Tag Archives: Psychosis

Dissociation #Write31Days

31 Days of Mental Health

Welcome to day 28 in the 31-day writing challenge on mental health. Today, I will be discussing dissociation. I used to have a diagnosis of dissociative identity disorder, but dissociation is also common in post-traumatic stress disorder and borderline personality disorder.

Dissociation refers to a detachment from reality: disconnection from one’s surroundings, one’s own body, one’s mental processes or one’s identity. there are five different domains of dissiociation:


  • Depersonalization: a disconnection from one’s own body or mental processes. People who experience depersonalization feel “unreal”.

  • Derealization: a disconnection from one’s environment. The world around people who are derealized seems unreal or vague, as if looking through a glass wall.

  • Amnesia or memory loss. People who experience dissociative amnesia can be triggered by things that remind them of an unpleasant memory, but they do not remember the unpleasant event. Amnesia can also refer to “time loss”, where the person does not know what happened during a specific time period. Identity amnesia refers to a person not remembering who they are.

  • Identity confusion. This refers to being unsure of who one is. I have always believed that everyone has a level of identity confusion, but when I did a structured interview for dissociation, it appeared as though this isn’t really normal.

  • Identity alteration or “switching”. This refers to a person becooming “someone else”. This ccan be apparent on the outside, like by the person having a change in non-verbal communication that is unlike them. It can also be apparent on the inside, where the person just feels as though they’re “someone else”.


Dissociation is different from psychosis in that people who dissociate are still aware of reality. Most people with dissociative experiences do not experience delusions or hallucinations, though a PTSD flashback coupled with dissociation can look like it. At least in my case, I’ve appeared quite disorganized and out of my mind when in a flashback.

Dissociation to a certain extent is normal. Most people on occasion get “lost” in a book or movie, for example. When dissociation is more severe, you may have a dissociative disorder. There are several different dissociative disorders.


  • Depersonalization/derealization disorder is characterized primarily by depersonalization and/or derealization. This disorder can only be diagnosed if the depersonalization/derealization is not due to another mental disorder, such as a panic disorder.

  • Dissociative amnesia is primarily characterized, as the name suggests, by amnesia.

  • Dissociative fugue. This is a subtype of dissociative amnesia where the affected person travels away from their home or work and has amnesia for their entire life prior to travelling away. They also often adopt a new identity.

  • Dissociative identity disorder is characterized by both amnesia and dissociative phenomena affecting identity, ie. identity confusion and alteration. DID is considered to be the most severe dissociative disorder.

Depersonalization and derealization can, as I said, be part of another mental disorder, such as panic disorder. There is also a subtype of PTSD which is characterized by depersonalization and derealization. Other causes of depersonalization and derealization include stress and certain substances, such as marijuana.

The other dissociative disorders are believed to be trauma-based. Treatment involves psychotherapy. The psychotherapeutic treatment of DID consists of three phases:


  1. Stabilization. In this phase of treatment, a person learns coping skills to deal with flashbacks, keep themself safe and stay grounded.

  2. Processing the trauma that caused DID.

  3. Integration. This can refer to merging of the alters, but also to rehabilitation.


In 2011, Onno van der Hart, Kathy Steele and Suzette Boon published a manual for skills training in the first phase of DID treatment called Coping with Trauma-Related Dissociation.

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Schizophrenia and Psychosis #Write31Days

31 Days of Mental Health

Welcome to day 24 in the #Write31Days challenge on mental health. As I said about a week ago, I’d write a post on schizophrenia and psychosis someday in this series. Today the day has come to write about this category of mental disorders. Most people admitted to psychiatric hospitals, and certainly most who are there long-term, have some form of a psychotic disorder. I do not and personally I find psychosis one of the most bewildering mental health symptoms.

Psychotic disorders are characterized by symptoms in one or more of the following five domains:


  • Delusions: fixed beliefs that do not change when the sufferer is presented with conflicting evidence. An example is the unfounded belief that one is being persecuted. Delusions are classified as bizarre when they are not understood by people from the sufferer’s culture and do not derive from ordinary life experience. In other words, a non-bizarre delusion is about something that could technically happen to the sufferer; a bizarre delusion is about something that is truly impossible. An example of a bizarre delusion is the belief that an outside force has removed one’s internal organs and replaced them by someone else’s.

