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Diagnostic challenges. This is something I'm studying at the moment. Basically the DSM is bullshit. It relies on the biomedical model, which is way too simplistic. Depression is caused by a lack of serotonin. The evidence for that isn't great but OK. What causes the lack of serotonin? Genes which influence the availability of serotonin in the synapse? The evidence for that isn't great either. Obviously it comes down to genes and neurotransmitters at some point, but that's obvious and doesn't get us anywhere. "The diagnosis of MDD does not yet map very well with underlying biology or treatment outcomes." Yet? You're assuming that it should. There are indeed no easy solutions.

I have to write an essay on this topic. The lecturers at the university I go to are very skeptical about the DSM, to put it mildly. I do sort of agree. Anti-depressants were discovered by accident and the theory followed. But the theory hasn't been able to muster much supporting evidence. SSRIs work for a lot of people, me included, but saying that it's due to a lack of serotonin cuts out any other factors. And those other factors are a better predictor of mental health problems.

Sorry. Rambling on. I haven't even started my essay yet. Something one of our lecturers said was that asking what is wrong with someone is the wrong question. Ask them why they think and feel like they do. I like that. Don't label people with an illness when it's probably a response to their experience. He gave an example of a woman he'd seen when he'd worked as a clinical psychologist. Yeah, horrific story. She finds it hard to trust people? That's a reasonable response to such shit. Maybe she needs some prozac to boost her levels of serotonin. Or maybe the fucked up world we live in made her feel like that. We can all agree that sexual assault is a bad thing right? It's not a problem with her, it's the fuckers who did that to her. And they don't need prozac, they need me to kick them so far up the arse that they can lick my boot clean.

Sorry. Rambling post which went on far too long.

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7 minutes ago, Fluent In Silence said:

It's not a problem with her, it's the fuckers who did that to her. And they don't need prozac, they need me to kick them so far up the arse that they can lick my boot clean.

and for THOSE people, it is probably a trauma response. From people who abused people as a response to trauma. And so it goes. There is a 1st testament verse that 6 or 7 generations of sons ay for sins. And modern thinking is intergenerational trauma takes 6 or 7 generations of people trying really hard to flush it  out and have healthy dynamics

 

but on the rest of your essay, have you read about HiTop model? https://renaissance.stonybrookmedicine.edu/HITOP/AboutHiTOP

 

like your uni, unis here hate the dsm

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Personally, I don't agree with much of the mental health industry as a whole, psychiatry, American psychiatry and the DSM in particular. However, I am what I consider to be one of those "especially mentally interesting people", because my presentation both takes a large shit on what the mental health profession believes about MDD, and has a lot to offer, that is if the given professional is willing to learn from me and it. 

That's because not only am I one of the poor fucking souls who has very treatment resistant MDD, but its clinical presentation and overall psychopathology comes from multiple perspectives, biochemical being only one of them, and even the biochemical component clearly shows that serotonin ain't the only neurotransmitter that can go wrong in MDD. In addition to the biochemical, there is also my developmental trauma and complex trauma's impact on physiology and psychomotor functioning, the gaps and deficits caused by child abuse and neglect and their impact on overall functioning, as well as complex trauma's impact on depressive thinking and behaviour. 

After that, there is also my experience as an autistic and trans person in this world. Both my autistic traits and behaviour have a significant impact on the way my MDD presents clinically, as well as on the efficacy of treatment, and so does the societal impact of being an autistic person in a neurotypical world, as well as the components of my child abuse history that are specific to being autistic. 

The same goes for being a trans person, particularly the societal component, as well as the legal limitations and dehumanisation that has brought, and still brings to my lived experience as a whole. Being a trans person significantly reduces my quality of life and is the main contributor towards my chronic suicidality, which obviously tie back to MDD also. 

