Passing

Today I heard another example of  “I would never have guessed in a million years that this person experienced mental illness” (because the person was affable and successful in business). When I heard it about myself, I used to take it as a compliment. It meant I was passing, that if I was depressed I was at least hiding it well.

Now I feel this kind of statement conveys less about the person being talked about and more about the speaker. Not being aware that people with mental illness can run Silicon Valley businesses, or manage their symptoms, or hide their symptoms, or be authentically happy some of the time and wretched at other times, strikes me as kind of ignorant.

(Meanwhile, people usually understand that “I don’t think of you as black” or “You don’t look Jewish” are not actually compliments.)

21% of Americans between 18 and 49 meet criteria for a mental illness each year. And it fluctuates over time – someone who met criteria for an illness last year might have fewer systems this year, so the percentage of people who have had a mental illness at some point is higher than that. You probably also know people like me whose combination of symptoms never technically met the definition of a disorder, but who sure weren’t doing well. We’re everywhere. And yet most of these people don’t have significant impairment – they’re still working, raising families, being members of Congress, etc.

Years ago I was shocked when my coworker, an older woman I revered, mentioned that she was in recovery from addiction. It didn’t square with my image of her, so I tried to hide my surprise and said nothing. I wish now I had said, “Congratulations,” that I had done something to honor her hard work and her ongoing success.

There’s nothing wrong with being surprised when you learn something that updates your sense of a person. But use it to better understand the world (now I know some blue-eyed people are Jewish! Now I know successful entrepreneurs can still develop life-threatening depression!) and not to convey your surprise directly to the person in question. It’s not fun to hear something that sounds like, “Wow, I didn’t know people like you could seem so normal!”

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Resource on handling mania and psychosis

A lot has been written about handling depression and anxiety, and with good reason! They are very common and can be very debilitating.

But this piece addresses some less common problems: mania and psychosis. These are not as commonly understood, so people are often ill-equipped to recognize or handle them when they come up.

I originally wrote this piece for the EA/rationality community, which has a lot of young adults and a lot of traveling, and thus has people particularly likely to experience these problems while in areas where they don’t have good access to supports and resources.

I think this information is worth knowing for anyone who knows a lot of young adults.

How common are these problems?

The National Institute of Mental Health estimates a 12-month prevalence for the following illnesses (the chance that an adult in the US met the criteria during the last year):

• Bipolar disorder: 2.6% (a proxy for people who experience mania)
• Schizophrenia: 1.1% (a proxy for people who experience psychosis)

In other words, if you’re friends with 100 random American adults, around four of them will likely meet the criteria for one of these disorders this year. This doesn’t include people who experience psychosis but don’t meet all the criteria for schizophrenia (for example, because the psychosis is drug-induced).

A person is most likely to have their first manic episode between age 20-25 (source). Men are most likely to experience a first psychotic episode between age 18-25, and women age 25-35 (source).

About mania

What is mania?

Mania (or, in its lesser form, hypomania) is a period of heightened emotion, activity, and energy. Some people experience both periods of mania/hypomania and periods of depression, while others experience only mania/hypomania — these are both forms of bipolar disorder.

Hypomania might include some of the below signs but be shorter and less intense and not disrupt the person’s life as much. Mania is a more intense version that impairs a person’s normal functioning (for example, through risky behavior).

A hypomanic or manic episode might look like:

• Decreased need for sleep
• Talking more or faster than usual
• Feeling euphoric or giddy, “on top of the world”
• More irritable or hostile than usual
• Feeling your thoughts are moving fast or won’t stop
• Feeling very motivated, engaging in lots of activities at once
• Lots of energy
• More sociable than usual, talking or arguing with everyone
• Easily distracted by unimportant details
• Unusually high self-esteem
• Pursuing fun and risky activities more than usual: shopping, sex, gambling, drug use, driving fast, unlikely business schemes, grand plans
• Feeling your brain is working on a whole new level, everything suddenly makes sense
• Might lose touch with reality (seeing, hearing, or believing things that aren’t real)

These symptoms can last from days to months. Some people experience some of these at the same time as depression (a “mixed episode.”)

• Common triggers of mania in people who are prone to it:
• Sleep disruption, including due to crossing time zones
• Stress
• Recently starting or raising dose of antidepressant medication
• Stimulants: caffeine, nicotine, cocaine, amphetamines, steroids, appetite suppressants, ADHD medications
• Some cold medicine and thyroid medicine
• Season/light changes — more common in summer
• Missing doses of psych meds

Is hypomania always bad?

Some people feel that the euphoria and creativity that comes with hypomania works well for them. Many others find that periods of hypomania, while enjoyable, are often followed by periods of depression or full mania which cause serious problems for them.

