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My Chaos Narrative

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This is a 100,000 word, 200 page, longitudinal, retrospective and prospective account of my experience with bipolar disorder and some other mental health problems over 70 years: from October 1943 to October 2013. This account is a personal, clinical, and idiosyncratic study of what some life-study students call a chaos narrative. This study focuses on an aspect of my life involving several mental health issues, but mainly bipolar 1 disorder. This account is now in its 13th edition. In my retirement, the years from 2001 to 2013, I have revised the account each year up-dating the content (i) as new information about the mental health issues I deal with are added to the science, and (ii) as I continue to deal with these mental health issues as I head to the age of 70 in 2014.

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My Chaos Narrative

  1. 1. QUEUE UPLOAD ADMIN LOGOUT . . Home Search author Search title Journals Browse language New Popular Site map . . . >> Essays and poetry by Ron Price About this document (click for more) edit q·edit archived diff Abstract: This is a 95,000 word (160 page font-12 or 200 page font-14) longitudinal, retrospective and prospective account of my experience with bipolar disorder and some other mental health problems over 70 years: from October 1943 to October 2013. Notes: This is a personal, clinical, and idiosyncratic study of what some life-study students call a chaos narrative. This study focuses on an aspect of my life involving several mental health issues,mainly bipolar 1 disorder. This account is now in its 13th edition. In my retirement, the years from 2001 to 2013, I have revised the account each year. See also bahai- library.com/price_pioneering_four_epochs. Account of 69 Years of My Experience With Bipolar Disorder: A Personal-Clinical Study of A Chaos Narrative by Ron Price original written in English. FOREWORD This is a 95,000 word(160 page, font-12; 200 page, font-14) longitudinal, retrospective and prospective account of my experience with bipolar disorder, as well as several other mental health problems over 70 years: from October 1943 to October 2013. This is a personal, clinical, and idiosyncratic study of what some life-study students call a chaos narrative. This study focuses on an aspect of my life involving several mental health issues, but mainly bipolar 1 disorder. This account is now in the 1st draft of its 13th edition. In my retirement, beginning in the first year of the 3rd millennium, that is 2001, .
  2. 2. I have revised the account each year to:(i) add the changes in my medications and life experience, and (ii) update the information base over the 70 years as information about BPD became available in cyberspace. This account aims to be as clinical as possible. It is not written as a narrative with episodes to keep readers wanting to read more, like a novel. It is not written to be an interesting, highly personal account, for publishers to market and achieve a big readership. It is, as I say above, clinical, medical, longitudinal and, for most readers, not a story to keep readers on the edge of their seats. It is written to be of help to those with an interest in this particular mental health problem, bi-polar disorder, and it is written to provide a life-narrative, one person's life experience of 70 years dealing with its manifestations in his life. PREAMBLE Part 1: The many manifestations of mental health problems like: neurotic and personality, psychotic and non-psychotic mental disorders are now one of the leading causes of death globally. The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association provides a common language and standard criteria for the classification of mental disorders. The DSM is used in the United States and to various degrees around the world. It is used or relied upon by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, and policy makers. The current version is the DSM-V-TR (fifth edition, text revision, comes out in May 2013). The current DSM-IV is organized into a five-part axial system. The first axis incorporates clinical disorders. The second axis covers personality disorders and intellectual disabilities. The remaining axes cover medical, psychosocial, environmental, and childhood factors functionally necessary to provide diagnostic criteria for health care assessments. My account is a far from systematic one dealing with each of this five-part axial system in turn. Being systematic in my approach was part of my problem when I began this account more than a dozen years ago. My story has become more systematic, but it has also become more idiosyncratic and personal. This 'chaos-narrative,' as some biographers and autobiographers call this genre of story-telling, has been strong longitudinal beginning as it does at my conception in mid-October 1943, and ending with the present, the months of 2013. Part 2: Mental disorders now account for a significant percentage of the non-fatal burden of disease. There is an estimated and staggering indirect cost of perhaps $200 billion a year in the USA alone when one includes the impact of: (i) incarceration, (ii) homelessness, (iii) the high rate of medical complications, (iv) dependence on emergency room care, (v) lower educational attainment, (vi) the reduced ability to hold jobs, and (vii) the burden on friends and families, inter alia. The above 7 factors and their application in the nearly 250 countries, as well as dependent and independent territories on the planet, could alone make for a separate
  3. 3. book on the subject. Indeed, there is already an extensive literature on these many factors and in many of those 200+ countries for those who are interested. Those who want to follow-up in these relevant areas of interest on the subject now have a burgeoning literature available.(note:U.N. Members: 193, U.N. Observer States: 2, States With Partial Recognition: 2, Inhabited Dependent Territories: 45, Uninhabited, Territories: 6, Antarctica: 1, Total: 249) A recent US Surgeon General's report on mental illness concluded that at least 30% of Americans currently suffer from some form of mental disorder, including disorders in any of the following general categories: anxiety (most common), mood, eating, sexual, substance use, sleep, cognitive, psychotic, and schizophrenic, inter alia. This figure is comparable in Canada and many countries around the world. The three most common specific disorders appear to be: clinical depression, substance abuse, and social phobia or social anxiety disorder. For an extensive list of famous people with various mental illnesses and autobiographies go to: http://www.eddyelmer.com/pagestart.html?http://www.eddyelmer.com/celebrities- mental-illness.htm Part 3: All of the above, though, is not the focus of this story, this account which has now been at Bahá'í Library Online for several years, as well as at several other sites in cyberpsace. This account has now had at least 20,000 hits and, arguably, as many as 40,000. It is impossible to know how much of it has been read and by how many, even if the number of clicks or hits can be quantified. Readers will find below my personal account and experience of bipolar 1 disorder(BPD). It is my life-narrative and my experience with a special focus on the idiosyncratic manifestations of BPD in my life. For this reason, among others, I have posted part or all of what I call my 'chaos-narrative', as I say, at a number of internet sites. Mine, of course, is not the only story. There are now 100s, if not 1000s, of accounts of BPD in cyberspace. Mine is one of the most detailed due to its being the story, the experience of one person over his total lifespan of some seven decades. Some refer to such an account as 'coming-out-of-the-closet'. This experience has parallels to and with the experience of: lesbians, gays, bisexuals, transgender, pedophiles, people with criminal records and a host of others who keep some stigmatized social problem which is part of their lives---hidden as far as possible from others. Again, the literature on these several human predicaments is massive. Part 4: Severe mental tests are everywhere apparent, not only in the field of psychiatry and clinical psychology, disciplines whose role is to deal with these afflictions, but also across the wider culture in which we all live. These tests have been afflicting people across most cultures in the long history of humankind, but especially in the last century as the world‘s population has gone from 1.5 billion in 1914 to 7.5 billion in 2014. The onset of the Great War, 1914-1918, in some ways marked a new stage in the burgeoning problem of mental health and the tempests of our modern world. The new field of disaster psychiatry now plays a vital role in the evolving structures for
  4. 4. preparedness and response in the fields of disaster management. Science and experience now address the tragedies of mass catastrophe with new systems. The challenges are massive for integrating mental health contributions into the practical requirements for survival, aid, emergency management and---ultimately and hopefully---recovery. The human face of disaster and the understanding of human strengths and resilience alongside the protection of, and care for, those suffering profound trauma and grief are central issues in relation to disaster psychiatry. These tests, disasters and crises will continue in the decades ahead as the tempest afflicting society continues seemingly unabated. There are now available, though, a burgeoning range of resources in today‘s print and electronic media to help people understand this complex and extensive field of mental health. My life-narrative, which I hope will be of help with respect to BPD, is but one small resource for readers. I have posted sections of this account at internet sites which contain a dialogue between people interested in particular mental health issues about which I have had some experience. Part 5: There are many internet sites today, some organized for and by mental health experts and others organized by non-experts for the general public and especially for sufferers of mental-illness to provide information as well as opportunities to discuss issues. In the process sufferers can, if they want, obtain help for what has become a very large range of specific disorders. If one goes to their google search engine and inserts the following words: mental health, depression, bipolar disorder, affective disorders, OCD, PTSD, anger management, indeed, any one of dozens of other disorders in this field, one discovers a host of sites of interest and of relevance to one‘s special concerns. According to one source, one-third of all people in western cultures will suffer from a disorder or emotional problem during their lifetime and they would benefit from therapy. In the last half century there has been a revolution in treatment programs and regimes which have found better and permanent cures for many, if not most, of the mentally afflicted, but there are millions more suffering from mental illness as well. In this world mental illness is truly a heavy burden to bear. I leave it to readers to do more googling for there is much to read for those who are interested in this subject. Despite the plethora of treatment options for BPD, this particular mental health problem remains suboptimal from the points of view of clinicians and patients alike in relation to many sufferers. Whether measured by recovery time from manic or depressive episodes or preventive efficacy of maintenance treatments, BPD is characterized by sluggish responses, inadequate responses, poor compliance and recurrences in controlled clinical trials. Results of naturalistic studies additionally show pervasive, often chronic symptoms, multiple episode recurrences, very infrequent euthymic periods when measured over years and marked functional disability in many patients.(Euthymic means a normal, non-depressed, reasonably positive mood distinguished from euphoria) Despite the explosion of treatment options over the last quarter century(1987-2012) when lithium dominated treatment, treatment resistance, that is the resistance, the failure of compliance, of those who have BPD, remains a central problem in BPD. If measured by symptom or syndrome recurrence status or functional status, the majority of treated BPD patients have a less than satisfactory outcome. My life experience with BPD is a
  5. 5. good example of this reality, although at the age of 69 I have come to see my present treatment regime as "as good as it gets" in spite of at least 4 changes in my medication regime in the last 5 years. Part 6: I have joined over 100 of the internet sites in relation to mental health issues and participate, as circumstances permit, in the discussions on: mental health, bipolar disorder, depression and personality disorders among other topics in the field of psychiatry. What I have posted below is, as I say, also posted in whole or in part at many of these sites. I have posted this account here and at other locations in cyberspace because: (a)it is part of my own effort to de-stigmatize the field of mental illness and (b) it provides a useful longitudinal account of BPD for those who are interested. Many, if not most, BPD sufferers never go public about their problems due to the social stigma and my going public at this site among other sites is, as I say, part of my personal effort to destigmatize a part of the mental health problem that millions of people face. My own somewhat lengthy account below will hopefully provide mental health sufferers, clients or consumers, as they are variously called these days, with: (i) a more adequate information base to make some comparisons and contrasts with their own situation, their own predicament, whatever it may be, (ii) some helpful general knowledge and understanding, (iii) some useful techniques in assisting them to cope with and sort out problems associated with their particular form of mental health problem or some other traumatized disorder that affects their body, their spirit, their soul and their everyday life and (iv) some detailed instructions on how to manage their lives more successfully despite the negative consequences of their BPD or whatever trauma or illness affects their lives. For many readers the following post will be simply too long for their reading tastes and interests. In that case just file this document for future use, skim and scan it as suits your taste, go to the sections relevant to your interest or delete it now from your reading agenda. Apologies, too, for the absence of an extensive body of footnotes which I was unable to transfer to this document at BLO as this account developed.(2) Part 7: Trading in rumors and misinformation sensationalizes real disorders and leads to stereotypes and bigotry. This is evident by any cursory analysis of media coverage of the entire field of mental health. The media fuel the stigma that mental health is dangerous or scandalous and this fuel prevents people from seeking the life-changing help they need. Because untreated psychiatric disorders are more likely to result in violence, it makes tragedies like the Newtown Connecticut experience in December 2012 more likely to happen again. Speculating about the things we don't know goes on and on; we need to start focusing on what we do know. Additionally, a psychopathic, sociopathic or homicidal tendency must be separated out from mental illness more generally. While the mentally ill can sometimes be aggressive, this is usually because of a wide range of factors that this story discusses in its 200 page(font-14) ramble.Traumatic experiences like the recent(12/'12) Newtown killings are complex events and it is not my intention in this account of by BPD experience to deal with them except in some tangential sense.
