Tag Archives: Aggression

A – #AtoZChallenge on Mental Health

Welcome to the #AtoZChallenge on mental health. I discussed many topics related to mental health already last October for #Write31Days. As I menitoned in my theme reveal post for the #AtoZChallenge, I’m going to give short descriptions of several words for each letter (sometimes though I have only one). For today, my letter A post, I have quite a lot of words. Here goes.

Acute unit


Also called “admission unit” in the Netherlands, here is where people go if they’re in crisis. The acute unit is for short-term treatment only: up to three months. Even so, some people stay there much longer. Like, I spent sixteen months on an acute ward because the rehabilitation unit didn’t want me.

Addiction

Though addictions are typically treated in separate units or even by separate agencies than mental illnesses, many people with a mental health diagnosis also have an addiction.

Admission

The process of getting admitted to a psychiatric unit. If people are admitted to an acute unit, this is usually through the crisis service or psychiatric liaison in the emergency department. On treatment units, such as for eating disorders or personality disorders, people usually get admitted through their outpatient treatment team. An admission interview typically consists of a brief assessment of one’s symptoms and some standard questions (eg. does the patient know where they are and what date it is). Details of the patient’s initial treatment may also be discussed.

Aggression

Aggression is quite common among mentally ill people, especially those in inpatient care. This may not be a politically correct statement but it’s true. Most times, this consists of verbal aggression, but nurses and patients sometimes get attacked physically too.

Alcohol

Alcoholism is not as common among mentally ill people in inpatient treatment – they often take their addictions out on other drugs. However, still you get the occasional alcoholic on an inpatient mental health unit. Most instituttions don’t serve alcohol in the cafeteria, though near my institution is the railroad store where they do sell alcohol.

Attention-Seeking

Us mentals are supposed to crave attention more than do people without mental illness, hence the common belief that a mental illness is “attention-seeking” behavior. Well, let me tell you: mentally ill people often keep their symptoms hidden for a long time and most don’t crave attention more than do mentally healthy people.

Attitude

A similar myth about mental illness is that it’s an attitude problem. It’s not. I wrote a post on mental illness and attitude last October. The idea that mental illness is an attitude problem is very damanging to people with mental illness, who often have a lot of shame as is. There is a group of people wiht an attitude problem here and they’re the people who think they can judge another person’s attitude like this.

#HighFunctioningMeans I Can Hold It Together Until Finally I Can’t

I had been doing quite well mental health-wise for a few weeks. I was in fact doing so well that I was beginning to doubt anything is wrong with me. Maybe I don’t have autism and borderline personality disorder after all.

Then on Thursday, I started feeling a bit cranky. I thought I was coming down with the flu again, as many people seem to get it a second time around. The self-doubts also became worse. Maybe I am too “high-functioning” to be in an institution, like so many parents of “low-functioning” autistic children used to say when I still had stronger opinions on autism than I do now. Maybe I fake the whole of my mental illness and developmental disability.

Then on Friday night all came crashing down. I had this huge autistic, borderline meltdown. I ran off the ward with just socks on my feet not realizing it was too cold and rainy for not wearing shoes. I was actually very confused. When a few people came by, I called out for help, but they went on chatting and, I thought, filming me. I have never been truly psychotic, but psychotic-like symptoms are common with both some forms of autism and borderline personality disorder.

Long story short, after melting down more on the ward once the staff found me, I spent the night in seclusion. I don’t advocate forced seclusion on anyone who isn’t physically harming anyone, and I wasn’t at the time, but I was confused enough that I could physically harm myself. I went into seclusion voluntarily.

About a week ago, some autistic bloggers launched a hashtag on Twitter: #HighFunctioningMeans. They meant to raise awareness of what it is like to be (seen as) high-functioning but still be autistic. I would like to contribute to this hashtag with this post.

I don’t have meltdowns everyday. Not anymore since going on a high dose of an antipsychotic. Before I went on medication, a day without meltdowns was indeed a rarity. Though I don’t become physically aggressive towards other people anymore, I have broken a huge amount of objects and become self-injurious. I in fact have done all the things parents of “low-functioning” autistics say their child does while in a meltdown, including as a teen becoming physically aggressive towards people. Now that I’m an adult, I still hand-bite, head-bang, throw objects, run into the streets, etc.