About psychosis

What is psychosis?

Psychosis is losing touch with reality.

This may look like:

• Hallucinations (hearing, seeing, smelling, or feeling things that aren’t there). Sometimes people recognize that these aren’t real, while other times they’re very sure they’re experiencing something real. This can be very distressing for them.
• Delusions (strongly held beliefs despite evidence to the contrary). Common delusions include:
  • Belief that people are trying to follow or harm you (paranoia)
  • Belief that things refer to you: thinking strangers are talking about you, that insignificant events have special importance, that mass media like TV has special messages for you
  • Belief that something is wrong with your body, in the absence of evidence
  • Belief that people are romantically or sexually interested in you, in the absence of evidence
  • Hugely overestimating your own importance and abilities
• Unusual or bizarre behavior
• Changes in physical motion: repeating meaningless motions, or not moving at all
• Thoughts and speech seem disorganized, not making sense
• Showing and feeling no emotion, “blank” look
• Loss of interest in usual activities, apathy

Many of these symptoms may also occur for other reasons. Some may come from physical problems with the brain (for example, a stroke). This is one of the reasons it’s a good idea to get medically evaluated if things seem off.

Early symptoms

Some people may experience these symptoms before a full psychotic episode:

• Trouble concentrating
• Feeling your mind is playing tricks on you
• Hearing things like your name being called
• Seeing glimpses of that aren’t there out of the corner of your eye, or seeing moving patterns or shadows

Common triggers of psychosis

• Extreme sleep deprivation
• Trauma or extreme stress
• Some medications or drugs, especially marijuana, psychedelics, MDMA
• Withdrawal from some drugs, especially alcohol
• Physical illness or injury (head injury, infection, blood sugar imbalance, electrolyte imbalance, brain disease such as Parkinson’s)
• The weeks after childbirth
• No special trigger, just underlying genetic predisposition

Does someone who experiences psychosis have a particular illness?

A psychotic episode may or may not indicate an ongoing mental health problem. After a first episode, about ⅓ of people will have another episode within 3 years (source). In some circumstances, like sensory deprivation or bereavement, hallucinations are very common and not predictive of future problems.

Some people have only one episode and recover fully. Others have multiple episodes and benefit from ongoing treatment but retain basically normal functioning between episodes. Others get progressively worse. People with recurring episodes would probably be diagnosed with one of the schizophrenia spectrum disorders.

Family history

Bipolar disorder and schizophrenia seem to have some common genetic risk factors. People with a family history of either disorder are more likely to develop one of them.

Drug use

Drugs that may be relatively safe for some people may be much less safe for others.

There’s not clear evidence as to whether marijuana increases risk for psychosis, but it seems very plausible that it worsens existing psychosis and makes people who already have risk factors (like a family history) more likely to develop psychosis.

While drugs such as MDMA have been tested as therapies for conditions like PTSD, the findings of these studies may not be very generalizable because:

• The studies screen out participants that are seen as being at high risk (for example because they already had other medical or mental health problems).
• The participants were given actual MDMA, while what’s bought on the informal market is often diluted with other substances, ranging from harmless (chalk) to ones that may cause unwanted effects (methamphetamines, which like other stimulants can kick off mania in some people).

In other words, what was safe for carefully selected study participants with carefully selected drugs may not be safe for you.

The Drug Policy Alliance’s statement on psychedelics:
“An individual’s experience using a psychedelic drug is strongly influenced by two key factors: set and setting. The set is the internal mental environment, and the beliefs, of the person who has ingested the substance. Setting is the external environment. If someone uses a psychedelic in a threatening or chaotic set or setting, that person is more likely to have a threatening or chaotic experience. Likewise, if psychedelics are used in a safe, supportive environment, it will be easier for the person to allow his or her experience to develop in a coherent, potentially meaningful manner – though some parts may still be overwhelming or psychologically jarring.”

How to help

Most people don’t get help soon enough. Someone who experiences psychosis usually doesn’t get treatment until more than a year later. Someone with bipolar typically isn’t diagnosed until more than three years after their first mood episode.

A survey by the National Alliance on Mental Illness asked people who have experienced psychosis who helped them during the early stage of their illness. The most common answer was “no one.” (Parents, psychiatrists, and therapists were the next most common answers.)