All of them are connected, but still need to be addressed as their own, individual things. The largest contribution towards why I have not found any successful treatment is the profound lack of multifaceted and individual (to the person) approaches, and the lack of humane practices and acceptance of the societal and human rights problems that contribute to my presentation. Although that is putting it rather simply, which yes, is not the reality of how any severe mental illness works. There is clearly also a problem that derives from the lack of other biochemical approaches and research, problems from lacking disability accommodation, and so forth. 

Part of my child abuse also included severe head trauma that has left me and some lobes in my brain with permanent damage and injury that equally has an effect on my mental health and functioning, and part of my child abuse history is that I experienced prolonged bouts of catatonia in my childhood and adolescence that I am yet to fully recover from, and may not ever fully recover from. 

When mental health professionals meet me and get to see and know how I work, and how my autistic brain works, to say they are shocked and that my presentation isn't expected is a massive understatement, and unfortunately, that alone means they either refuse to treat me, or are not able to, because they lack the knowledge and expertise. 

One of my pet peeves is the fact that communicating with most of them is not only a huge drain on my already extremely limited energy, but is like trying to have an adult conversation with a 2 year old who can only say about 6 words. Except when you communicate with said 2 year old, you go into the interaction knowing they are 2 years old and have limited speech and cognitive capacity. You do not go to a grown ass mental health professional with extensive higher education and qualifications expecting them to be a right cunt who is as competent as a pile of lifeless dog shit on the ground, or at least most people don't. I do, because that is what experience has taught me to do. 

But you get the point. It is still beyond flabbergasting and a source of disillusionment when you go to a professional, and you are the more educated and competent one, and instead of receiving help and a way forward, or at least some kind of treatment, you walk out utterly exhausted, having wasted your time, wishing you could plummet from a high rise building to finally put an end to this existence that is filled, and has always been filled with exactly nothing but unnecessary suffering and relentless trauma.

 

Edited by Hopelessly Broken
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Yes. That doesn't mean they consistently use all of them or that they use them correctly. Nor do they speak in congruent sentences, as opposed to just singular words and sounds, nor do they even necessarily make sense. That is my point.

Edited by Hopelessly Broken
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I remember that in one of the foster placements I was in as a teen, there was another autistic boy, but he was 2 years old. He was a foster kid who was only there for respite. His speech was a lot more limited than a neurotypical 2 year old's and mostly consisted of echolalia, however he had a couple of things he said that weren't echolalia. 

One of them resulted from the first time he was given spaghetti bolognese. He called it pooketti, because the mince beef looked like bits of poo to him and he couldn't pronounce spaghetti. He absolutely hated pooketti because of the fact it, to him, had poo in it, and you obviously don't eat poo. If you gave him pooketti, he would refuse to eat it and have a legitimate meltdown, understandably. 

Not long after he started saying pooketti, he began referring to everything else he hated as pooketti, because no one had taught him how to express his hatred or dislike, or general negativity. He started going to kindy not long after. 

Someone asked him how his first day at kindy was. Pooketti, he said. At least that actually makes some sense. I have come across several mental health professionals who didn't have even that level of sense or communication skills.

 

Edited by Hopelessly Broken
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3 hours ago, Fluent In Silence said:

asking what is wrong with someone is the wrong question. Ask them why they think and feel like they do. I like that.

I don’t. It sounds a great deal like a great step backward to Freudian psychology to me. No, Dr. Freud, my refractive MDD has not one thing to do with anything situational, circumstantial, or œdipal. Now, to be fair, my particular flavor of MDD appears not to have a great deal to do with serotonin either, because SSRIs have done fuck-all to relieve my distress. Meds that regulate dopamine, however, have. Therefore, empirically, I feel confident in saying that some failure of my dopamine system is at play, and we can point to a biomedical issue as a strong candidate for causality, at least in part.

Asking the patient why they think and feel the way they do strikes me as throwing the onus of diagnosis back onto the patient - if the patient knew the answers to those questions, he wouldn’t need the psychiatrist. And if the psychiatrist is asking himself those questions about the patient, the answer (if the doctor isn’t a Freudian quack) is eventually going to circle right back around to a need for data-based, quantifiable diagnostic criteria, and a guideline like the DSM.