I am not proud of these behaviors. I wouldn’t medicate myself with heavy duty medications if I were. I do advocate finding better treatments for autistic irritability. The reason I write this, however, is to demonstrate that those who appear to be “high-functioning” on the Internet, or even those who appear “high-functioning” when you first meet them, can be severely disturbed when eventually they can’t hold it together anymore.

Borderline Personality Disorder and Anger

As you may’ve noticed, I like to pick my topics for my blog posts in the “mental health” category from recovery or awareness challenges. I don’t usually finish the challenge or answer the questions exactly as they’re asked, but I like to get them to zap me out of writer’s block. One such challenge is the “31 days of BPD” challenge. It asks 31 questions – one for each day – about life with borderline personality disorder. The first one asks you to describe why you were last very angry.

Now the thing about anger in my case is that I don’t usually remember why I get angry, or even what happened. Another thing is that I tend to get angry over the slightest things but then get to make my anger about lots of big and only partly related issues.

For example, a litle over a month ago, I got angry because the staff were decorating the unit for Christmas. I don’t even remember what exactly preceded my blow-up. I ended up running off the ward, wandering, and eventually taking some of my cltohes off so that I froze. When security got me back to the ward, I went into seclusion (voluntarily). I was determined I wasn’t going to go back to my ward. I was angry at the staff on my ward in general for there not being enough support for me or structure to guide me through the day. I eventually even said I wanted to be discharged if my only options were to stay in seclusion or go back to my ward (which indeed were my only options). Eventually, I did go back to my ward.

When I’m angry, I don’t really pick fights or become particularly angry at a specific person. Even when I do direct my anger at someone in particular, I usually don’t mean to single them out for my rage. I don’t ever become physically aggressive towands people, but I do usually shout obscenities and may direct my aggression towards objects.

For me, anger is usually accompanied by a fight-or-flight response. I usually flee in anger indeed, as was the case with the rage over the Christmas decorating I experienced last month. It seems in a way anger for me is close to other emotions, such as anxiety.

It is also closely related to sadness. I usually can’t cry unless I’ve been angry first. Often, also, when I’ve been depressed for a while, it tends to turn into irritability and may even turn into rage. The same occasionally happens with excitement, where I get so excited it turns into rage. In fact, any strong emotion in my case can turn into anger. It’s probably because, with BPD, my emotions tend to shift so rapidly. Maybe even anger is the only “bad” emotion I know.

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The Realities of an Asperger’s Diagnosis

A few weeks ago, I read an article in a women’s magazine about autism. It started out by explaining that autism is a spectrum and then went on to say that Asperger’s Syndrome is the mildest form of autism. Someone sent in a response saying that Asperger’s can be severely disabling too and, because it is often misunderstood, may be more severe in some ways than classic autism.

I have an Asperger’s diagnosis. I also have a high IQ. I can attest to the common misconcetpions surrounding an Asperger’s diagnosis. For one thing, the ability to speak does not necessarily mean that someone can communicate effectively. Even if speech on the surface makes sense, that doesn’t mean the Aspie’s words come out of their mouth as they were intended. However, because we have normal to above-normal intelligence, we’re assumed to “know better” and our miscommunicatin is understood to be willful misbehavior.

Speaking of behavior, it is a common misconception that Aspies don’t have as severe or as frequent aggressive or self-harming outbursts as those with classic or “low-functioning” autism do. H.L. Doherty, a father of a child with classic autism and an intellectual disability, often makes this mistake. He does so again when he talks about shards of severe autism reality. In this post, Doherty describes the consequencces of his son’s self-injurious meltdowns, and accuses autistic advocates of ignoring this reality. He connotes that those with “high-functioning” autism, ie those who can disagree with Doherty on the Internet, do not have these experiences. I, for one, do.

When I still lived in independence training, I had meltdowns almost everyday. An experience like the one Doherty describes is quite familiar to me and occurred regularly until I went on medication in 2010. My last episode of severe self-injury was two months ago, and it was so scary that I went into seclusion for a night.

Now I for one agree with Doherty on some controversies. I disagree on others. My agreeing or disagreeing and how eloquently I can put this into writing, does not change anything about my functioning level in any other area than written communication about a specific topic. I am too ashamed to write about some of my Aspie realities. The details of my severe self-care difficulties, for example. I know that Doherty and his supporters would not believe me anyway. After all, I’m so intelligent. Yes, I am. Relative intelligence is required for an Asperger’s diagnosis. That does not cause any of my difficulties to go away.