In the survey, people who had experienced psychosis listed ways others had helped them:

• Identifying problems early
• Listening patiently and compassionately, without making judgments
• Making suggestions without being confrontational; remaining gentle and calm
• Keeping them from harming themselves
• Taking them to an emergency room or making appointment and taking them to a doctor
• Providing a safe place to rest or recover
• Traveling long distances to be with them
• Explaining the nature of the illness and what was happening
• Building trust by making decisions together
• Prescribing the right medication
• Prescribing cognitive behavioral therapy
• Providing child care, cooking, or taking on other daily chores
• Providing financial support
• Encouragement that “normalized the experience,” such as to finish school or return to work

They also listed their most important needs during periods of crisis:

• Getting rid of voices and paranoia
• Knowing the difference between what was real and unreal
• Hospitalization, medication and stabilization
• A safe place and protection
• Access to a good psychiatrist or counselor
• Sleep
• Validation of their experience; someone to listen who could be trusted
• Information and explanation
• Financial assistance

Professional help

Seek medical care if you’re concerned that you or someone else isn’t doing well. This is the standard advice for a good reason, which is that things may get worse if you try to just wait it out. You may miss the opportunity for treatment that would have been helpful. The problem may be due to something you don’t expect (like a neurological problem, a substance you didn’t realize the person took, or an infection). Or it may get beyond what you can safely handle.

US

• In an emergency, call 911 or go to an emergency room (would be called A&E in UK) at a local hospital.
• Many areas have a psychiatric crisis team that can send trained mental health staff to where you are; call 911 or the local non-emergency police number.
• National suicide prevention chat or hotline: 1‑800‑273‑8255
• Suicide crisis text line: Reach a counselor 24/7 by texting 741-741
• National Alliance on Mental Illness (NAMI) hotline: 800-950-6264

UK

• In an emergency, call 999 or go to an A&E department (would be called emergency room in US) at a local hospital.
• Mental health helpline: 116 123
• More helplines
• NHS mental health services
• Crisis teams

Other types of help

If for some reason you decide not to get medical help, here are some basic safety tips.

• Get the person to a calm, quiet environment.
• Help them establish a regular routine of sleeping, eating, and quiet activity. During mania, trying to “work off” excess energy through activity is counterproductive; getting lots of rest is better.
• Help them stay hydrated, particularly if they’ve had a lot of alcohol or MDMA.
• Contact someone who knows more about what’s been helpful to them in the past, like their family.
• If they’re agitated or aggressive, take this seriously. Keep yourself safe and re-consider calling for medical help.

Other resources

Someone I know is in crisis from Treatment Advocacy Center

Harm Reduction from Robot Hugs

Some people find that mood/sleep tracking apps help them recognize when a manic episode is approaching.

Advance directives for mental health, sometimes called wellness plans or mad maps. These are plans for what steps you want to take when. This includes information like:

• What I’m like when I’m well
• Things that have helped in the past
• Symptoms that indicate I’m no longer able to make decisions for myself
• People I do and do not want involved in my care
• Preferred treatments and treatment facilities
• Contact information for people you would want to contact in a crisis

How to get therapy from Kate Donovan

Things that sometimes help if you have depression from Scott Alexander (including info on why people with bipolar need different treatment from people with depression).

Navigating Crisis from Icarus Project

Supporting a person with mania or hypomania

Reducing bipolar triggers

Helping a loved one manage a manic episode

Dealing with Psychosis: A Toolkit for Moving Forward with Your Life

National Alliance on Mental Illness

Antisocial personality disorder in prisoners

(I’ve been sitting on the raw material for this post for almost two years and finally wrote it up.)

When I worked in the jail, I asked myself fairly often whether my clients had anti-social personality disorder.  Supposedly almost half of male prisoners have it, and in that setting you do have to constantly ask yourself whether someone is trying to take advantage of you in some way.

“Anti-social” almost seems redundant in a jail, but it’s not clear what the term should mean. It’s also been called sociopathy and psychopathy, and people don’t agree about whether those are actually different things. The seminal work on the topic is Hervey Cleckley’s The Mask of Sanity, which describes psychopaths as not truly experiencing emotions, especially love. Lots of other books give advice on how to avoid such people.

The DSM IV-TR, which we were mostly using at the time, required three or more from this list for a diagnosis of antisocial personality disorder:

1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
3. impulsivity or failure to plan ahead;
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
5. reckless disregard for safety of self or others;
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

Jails obviously have a lot of people with these characteristics. But they are also full of people with addiction and trauma histories, which can explain almost all the symptoms:

1. Everyone in jail has been arrested, so that’s a given.
2. Lying and conning for personal benefit are probably adaptive behaviors in harsh environments like the foster system, abusive relationships, and homelessness. (As my supervisor told me the first time I had my feelings hurt by a client who successfully conned me into making a phone call for her, “This is how she’s survived.”)
3. Impulsivity and failure to plan ahead: A ton of people are in jail because of this. Executive function is not the strong suit of prisoners. You see a lot of ADHD, a lot of traumatic brain injury, and a lot of substance use (which is both cause and effect of impulsivity).
4. Irritability and aggressiveness: again, aggression can be adaptive in a dangerous environment. A lot of young men learn this as a way to avoid being victimized. The irritability could also be substance use or withdrawal.
5. Disregard for safety: A common response to trauma.
6. Irresponsibility: I read this as “often unemployed,” which isn’t surprising in someone coming out of an unstable family and/or a broken school system. Also would be pretty predictable as a consequence of substance abuse.
7. Which leaves us with lack of remorse: the only one I can’t explain away even in this population.