  6. 6. The extreme sensory sensitivities of many of the mentally-ill is just one of many contributing factors to the endgame of violence. Often the aggression of those with mental health issues is typically harmful to themselves. In the very rare cases where their aggression is externally directed, it does not take the form of systematic, meticulously planned, intentional acts of violence against a community. The media has already come under much scrutiny for its reporting many stories connected with mental health. Television reporters were hotly criticized for interviewing eyewitnesses, many of whom were children at Sandy Hook Elementary School in Newtown right after the trauma of the killing of many teachers and children om that morning. Some media outlets have refused to cross certain lines in their coverage. The internet now has a substantial number of posts on this topic for interested readers. Part 7.1 For two alternatives to reading my somewhat clinical story go to (3) and (4) below. There are now online many life-narratives, narratives which make more interesting reading than my more clinical account. There is, too, an excellent bibliography of the accounts of people's experience with BPD and an analysis of its presence in society.(5) -----------------------------FOOTNOTES------------------------------------------------------------ --------------------- (1) There is now a list of neurotic and psychotic, personality and non-psychotic mental disorders on the internet. The internet has excellent overviews of each and all of these mental health disabilities. (2) I have had difficulties placing footnotes into this document and so readers will not find the full list of annotations that I originally placed here. I hope to remedy this problem in a future edition. (3) The definitive medical monograph, at least for me, on the subject of BPD is: (Manic- Depressive Illness, with Frederick K. Goodwin, 1990; second edition, 2007) and a personal memoir (An Unquiet Mind, 1995). (4) For a more readable narrative than my rather clinical autobiographical account---go to Charlotte Pierce-Baker's "This Fragile Life: A Mother's Story of a Bipolar Son." This could very well have been my mother's story except for several factors which I discuss in my 160 page and 95,000 word account below. Charlotte did everything right when raising her son, providing not only emotional support but the best education possible. At age twenty-five, he was pursuing a postgraduate degree and seemingly in control of his life. She never imagined her high- achieving son would wind up handcuffed, dirty, and in jail. This is a moving story of an African American family facing the challenge of bipolar disorder, This Fragile Life provides insight into mental disorders as well as family dynamics. Pierce-Baker traces the evolution of her son‘s illness and, in looking back, realizes she mistook warning signs for typical child and teen behavior. Hospitalizations, calls in the night, alcohol and drug relapses, pleas for money, and continuous disputes, her son‘s journey was long, arduous, and almost fatal. This Fragile Life weaves a fascinating story of mental illness, race, family, the drive of African Americans to succeed, and a mother‘s love for her son.
  7. 7. (5) Two among the many books now available which readers who have the interest can google with a little digging are: The Natural Medicine Guide to Bipolar Disorder, Charlottesville, VA, Hampton Roads Press, 2003; and Emily Martin, Bipolar Expeditions: Mania and Depression in American Culture, Princeton UP, Princeton, NJ, 2007. BIPOLAR DISORDER: A 70 Year Chaos Narrative A Longitudinal Context: October 1943 To October 2013 13th Edition, Draft #1 By: Ron Price of George Town Tasmania Australia (160 Pages: Font 12—95,000 words); Font-14-200 pages Disclaimer: This on-line book is offered for informational purposes & as an aid to others. It is NOT a substitute for medical advice. I make every effort to offer only accurate information, but I cannot guarantee that the information I make available here is always correct or current. Below readers will find my personal, idiosyncratic, story. Consequently, no one should rely upon any information contained herein, nor make any decisions or take any action based on such information. Consult your doctor before starting any diet or exercise program, taking any medication or, indeed, taking any action at all as a result of reading this work. I am not responsible for any action taken by those who rely in one way or another on the information contained herein and for any damages incurred, whether directly or indirectly, as a result of my errors, omissions or discrepancies contained in this account. The following information is NOT intended to endorse drugs or recommend therapy. While this account might be helpful it is not, as I say, a substitute for the expertise, skill, knowledge and judgement of healthcare practitioners in patient care. 1. Preamble and Introduction: 1.1 This medium-sized book was once very small, indeed, not much more than a long essay of about 2000 words. It started out as that very short essay twelve years ago in 2001: (a) as a statement to obtain a disability pension in Australia and (b) as an appendix to my memoirs, a five volume 2600 page opus found in whole and in part at various places on the internet. Both this statement and that book of my memoirs could benefit from the assistance of one, Rob Cowley, affectionately known in publishing circles back in the seventies and early eighties as ―the Boston slasher.‖ His editing was regarded by some as constructive and deeply sensitive. If he could amputate several dozen pages, several thousand words, of this exploration of my life experience of bipolar disorder(BPD) with minimal agony to my emotional equipment I‘m sure readers would be the beneficiaries. But, alas, I think Bob is dead. I did find an editor, a proof-reader and friend who did not slash and burn but left my soul quite intact as he waded through my labyrinthine passages, smoothed them all out and
  8. 8. excised undesirable elements. But this editor is in the late evening of his life and, after editing several hundred pages of my writing, he has tired of any continued exercise in my literary fields and so I am left on my own. I have begun to assume the role that both Cowley and my friend exercised, but it is a difficult and relentless role and I, therefore, only take it up sporadically given the quantity of my writing which does require editing. Without my editor friend, who is now nearly 80 and leads a quiet non-editing life, I advise readers not to hold their breath waiting for me to do what is a necessary edit in this now lengthy work. Each edition of this work has involved editing and, as is often the case with editing manuscripts, one can literally edit forever. 1.1.1 John Kenneth Galbraith, the famous economist and a fine writer, had some helpful comments for writers like myself. So, too, did Galbraith‘s first editor Henry Luce, the founder of Time Magazine. Both Luce and Galbraith were aces at helping a writer like me to avoid excess. Galbraith saw this capacity to be succinct as a basic part of all good writing. Galbraith also emphasized the music and the rhythm of the words as well as the need to go through many drafts. I've always admired Galbraith, a man who helped me understand some of the mystery that is economics. He passed away while I was writing this book. I‘ve followed his advice on the need to go through endless drafts. I‘ve lost count of the number of changes, of additions and of deletions to this text. I know I have not avoided excess or repetition among other writing weaknesses that readers will find in the following pages. In some ways I have found that the more drafts I do, the more I have had to say. Excess is one of the qualities of my life, it seems to me, as I muse over seven decades of living, if I may begin the confessional aspect of this work in a minor key. And so it is that I have Galbraith watching over my shoulder and his mentor, Henry Luce, as well. Galbraith spent his last years in a nursing home before he passed away in 2006 at the age of 98. Perhaps his spirit will live on in my writing as an expression of my appreciation for his work and for a man who lived and worked not far from where I grew up and studied in Ontario, in Canada. His spirit is needed here for there is much editing that is required in this far too-lengthy work; but I do not have the energy or enthusiasm or, perhaps, even the skill, to take on the task. Spontaneity did not begin to come into this piece of exposition until, perhaps, one of the drafts of its fifth edition back in 2005. Galbraith says that artificiality enters a text along with spontaneity because of the process of writing many drafts. I think he is right; part of this artificiality is the same as that artificiality which one senses in life itself: at least that I sense. Galbraith also observed with considerable accuracy, in discussing the role of a columnist, that a literary man or woman is obliged by the nature of their trade to find significance three times a week in events, often, of absolutely no consequence. I trust that the nature of my work here, as I say a part of my memoir, what I have come to call my chaos narrative, will not result in my being obliged to find significance where there is none. I‘m not optimistic though. Perhaps I should simply say ―no comment‖ and accept the reality of the presence of the inevitable gassy emissions that are part of the world of memoirs. 1.1.2 This is not your usual book about illness where someone gets sick, someone gets well, and the story serves as an inspiration. People feel a need to talk or write about their illnesses, and most of us read these accounts with close attention if we have an interest in a particular illness. Such books are written to inform and encourage others, to bear
  9. 9. witness to our common fate, and to give advice about how to avert some illness. The more inspiring, cautionary, and tutelary the book, the more eagerly the book is read. The book may even make the best-seller lists. This is not such a book. If it has any function as inspiration, it is far too clinical to ever be popular. It does not reflect the spiritual, metaphysical or religious disquietude that affliction provokes, although some aspects of my subjective, my intuitive, and my religio-philosophical experience are part of my story. There‘s a roster of distinguished preceding examples of the more popular type from Helen Keller‘s The Story of My Life to the moving book The Diving Bell and the Butterfly by Jean-Dominique Bauby, victim of the ―locked-in syndrome‖ from a massive stroke at age forty-three, which left him imprisoned in his paralysed body but with his mind intact; from Montaigne‘s description of what it‘s like to pass a kidney stone, to Alphonse Daudet‘s In the Land of Pain, as he lay dying of syphilis, to Betty MacDonald on her tuberculosis in The Plague and I. There are books on just about any medical condition written from the point of view of the sufferer, the doctor, or a family member, valued testimonials to an apparently inevitable part of the human lot, often treated in painting too, though seldom in fiction, as far as I know, although I have yet to examine this field. 1.2 This is a longitudinal, retrospective account going back to my conception in the last half of October 1943. The story continues up to October 2013, with a few paragraphs in Appendix 10 to foreshadow my final years beyond October 2013, the final years of my life whatever number of years that may be, years that this story will deal with in the years ahead as I continue this online account. This statement, even at nearly 95,000 words and 160 pages, is still a work in progress, as they say these days, some 70 years. 1.2.1 Neurobiological, neuropsychiatric and affective disorders like BPD are found in diverse forms as well as in a broad range of age of onset and in a specificity of symptoms. Little is still known about its pathogenesis, that is, the origin and development of the disease. What follows is one person‘s story, one person‘s life experience of BPD, an illness that silently and not-so-silently shaped my life. It is a focussed account on a part of my personal life-narrative with the many manifestations, the symptomology, of BPD as I experienced it. BPD shaped, but did not define, all that has been my life. It was a medical affliction that made for a certain inconstancy in living, a certain impulsivity, tendency to take risks, a vulnerability to addictions, and much else. BPD is treatable but not curable. My story of that ‗much else‘ to which I refer is found here. My entire autobiography is not found here for there is more to my life than this disorder and my experience of its highs and lows, its joys and sorrows. 1.3 I make reference to a strong genetic contribution to the aetiology of BPD, a genetic predisposition, a genetic susceptibility as a factor in the pathogenesis of BPD. No specific gene has yet been definitively linked to BPD, although some chromosome regions have been implicated by several studies. Thus, despite extensive research efforts, the underlying patho-physiology of BPD remains unknown. I have been and still am part of an ongoing study into BPD conducted at the University of New South Wales and, I trust in due course, this illness like so many others will find better and better treatments, if not cures. 1.3.1 A family history, what is sometimes referred to as a family pedigree, of affective