Medicating Away for Autism: Dilemmas and Disillusions

A few weeks ago, I saw an old post on autism and medicating and what’s the dilemma being tweeted again. It got me thinking about my own journey on the path of the medication controversy.

I first learned about autism and medication from the likes of APANA (Autistic People Against Neuroleptic Abuse) and Autistics.org. It was communicated clearly on these sites that autistics should only take medications if the right supports are in place, they’re themselves suffering (as opposed to the parents suffering from the autistic’s behavior) and if the medication is not an antipsychotic. I took this information at face value. When I was myself diagnosed with autism, I became an enthusiastic autistic advocate. I was soon disillusioned.

When the option of medication was first mentioned to me, I was miserable. I had the right supports, although I was soon going to lose them due to moving into independent living. An antipsychotic wasn’t the first medication mentioned. But it was what I ultimatley ended up on. I wrote a blog post the next day about really well-informed consent. I wasn’t really aware of the fact that I had truly been mildly coerced into consenting and that 95% of the “really well-informed” bit came from my own Internet searching rather than the psychiatrist.

I quit my antipsychotic eventually when I realized it was being used as a substitute for proper care. I used the side effects as an excuse, but really I was still miserable, only just not miserable enough for increasing my supports. I was really fortunate that the psychiatrist who ended up admitting me to the hospital three weeks later, didn’t consider prescribing me the same antipsychotic, or any antipsychotic, again.

For years, I was without daily medication. I noticed how the use of PRN oxazepam was coerced, and I wasn’t going to go along with it – unless I was truly miserable. Or unless seclusion was touted as the only alternative.

In late 2009 and early 2010, I had the worst irritability I’d had in years. I knew that I might benefit from more support, but I also knew this wasn’t feasible, and my support was okay at least. So when my psychologist proposed I talk to the psychiatrist about medication, I consented. The psychiatrist gave me plenty of inforation, including many of his reasons for and against particular drugs (mood stabilizer vs. antipsychotic and if an antipsychotic, which one). He also gave me a week to think, and I consider the consent I gave this time for taking the antopsychotic Abilify to be really well-infomred.

My dose, however, had to be increased several times. I remember once telling the substitute psychiatrist, a much less considerate doctor than my regular psychiatrist, that I felt I needed more support, but I was bluntly told off and prescribed a higher dose of Abilify. Of course, legally I could’ve refused, but the irony of informal hospitalization is that you’re mde to believe you have a choice, only you don’t. I had, after all, been threatened with forced discharge if I didn’t consent to seclusion a few years prior, and this time, I didn’t even have a home to go back to, so what choice did I have?

For three years, I did fine on a moderate dose of Abilify. I did get a low dose of the antidepressant Celexa added, which forutnately never had to be increased. Then, in the summer of 2013, I moved to my current institution and soon found I had more meltdowns. I was threatened with the locked ward, in the kind of way where nurses don’t really mean it but just want to scare the crap out of you, so what choice did I have but get my Abilify increased again. And again?

I’m now at almost the highest dose of Abilify that can be prescribed, a five-fold increase from my original dose. I’m feeling really drugged up lately and in a kind of agitated state where I’m too drowsy to get out of bed yet feel irritable nonetheless. I’ve raised this issue with the staff and my psychologist several times, but nothing has come out of it.

Currently, I’m taking an antipsychotic to manage behavior that other people suffer more from than myself while I don’t have proper support. After all, proper support isn’t needed when you aren’t a pain in the neck of the staff, and when you are a pain in the neck, it’s all “attention-seeking” and “overreactivity” and they’ll treat you like crap until you’re begging for a PRN pill. Is this what Autism Daddy means? I’m assuming he wants the right support for his son, but he doesn’t care that other people are drugged up for a dentist’s appointment. Now I know that his son is more severely aggressive than I was when I gave my really well-informed consent to the original dose of Abilify, but I’m still worried.,/P>

As I wrote in my previous post, my psychologist considers medication to be a substitute for proper support. I disagree, but I’m afraid that I just got to go along with it, and the fact that I’m an informally admitted patient only makes this a little harder.