  • Hallucinations: sensory perceptions (eg. smelling, hearing or seeing something) that occur without an external stimulus. Hallucinations are as clear and vivid as ordinary sensory perceptions. Hallucinations may occur in any sensory modality, but auditory hallucinations are most common in schizophrenia and related disorders. (Visual hallucinations are more common in neurological conditions.)

  • Disorganized thinking (speech). Formal thought disorder (disorganized thinking) is generally apparent through a person’s speech. For example, a person may switch from one topic to another (derailment or loose association). Rarely, a person’s speech may be so severely disorganized that it is barely comprehensible. These people’s speech is referred to as “word salad” (thhat’s the actual term used in DSM-5).

  • Grossly disorganized or abnormal motor behavior. An example of this is catatonia, a marked decrease in reactivity to the environment. People may “freeze” in a (usually odd) position. Other examples are complete lack of speech (mutism), repetitive, purposeless movements or repeating someone else’s words (echolalia) or actions (echopraxia).

  • Negative symptoms. These include reduced emotional expression and avolition. Avolition is a decrease in motivated, self-directed, purposeful activity. People may sit for hours and not be motivated for occupational, social or even simple household activities. They may therefore appear lazy.

Psychotic disorders may affect only one domain of symptoms. For example, delusional disorder is characterized by delusions only and no other psychotic symptoms. Sometimes, a person experiences more severe psychotic symptoms but the symptoms disappear within a month. This is called a brief psychotic disorder.

Schizophrenia is the most severe form of psychotic disorder. Individuals with schizophrenia experience symptoms in at least two of the domains listed above most of the time over a period of at least a month (or less if successfully treated). At least one of these symptoms must be delusions, hallucinations or disorganized speech. Since the onset of their symptoms, their functioning has declined significantly relative to their pre-illness level of functioning (in children or adolescents, consider failure to meet expected achievements in functioning). Even if the active phase of psychosis has subsided after a month, signs of disturbance remain for at least six months. If a person has residual symptoms for less than six months, they should be diagnosed with schizophreniform disorder.

The course of schizophrenia includes an active phase (at least one month during which at least two psychotic symptoms are present). This active phase may be preceded by a prodromal phase and followed by a residual phase. During the prodromal and/or residual phase, a person may experience only symptoms in one domain (usually negative symptoms), or they may experience two ore more psychotic symptoms but in a less severe (attenuated) form. Attenuated psychotic symptoms are symptoms that are similar to hallucinations, delusions etc. but are not full-fledged. Examples include odd beliefs or unusual perceptual experiences. Almost everyone experiences these at times. They become significant when they appear regularly and interfere with a person’s daily functioning. Some research shows that having attenuated psychosis symptoms is a risk factor for actual psychosis. However, there is no evidence so far that antipsychotics can prevent full-fledged psychosis in people who have only experienced attenuated symptoms.

Mental Illness: Nature or Nurture? #Write31Days

31 Days of Mental Health

Welcome to the seventh installment of the 31 Days of Mental health series. Today, I picked another of the 30 questions from the 30-day awareness challenge: do you believe nature (biology, physiology, etc.) or nurture (your psychosocial environment) causes mental illness? I am very tired, too tired to find the scientific evidence to back my post up with. will share what I do know off the top of my head, but please don’t ask me to cite my sources.

In medicine in general, there used to be a strictly nature-based model of illness and health. This determined that biological and physiological processes in the body caused illness and there was no contribution of psychological or social influences. This model is called the biomedical model and my health psychology book used it to describe the history of views on physical illness.

In mental illness, there have been many schools of thought that laid blame on the environment, in fact. For example, Freud blamed fixations in one’s psychosexual development for mental illnesses. The school of behaviorism also blamed the environment. Watson, the founding father of behaviorism, at one point said that, if given a handful of babies at birth to raise, he’d be sure he could make whatever you wanted the babies to become from them purely by processes of conditioning (behavioral learning).

It is interesting that there is such a distinction between the biomedical views on physical illness and the psychosocial views on mental illness. After all, though religion may say otherwise, scientists usually see the mind as part of the body. At least the brain is and dysfunction in the brain can cause mental disorders.

I currently study healht psychology at university. Health psychology feels illness as resulting from an interplay of biological, psychological and social factors. Again, they usually study physical illness, but I must say I believe the same goes for mental illness.