Before I ever took meds, I tried to treat my condition with therapy alone for a decade. While that work gave me a solid set of cognitive skills to cope with the worst, it became clear that talking about why I feel the way I feel wasn’t going to cure anything. Why not? Because being ignorant of the way I felt or why I felt it wasn’t the cause for my feeling it.

Without a doubt, trauma is at least partially causal for some types of MI, or may exacerbate existing biochemical dysfunction. But my pdoc is the one who actually makes my life tolerable, and he does it by treating my neurotransmitters.

The history of the development of the DSM is interesting reading. The DSM is absolutely a flawed document, but it isn’t useless, and there isn’t really a workable alternative. Certainly not such that anyone can credibly pooh-pooh it and say “let’s forget that and do something else”. It’s not that easy.

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this is quoted from a letter which i wrote to one of my doctors earlier this year

 

"

One of my old psychiatrists, Dr green in Ballarat used to ask routine screening questions. One of them was “What causes mental illness, and why has it chosen you and not someone else?” And if I was asked that question now, I would say genetics generated the core, but health professionals and the health care system compounded it, made it worse. And added whole new issues

"

 

the question was a screen for delusional thinking, and captured a bunch of trauma etc responses too

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By the way, just to clarify. I am not saying that the DSM doesn't exist for a reason or that it is completely wrong and invalid, nor that psychiatry and the mental health industry as a whole are. Not saying that there shouldn't be, and doesn't need to be a biomedical, clinical and diagnostic model, whether that be chemical or otherwise. Just that it is important to recognise and accept that all of them have flaws and all of them have done, and can do wrong. That all of them, by no means are a complete strategy for managing mental illness, and especially not any severe or complex mental illness. 

People do the same in regard to models of disability and disability service. People ask which is superior, the medical model or the social model. They should be asking what is right and what is wrong in both of them, because they also both have their flaws and limitations. What a disabled person takes from both of them should be up to them and their individual circumstances, and it goes without saying that ought to include that people should have the right to say when reality is that they have needs that cannot be met by either of them, when alternative measures are required. 

The same should be the case for this, in my opinion. 

Edited by Hopelessly Broken
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11 hours ago, Fluent In Silence said:

Diagnostic challenges. This is something I'm studying at the moment. Basically the DSM is bullshit. It relies on the biomedical model, which is way too simplistic. Depression is caused by a lack of serotonin. The evidence for that isn't great but OK. What causes the lack of serotonin? Genes which influence the availability of serotonin in the synapse? The evidence for that isn't great either. Obviously it comes down to genes and neurotransmitters at some point, but that's obvious and doesn't get us anywhere. "The diagnosis of MDD does not yet map very well with underlying biology or treatment outcomes." Yet? You're assuming that it should. There are indeed no easy solutions.

I have to write an essay on this topic. The lecturers at the university I go to are very skeptical about the DSM, to put it mildly. I do sort of agree. Anti-depressants were discovered by accident and the theory followed. But the theory hasn't been able to muster much supporting evidence. SSRIs work for a lot of people, me included, but saying that it's due to a lack of serotonin cuts out any other factors. And those other factors are a better predictor of mental health problems.

Sorry. Rambling on. I haven't even started my essay yet. Something one of our lecturers said was that asking what is wrong with someone is the wrong question. Ask them why they think and feel like they do. I like that. Don't label people with an illness when it's probably a response to their experience. He gave an example of a woman he'd seen when he'd worked as a clinical psychologist. Yeah, horrific story. She finds it hard to trust people? That's a reasonable response to such shit. Maybe she needs some prozac to boost her levels of serotonin. Or maybe the fucked up world we live in made her feel like that. We can all agree that sexual assault is a bad thing right? It's not a problem with her, it's the fuckers who did that to her. And they don't need prozac, they need me to kick them so far up the arse that they can lick my boot clean.

Sorry. Rambling post which went on far too long.