I met very few clients who obviously met the “no conscience” model. They were particularly likely to be pimps, I guess because that’s a career particularly well-suited to remorselessness.

The most obviously low-on-conscience guy I worked with got offended once when I asked why he did the right thing in one case when it didn’t seem to benefit him, which made me think he had occasional moments of decency and maybe thought of himself as a decent person. But there were so many other examples of him doing the non-decent thing whenever convenient that this might have just been a front.

Another client was terminally ill and decided during his last weeks that he’d like to discuss his life history with someone. He told me about a variety of horrible things he had done (starting with arson) with no apparent remorse. But he appeared to have genuine love for his dog and spoke fondly of how he hoped to be released in time to go visit it.

At one point I went over my client list and picked the last 60 clients that I had talked with enough and remembered well enough to have an idea of whether they seemed to have a lack of empathy or remorse. 11 (18%) had said something that indicated this (though again, not consistently so—everyone in the sample at least appeared empathetic in certain situations). Another 10% were maybes in that they seemed to maybe have done really callous things but I wasn’t sure. And the remaining 72% didn’t seem to be deficient in empathy. They were mostly locked up for things in the “poor impulse control” department.

I came away from this feeling that:

• a lot of the diagnostic criteria only make sense for someone coming from a basically ok background where you wouldn’t normally expect to see survival-type lying, violence, etc. The DSM 5 criteria seem much better in this regard, since they now ask you to rule out socio-cultural environment, substance use, and head trauma as causes.
• this thing seemed a lot more like a spectrum than like a separate category of people.

Recognizing problems as temporary

Sometimes a situation becomes worse because you interpret your inclination to do a bad thing as a prediction that you will actually do it. Realizing that it’s possible to successfully get past this feeling has been helpful to me. Three examples I’ve noticed:

• Several older women in my family speak openly about the times they felt like hurting their babies. It’s been really helpful to hear them—successful matriarchs who have loving relationships with their adult children—say this, and know that wanting to throw your baby at 3 am after six months of sleep deprivation is normal and doesn’t mean you are actually going to do it. It’s reassuring to have the interpretation “I am going to get through this somehow, and in thirty years we’ll all laugh about it” rather than “I am a terrible mother who is actually going to throw this baby.”

  Of course, you also have to take steps to not hurt the baby! Lily’s great-grandmother, when raising kids on an isolated farm, would put the baby in the baby carriage and wheel it out into the field until she couldn’t hear the crying anymore from the house. When she could see the carriage stop shaking, she knew the baby was asleep and would wheel it back within earshot. This is the kind of thing the health pamphlets tell you to do (“step away right away”), but it’s more reassuring to know that your husband’s beloved grandmother did it and not something that only bad parents in pamphlets need to do.

• Many of the older dancers in my folk dance group have been part of the team since the 1970s or early 80s. Some of them brought their little kids to every event, but others took time off and one central member took about a decade off when she had a child. These days I’d often rather fall into bed as soon as possible than go to practice, and I don’t go to most of the gigs because traveling with baby in tow feels like more trouble than it’s worth. If this were a group with less institutional memory, I’d assume this meant I was drifting away from the team and that it soon wouldn’t be a part of my life anymore. But because I have the model of people rejoining the team after early parenthood, I see this as a temporary and not a permanent separation.

• A friend noted that sometimes when he feels he wants to sleep forever, he worries a lot about the fact that he’s feeling suicidal. He found that if he takes a nap he usually feels much better, and that the problem is temporary exhaustion more than ongoing suicidality. So now he doesn’t assign much importance to the feeling when it happens.

Planning for altered mental states

On Friday night I helped my sister-in-law while she gave birth. (I had my own baby strapped to my front the whole time, so I wasn’t particularly hands-on, but I helped Skype in the baby’s father who was in England at the time.)

My own labors were unusually easy, and seeing someone go through a more typical labor was eye-opening. This woman is a medical student who’s done her obstetrics rotation, but the pain made a different person out of her. A frightened, exhausted, anguished person.