I remember when I was still diagnosed with dissociative identity disorder reading a scientific article that said in part that the role of psychological trauma in the cause of what is often diagnosed as DID may be less significant than people think. They used the analogy of borderline personality disorder, which they said most people diagnosed with DID truly have. BPD is commonly thought of as a developmental trauma disorder, but research shows that there may be genetic and other biological factors predisposing to its development. Then again, trauma researchers have made it very clear that trauma and other strong environmental factors alter the brain.

I personally tend to believe there is not a single mental illness that is solely caused by nature or nurture. There are illnesses where biology is the main causative factor, such as schizophrenia, and illnesses where psychosocial factors are the main cause, such as post-traumatic stress disorder. However, stress can trigger psychosis in vulnerable people and trauma only causes PTSD in some of its victims, presumably those biologically predisposed to PTSD.

As for my own mental illness, there are biological factors predisposing me to developing mental disorders. Though I don’t have any family members diagnosed with a mental illness, autistic traits run in my family. NOw again I don’t see autism as a mental illness, but autistic people are more vulnerable to mental illnesses than neurotypicals. I also was a preemie, which may’ve caused brain dysfunction. Lastly, though none of my famly members are mentally ill, a difficult temperament tends to run in my family.

As for psychosocial factors, I am a childhood trauma survivor. I also have had high levels of stress in my life, possibly due to the incongruence between my autistic self and the neurotypical environment. It was a stressful event that sent me over the edge, but it was probably biology that predisposed me to vulnerability to stress.

Love to Perseverate: Rare Diseases

This week at the spin cycle, we share something we love that everyone else seems to hate or something we hate that everyone seems to love. When it comes to interests and hobbies, my famiy is quite diverse. I, like my mother, am into crafting and reading. Like my father and possibly my husband, I like learning all kinds of new things from Wikipedia or the university library. I, however, am the only one who is interested in psychology and particularly psychiatry. It could be because I’m a nut case myself, though I also love learning about other fields of medicine.

It is not a terribly uncommon interest, but it just sounds weird saying you’re interested in rare diseases. Like, I can’t bring myself to like pages on Facebook on diseases that aren’t at least remotely related to my own conditions, just in case my family believes I’ve decided I have Zellweger Syndrome. For your information: this is a debilitating genetic syndrome from which affected children die early on.

Many people do read inspirational books by people who’ve overcome tragedies, including rare diseases. Brain on Fire by Susannah Cahalan, which I just finished, was a bestseller in the United States and possibly in the Netherlands too. I read the Dutch translation, because my BookShare account has still not been activated (still waiting on my doctor to write the proof of disability thing) and I didn’t want to buy the eBook when the Dutch audio book is available at the library for the blind for free. Anyway, while many people read the book, I’m sure most people didn’t remember every tiny detail on Cahalan’s condition, except for those who think they or their relative might have the same disease. And just so you know, Cahalan does link her condition, anti-NMDA receptor encephalitis, to some diagnoses of regressive autism, but I have no reason to believe I have this condition.

In Brain on Fire, Susannah Cahalan, a reporter at the New York Post, describes the process of her sliding down into madness. For a month during the spring of 2009, for which she herself has no memory, she has seizures and psychotic symptoms and finally becomes catatonic, hardly able to move or talk. Because her parents insist that she be hospitalized on a neurological unit, she is admitted to NYU Medical Center. There, neurologists and psychiatrists are completely baffled as to what is wrong with her. One diagnoses post-ictal psychosis (psychosis after an epileptic seizure), the next diagnoses schizoaffective disorder, and so on. Finally, Dr. Souhel Najjar joins Cahalan’s team after her previous neurologist gives up on her. Najjar thoroughly examines Cahalan and finds, when he asks her to draw a clock, that she places all the digits on the right side of the clock. This causes Najjar to realize that in fact Cahalan’s right brain hemisphere is seriously damaged. It isn’t saidhow he realizes that, in fact, her brain is on fire, being attacked by her own body. It also isn’t too clear what ultimately leads to the diagnosis, because Cahalan gets a brain biopsy but she later writes that only a small portion of people with anti-NMDA receptor encephalitis get brain biopsies.

