July 17, 2011

Marsha Linehan

Renowned American psychologist and researcher Marsha Linehan recently acknowledged that she struggled with borderline personality disorder--a notoriously treatment-resistant disorder characterized by dysfunctional interpersonal relationships, emotional instability, and self-harming or suicidal behaviour--in her adolescence and early adulthood. This is big news: it's not every day that a senior and distinguished psychologist reveals that she suffered from a severe mental illness, particularly one that is as heavy with stigma as is BPD. The story is all the more interesting because researching and treating borderline personality is Dr. Linehan's life work.

According to the New York Times article, as a self-destructive and chronically suicidal teenager, Linehan was hospitalized for symptoms that would meet the current DSM criteria for BPD. Diagnosed instead with schizophrenia, Linehan was treated with Freudian analysis, seclusion, antipsychotics, and electroshock therapy. When she was discharged from the hospital at age 20, the doctors gave Linehan little chance of surviving.

Subsequent to a quasi-religious experience in her 20s, Linehan discovered and embraced the concept of radical acceptance. Radical acceptance is a Buddhist concept that means accepting on a deep level, without judgment. According to Linehan, she stopped feeling suicidal and began to love herself when she stopped focusing on the gulf between the person she wanted to be and the person she was. Linehan went on to study psychology and used the concept of radical acceptance to form the foundation of Dialectical Behaviour Therapy, an effective treatment for BPD. Based on the opposing principles of acceptance and the need to change, DBT succeeded where other treatments for BPD failed.

No matter how you feel about religious epiphanies, Linehan's public exposure of her past is significant. First, her admission offers the hope of a meaningful and fulfilling life to individuals with BPD and other serious mental illnesses. Second, Linehan is lending a famous face to mental illness (à la Margaret Trudeau), showing the public that mental health problems aren't just something that happens to people in movies, psychiatric hospitals, and homeless shelters. Third, that Dr. Linehan's experience suffering from BPD informed the development of one of the first empirically-validated treatments for the disorder collapses the usual divide between the world of academic research and the patients who benefit from the research.

Finally, Dr. Linehan's disclosure demonstrates significant courage. BPD is a diagnosis given primarily to women, and is burdened with more stigma and stereotypes than perhaps any other psychiatric disorder. By admitting to BPD, Linehan has made herself vulnerable to skepticism, sexism, and invalidation. However, I expect that in this case, the disclosure will only more firmly entrench Dr. Linehan as a valued pioneer and significant contributor in the field of psychology.

July 14, 2011

Criteria Controversy

How do you know if a given behaviour or group of symptoms constitutes a psychiatric or psychological disorder? This is an important question, and particularly relevant right now as psychiatrists work on the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), to be published in 2013.

Proposed additions to the DSM like Internet Addiction and Premenstrual Dysphoric Disorder (PMDD) are raising the ire of DSM critics who argue that the manual medicalizes and pathologizes normal behaviour. While this criticism is valid and worthy of discussion, people making this argument have the frustrating habit of selecting one symptom from the list of DSM criteria for a given disorder and using it to claim that the criteria describe normal behaviour. The most recent person to do so is Ian Brown of the Globe & Mail. In his article, Brown gives the example of one criterion for the proposed DSM-V diagnosis of compulsive hoarding: "Persistent difficult discarding or parting with possessions, regardless of the value others may attribute to those possessions."

According to Brown, this symptom describes "anyone with a basement." Such is the problem of selecting and criticizing a diagnostic criterion in isolation. Anyone wishing to make a similarly unsophisticated argument could choose "Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances" from the proposed criteria for binge eating disorder (BED) or "Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection) prior to most menstrual cycles" from the proposed criteria for PMDD. They could argue that they often overeat at dinner parties and experience mood swings before they menstruate and that the inclusion of BED and PMDD in DSM-V would unfairly pathologize their behaviour.

This argument fails to acknowledge a) the other diagnostic criteria for the respective disorders and, importantly, b) the additional criterion of significant distress. The diagnostic criteria for most of the DSM disorders include "Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." This is a key criterion: If you have a basement full of junk, but it's not bothering you or anyone else (and not causing a health or safety risk), no one is going to accuse you of being a compulsive hoarder. If you overeat at dinner parties and binge on chips during the Superbowl, but it doesn't cause you lasting distress (or health problems), no one is going to label you with binge eating disorder. Writers like Brown are advised to keep the distress criterion in mind--as well as the entirety of the criteria for a given disorder--when they're fretting about the pathologizing of normal behaviour.

NB: My endorsement of the significant distress criterion is not a defense of the singular use of the DSM to decide what is and isn't a clinical problem. If your symptoms or behaviour don't cause you distress or impairment, you probably don't have a clinical problem. But: if you experience significant distress or impairment despite having only minor symptoms, it's still a problem. That is, if you binge eat only four times per year at holidays or only experience mood swings every third time you menstruate--but it causes you significant distress or impairment--ignore the doctor telling you your symptoms are subclinical according to the DSM, and seek help elsewhere. Distress is distress.

July 05, 2011

Emotions About Emotions

Mental health tip: Don't have emotions about your emotions.

Psychologists differentiate between primary or "clean" emotions and secondary or "dirty" emotions. The first are the emotions you feel in direct reaction to what's going on. You feel sad because your cat died, or jealous because your colleague got the job you wanted, or lonely because you're alone. Secondary or "dirty" emotions are the ones you feel in reaction to your primary emotions. You feel guilty that you're sad about your cat when your friend's brother just died, or ashamed that you're jealous of your colleague's new job instead of happy for her, or embarrassed that you're not good at spending time alone.

Secondary emotions indicate a struggle against or judgment of the initial emotion. They are the direct result of thinking I shouldn't feel this way. This reaction is common; one major culprit is the widespread belief that happiness or contentedness is the norm, and that strong or negative emotions are bad or abnormal or harmful and should be avoided at all costs. Despite ample evidence to the contrary, many of us believe that happiness is the normal baseline, and use this belief to berate ourselves for feeling bad.

The idea of happiness as normal is being challenged by a relatively new therapeutic approach called Acceptance and Commitment Therapy (ACT). ACT is based on, among other things, acceptance of difficult emotions, thoughts, and impulses. A primary objective of ACT is to use mindfulness to accept difficult or negative experiences (emotional or other) as normal, and to let go of the struggle to be free of them.

If you're thinking "Isn't this kind of incongruent with CBT, where you're supposed to identify the distorted thought that created the negative emotion and adjust the thought so you can get rid of the emotion?" the answer is yes. This is a critical debate between CBT and ACT. Proponents of ACT think that CBT is too focused on changing or getting rid of negative emotions, promoting the idea that pain, anger, and anxiety (among other emotions) are bad or abnormal.

I believe in both. If your unpleasant emotion is the result of a distorted thought, then by all means: identify the distortion, modify the thought, and enjoy the accompanying shift in feeling. However, if you're experiencing a primary emotion in reaction to something that's really happening, consider that strong negative emotions are normal and part of what makes you human. Try saying to yourself "I should feel this way. Given what's going on, of course I feel this way." Give yourself a break and don't pile on that unnecessary second round of judging emotions.

NB: The examples above of primary or clean emotions are not the only acceptable ones. If you feel relieved that your cat died or angry because you're lonely, that's okay too! When we feel less intuitive emotions, that's when we're even more likely to start layering secondary emotions, and probably when it's most important not to.