  10. 10. disorder in a first-degree relative, in my case my mother(1904-1978) is relevant to this narrative. My mother had a mild case of what may very well have been BPD, at least I have come to think of her mood swings as falling into a significantly high place in what is sometimes called the BPD or affective spectrum during her 75 year life. Her mood- swing disability or affective disorder, though, was never given the formal medical diagnosis manic-depressive(MD), a term which developed from several concepts as early as the 1850s if not centuries before. The term MD was replaced in 1980 after my mother died in 1978 by the term BPD. In retrospect my mother exhibited symptoms which may be more accurately labelled: (a) explosive disorder disability, (b) neurotic disorder: anxiety state or (d) depressive disorder. I know nothing of the mental health of my mother‘s parents or grandparents and so am unable to draw on what could be a useful knowledge base to explain the origins of my BPD. 1.3.2 Definition: Bipolar disorder (BPD) or manic-depressive disorder (also referred to as bipolar affective disorder or manic depression (MD)) is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood and one or more depressive episodes. The elevated moods are clinically referred to as mania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both mania and depression are present at the same time. There is a defect in the transmission of sense impressions to the brain, a flaw in communication. (See: Monica Ramirez Basco, The Bipolar Workbook: Tools for Controlling Your Mood Swings, 2006. p. viii). These episodes are usually separated by periods of "normal" mood, but in some individuals, depression and mania may rapidly alternate, known as rapid cycling. Extreme manic episodes can sometimes lead to psychotic symptoms such as delusions and hallucinations. BPD has now been subdivided into: bipolar I, bipolar II, cyclothymia, and some other types based on the nature and severity of mood episodes experienced. The range of types and experiences is often described as the bipolar spectrum. –See Bipolar Disorder, Wikipedia, the free encyclopaedia. For an excellent overview of the subject of depression go to this link: http://www.nybooks.com/articles/archives/2007/dec/06/talking-back-to-prozac/?page=2 ...The internet is now overflowing with information and stories about depression. 1.3.3 Bipolar I disorder is the name given to the diagnosis when a person has hypomanic and, in most cases, depressive episodes. The several typicalities or the spectrum of episodes for BPD I include: (i) single manic or hypomanic episode, (ii) most recent episode hypomanic, (iii) most recent episode manic, (iv) most recent episode mixed, (v) most recent episode depressed, and (vi) most recent episode unspecified. To the extent that I am labelled BPD I, I would fit into sub-categories (ii), (iv) and (v). In April 2012 a new psychiatrist diagnosed me as BPD I. In the immediate future, the years from, say, 2013 to 2023, this new psychiatrist will be the major professional doctor on whom I will draw when necessary. 1.3.4 The diagnosis of Bipolar II disorder is reserved for those who have primarily one or more depressive episodes and one or more elevated moods. They have highs and lows but never have a hypomanic or manic episode. In BPD II, if the patient does have a hypomanic episode it does not necessarily cause the impairment of their working or family situation. It may even be associated with good functioning and enhanced
  11. 11. productivity. Without proper treatment, though, hypomania can develop into mania in some people or can switch into depression. In my case, my elevated mood switched into depression in October 1963, August 1964, and some time in the early months of 1978. I was BPD II or mildly schizo-affective in my four years at university(1963-1967). My mood also switched from normal to manic in May 1968 and May 1980. These were the two times when I went through a full manic episode. 1.4 My father also suffered from what seems to me now, in retrospect, a mild case of what today is sometimes called intermittent explosive disorder(I.E.D.) or impulse control disorder(I.C.D.), as opposed to planned acts of violence or a simple temper. Given the rarity of I.C.D., it seems to me that my father had only a mild I.C.D. Other names for I.E.D. include: rage attacks, anger attacks and episodic dyscontrol. People with I.E.D. experience anger which is grossly disproportionate to the provocation or the precipitating psychosocial stresser. My father may have been exposed to this type of behaviour as a child and so his I.E.D. may have been learned rather than organic and brain-centerd. There are also complications associated with the diagnosis of I.E.D. and they include job or financial loss. My father lost much money on the stock market in his early 60s. My father was also genuinely upset, regretful, remorseful, bewildered or embarrassed by his impulsive and aggressive behavior. This description is an intuition since he and I never talked about his anger. In my father‘s late 60s, and perhaps at earlier stages in his life, his disorder also exhibited, or so it seems to me now in retrospect, co-morbidity perhaps due to his genuine sense of remorse, but I don‘t know for sure. I know nothing, either, of the mental health of his parents or grandparents all born in the 19th century. My conclusions regarding my father‘s emotional disability are largely, as I say, somewhat tentative. Perhaps he just had a bad temper as they used to say until the last three decades when psychiatry began to give his disorder a label. 1.4.1 About half of all patients with BPD have one parent who also has some form of mood disorder. There is then, or so it seems to me, a clinical significance in my mother‘s and father‘s mood disorders in the explanation of the origins and diagnosis of my own BPD. The high heritability of BPD has been well-documented through familial incidence, twin and adoption studies. There is an unquestionable justification for the inclusion of my family in the understanding of my BPD. No specific gene has yet been identified as the one bipolar gene. It appears likely that BPD is caused by the presence of multiple genes conferring susceptibility to BPD when combined with psychosocial stressors. 1.4.2 Advanced paternal age is a risk factor for BPD in the offspring. Since my father was 55 when I was born, the hypothesis that advancing paternal age ―increases the risk for de novo mutations in susceptibility genes for neurodevelopmental disorders‖ has some relevance to my having BPD.‖(Psychiatric News, November 7, 2008, V.43 No. 21, p. 18.) The offspring of men 55 years and older, that same article went on to say, were 1.37 times more likely to be diagnosed as having BPD than the offspring of men aged 20 to 24 years. The maternal age effect was less pronounced. For early-onset cases, that is BPD onset under the age of 20, and that was the case with me, the effect of paternal age was much stronger; whereas no statistically significant maternal age effect was found. 1.5 For an elaboration of the subject of the genetic connection of BPD and in utero BPD see: David Healy‘s Mania: A Short History of BPD Johns Hopkins, 2008. A short history of BPD is also available on the internet. Genes may also contribute to the age of
  12. 12. onset of BPD and this is analysed now in the context of a phenomenon called genetic anticipation. Anticipation refers to the phenomenon of an illness occurring in successive generations at earlier ages of onset and/or increasing severity. In a recent study using registry data of BPD subjects, age at onset of the first illness episode was examined over two successive generations. Subjects born from 1900 through 1939(my mother) and from 1940 through 1959(myself) were studied. The median age at onset of the first episode of BPD was lower by 4.5 years in subjects born during or after 1940. It was not until my mother was in at least her twenties that her first episode of BPD occurred, although this is somewhat of a guesstimation. 1.5.1 BPD and affective disorders of various kinds run in the family. I am unable to trace my BPD back several generations. If I knew more about the many generations that preceded me in my birth family and their: episodes of hearing voices, delusions, hyper- religiosity, and periods of not being able to eat or sleep—that knowledge could prove useful and, possibly, predictive due to the genetic causal factors in relation to BPD. These episodes, these types of experiences, are often remarkably similar across generations and between individuals according to some studies within modern psychiatry and its pharmacological treatments. This is the story of my BPD and my treatments especially since September-October 1963. 1.6 The goal of what is sometimes called ‗personalized medicine‘ is to utilize a person's genetic makeup for appropriate disease diagnosis and treatment, an idea conceptualized initially in the recent years of the Human Genome Project. The current conceptualisation of MD/BPD can be traced back, as I indicated briefly above, to the 1850s, although its history can also go back as far as Turkey in ancient history. Both terms, MD and psychosis, were coined in 1875 by Jules Falret, a French psychiatrist and he recognized its genetic link. German psychiatrist Emil Kraepelin (1856–1926), the founder of modern psycho-pharmacology, also made a major contribution to the early understanding of MD/BPD, only one of the many disorders in the general mood disorder category, but a cyclical mood disorder associated with a circularity between D and euphoria. 1.7 About 37,000 years ago Neanderthals arguably intermingled with modern humans and thus a new gene entered the human genome, the DRD4 7R gene. This gene arguably originated from Neanderthals. This gene is associated with risk-taking, sensation-seeking and novelty-seeking, and correlated with openness to new experiences, intolerance to monotony, and exploratory behavior, features of Neanderthal behaviour. About 10% of the population have the activated DRD4 7R gene. So goes yet another theory on the genetic predisposition to BPD. 1.8 All manifestations of BPD share uncertain etiologies, with often opaque, obscure, relationships between genes and environment. Some medical experts and theorists in the field of such studies posit latent changes in the expression of specific genes initially primed at the developmental stage of life. Some studies and some experts emphasize that certain environmental agents disturb gene regulation in a long-term manner, beginning at early developmental stages in the lifespan perhaps even in utero. There may be, in fact, pervasive developmental disorders that involve a triad of deficits in social skills, communication and language. For the underlying neurobiology of these symptoms, disturbances in neuronal development and synaptic plasticity have been discussed, but I don‘t want to comment on this area of complexity, this puzzling area and the aetiology of BPD.
