99 said...

I looked it up: a combination of borderline, antisocial, histrionic, and narcissistic personality disorders, in other words, weapons-grade flaky and irritating.

herfsi said...

as a fellow mental health worker - what you wrote should be the Intro to the DSM-V (& you should the be paid royalties:)

a lot of personality disorders begin statements with "get this!" & end them with "think about that!"

along those lines, i am currently light-reading "jesse venture's marijuana manifesto" (yes, his name is part of the title:) & god bless him - those 2 statements are in there a lot! yikes:) ah well, that one's an easy call. at least he's a very likable character!

lelia said...

Wow. Fascinating.
And about the name thing: DARN IT! We renamed our adoptive daughter Krystal to Amber Rose, because it was pretty and we had never heard of anybody with that name. A few months ago our daughter told us she sometimes gets hassled because some famous strip pole dancer is named Amber Rose. You can't win.

Jonathan said...

Great stuff, AVI.

Related: To a person with Borderline Personality Disorder “No one is listening to me,” means “no one is agreeing with me.”

Corollary: "I hear you", when used as a response in an argument, means "I'm not listening, because I don't agree with you".

Gazing intently slightly upward -- choosing among several things to say (Lots of people do this.)

This might also mean: choosing among several things to say, in order to spare the other person's feelings.

If it’s Friday afternoon and it’s a crisis, there’s a personality disorder behind it.

Also true in many business situations.

When someone challenges or asks for your credentials, their only intent is to tear them down.

Also often true in business.

Retriever said...

Just what I needed this after a day being told what to do by someone with a son named Justin...Loved the French borderline in international politics....(despite having some French ancestry, and loving France and the French...)_

Tom Bridgeland said...

When Psych can't justify discharge but wants to be temporarily shut of a patient...document a heart rate > 100, voila! Tachycardia and a few days on the Cardiac Telemetry floor is medically justified.
We see this once in a while. Our Psych unit is small and overwhelmed.