If you’re quoting the DSM as saying they don’t know the biomedical cause of depression, that means they do not present serotonin to be the sole cause of depression. And I think that saying “not enough serotonin” is the common psychiatric theory  might be overly simplistic. SSRIs can increase available serotonin, but that doesn’t mean serotonin is the direct cause of anything, and I think many psychiatric professionals acknowledge this without argument. I am also in agreement that following the DSM can be perilous, but we also have to remember it is meant a) target majority population presentations, so (as mentioned above) atypical presentations definitely get shorted but empirically many people won’t and b) provide continuity of care. Psych services are already so fragmented, if there wasn’t some sort of common language things would go from shitty to more shitty very quickly. 
Good prescribers know that DSM/biomedical approaches need to complement psychosocial factors, which helps to make things less evil 

Edited by Iceberg
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7 hours ago, Iceberg said:

that doesn’t mean serotonin is the direct cause of anything, and I think many psychiatric professionals acknowledge this without argument.

That is true and it's something I wondered about. Nobody really thinks that it's as simple as a lack of serotonin right? Not really, but we seem to act as though that was the case. When I first went to the doctor to seek help I told her that I was depressed. She gave me the PHQ-9 to fill in and told me that yes I was depressed and should take these pills. Yeah fine, meds have helped and I'm not at all against them. There's a lot of other things she could've asked about though. Depression isn't the same as having a rash but that's how it gets treated. Maybe that's unfair. I haven't had much experience with mental health services (I tried once but it didn't go anywhere) so maybe people who have had more experience think differently. It does always seem to be the default thing though. I just need more serotonin, nothing at all to do with social isolation and borderline alcoholism. The meds helped but maybe if she'd prescribed me a course of hugs it would've helped even more. Although needing a prescription to get a hug sounds bleak. God I'm talking shit again!

15 hours ago, Cerberus said:

I don’t. It sounds a great deal like a great step backward to Freudian psychology to me. No, Dr. Freud, my refractive MDD has not one thing to do with anything situational, circumstantial, or œdipal. Now, to be fair, my particular flavor of MDD appears not to have a great deal to do with serotonin either, because SSRIs have done fuck-all to relieve my distress. Meds that regulate dopamine, however, have. Therefore, empirically, I feel confident in saying that some failure of my dopamine system is at play, and we can point to a biomedical issue as a strong candidate for causality, at least in part.

Asking the patient why they think and feel the way they do strikes me as throwing the onus of diagnosis back onto the patient - if the patient knew the answers to those questions, he wouldn’t need the psychiatrist. And if the psychiatrist is asking himself those questions about the patient, the answer (if the doctor isn’t a Freudian quack) is eventually going to circle right back around to a need for data-based, quantifiable diagnostic criteria, and a guideline like the DSM.

Before I ever took meds, I tried to treat my condition with therapy alone for a decade. While that work gave me a solid set of cognitive skills to cope with the worst, it became clear that talking about why I feel the way I feel wasn’t going to cure anything. Why not? Because being ignorant of the way I felt or why I felt it wasn’t the cause for my feeling it.

Without a doubt, trauma is at least partially causal for some types of MI, or may exacerbate existing biochemical dysfunction. But my pdoc is the one who actually makes my life tolerable, and he does it by treating my neurotransmitters.

The history of the development of the DSM is interesting reading. The DSM is absolutely a flawed document, but it isn’t useless, and there isn’t really a workable alternative. Certainly not such that anyone can credibly pooh-pooh it and say “let’s forget that and do something else”. It’s not that easy.

Freud can go fuck himself. Or go fuck his mother. I remember once nearly making everyone here hate me by suggesting that personality disorders aren't real. The distress and difficulties people face are completely real of course, but personality disorders, and mental health conditions generally, are just an abstract concept, which has its uses but shouldn't be taken too seriously (the concept I mean. Not saying people with mental health problems shouldn't be taken seriously). I was talking about this with someone who isn't studying psychology, but she asked me some good questions  which get to the heart of it. How do we define normality? We can't. I'm an atheist, so people who do believe in God(s) have a completely different conception of reality to me. People who think that the CIA has implanted chips in them in order to monitor their every move are crazy. People who believe that there's someone up there watching over us is spiritual. I know this might sound like I'm trying to insult religious people but I really don't mean to. The point is that we can't agree on normality. So how do we define abnormality?