  13. 13. 1.8.1 These disturbances, these perturbations, as they are sometimes called, might not have pathological results until significantly later in life. In retrospect, as I look back from these middle years(65-75) of late adulthood, the years 60 to 80 as some developmental psychologists call these years of the lifespan, these perturbations and pathological results were clearly manifested at the age of 18. I could easily theorize an earlier onset on the basis of behavioural perturbations manifested in early childhood and into adolescence and I do such theorizing later in this account(see sections 2.7.1 and 2.7.2 below). The change from psychodynamic models of psychiatry to neurobiological models that dominate the discipline today has been a critical determinant in both my story and its treatment by the psychiatric profession. 1.9 I received 2 diagnoses before 1978 and after 1962 from friends, family and concerned others. These two diagnoses were: depression and "a person with complicated troubles", to put it colloquially and in the daily vernacular. I received 2 diagnoses from psychiatrists during this time. The psychiatric diagnosis in 1968 was: a mild schizo- affective state; the diagnosis in 1978 when another episode of low mood, or depression, occurred. The psychiatrist I went to at the time, in Ballarat Australia, treated me with stelazine (trifluoperazine HCl). This was supposed to be effective as a short-term treatment of generalized non-psychotic anxiety. 1.9.1 The diagnosis that was made in 1980 was BPD. BPD is a diagnosis that is standardized according The Diagnostic and Statistical Manual of Mental Disorders (DSMMD-III: 1980, DSM-IV: 1994, DSM-V-5/2013) which provides diagnostic criteria for mental disorders. I use the term BPD not MD throughout this document and I use that acronym. In the DSM-IV MD is a 5 axis/level system of diagnosis that is used. 1.9.2 In my case, axis/level 1 is for clinical disorders that are mood disorders. Axis 3 in this system is for what they refer to as acute medical concerns that relate to BPD; axis-4 is for psycho-social and environmental problems that contribute to BPD and axis-5 is an overall caregiver‘s assessment of my functioning on a scale 1 to 100. Most of the successful diagnoses and treatment of my BPD have come from psychopharmacology and its roots in physiological assumptions. In the last decade, say, 2001 to 2011, talking cures and behaviour modification techniques like cognitive behaviour therapy with their roots, their emphasis on assumptions in the domain of intrapsychic experience have also been successful as adjuncts to medications or separate from them. 1.9.3 In my case, my caregiver, namely my wife, evaluated me at 61-70 on the numeric scale in 2007 while I was on what I hoped was my last, my final, medication package. This place on the scale reads as follows: ―this adult has some mild symptoms as well as some difficulty in social and occupational functioning. Generally, though, he functions pretty well. He also has some meaningful interpersonal relationships." The bar is set quite high by government departments in order for my wife to get a Caregiver‘s Allowance and so it is that she and I have not seriously considered applying for such an allowance. My symptoms are not sufficiently extreme for her to qualify as my Caregiver. Of course, many people do not deal with their BPD story and the relevant government departments honestly and they obtain government assistance when, in all honestly, they should not. Due to the complexity of BPD and its behavioural manifestations it is difficult for all concerned to monitor and report. Readers wanting access to this diagnostic tool can easily find it on the internet. I have appended it to this statement in
  14. 14. appendix 2. 1.9.4 With the introduction of psychoactive drugs in the 1950s, and sharply accelerating in the 1980s, the focus in psychiatry shifted from talk therapies like Freudian psychology, to the brain. Psychiatrists began to refer to themselves as psycho- pharmacologists, and they had less and less interest in exploring the life stories of their patients. Their main concern was to eliminate or reduce symptoms by treating sufferers with drugs that would alter brain function. An early advocate of this biological model of mental illness, Leon Eisenberg, a professor at Johns Hopkins and then Harvard Medical School, in his later years became an outspoken critic of what he saw as the indiscriminate use of psychoactive drugs, driven largely by the machinations of the pharmaceutical industry. I mention this here because the subject of psychiatry and the various treatments for mental illness has become highly controversial and complex. The field has always been complex. For some of the claims and some of the defence from critics of medical and therapeutic advances in psychiatry go to this link:http://www.nybooks.com/articles/archives/2011/aug/18/illusions-psychiatry- exchange/ 1.10 The literature now available to those wanting to explore the subject, the field of BPD, is massive both on the internet and off and much of it should be considered by readers wanting to become more familiar with BPD. My story is only one of thousands, if not 100s of thousands, now available. Readers wanting what to me is the best resource to help them deal with BPD should go to Sarah Freeman, The Bipolar Toolkit, 2009. It is far better than this personal, idiosyncratic and non-systematic account. 1.10.1 A good example of one of the most recent findings is from psychologists at the Universities of Manchester and Lancaster in a study published in April 2011. These psychologists say their findings are important because they mean talking therapies, like cognitive behavioural therapy (CBT), could prove effective treatments for BPD. Mood swings of people with BPD, these findings indicate, can be predicted by the current thoughts and behaviour of BPD sufferers. People with BPD are prone to extreme mood swings that take them from great emotional highs to the pits of depression; the cause of these mood swings is often put down to the patients' genes and biology rather than their own thoughts and actions. In a recent study published in the American Psychological Association journal Psychological Assessment, researchers followed 50 people with BPD for a month. The team found that the patients' thinking and behaviour predicted their future mood swings even when their medical history had been accounted for. "Individuals who believed extreme things about their moods; for example, that their moods were completely out of their own control or that they had to keep active all the time to prevent becoming a failure, developed more mood problems in a month's time," said study lead Dr Warren Mansell, in Manchester's School of Psychological Sciences. "In contrast, people with BPD who could let their moods pass as a normal reaction to stress or knew they could manage their mood, fared well a month later," said Mansell. These findings are encouraging for talking therapies such as CBT that aim to help patients to talk about their moods and change their thinking about them." A new form of CBT, known as TEAMS (Think Effectively About Mood Swings), is being developed by Dr Mansell and colleagues, at The University of Manchester. It aims
  15. 15. to improve on previous therapies by focusing on current problems, like depression, anxiety and irritability, and helping patients to set goals for their life as a whole. The aim of this new approach is to encourage patients to accept and manage a range of normal emotions – like joy, anger and fear – and a controlled trial is about to start following a successful case series of the TEAMS approach. The researchers will use the TEAMS approach to follow up their current findings with a larger study that identifies who relapses and who heads towards recovery in the long term. In addition, MRP (The Mind Resonance Process) totally unrelated to CBT claims to permanently and completely delete the negative thoughts, emotions (and negative memories responsible for the former) and helps to restore resilience, self-esteem, self- confidence, and much more. Clients who have failed CBT, EFT, EMDR, psychotherapy, NLP, hypnosis, etc. often achieve significant and permanent life changing success with MRP empowerment coaching. We all have a life history "movie" which is always playing in the background and acting as a "set point" to which we always are drawn (down) back to. We all carry our history in this script or movie form and are simply not able to transcend it easily. Hence the need for all the talk and all the medications. 1.10.2 The original conceptualization of stress and the stress response has been developed based on the understanding that certain environmental exposures and life events can be both detrimental to individual's health and well-being, and also promote physiological responses that can be adaptive. I have little doubt, as I review those episodes of BPD in my life, that my exposure to environmental and life events at the time preceding those episodes were detrimental to my health. My vulnerability to stress, or the negative consequences of stress may have been due to a lack of resilience. Only recently has the field of psychiatry started focusing on the concept of resilience, exploring the possibility that, similarly to stress vulnerability, there could be unique mechanisms involved in resilience to stress. For more on this topic go to this link: http://www.nature.com/npp/journal/v37/n2/full/npp2011259a.html?WT.ec_id=NPP- 201201 1.11 BPD is not medically curable, as I point out elsewhere in this account, but it is possible through psychiatry, medicine, some types of talk therapy like the one indicated above, and nutritional supplements or adjuncts, to achieve varying degrees or periods of long-term stability. BPD needs to be managed like many other chronic diseases, with combination therapies and long-term treatment in order to achieve sustained success. I feel I have achieved this stability and this success by degrees since the 1960s. This is not to say that I have never had any more episodes since those 1960s, that I have not become hypomanic(i.e. mild mania) again, nor exhibited other symptoms of BPD. I have had five, and arguably as many as seven, decades of experience of BPD symptoms and some of these symptoms are still in my day-to-day life. This lengthy 90,000 word statement is an account of my experience in achieving varying degrees of stability at various periods of my life. 1.11.1 I should emphasize at the outset of this statement that some research shows that some forms of psychotherapy or talk therapy are an effective substitute for or