One childbirth book I read (The Birth Partner, which is my favorite for women giving birth as well as support people) advocates using safe words for pain relief. It gives you the freedom to say “I want morphine” in the heat of the moment when you don’t fully mean it, and if you really mean it you’ll say “eggplant” or whatever and your support people will know to take it seriously. A birth plan is also good for this. In this case, my sister-in-law had asked in advance not to be given an epidural unless she repeatedly asked for one over a period of time, so when she said things like “I want an epidural” and “I want a c-section” her doula and midwife helped her find other ways to cope rather than calling an anesthesiologist.

It felt very strange to watch her in agony, to hear her asking for relief, and to know that the person she had been 6 hours ago and the person she would be in 6 more hours wouldn’t want her to get it. (Women who get epidurals report less pain but no greater satisfaction with their overall experience, probably because the side effects are so annoying.)

For both medical and psychiatric care, some people use some form of Ulysses contract, named for Ulysses who tied himself to a mast to be able to hear the Sirens’ tempting song without following it to his doom. It’s the act of a person who knows they’ll be in an altered state in the future. It’s treating your future self as a different person with different preferences, and forcing them to obey your current preferences.

The last day of her life chronicles Sandra Bem’s plan for her own death after an Altzheimer’s diagnosis, knowing that by the time her mind had deteriorated she would no longer want the death she had planned. My lovely wife in the psych ward is from the viewpoint of the husband of a woman with serious psychiatric problems.

DuBrul introduced me to the concept of mad maps. Like advanced directives for the dying, DuBrul explained, mad maps allow psychiatric patients to outline what they’d like their care to look like in future mental health crises. . . . We started trying to create Giulia’s map by discussing the pills in the medicine cabinet. Under what circumstances would Giulia take them, and how much would she take? I took a hardline approach: No sleep for one night, pills at maximum dosage. Giulia wanted more time before jumping to medication, and favored starting the dose out light.

They’re not failsafe: a birth plan only communicates your preferences, and you should go in with the understanding that you may need an emergency c-section or whatever. A mad map can plot out actions in anticipated situations, but unanticipated situations may throw the old plans out the window.

But I think we’re much better off planning, to the extent that we can, for times when our preferences will be different than they are now. From my coworker who’s set her computer to shut off the internet at 11 so she’ll go to bed on time, to a person planning how they want their death to go, sometimes it’s better for your self-in-the-moment not to have the reins.

Confusion about mental health and trigger warnings

People are reposting yet another article about how trigger warnings are ruining college by allowing students to avoid material that makes them uncomfortable, and possibly by making them more anxious and prone to traumatization via the power of suggestion.

This one indicates that while people with anxiety or depression should get cognitive-behavioral therapy to challenge their irrational thoughts, catering to their fears will worsen them, and possibly create anxiety in people who didn’t previously have it.

Thanks, journalists, for your amateur mental health advice.

. . . .

These articles love to cite exposure therapy as the opposite of trigger warnings.

To quote Scott Alexander (a psychiatrist) on the inadvisability of springing “treatment” on people:

Psychotherapists treat arachnophobia with exposure therapy, too. . . . Finding an arachnophobic person, and throwing a bucket full of tarantulas at them while shouting “I’M HELPING! I’M HELPING!” works less well.

And this seems to be the arachnophobe’s equivalent of the PTSD “advice” in the Pacific Standard. There are two problems with its approach. The first is that it avoids the carefully controlled, anxiety-minimizing setup of psychotherapy.

The second is that YOU DO NOT GIVE PSYCHOTHERAPY TO PEOPLE WITHOUT THEIR CONSENT.

One other thing I think people might not understand, is that exposure therapy is really intense and long. Reading or talking about something in class is not exposure therapy, and even if you were engaged in exposure therapy it’s entirely possible that a particular class discussion would still not be a good idea for you.

An example of what exposure therapy is not: I once spent a school year living where the most convenient route to where Jeff lived was across a railroad bridge. It was safe to walk across (it had a sidewalk-type thing next to the tracks, so even if a train crossed I would not have been hit) but passed over a deep gorge with treetops far below.  I’m afraid of heights, and I found this terrifying every single time I did it, which was a couple of times a week for eight months. It never became less frightening. If I were doing exposure therapy I might have spent time on the bridge every day for progressively longer times. This experience makes me doubt that reading about or discussing a topic that someone finds disturbing, even repeatedly, will make them find it less disturbing.

. . . .