Another thing she mentioned was how homosexuality used to be considered a mental disorder. It was in the DSM until the 70s I think. I don't know what the diagnostic criteria was. "How many times a week do you feel fabulous?" Sorry. Stereotypes. I imagine a lot of gay people did have mental health problems. The prejudice they had to face would've taken its toll. But us heterosexuals finally decided that it's fine to be gay. Turns out it wasn't a problem with you, it was a problem with our dumb fucking homophobic thoughts. I know I'm arguing against the DSM but homophobia should be classified as a mental illness. What the fuck is wrong with these people? I'm not gay myself but.

Sorry. I've probably answered none of your questions despite quoting both of you. Just rambled on with some bullshit, which was hopefully entertaining. God! Shut the fuck up!

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56 minutes ago, Fluent In Silence said:

I was talking about this with someone who isn't studying psychology, but she asked me some good questions  which get to the heart of it. How do we define normality? We can't. I'm an atheist, so people who do believe in God(s) have a completely different conception of reality to me. People who think that the CIA has implanted chips in them in order to monitor their every move are crazy. People who believe that there's someone up there watching over us is spiritual. I know this might sound like I'm trying to insult religious people but I really don't mean to. The point is that we can't agree on normality. So how do we define abnormality?

there's been some interesting discussion around this with regards to "bill gates 5g vaccine" theories

 

not that many people suffer psychosis. So WTF is all that about? "group hysteria"

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9 hours ago, Fluent In Silence said:

The meds helped but maybe if she'd prescribed me a course of hugs it would've helped even more.

Because all we need to ‘snap out of’ our treatment-resistant Major Depressive Disorder - or our alcohol addiction - is a hug. Fuck that noise. If she had prescribed you a course if hugs she would have cemented her credentials as a charlatan.

9 hours ago, Fluent In Silence said:

I'm not gay myself but.

Flue.

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1 minute ago, Cerberus said:

Because all we need to ‘snap out of’ our treatment-resistant Major Depressive Disorder - or our alcohol addiction - is a hug. Fuck that noise. If she had prescribed you a course if hugs she would have cemented her credentials as a charlatan.

Flue.

To tie this back to OP. I think that it was a comment that MDD encompasses a few separate issues that get lumped under 1 label 

 

Yours might be chemical. Flues might be upbringing. Others might be 50/50 but it all gets approached the same 

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44 minutes ago, DogMan said:

might be 50/50 but it all gets approached the same 

Of course it gets approached the same. It’s a diagnostic manual to guide objective observation of symptoms. Read the actual text of the book. The criteria for diagnosis of MDD say not one single syllable about neurotransmitters. Nada. Why? Because they can’t be observed or measured to determine whether they factor into a diagnosis. Instead, the criteria are all based on observation about the affective appearance of patient symptoms, both outwardly observed and, yes, related by the patient. How does the psychiatrist know the patient has been feeling sad? Because the patient says so.

The difficulty lies in the way psychiatrists interpret the criteria, based on the philosophy of mental pathology that they have been trained in. The criteria are limited because the book would probably better be title the DMEG - the Diagnostic Manual of Educated Guesswork - because science still doesn’t fully understand a great deal about brain function. But I don’t think the answer lies in throwing out the combined observational experience of many years if professionals attempting to find a way to guide diagnosis in favor of just trying to “feel out” what’s wrong with a patient.

Additionally, mental illness is dysfunction in the brain, which is an organ. Even if the MI has its origin in traumatic events in upbringing, that trauma must have in some way affected the function of the organ such that it is no longer capable of generating properly modulated thought processes - thoughts don’t think themselves, they have to be generated by the organ. So there’s ultimately no getting away from considering the medical implications when dealing with significant impairment.

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