  16. 16. accompaniment with medication. Medication plus a structured psychotherapy has been compared to medication plus a less structured psychotherapy or medication alone. Building on earlier studies over the last 5 years, a variety of psychotherapy techniques have been evaluated, including family-focused treatment (FFT), cognitive therapy (CT), group psychoeducation, and interpersonal and social rhythm therapy (IPSRT). For all approaches, the addition of the structured psychotherapy added additional benefit, as measured by a variety of outcome variables, including longer survival time before relapse, fewer relapses, greater reductions in symptom rating scales, enhanced compliance, fewer days in mood episodes, improved social functioning, and fewer and shorter hospitalizations. At the age of 69 and generally happy with my medication regime, at least in many respects, I do not seriously entertain these psychotherapeutic approaches after more than 30 years of dependence(1980-2013) on mood stabilizers, anti-psychotic, and anti- depressant medications. I may seriously consider engaging in talk therapy in the years ahead; I may also entertain a change in my medications. Time will tell. I have taken medication in some form for more than 40 years, as far back as June 1968. Although I acknowledge the research showing that health food and nutritional supplements like fish oil, for example and/or vitamins and minerals and/or amino acid(s) are of some value for BPD, and although I in fact take these supplements, I am still not prepared now after all these years to ‗go-it-alone‘ without the medication. Both my GP and my psychiatrist concur with this decision. Symptom reduction is one of the main aims of any talk therapy or psychotherapy in general, and can be regarded as the benchmark against which the success of behavioural and cognitive therapies is to be measured. Elucidation of the neural correlates of symptom reduction is a primary goal of any investigation into the biological mechanisms of psychotherapy. But, as I say, I don't go down this road and haven't since going onto lithium in 1980. 1.11.2 I could go to see a counsellor, general psychologist or a clinical psychologist for some talk therapy, perhaps CBT. My psychiatrist is a specialist in pharmacology and in treating BPD among other psychiatric illnesses. Psychiatrists are more trained in pharmacology than psychologists. Some critics of psychiatry and psychiatrists go so far as to say pharmacology is their "weapon" against mental illness. I do not see my shrink, my psychiatrist, as using pharmacology as a weapon in his arsenal. I have not seen my old, my previous, psychiatrist for nearly five years, since November 2008. In April 2012 I began seeing a new psychiatrist because I believed my needs to be chemical, pharmacological. I had been taking the same 2 meds for five years(2007-2012) and my wife wanted me to have a second psychiatric opinion. If I want to tweak my meds I can visit him or just work out a different package in consultation with my wife and/or my GP. I have discussed my memory and OCD issues with my psychiatrist several times, but both my psychiatrists have felt these were not serious enough problems with which I should be concerned. Often my regular doctor, my GP, nails my problems and takes away any need I have to see my psychiatrist. After four visits to my new, my latest psychiatrist in April-May 2012, I now work out any issues arising from my BPD with my wife. 1.11.2.1 Thanks to: (a) shock anti-schizo-affective treatment and supportive psychotherapy in the 1960s, and (b) ongoing medications--I have had quite a ―normal‖ life. In my case this normality is found in: (i) my capacity to devote my time and my
  17. 17. professional life to intellectual and service occupations, basically teaching in the social sciences and humanities, and (ii) my maintaining an active intellectual life, with hope, strength, and making sense of reality. Another important point in this complex of normality has been my religious faith. Without these several factors, the pharmacological treatment alone would, quite likely, have failed. BPD1 is a horrible illness for most who have to deal with it, but nowadays I can say it is possible to have a ―friendly‖ relationship with this enemy of the mind. People with BPD have, in some ways, a fragile purchase on the world, and it is much more important that they have somebody—a professional in the public world and a friend in their private world—who can, over time, create that state of trust that is essential for ongoing daily life. This is true, of course, for all of us with or without mental illness, when the dark clouds of life roll in and overwhelm us. I have been fortunate to have such people as far back as the first episodes of BPD. 1.11.2.2 Though not as severe as full-blown Alzheimer‘s disease or other forms of dementia, mild cognitive impairment is often a portent of mind-robbing disorders like Alzheimer‘s. One study described seven stages of Alzheimer‘s disease. Mild cognitive impairment was seen as a mild Stage 3 of Alzheimer‘s. It is a condition of subtle deficits in cognitive function that nonetheless allow most people to live independently and participate in normal activities. Mild cognitive impairment could be described as an intermediate state of cognitive function, somewhere between the changes seen normally as people age and the severe deficits associated with dementia. At worst this is what I have, a mild cognitive impairment, but I am strongly disinclined to think so; at the age of 69 this is just a guess when I focus on the negative aspects of BPD. 1.12 Defining what psychiatry is & what mental illnesses are can often seem a circular process; it is also an increasingly complex process. Psychiatry, as it is currently constituted, is a branch of medicine. While contemporary psychiatrists tend to aspire to practice their training & the structure of the vast majority of psychiatric practice fits a medical model. People present with symptoms and exhibit signs which are examined. If these symptoms and signs are deemed to provide evidence of pathology, they lead to a diagnosis of an illness. Investigations and treatments are ordered. Medications and other interventions are prescribed to treat the illness. The cessation of the symptoms and signs marks recovery from the illness. This is, on the surface, similar to how an ophthalmologist would approach cataract, or a respiratory physician chronic obstructive pulmonary disease.Dictionary definitions of psychiatry describe it as the medical specialty concerned with mental illness (Oxford English Dictionary, 2007) Psychiatry textbooks generally gloss over the actual meaning of mental illness; they also assume it has a readily understood and commonly accepted meaning. 1.12.1 ―Diagnostic validity‖ means that a diagnosis is in fact a correct one. It differs from a related concept, reliability, which describes how well diagnoses match each other—a reliable diagnosis of BPD means that other clinicians would come up with a diagnosis of BPD given the same case. It is possible for a diagnostic process to be reliable but not valid, although validity implies reliability. Validity implies that one is describing an entity whose existence and nature is not disputed. It does not address fundamental questions of what this entity actually is. Psychiatrists spend much of their time trying to improve the image of psychiatry within medicine by insisting it is a scientific enterprise characterised by the assumptions of expertise, specialist knowledge
  18. 18. and greater objectivity that it is assumed are possessed in full by other medical specialties. However psychiatry, as shall be seen, is also intimately concerned with values and the concerns of the humanities. The tension between the worldviews of ethical and political philosophy on the one hand and the traditional scientific view on the other is particularly acute in psychiatry. The concept of ―mental illness‖ can be considered an assumption in common usage within the psychiatric profession and, perhaps,in wider society. This concept has been subjected to a thoroughgoing critique from philosophers,psychiatrists, psychologists, social workers, political scientists, feminists and many other figures. 1.12.2 This critique has taken five main approaches: -a psychological model, as exemplified by the British • psychologist Hans Eysenck, arguing that mental disorders are in fact learned abnormalities of behaviour (Eysenck 1968) • a labelling model, as exemplified by the American sociologist Thomas Scheff, who argued that the features of mental disorder are in fact a response to the labeling of an individual as ―deviant‖ (Scheff 1974) • a ―hidden meaning‖ model, postulating that the apparently irrational, harmful or meaningless behaviour associated with mental disorder is in fact meaningful. The Scottish psychiatrist R.D. Laing, for instance, argued that ―madness‖ was a sane response to an insane society. (Laing, 1960) • an ―unconscious mind‖ model, influenced by psychoanalysis, which postulates that, again, the apparently irrational can be comprehended, this time with reference to the unconscious mind. • political control models—this critique of psychiatry sees it as a legitimising the social status quo and allowing those who dissent from it to be labelled mentally ill. The practice of psychiatry in the former Soviet Union exemplifies this. Another example is the feminist critiques of post-natal depression, which feminists would argue reflects society‘s treatment of mothers rather than being a disease per se. Thus legitimate distress at the unfair structure of society is pejoratively labelled an illness. Similarly, the Franco-Algerian psychiatrist Frantz Fanon argued that psychiatry was a tool of colonial control and part of the hegemonic order of industrial capitalism. 1.12.3 This questioning, much of which has been posed by psychiatrists, has forced psychiatry to scrutinise its own concept of what constitutes mental illness. Many of the critiques are more about the role of various psychological, social and political factors in the development of mental illness, rather than being an attack on the basic concept of mental illness. Other critiques have not so much been of psychiatry as a discipline or practice, but on the cultural significance of a therapeutic ethos, for instance that of Philip Rieff in ―The Triumph of the Therapeutic.‖ (1965) For Rieff, the rise of psychotherapy and the ―psychological man‖—marked a turning point in human culture, being the death- knell of a Western culture whose ideals had lost their power to deeply pervade the characters of its members. In a therapeutic ethos, truths are contingent and negotiable, and commitments or faiths only survive as therapeutic devices easily discarded in the
  19. 19. interests of therapy. For Rieff, this is a symptom of Western cultural decadence and decline. 1.12.4 Much of the ―antipsychiatry‖ critique has been absorbed into mainstream psychiatric thinking and practice. Psychiatry is generally practiced in the community in a multidisciplinary, biopsychosocial fashion, and psychiatrists themselves lobby for extra resources to achieve this. Government policies enshrine the concept of patient-centred care that meets holistic needs and aims for ―recovery‖ that goes beyond the simple alleviation of symptoms (Expert Group on Mental Health, 2006.) Compulsory treatment of those diagnosed as mentally ill is surrounded by tight regulatory control in Western societies. However, for the most thoroughgoing anti-psychiatrists favour not tighter controls on compulsory admission, but the complete abolition of the phenomenon.One of the most influential critiques is that of Szasz (Szasz, 1960). 1.12.4.1 Szasz disclaims the label ―antipsychiatrist‖ and also insists he is not a philosopher, however his work could be seen both as the quintessence of ―antipsychiatry‖ and as having a strong influence on philosophical approaches to mental illness. Throughout his career he has stated emphatically that illness requires the presence of a physical lesion which causes disease. With mental illnesses, there is no identifiable physical lesion. Therefore ―mental illness‖ is a myth. This is not to say that the phenomena described as mental illnesses are not actually happening, but that they are not illness. ―Mental illness‖ involves a value judgement, whereas the diagnosis of bodily illness does not. What has formerly been termed mental illnesses are in fact ―problems of living.‖ This leads Szasz to a radical and continuing critique of psychiatry as a discipline (Schaeler, ed, 2004.) This subject is discussed in 100s of articles in cyberspace and I leave it to readers with the interest to follow the subject-up in detail. 