Murder of Autistics: Understanding, Advocacy, Excusing

As H.L. Doherty writes, a mother killed her severely autistic child and herself. This is not the first murder/suicide where autism is involved, and it sadly will not be the last case I’m afraid. Doherty goes on in his post to shame autistic advocates who doubt that severe autism was the reason for this murder/suicide. I have to agree with the autistic advocates, in part: while circumstances can drive a person to murder or suicide, it is not like autism parents somehow need extra sympathy if they’ve killed their children. All parents of disabled children, and disabled people of any age themselves need understanding and support.

Let me tell you my experience. In 2007, I was quite severely disabled by my autism. I was aggresssive and self-injurious, including smashing my head into the brick walls of my apartment and trying to jump out of a moving car. I wasn’t being taken seriously by the crisis team, who said that admission to a hospital would not be good either. On November 2, I threatend suicide in my parents’ city, and the crisis team there took me seriously and admitted me to hospital. I got slightly bettter there, but still struggled. After years of having many meltdowns, I finally found medication that helped reduce my irritability. I have a post in the works about my changing attitude towards medication, recognizing that many autistic advocates are against the type of medication I take.

By 2015, I may or may not fall under the Long-Term Care Act. If I do, I’m entitled to residential care for as long as I need it. If I don’t, I need to get support at home, which I got a lot of already when I was in this severe state in 2007. Please note that I was quite aggressive and self-injurious all my life, and that it just escalated in 2007.

Please also note that I’m not the most severely autistic person imaginable. For one thing, I don’t have an intellectual disability and am mostly verbal. I do not claim to know what it is like to have an intellectual disability or be completely non-verbal. What I do claim to know about is the despair of having to deal with complex needs in a system that is facing massive budget cuts.

That being said, of course we need more supports for people with complex needs, including those with more severe autism than mine. Of course we need to understand how hard it can be to care for a person who has these complex needs. What I ask Doherty, however, is to also understand those people who live with significant disabilities.

Please understand, Mr. Doherty and supporters, that we don’t choose to be self-injurious, aggressive or have complex care needs for other reasons. We agree with you that more support is needed. I, for one, am realistic enough to admit that some people need drugs to curb severe aggression. (I take a high dose of an antipsychotic to prevent milder irritability, but I am not going to advocate that children or adults who can’t consent are forced to take this.) I, for one, have myself been suicidal, so I know what it’s like to want to end your life because of lack of care.

Where I disagree with Doherty and his supporters, is where he connotes that auitsm is the cause of murder/suicides like this one, in a tone as if to say that, as long as severely disabled autistics exist, we’re asking to be killed, or at least that killing us is understandable. And it is not. Writing about murder as if it’s somehow provoked by the victim’s disability, is denying the disabled victim the basic human right to life. It is not the call for support we, the autistic community, are fighting against, or even the fact that people with severe autism and an intellectual disability exist. However, I ask that Doherty et al. please stop excusing murder just because it offers an opportunity to advocate. No-one should be murdered. Stop excusing it.

I Am Astrid’s Functioning Label

Back in 2008, Bev over at Square 8 wrote a post entitled I Am Joe’s Functioning Label. The post struck a chord with me right the first time I read it, and, over the years, it has become more relevant. For those who don’t want to hop over to read the post, it’s about what the label “high-functioning” is perceived to say about an autistic person, and how this impacts the way autistics are treated.

For clartiy’s sake: I am not saying that people with an intellectual disability have it easy. The cuts to care and the accompanying independence doctrine affect them too. What I do mean is that it is often easier to understand why a person with an intellectual disability needs care than if you have a high IQ.

It is often presumed that a person who can do a cognitively challenging task like operate a computer, can also do more basic tasks like brush their teeth. In reality, these skills have nothing to do with each other. Another assumption is that people who know how to perform a task and/or why it’s necessary, can also perform that task. I remember even years before Bev’s post reading on Autistics.org about a woman who was getting ulcers beecause social services presumed that if she knew about hygiene, she must be albe to wash herself.

There are many more assumptions about people labeled high-functioning. Here are a few that are affecting my life.


  1. Because of my functioning label, I am presumed to be safe in traffic. Since starting to learn a tiny route around the building, I am not only allowed to leave the ward alone without any purpose, but am expected to leave the ward if I’m angry.