Another mistake the articles make is the assumption that trigger warnings always result in readers simply avoiding material. Miri Mogilevsky does an excellent piece on “Ways I have used trigger warnings“:

1. [ignores, continues reading]
2. “Oh, yikes, this is going to be pretty serious. Ok, I’m ready. Let’s do it.”
3. “I think I need to take a few minutes to mentally prepare myself before reading this.”
4. “Welp, that’s just too much right now. I’m going to wait a few hours or days until I’m in a better brainspace and then engage with this.”
5. “Ok, this is totally fine for me, but it’s nice to know what I’m getting into.”
6. “I can do this. But I’m going to message a friend and talk to them while I read it, or maybe pet the purring kitty.”
7. “I’m going to read this, but I already know I’m going to be a wreck afterwards, so I’m going to set up some hot tea/some time with a friend/Chinese food/a fun TV show to help me afterwards.”
8. “You know what? I don’t need to read this. I’ve lived this. I know this. There’s no reason to make myself think about it again.”

. . . .

There are some valid points in these articles. Requesting that disturbing material be eliminated from curricula, as have apparently been made at some colleges (where? the articles don’t say), are too much. But the authors apparently find it problematic that anyone would want a trigger warning on Ovid’s Metamorphoses, which makes me question whether the authors have actually read Metamorphoses and whether they seriously think rape survivors should get no warning before reading the story of Philomela.

There’s a legitimate concern that certain triggers are “warned” for (violence, sexual assault) even though lots of people have triggers that other people don’t think of as such. But this seems a bit like refusing to label a really common allergen like soy because some people have rarer allergies like to mangoes.

I’ve heard some concern that popularizing trigger warnings creates problems for people with actual mental health problems, because their very legitimate requests get conflated with “irritating liberals asking for stuff they don’t really need.” But I think this problem has more to do with articles like these than about the actual trigger warnings, and it’s unclear how to somehow provide trigger warnings only to people who need them.

It’s also not clear to me that you need a diagnosis like PTSD to have a good reason to avoid disturbing content. Since having a child, I find content about bad things happening to children painful in a way I never did before. As Miri points out, I’m not avoiding these scenarios in order not to think about the content. The content already plays inside my mind far more often than I would like, and seeing photos of it is not something that’s usually a good idea. I will sometimes use it to motivate myself (for example, to contact my representatives about allowing more Syrian refugees in), but I’m not willing to do it for no reason.

Reducing schizophrenia risk

Schizophrenia affects about 1% of the population. It usually develops during or after adolescence and involves losing your grip on reality in a way that people find really debilitating and unpleasant.

I started researching this because I knew some people (like those with a family history) have elevated risk, meaning above 1%. If some people’s risk is higher than 1%, and the population averages 1%, people without risk factors must have lower than 1% risk. My plan was to reassure myself that my kids were unlikely to get schizophrenia, but it turns out reading a lot about schizophrenia was not a good way to put myself at ease.

If you find this topic interesting and not nervous-making, go ahead. If not, I really didn’t find anything very actionable, so feel free to stop reading.

Schizophrenia.com has a very complete list of factors that may increase schizophrenia risk. I started reading these with the intent of actually doing things differently to reduce my kids’ risk, but a lot of the suggestions either seem spurious or things you were going to do anyway (“try not to have traumatic experiences,” “don’t drink during pregnancy.”) Some of the recommendations were based on pretty ridiculous evidence, like the ones on dental x-rays and dry cleaning.

Here are the ones I found interesting.

Radiation

The radiation thing hinges on two studies. One is that people whose mothers got dental x-rays during pregnancy have higher schizophrenia risk. But the level of radiation you get from dental x-rays is really low, less than you get in a normal day from things like sunshine. I think the actual explanation is that they won’t give you x-rays if you tell them you’re pregnant, so the only people who get dental x-rays during pregnancy are women who don’t know they’re pregnant (and are probably still drinking or doing other things that aren’t good for fetuses).

Second, there’s a study that 8 rhesus monkeys exposed to high amounts of radiation in utero developed cognitive symptoms including hallucinations once they hit adolescence (not sure how you tell if a monkey is hallucinating). This made me worried about flying until I realized the low dose in this study was roughly equivalent to flying across the US 2000 times in ten days. That helped me decide I was okay with a few flights.

Rh incompatibility

Speaking of rhesus monkeys, Rh incompatibility increases schizophrenia risk, but the study came out in the year before Rhogam, so these were untreated pregnancies. Fun fact about pregnancy: if you have an Rh-negative blood type and your baby is Rh-positive, if you’re exposed to their blood (often during birth), you essentially develop an allergy to your baby. The first baby is usually okay, but after you develop the reaction your blood recognizes and attacks the blood of subsequent Rh-incompatible babies. This is one explanation for why Henry VIII had live births from his wives’ first pregnancies but so many miscarriages thereafter—he may have had an Rh-positive blood type and the wives had Rh-negative blood.