1.13 This is a useful juncture to say a few things about co-dependency. Codependency is, at it's core, a dysfunctional relationship with self. We do not know how to love our self in healthy ways because our parents did not know how to love themselves. We were raised in shame-based societies that taught us that there is something wrong with being human. The messages we got often included that there is something wrong: with making mistakes; with not being perfect; with being sexual; with being emotional; with being too fat or too thin or too tall or too short or too whatever. As children we were taught to determine our worth in comparison with others. If we were smarter than, prettier than, to receive better grades than, faster than, etc. - then we were validated and got the message that we had worth. In a codependent society everyone has to have someone to look down on in order to feel good about themselves. And, conversely, there is always someone we can compare ourselves to that can cause us to not feel good enough. 1.13.1 Codependency could also be more accurately called outer or external dependence. The condition of codependence is about giving power over our self-esteem to outside sources/agencies or external manifestations. We were taught to look outside of ourselves to people, places, and things; to money, property and prestige, to determine if we have worth. That causes us to put false gods before us. We make money or attain some degree of achievement or popularity or material possessions or the "right" marriage and these things are a type of higher power that determines if we have worth. We take our self- definition and self-worth from external manifestations of our own being so that looks or talent or intelligence become the Higher Power that we look to in determining if we have worth. It seems to me that everyone is, to some extent, co-dependent, and for this reason
  20. 20. I have included this brief discussion here in my BPD account. For a comprehensive overview of the nature of co-dependency go to this link:http://www.survivingbipolar.com/green_codependence.htm 1.13.2 In the DSM-4(1994), and in the DSM-5(2013), it is much easier to get a diagnosis of BPD. Allen Frances, a critic of both the DSM-4 and the DSM-5, says that this ease, this extension, this widening of the definition and criteria for diagnosis, has created an incredible opportunity for drug companies. "Drug companies got indications for treating BPD," Frances says. "Not just with mood stabilizers, but also with the newer antipsychotic drugs. And they began very intensive ubiquitous advertising campaigns. The rates of BPD have doubled since the early 1990s. Many people have now had too much antipsychotic and mood stabilizing medicines. And these aren't safe drugs." "If diagnosis can lead to over-diagnosis and overtreatment, that will happen. Doctors need to be very, very cautious in making changes that may open the door for a flood of fad diagnoses." As far as Frances is concerned, the new DSM-5 is proposing too many diagnoses that are written in too broad a way, meaning that ultimately a huge number of new people will be categorized as mentally ill. But there are others, many, who do not agree with Frances. They see this new definition of BPD as an enabling process so that those who would not otherwise get treated will. 1.13.3 Since 1952, the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM, has been providing brief descriptions of each psychological malady said to afflict a patient. This bible of mental health treatment is published by the American Psychiatric Association (APA). Over the decades, the manual, adapted from a guide for mental diseases developed by Army and Navy psychiatrists, has ballooned. The number of listed disorders tripled to nearly 300. A few have been discredited and dumped along the way. As the task force producing DSM-5 posted drafts on its website: http://www.dsm5.org/Pages/Default.aspx an undercurrent of dissatisfaction exploded into a full-scale revolt by members of U.S. and British psychological and counselling organizations. The chief complaint is that the newest version will lower the criteria needed to diagnose some conditions, creating ―sub-threshold‖ disorders, and generally making it easier for healthcare professionals to label a person with a psychiatric disorder and medicate him or her. 1.13.4 Should a future DSM, however, adopt softer criteria, we may well see bipolar disorder broken down not only into I and II, as it has been since the 1994, but also bipolar III, IV, and maybe even V. We are talking about a multipolar phenomenon. A Dr Akiskal has been the main proponent of an expanded definition of BPD, one that would incorporate a good deal of the current unipolar population. Dr Akiskal has pointed out that many patients with so-called unipolar depression exhibit certain hypomanic (mild mania) symptoms. Though these symptoms may not add up to an actual hypomanic episode, Dr Akiskal maintains they constitute sufficient evidence of bipolarity. He thus has urged that this population be diagnosed accordingly. Even the best psychiatrist in the world is only as good as what you tell him or her, and his own knowledge base and set of biases. As well as confiding to your psychiatrist about how miserable you are, you should come prepared to talk about those times you felt agitated and irritable and even a little hyper. In other words, give your psychiatrist something to work with. The profession is still learning, but even a marginal improvement in outcome can make all the difference in the world, insofar as these factors are taken into consideration.
  21. 21. Go to these two links for more information: http://www.mcmanweb.com/multipolar.html and http://www.salon.com/2011/12/27/therapists_revolt_against_psychiatrys_bible/singleton/ 1.13.5 There is a world of language associated with an attempt like this to describe a lifetime of BPD. I only try to define some of the terms. For me the words short term apply to: today, this week and this month; medium term applies to a period of two months to a year. The two words "long term" applies to all the time after one year in my personal medical history, retrospectively or prospectively. I try, as far as it is logically possible, to use the term mental health or mental distress and not mental illness. This has been a recent emphasis in mental health discussions and in the literature. Apologies at the outset of this statement for the occasional use of complex language. The field of mental health is replete with complex terminology. It is helpful for those with different types of mental health problems to become as familiar as they can with this language. I try for the most part to use simple language—but I do not always achieve this aim. 1.13.6 A good example of the language difficulties is the following part of this paragraph discussing the neurobiological bases of behavioural differences. The language used by specialists is often way over one‘s head, both the head of the sufferer from BPD and the heads of others wanting to understand the disability. (See Erik Kandel, ―A Biology of Mental Disorder,‖ Newsweek, June 27, 2009; and C. Langan & C McDonald, ―Neurobiological Trait Abnormalities in BPD,‖ Molecular Psychiatry, Vol. 14, pp. 833– 846, published online on 19 May 2009) These two sources provide many excellent examples of this language complexity. The abstract of this article with this complex language is as follows: ―Dissecting trait neurobiological abnormalities in BPD from those characterizing episodes of mood disturbance will help elucidate the aetiopathogenesis of the illness. This selective review highlights the immunological, neuroendocrinological, molecular biological and neuroimaging abnormalities characteristic of BPD, with a focus on those likely to reflect trait abnormalities by virtue of their presence in euthymic/normal patients or in unaffected relatives of patients at high genetic liability for illness. Trait neurobiological abnormalities of BPD include heightened pro-inflammatory function and hypothalamic– pituitary–adrenal axis dysfunction.‖ 1.13.7 This problem of language is dealt with at the following link:http://www.healthyplace.com/blogs/breakingbipolar/2010/06/are-bipolars-crazy-i- am/ I like the word 'crazy' which the author of the above blog emphasizes and uses in her daily life with others. But the word, 'crazy' like 'mentally ill' or even such terms like 'mental health problems/issues', have their downside. In some ways, the problem raised is one of language. There is a world of language associated with attempts to describe one's experience with BPD over the short term or over a lifetime. There is the problem of the use of complex language. The field of mental health is replete with complex terminology. It is helpful for those with different types of mental health problems to become as familiar as they can with this language. I try for the most part to use simple language—but I do not always achieve this aim. Language is a problem not only with respect to mental illness but also with respect to many other complex problems in society. KISS, keep it simple stupid, does not solve all problems. Whom the gods would
  22. 22. destroy they first make simple and then simpler and then simplest. I will leave this problem here. 1.13.8 The term "Mental Illness" encompasses a wide range of conditions that have to do with the way the mind operates. Some of these conditions are caused by physical dysfunctions of the brain. Some are caused by various forms of emotional and psychological trauma. Some are primarily cognitive in nature. Some are primarily emotional in nature. 1.14 BPD presents particular challenges with regard to assessing response to therapy. Criteria for determining remission and recovery have been suggested for mood disorders, but the clinical usefulness of these terms in BPD is elusive. Formal psychological rating scales may be impractical in a routine medical practice setting. As an alternative, clinicians might probe for information about particular "signal events," such as sleep disturbances, that may herald mood fluctuations. The ultimate goal of bipolar management should be complete and sustained remission, whenever possible, although most patients will not achieve this status for any significant length of time. As I write this at the age of 69 sleep is still a problem: I spend 10 to 12 hours in bed daily, and get 8 to 9 hours sleep daily, on average. Often, although not always, two of these hours are in the day and evening. The side effects of each of the two medications I take include drowsiness(seroquel and effexor). After a meal I nearly always feel a need to have a sleep or rest; after two hours of human-interaction sleep or rest is also needed. 1.14.1 People tend to sleep more lightly and for shorter time spans as they get older, although they generally need about the same amount of sleep as they needed in early adulthood which, in my case, was 8 hours. About half of all people over 65 have frequent sleeping problems, such as insomnia. Deep sleep stages in many elderly people often become very short or stop completely. This change may be a normal part of aging, or it may result from medical problems that are common in elderly people. It may also result from medications and other treatments for those problems. For an excellent overview of the topic of sleep and bipolar disorder go to this link: http://www.survivingbipolar.com/green_sleep.htm 1.14.2 Overaggressive management might entail pushing medication doses to intolerable levels. Individual treatment goals should always take into account patient acceptance of the side effect burden, allowing for trade-offs between treatment effect and quality of life. Noncompliance with therapy, notoriously common among patients suffering from BPD, can stem from drug side effects, treatment ineffectiveness, or even treatment success if the patient misses the manic symptoms. Despite effective treatment, relapse is common. Realistic treatment goals should strive for sustained symptom abatement while maximizing patient quality of life from visit to visit. Ineffective therapy is disturbingly common. Therapy for the BPD in my life has been a complex and somewhat tortuous process with sometimes steep, sometimes very gradual, and seemingly non-existent learning curves. 1.14.3 According to a 2010 study published in the American Journal of Psychiatry, 42 percent of people in psychotherapy use 3 to 10 visits for treatment, while 1 in 9 have more than 20 sessions. A recent study by the National Institute for Health and Welfare in Finland found that ―active, engaging and extroverted therapists‖ helped patients more quickly in the short term than ―cautious, nonintrusive therapists.‖ More than an oasis of