  2. Because of my functioning label, I am presumed to be able to take care of my personal hygiene without reminders or help. This is in a way somehting I don’t want to change, because the reason I’m not able to perform some skills of personal care is because of sensory issues.

  3. Because of my functioning label, I am presumed to know how to solve problems myself even when anxious or overloaded (my fuctioning label dictates that overload is just an excuse to avoid demands). I am presumed to be able to make my needs known in very specific terms.

  4. Because of my functioning label, I am thought to be able to perform practical skills like making a bed or pouring coffee myself. Ironically, the motor deficits which cause me to be unable to perform these tass, were originally thought to be especially common in Asperger’s Syndrome.

  5. Because of my functioning label, I apparently don’t need a lot of structure. This means I am presumed to be able ot schedule activities without help.

  6. If I get overloaded, my functioning label dictates that it was my own choice and I’m depriving other people of the right to make noise.

  7. If I have a meltdown because my routine is interrupted, again, my functioning label dictates that I’m just spoiled and trying to always get my way.

  8. Because of my functioning label, I am presumed not to engage in aggressive or self-injurious behavior. If I do, it’s obviously because of BPD-related attention-seeking.


Yes, I see that a lot of these assumptions are not just based on my functioning label, but also on my co-occurring diagnosis of BPD. Before I had this diagnosis, not only was I not presumed to be unwilling to act normally, but my autism was presumed not to be as mild as it is now. Hence, an additional diagnosis makes it seem as though I’m less severely affected. Isn’t that ironic? By the way, if instead of Asperger’s and BPD, my diagnosis had been multiple complex developmental disorder (McDD), which is characterized by practically the same symptoms, I would likely have been seen as quite severely autistic.

Gender and Autism Stereotypes: Problems for Autistic Girls

Yesterday, I bought Parenting Girls on the Autism Spectrum by Eileen Riley-Hall. I’ve only read bits and pieces of it yet, but what struck a chord with me are the problems faced by both passive and aggressive autistic girls due to gender stereotypes and stereotypes about what autism should be.

First, most girls on the autism spectrum are passive. This can easily lead to them being ignored in a classroom or even at home. I notice this on my ward, too, because I’m fairly withdrawn. Because of this, my needs are not always met, as there are many patients who act out to get what they need. In the book, Riley-Hall talks about a girl in her daughter’s nursery who was so shy that she could easily be isolated if not for her attentive teacher. Passive autistic girls, according to Riley-Hall, need as much one-on-one attention as possible. This seems coutnerintuitive, because they aren’t causing any trouble or being a danger to themselves or others. Then again, they too need to learn to relate to others. It is sad in this respect that isolation is no longer a ground for care in the Netherlands. Apparently, you need to be aggressive to be seen. Please note that, in DSM-IV, passive autism is seen as more severe than the active-but-odd type.

Yet aggressive autistic girls are also often mistreated. According to Riley-Hall, gender stereotypes dictate that less aggression should be expected and tolerated from girls than from boys. Consequently, if an autistic girl acts out, she’s punished more harshly than a boy. Riley-Hall does not say this, but it is my expereince that aggression in women and girls is also interpreted differently than in males. For example, many more women are diagnosed with borderline personality disorder rather than for example ADHD. Fortunately, researchers and clinicians are becoming more and more aware of gender differences in the symptoms of psychiatric and neurodevelopmental disorders.

Disciplining the Autistic Child

Many autistic people, if not all, exhibit challenging behavior, such as anger, aggression, obsessive-compulsive behaviors and sterotypical (self-stimulatory) behaviors. Whether and how you intervene with these behaviors, depends on their function. Autistic children exhibit normal childhood misbehavior too. For example, they may nag and tantrum when you won’t give them candy, refuse to tidy their room, or be rude. This behavior can be punished in the same ways that you would use for a same-age typical child, such as by time-out, loss of computer or TV time, etc. Take into account that some consequences may not work for your child. For example, an aloof autistic may find time-out comforting, and most autistics do not get non-verbal cues. Therefore, even with an older child, you need to say explicitly that you are disapproving of their behavior. You also need to make sure the autistic child understands what they are punished for. If they are rude, for example, explain what they said that was rude, how they can make amends, and what they need to do differently the next time. When sending a child to their room, onto the naughty chair, etc., make sure they understand when they can come back. I was often sent to my room and stayed there for hours because I didn’t know when it was okay to come back. Don’t tell a child to come back when they “can behave”. Instead, set a specific time or make concrete rules on what they must do to come back.