Fortunately, Rhogam (Rho(D) immune globulin) is one of the miracles of modern medicine and means that Rh-negative women like me can have healthy pregnancies, because it prevents us from developing the reaction to your baby’s blood. I assume that if you get the treatment in time, your child’s schizophrenia risk is not elevated.

Birth interval

This part is just weird. For a second child born a short time after their older sibling, the risk is fairly low. The risk increases if you’re spaced 15-26 months apart (with 18-20 months being the worst). Then risk decreases again with longer intervals, being the lowest after 45 months of space between siblings. They think it might be related to folate—pregnancy and breastfeeding deplete your folate, so your second child might not get enough if your body is still recovering from the first pregnancy. That explains why a long interval is best, but why is a short interval better than a medium one? You can only have Irish twins if you’re not breastfeeding much (since breastfeeding suppresses the return of ovulation). So perhaps mothers who don’t breastfeed are able to replenish their folate faster than mothers who do.

But even the worst-off second children have about the same rates as only children. So the folate thing doesn’t make a lot of sense. Unless first-time mothers aren’t taking prenatal vitamins at the time of conception, but start taking them and are still taking them at the time they conceive their second child, since you’re supposed to take them after birth and the whole time you’re lactating? But the study started with children born 1950-1983, and for at least part of that period I don’t think folic acid supplements were a thing.

Rather than folate, it might also have to do with an older sibling bringing home germs from daycare, or how stressed your mother is about being pregnant while minding a toddler. This all seems inexplicable enough that I decided not to take it too seriously.

Paternal age

Older fathers are more likely to have schizophrenic children. This seems like one of those that would be nice to plan around if you can, but I don’t know who really makes major life decisions based on a slight shift in likelihood of something that’s already unlikely.

Birth season

Children born in late winter in un-sunny places have higher schizophrenia risk. Some people think taking extra vitamin D is a good idea. But these are big population studies that don’t control for things like maternal infection (the other obvious difference between winter and summer babies), because checking the birthday of people with schizophrenia is much easier than finding out whether their mothers got the flu during third trimester.

(Also dredged up during this part: lesbians and baseball players are more likely to be born at the end of summer; gay men are more likely to be born six months opposite.)

Dry cleaning

Schizophrenia.com recommends recommends avoiding dry cleaning chemicals during pregnancy, but this turns out to be based on 4 people with schizophrenia whose parents were professional dry cleaners. And the Last Psychiatrist points out that 3 of these 4 dry-cleaner parents were fathers. It’s plausible that their sperm were affected, or that they contaminated their homes and wives enough to have an effect. But this doesn’t seem like a very strong basis for advice to avoid dry cleaned clothes during pregnancy. More like “avoid having babies with professional dry cleaners.” Or perhaps they should be advising men, not pregnant women, to avoid the chemicals before conception.

Marijuana/street drugs

Schizophrenia.com is very anti-drug, unsurprisingly. Slate Star Codex addresses the topic in a post on marijuana. (It’s a long post; search for “psychosis.”) There are lots of studies that show a correlation between using drugs like marijuana, LSD, and ecstasy and later being diagnosed with a psychotic disorder like schizophrenia. But it’s not clear whether marijuana and other drugs like LSD, meth, and ecstasy actually increase risk, or if teens in the early stages of developing psychosis are more drawn to drug use. I plan to tell my kids that we don’t know which way the causality goes here, and the risk is something they should consider.

There also seem to be certain genetic mutations that make this effect, if there is one, more likely for some people.

Painkillers

A British study found that women who used painkillers during the second trimester of pregnancy were several times more likely to have children with schizophrenia (and yes, they controlled for viral infections, which could be a cause both of taking painkillers and of damage to the fetus). This study looks weird to me, though, because fewer than 2% of participants reported taking painkillers during any given trimester, which seems awfully low given that about 20% of people use over-the-counter painkillers in a given week.

Other stuff

Pretty much everything else on the list can be described as good prenatal, physical, and mental health. Everything you’re supposed to do during pregnancy (eat vegetables and omega-3s, exercise, take your vitamins, try not to get sick, avoid alcohol, avoid toxins) helps reduce the child’s risk of schizophrenia. After birth, a nurturing, low-stress environment (caring for your own mental health, breastfeeding, giving the baby plenty of touch, living in less urban environments, not yelling, helping children handle stress in healthy ways) also helps. Other bad things during childhood: head injuries, emigration, psychological trauma.

On switching places

I’ve been reading some of the discussion on Scott Aaronson’s comment on his difficult youth as a shy geek with a very conscientious style of feminism. An excerpt:

My recurring fantasy, through this period, was to have been born a woman, or a gay man, or best of all, completely asexual, so that I could simply devote my life to math, like my hero Paul Erdös did. Anything, really, other than the curse of having been born a heterosexual male, which for me, meant being consumed by desires that one couldn’t act on or even admit without running the risk of becoming an objectifier or a stalker or a harasser or some other creature of the darkness.