  23. 23. kindness or a cozy hour of validation and acceptance, most patients need smart strategies to help them achieve realistic goals. As the years have gone on, the decades of treatment regimes, it is this that I have come to seek in my psychiatrist. To see more on this subject go to this link: http://www.nytimes.com/2012/04/22/opinion/sunday/in-therapy-forever- enough-already.html?ref=mentalhealthanddisorders 1.14.4 Some patients are unable or unwilling to step into the difficult and uncharted explorations that treatment for BPD and other psychiatric and psychoanalytic work entails. I had this problem, off and on, from 1968 to 1991. Each psychiatrist I had over the years made his effort to establish analytic contact and a therapeutic relationship. This was important to me in obtaining a level of valuable support, containment of my problems, and growth in dealing with my illness. Some patients, and I was certainly one during the quarter century from, say 1968 to 1992, may display great resistance to the challenge of psychiatric and psychoanalytic treatment. I was not what psychiatry calls "a turbulent patient," but I did have trouble with complaince. I never left treatment in a very abrupt and unprocessed manner, but I often would have liked to do so. For many their treatment is suddenly all over and that is that. This abrupt dismissal is usually a continued expression of their remaining pathology and the presence of conflictual phantasies that had been played out throughout the span of their treatment and the analytic process. This cannot always be prevented. 1.15 My wife, Chris, has suffered from different disorders and health problems all of our married life as well as in the years before our marriage in 1975. Her story is long with invasive surgery for two mastectomies and a hysterectomy as well as post-natal depression following two pregnancies and major psycho-social-family problems. I have not included her story here in any detail except in a tangential way when it seems relevant to my own experience of BPD. The references in this account to the three major families in my life: my consanguineal family(birth), my two affinal families(marriages) and their many extensions(children and cousins, aunts and uncles, etc.), my work experience and my values are emphasised in this account, but only briefly and only en passant. My religion, the Baha‘i Faith, which provides the major base for my values, beliefs and attitudes, is also important--but I do not focus on this Faith here, except in an indirect way. However important this religion has been to me in the past and in the present I do not refer to it except, as I say, in passing in my elaboration of my experience of BPD. 1.15.1 "Spirituality" as I define it here, is the basic feeling of being connected with one's complete self, others, and the entire universe. If a single word best captures the meaning of spirituality and the vital role that it plays in people's lives, that word is "interconnectedness." Spirituality should not be treated as a jargon to find place in philosophical books but it encapsulates the very essence of practising life with simplicity and being aware at the same time, of the immense complexity of life. Spirituality in the workplace can be of great help in increasing the productivity of each individual and organization in totality. In contrast to religion that is organized and communal, spirituality is highly individual and intensely personal. One doesn't have to be religious in order to be spiritual. A values-based organization results when the founders or heads of that organization are guided by general philosophical principles or values that are not aligned or associated with a particular religion as is the case with the vast majority of secular institutions: state and government, schools and hoispitals, inter alia.
  24. 24. In the changing business scenario there is a need to integrate spirituality into management. No organization can survive for long without spirituality and soul. Ways of managing spirituality without separating it from the other elements of management need to be understood and implemented for the holistic development of individuals and organization. The importance of practising spirituality in the workplace for that workplace to progress from cognitive intelligence to emotional intelligence and ultimately to spiritual intelligence which acts as a catalyst for inspirational leadership and management excellence is importnat for mental health. I have drawn on Rekha Attri's article "Spiritual Intelligence: A Model For Inspirational Leadership," in the International Journal's Research Journal for Social Science and Management, Vol. 1, No.9, 2012, for this concept. 1.15.2 A growing literature suggests that clinicians should consider the religion or spirituality of their patients as part of the psychiatric evaluation, one more piece of the puzzle that makes up the person, whom we try to understand as well as possible so we can provide help to the best of our ability. Studies to date have suggested three conclusions, all of which can be debated: 1) individuals with no religious affiliation are at greater risk for depressive symptoms and disorders, 2) people involved in their faith communities may be at reduced risk for depression, and 3) private religious activities and beliefs are not strongly related to risk for depression. Depression has been the most frequently studied of the psychiatric disorders in relationship to religion or spirituality, in large part because of the overlap in expression of both. For example, guilt associated with depression often is connected with a religious belief system, and apparent depressive symptoms (such as the ―dark night of the soul‖) are associated with religious experiences. For more on this subject go to this link:http://ajp.psychiatryonline.org/article.aspx?articleid=181239 1.16 The new diagnostic term, BPD, is now found in the Diagnostic and Statistical Manual of Mental Disorders-IV published by the American Psychiatric Association in 1994. DSM-III had 300 disorders twice as many as in the DSM-II. DSM-V is due for publication in 2013. The DSM is considered the bible by specialists and by the various professions and other interest groups. It is considered by many as a core/basic information source, a major scientific instrument in the field of mental health. In the DSM-IV the term maniac was deleted and the one-size-fits-all classification system for MD and BPD was more finely tuned by the 4th edition published in 1994. The exact discourse that has come to have jurisdiction in this labelling process, the circumstances that have come to result in a person given some mental illness label are due to: (a) norms and expectations as well as (b) medical, psychological, physiological and (c) most recently, neurochemical and electrical brain activity as seen in brain imaging. 1.17 This account also provides a statement of my most recent experiences with BPD in the last five years, 2007-2012. Some prospective analysis of my illness is also included with the view to assessing: potential short term, medium term and long-term strategies, appropriate lifestyle choices and activities in which to engage in the years ahead in these middle years(65-75) of late adulthood(60-80) and old age(80++), if I last that long. For the most part, though, this account, this statement I have written here in some 90,000 words, is an outline, a description, of this partially genetically predisposing family-based illness and of my experience with it throughout my life. 1.17.1 I would, though, discourage others from blaming their parents for their genetic
  25. 25. contribution to the disorders. I would also discourage them from blaming other family members for their contributions in the form of psycho-social stress and conflict and failure to understand. Rather than wasting time and energy in finger-pointing or bemoaning the fact that one has BPD, I would encourage sufferers to learn how to best use available treatment programs, or modalities as they are sometimes called in the literature, to minimize their symptoms and to find success and satisfaction in their lives despite their disorder. 1.18 Some of the personal context for this illness over the lifespan in my private and public life, in the relationships with my consanguineal family(family of birth) and in my two affinal families(families by marriage), in my employment life(1955-2005) and now in my retirement(2000-2013) are discussed in this document. I include in the description and analysis of my BPD some of what seems to me my major and relevant life events, not as triggers in my experience of BPD but as accompanying factors: (a) personal circumstances as they relate to my values, beliefs and attitudes--what some might call my religion as defined in the broad of senses; (b) family circumstances; for example, my parents‘ life, my wife‘s illnesses, the life-experiences of my three children as well as significant others in my lifespan like my father and mother and my first wife; (c) employment circumstances involving as they did: (i) psycho-social stress, (ii) movement from place to place and (iii) my sense of identity and meaning; (d) aspects of day-to-day life and their wider socio-historical setting and (e) details on other aspects of my medical condition to help provide a wider context for this BPD in the last two years. 1.18.1 I could explore section (d) above in some detail, but to be brief, let me simply add here that: processes of social inequality, poverty, human exploitation, besides many other ideological processes, install emptiness, disempowerment and lack of meaning in life. This is a frightening discovery because if we assume that this constitutes illness, the treatment for psychopathology should be a lot more complex than what have been traditionally used in clinical psychology and in psychiatry. It should give priority to political and community processes which help to make it possible and preserve mental health in addition to any neurobiological processes. 1.19 This lengthy account will hopefully provide mental health sufferers, clients or consumers, as they are now variously called these days, with: (i) a more adequate information base to make some comparisons and contrasts with their own situation, their own predicament, whatever it may be, (ii) some helpful general knowledge and understanding, (iii) some useful techniques in assisting them to cope with and sort out problems associated with their particular form of mental health problem or some other traumatized disorder that affects their body, their spirit, their soul and their everyday life and (iv) some detailed instructions on how to manage their lives more successfully despite the negative consequences of their BPD or whatever trauma or illness affects their lives. I am registered at over 100 mental health sites and contribute in ways that seem appropriate. But I do not assume the role of coach or mentor on the internet as some doctors, specialists and people who have experienced various forms of mental illness do at many sites on the world-wide-web. 1.19.1 Conventional research into mental health disorders is based on the assumption that professionals are better equipped to interpret the experience of sufferers because of their distance from the experience of the sufferers. It is perhaps now time for mental health service users to question the assumption that the greater the distance there is