The NMDA receptor, Wikipedia tells me, is a specific type of receptor for glutamate (a very important neurotransmitter). It is important in learning and memory. When antibodies attack this receptor, the disease Cahalan suffered occurs. Some people experience flu-like symptoms or headaches weeks or months prior to onset of the characteristic symptoms. Usually, the disease starts with behavior changes, which may vary depending on the patient’s age. Children may show violence and increased agitation, while adults may experience psychotic symptoms. As the disease progresses, symptoms may include paralysis of one side of the body, jerky movements (ataxia), autonomic dysfunction (problems with heart rate or blood pressure), or catatonia. These symptoms require urgent medical attention, because the patient may slip into a coma and die.

The book is much more intriguing than my boring summary of Cahalan’s disease. I just love perseverating on rare diseases, like I said, and this is the perfect opportunity.

#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.

Multiple Complex Developmental Disorder (McDD)

Multiple Comlex Developmental Disorder (McDD) is recognized as a subtype of PDD-NOS in the Netherlands. It is an autism spectrum disorder in which people also suffer from emotion regulation problems and thought disorders. Its proposed criteria according to the Yale Child Study Center are as follows:


  1. Impaired social behavior/sensitivity, similar to that seen in autism, such as:

    • Social disinterest

    • Detachment, avoidance of others, or withdrawal

    • Impaired peer relations

    • Highly ambivalent attachments

    • Limited capacity for empathy or understanding what others are thinking or feeling


  2. Affective symptoms, including:

    • Impaired regulation of feelings

    • Intense, inappropriate anxiety

    • Recurrent panic

    • Emotional lability, without obvious cause


  3. Thought disorder symptoms, such as:

    • Sudden, irrational intrusions on normal thoughts

    • Magical thinking

    • Confusion between reality and fantasy

    • Delusions such as paranoid thoughts or fantasies of special power



In The Netherlands, slightly different criteria are used. For example, social disinhibition is proposed as a possible symptom in the social impairments category.

In the Dutch Wikipedia, McDD is referred to alternatively as juvenile schizophrenia and juvenile BPD. However, most parent-directed sources highlight the intense anxiety which is at the core of McDD. Psrenting, therefore, needs to be aimed at providing structure and boundaries and helping the child reduce their anxiety and emotional lability. Parents need to refrain from showing too much emotion to prevent the child from absorbing the parent’s emotions.

Children with McDD often experience psychotic symptons or full-blown psychosis in adolescence. The emotion regulation problems become less pronounced as individuals with McDD grow into adults, but social problems an thought diosorders often remain significant. Antipsychotic medications can be used to help reduce psychotic symptoms. Even so, most McDD individuals will need lifelong support.

I do not have a diagnosis of McDD, although I think I may meet its criteria. I remember my parents were asked about thought disorder symptoms and unprovoked emotional outbursts at my first autism assessment, but they said I didn’t have them. In reality, I had a lot of bizarre thoughts as a child and still do have them sometimes, and my parents were confused about the questions on unprovoked outbursts. I have, interestingly, foudn that antipsychotics help more with the emotion regulation problems than with the thought disorder symptoms. This does mean that I suffer in silence soometimes, because I do have strange fears and bizarre thoughts, but am too drugged up to act on them.

The BPD Behavior Double Bind

Attention-seeking, manipulation. Many borderline personality disorder patients are accused of these, and I struggle as I come to terms with the fact that, indeed, a lot of my behavior at least comes across like this. For example, a few weeks ago, my crisis prevention plan was changed to the effect that staff no longer need to make me come back if I run off. It’s up to me to decide whether to run off and, if I do, what to do about it. After trying to communicate my discomfort with this change and being told off with references to choices and responsibility a few times, I ran off and wandered for about an hour until the staff eventually decided to find me.

I can see in a way how this can be interpreted as manipulative. The staff also said I have tremendous power when deciding to run off, because there is no way the staff can responsibly not take care of me eventually.

To my defense, I find myself in situations many times where I communicate in a normal way that I need support and am not being heard because other patiets, with different diagnoses, are acting out more. For example, today I asked the staff to take me on a walk because I was feeling irritable. They couldn’t, because there are several patients in a psychotic break right now. I rationally understand that my needs need to go on the back burner when people are in more severe conditions, but at the same time, this feels like a double bind. If I act out, I’m attention-seeking, manipulating and it’s my responsibility, but if I ask for support in a normal way, I’m obviously not sick enough to need it. In this situation, how am I supposed to show that I’m genuinely not coping?