Someone replied, essentially, “You can’t really mean you would trade places with truly oppressed people.” Aaronson replies:

I feel incredibly lucky to have gotten to a place in life where I’m happy to be who I am, with a wonderful wife and daughter and a job doing what I love. But with a slightly-different roll of the dice? I would absolutely have traded places with any of the people you mentioned—the poor black kid, the gay kid, any of them. I wouldn’t even have to think about it. Are you kidding me?

I wouldn’t have written what I did, if that wasn’t honestly how I felt. And I wonder if this isn’t the crux of so many people’s failure to understand me: the only possibility they can contemplate, is that I can’t grasp how badly other people have it. That I would’ve gladly traded places with them, despite knowing how badly they have it, is a fact they won’t assimilate no matter how often I say it.

Which got me thinking about how different people’s experiences can be wildly different even within the same group.

One noticeable thing about jail is that people react very differently to it. Most everyone is miserable, but some of them put together a semblance of normal life (working out, writing letters, conducting intrigues, reading all the Game of Thrones books). One of the most charmingly normal things I ever saw on a segregation unit was two women playing “battleship” from their respective cells, calling out coordinates through the cinderblocks.

Recently a client on his first real incarceration told me he wasn’t sure what was so bad about jail. There was nothing that really felt like punishment to him, no physical torture. His childhood was worse: “I was always getting beat and stuffed in closets, so this ain’t a big deal to me.”

But some people lose their minds. Some people (especially immigration and other non-criminal detainees) can’t handle the loss of status, the shame of wearing a uniform and shackles. Some people have panic attacks. Some can’t eat or sleep. Some lose touch with reality.

The same circumstances can have vastly different effects on different people. So to say, “I would rather have been poor or gay or black than geeky and shy” doesn’t make a lot of sense. Who is the you that is being transformed? Is that person still shy? Is that person still prone to feeling horribly sad and ashamed? Because you might just have a terrible time in whatever group you land in.

Fine?

This week (one month before my due date) the midwife told me that the baby would be “fine” if she were born now.  “But there’s still a lot more brain development for her to do,” I pointed out.

“She would be fine,” the midwife repeated.  I decided to drop the issue.

Here’s the length of pregnancy (40 weeks being standard) mapped against children’s IQ at age 6.5:

Source

I appreciate that the midwife was trying to allay any fears I had, but it sure looks like there are variations on “fine.”  This  graph also makes me less sure about the “induction isn’t necessary, birth will happen when it’s meant to happen” rhetoric and more worried about a post-mature baby.  (One danger with inducement being that if you’re wrong about your conception date, you end up with a premature baby instead of a post-mature one.)

I heard the same kind of thought process early in the pregnancy when I was going to a techno contra dance.  I debated whether to draw on my skin with highlighter, like I usually do (the ink glows under the blacklights).  I doubt highlighters are all that toxic, but I also doubt anyone has tested the effects of maternal skin absorption of fluorescent yellow ink on a fetus. “I’m sure it will be fine,” someone said.  And she was right, in the sense that my baby wouldn’t come out with three heads or any other symptoms that would make us say, “It was the highlighter.”  But little things can add up.

There is not some cutoff for when a baby (or a child, or an adult) is “fine.”  We all have our glitches, and some glitches are bigger than others.

You can’t avoid all risk, and for the sake of your sanity you have to consider some things “good enough.”  But your choices — like “Should I have labor induced?” or “Should we renovate our house, which is full of lead paint, while living with young children?”  — really do have effects.

Metaphor gone wrong

Mental health professionals love to compare mental illness to diabetes.  The idea is: both diabetes and mental illness are chronic conditions, and you need to manage them for the rest of your life.  If you go off your meds, bad things will happen.

I’ve seen this go well.  I had a young client who heard this metaphor for the first time and immediately said, “That was helpful.”  To her, it lessened stigma and made taking medication seem like a more normal thing to do.

I’ve also seen it go badly.  One man insisted, “I cured myself of diabetes.”  Which may have been more or less true, if he had type 2 diabetes.  In any case, he was firmly convinced this also meant he would not need to continue psych meds either, which was not what his doctor had in mind when introducing the diabetes metaphor.

I also saw this go wrong with a client who had very little concept of what diabetes was.  The worker kept asking him, “Tell me what you know about diabetes.  You know, sugar.  Azucar.” And the client kept shrugging, puzzled about why she was going on about this, until the worker finally gave up.

(Now that I look into it, someone with schizoaffective disorder already wrote a good essay on the failures of this metaphor.)