As I said, whether and how you intervene with your autistic child’s behavior, depends on its function. Often, a function is presumed based on typical chhild development. For example, suppose your child refuses to tidy their room. You assume they are defiant or lazy, but do they know how to tidy their room? Even if you’ve shown them before or they’ve helped, you cannot expect all autistics to know when or how to do their own tidying or cleaning. I remember when I went to live independently out of an independence training home, my support worker told my knew staff that I knew how to clean. I did, but I had no idea where to start in my new apartment. This may in part be due to blindness, but even as I became familiar with my apartment, I still didn’t know how to organize my cleaning.

Then there are those behaviors that are often due to autism, such as sensory overreactivity, self-stim, or meltdowns. Give yoru child a time and place to engage in self-stim or compulsions, of course with the premise that they won’t damage property or harm themself or others. In 2007, when I was diagnosed with autism, my diagnostician told me that I really needed to unlearn to twirl my hair. Indeed, my parents had told me countless times that I needed to stop this behavior. While it is true that it is annoying and distracting to others, autistics need to be allowed their time to stim. Home is where a child should be safe to be themself. When talking about self-stim and how annoying it is when it’s an autistic doing it, I often refer to a lecture I was going to in college prep. Two students were modeliing appropriate and inappropriate communication skills in their filed. One of them was constantly clicking his pen, and I was assuming at first that this was meant to be inappropriate. It wasn’t. My point is, neurotypical people stim too.

When an autistic person becomes aggressive, be it verbally or physically, you need to intervene. However, it is still important to recognize the function of the aggression. For example, if a child constantly screams or hits when there’s loud noise, screaming at them to stop, will make it worse. Time-out in a quiet place where the child can rage away may be the most appropriate intervention. I strongly disagree with locking up an aggressive person in their time-out area unless there is no other way (except for restraint) to get them to stop. Locking the child up should never be used as a threat or for punitive purposes, and I doubt its effectiveness for verbal aggression. That may be my blindness though, as verbal aggression to me is as scary if it happens in the locked room next door. As for restraint (physically holding the child down), that’s only okay if a person is physically aggressive towards people.

One important point I want to make to finish off: be mindful of your own feelings when handling your autistic child. The moment you start feeling powerlessness or feel you’re going to lose your temper, step back. My parents often lost their temper with me, and this usually only made the situation much worse. I won’t say that you can always feel calm when handling your autistic child’s behavior, but strong emotions can be best handled away from your likely already distressed child.

Antipsychotic Use in Autistics

Someone in a support group for pathological demand avoidance (a form of autism that is mostly only recognized in the UK) asked about using Risperdal (risperidone) for aggression and anxieyt. This prompted me to write about my experiences of medication use, and I want to elaborate on them, particularly as I made an interesitng self-observation today.

There is a lot of controvery surroudning the use of medications, particularly antipsychotics, for autism spectrum disorders. I personally do not disagree with the use of antipsychotics. They have a relatively solid evidence base, especially Risperdal and Abilify (aripiprazole). I have used both myself and currently take Abilify in a fairly high dose.

I have pointed this out before, but I want to say it again: if there are other changes in treatment, placement or support happening near the time you’re wanting to start medication, that’s not a wise moment to start medication. I started Risperdal a week before my move into independent living, and, if it had any effect at all, this was annihilated by the effects of the move. Also, don’t expect antipsychotics to get someone through a rough time These drugs are designed for long-term use and usually take several weeks to kick in. Benzodiazepines are better in this case, but don’t expect medications to cure support needs. Autistic people will always need support.

Antipsychotics are commonly used for aggression and irritability, but I made this interesting self-observation that my Abiilify also seems to help with rigidity and the resulting asocial behavior. I remember a few years ago reading a case study on the use of Abilify for core symptosm of Asperger’s (I’m too lazy to look up the reference). This may pose its own ethical dilemmas, cause what do we want to change about a utistics (especially children or others who are incapacitated) and what falls within the realm of acceptable neurodivergence? I wont’go into this right now.