  26. 26. between direct experience and its interpretation, the more reliable it is. Such an approach explores instead the evidence and the theoretical framework for testing out whether: the shorter the distance there is between direct experience and its interpretation then the less distorted, inaccurate and damaging resulting knowledge is likely to be." For an interesting discussion of this topic go to this link: http://www.qualitative- research.net/index.php/fqs/article/view/1790/3311 1.20 I like to think that what has become over the last few years this book of 160 pages has advice that could be used by many people with BPD as well as others without BPD. Keeping detailed records, for example, written or mnemonic, ingrained in memory and/or with signs for immediate recall when required--of one‘s feelings and relationships and, in the process, taking responsibility for maintaining and improving them, might help BPD sufferers and others deal with their problems and have more successful lives. As for the meaning of successful, I prefer Thoreau's evocative lines: "If the day and the night are such that you greet them with joy and life emits a fragrance like flowers and sweet- scented herbs; if life is more elastic, more starry and more immortal in the process--that is your success." Even ‗Abdu‘l-Bahá‘s ‗oft repeated phrase: ―Be Happy!‖ is a simple enough aphorism and yardstick for measuring your daily life, your sense of well-being and the extent to which you are well-oriented and well-positioned to assume the responsibilities that are the result of your interests and commitments. Of course, in using such definitions of ‗success‘ like this, one must recognize that millions of people without mental health issues don‘t have success defined in these terms. Finally, success and happiness are highly idiosyncratic terms and how each person sees them, defines them and experiences them are their own--even if there are many common threads from person to person. 1.21 There are two kinds of lists that BPD sufferers need to keep in mind in going about their daily lives in dealing with this disorder. So wrote one writer and, liking what he wrote, I include his ideas here. The first list is what you could call risk-factors that increase the chances of BPD sufferers becoming ill and/or having their symptoms dominate their daily life and produce ill-effects for themselves and others in their environment. Such socio-environmental factors as: family distress, psycho-social stress, drinking alcohol or using drugs, sleep-deprivation or missing medication are in this category. A second list of what could be called protective factors help to protect people with BPD from becoming ill, from having an exaccerbation of their symptoms. They include: keeping charts of one‘s moods and sleeping patterns, going to bed and getting up at the same time every day, staying on one‘s programs/regimes of medication and psychotherapy and avoiding psycho-social stressors that one knows will precipitate negative symptoms of BPD. 1.22 My note-taking and list-making are works-in-progress so to speak, and have been for years. How they are implemented varies from year to year and decade to decade. Now, at the age of 67, I keep: (a) a medical file in 5 sections in a separate briefcase. Readers can see the outline of this file in Appendix 7; (b) this 95,000 word and 160 page book updated to outline my life-experience of BPD; and (c) a written autobiography in 5 volumes which I update, as well as 1000s of prose-poems. I continue to write poetry each week. All of this helps me monitor my experience of BPD both directly and indirectly. I have used many charts, made many plans and tried to implement various safety-nets over my lifetime. Freeman‘s description of the ones BPD sufferers can use is the best I‘ve seen.
  27. 27. 1.23 I like to think that this account is crammed full of useful information for patients with BPD and other illnesses, for their family members, for therapists, for friends, lovers, employers and anyone else interested in BPD. The insights I share were not acquired by reading the voluminous literature on BPD, although I have taken a serious intellectual interest in the subject in the last decade since I retired from FT employment in 1999. My insights come, in the main, from reflecting on 69 years of life since my conception in October 1943. 1.23.1 I have benefited from what you might call the collective wisdom of others about what it means to live with BPD and other conditions. This wisdom comes from the reflections of other writers, from specialists, indeed a range of commentators. Finding solutions to my BPD problems and telling about what works for me taps into my creative resources and it also requires investigating my own trial and error efforts to create a personally satisfying life in order to separate what works from what doesn‘t work. Finding solutions and what works in one‘s own life is a form of artistry that can result in highly individual and unique solutions and outcomes. I like to think that this book taps into both my own wisdom and experience and the collective wisdom of others looking for a better quality of life by writing about what has been helpful for them as sufferers with BPD or some other condition or, indeed, as a loved one or family member. The medical psychiatric perspective believes in the centrality of genetic and biological approaches to mental ill-health over psychosocial ones and, at least in my case, this perspective informs this account. To put this idea another way, this account is based on the psychiatric perspective of the centrality of genetic and biological approach to mental health. 1.24 There are other psychiatric disorders often confused or associated with BPD and sufferers with BPD need to be aware of these other disorders in their diagnostic dialogue with their doctor and as they go about negotiating their lives. Differential diagnoses, as they are sometimes called, include: ADHD, schizophrenia, obsessive-compulsive personality disorder; recurrent major depressive disorder, schizo-affective disorder, post- traumatic stress disorder, narcissistic personality disorder, borderline personality disorder, antisocial personality disorder, avoidance disorder and cyclothymic personality disorder. I have many of the features of any one of these disorders except schizophrenia at one time or another in the last seven decades. I was officially diagnosed by a psychiatrist in 1968 as having schizo-affective disorder. All of the other disorders I can partly, indeed, significantly, identify with when I read the list of symptoms associated with each of them. I would not list these disorders here if I did not exhibit or have not exhibited many of their symptoms in my lifetime. 1.24.1 In one study of 60 patients with BPD, 23 (38%) fulfilled the diagnostic criteria for at least one personality disorder. Those personality disorders most commonly were: narcissistic, borderline, antisocial, avoidance disorder and obsessive-compulsive. In my case the obsessive-compulsive personality disorder(OCPD) and post-traumatic stress disorder(PTSD) have been the most dominant; I can now see looking back over seven decades of living, 1943 to 2013, periodic manifestations of both OCPD and PTSD at various points in my life-narrative. The presence of these other disorders sometimes make BPD symptoms more intense and more difficult to treat; they also appear to increase the risk of suicide. I will deal with my suicidal ideation later in this account of
  28. 28. my chaos narrative. This account is about BPD, by a person with BPD. My account only ventures into these several other psychiatric illnesses and personality disorders to a limited extent, and only from time to time when it seems relevant. I will deal with these personality disorders in my life briefly in the next several sections before continuing this account of BPD. 1.24.2 A personality disorder is an enduring pattern of inner experience and behavior: (a) that deviates markedly from the expectation of the individual's culture, (b) that is chronic, pervasive and inflexible, and (c) that affects two or more of the following areas: thoughts, emotions, interpersonal functioning and impulse control. To be considered a personality disorder the behaviour should also have an onset in adolescence or early adulthood, that is the years 20 to 40, be stable over time and lead to distress or impairment. Because these disorders are chronic and pervasive, they can lead to serious impairments in daily life and functioning. 1.24.3 In a list of ten basic symptoms of obsessive-compulsive personality disorder(OCPD), I possessed six symptoms rated at 5 or above on a 10 point scale in January 2010. I will not list these symptoms of OCPD here since this narrative and analysis is a focus on BPD, but readers can easily Google OCPD, if they are interested. Wikipedia is an informative source for information on OCPD. The pattern of behaviours for my OCPD has been highly diverse rather than stable over the years as far back as my childhood and has become more dominant, as I say, in my late adulthood, the years after the age of sixty on a new medication regime of an anti-depressant and an anti-psychotic. I will discuss this new medication regime in more detail later in this story. People with OCPD are ridden with anxiety. This overstates my level of anxiety. By contrast, people with OCPD tend to derive pleasure from their obsessions or compulsions. This is the case with me. 1.24.3.1 The primary symptoms of OCPD are: (i) a preoccupation with details, rules, lists, order, organization, and schedules; (ii) showing a perfectionism that interferes with the completion of a task, (iii) excessive focus on being productive with time and (iv) excessively devoted to work and productivity to the exclusion of leisure activities and friendships. People with OCPD, when anxious or excited, may tic, grimace, or make noises, similar to the symptoms of Tourette syndrome or do impulsive, and unpredictable things. Children are sometimes born with a genetic predisposition to OCPD, but may never develop the full traits. Windows of vulnerability to stress exist across human cortical development and this has: (a) a critical role in determining the brain's capacity to respond to stress, and (b) has been implicated in the pathogenesis of psychiatric illness. The neonatal and infant period, specifically the period less than 130 days, and the late adolescent periods represent critical windows of stress pathway development. I could comment in more detail here, and I do later in this account, on my pre-natal and neo-natal experience and its role in the etiology of my OPCD as well as BPD. Looking back to my early childhood there is some evidence that I had OCPD. The literature suggests that much depends on the context in which such children are raised. Since anxiety, trust and everyday routines of social interaction are so closely bound up with one another, it is easy to understand how the rituals of day-to-day life become a type of coping mechanism. Small children love ceaseless repetition, and frequently act in

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