#i am speaking to a very specific clinical population whose brains do not work in a way that people outside of that population understand

[lhazaar]

hey. i'm turning my chair around and sitting in it backwards now because i want to speak specifically to people with ocd. this is a targeted post and is not meant to apply to the userbase of this website at large or to serve as a policy decision.

hi. do you know what scrupulosity means? it is a strong, intense, often painful concern about morality or religion. it's very common for religious people with ocd, actually—the fear that you've sinned, that you will sin, that your thoughts themselves are sinful. you're afraid of being an evil person. every thought and feeling you have is scrutinized to exhaustion in case it's proof that you're evil. this also happens for non-religious people with ocd, it's just that ours will look different; it's often a preoccupation with social justice issues. you care a lot about being a good person, right! most people do. you want to be a good person, you want to be kind to others and to dismantle oppressive systems where you can. i'm making some assumptions here, but they're based on my specific audience base.

so, there's this thing that happens online, especially on tumblr and twitter—not because bluh bluh platforms bad, but because of the ways in which information is propagated on here. people used to tag for these posts sporadically but don't do so as much anymore. you know posts that exhort you, the reader, specifically, to take action? they tell you not to look away, not to bury your head in the sand. they tell you to give and to agitate and to donate time, money, resources.

those posts used to make me intensely, deeply anxious. i don't mean mild agitation, i mean life-ruining, day-occupying panic that seizes your entire body, and thoughts that don't leave your brain. guilt that paralzyes you because you, personally, cannot go kill the politicians responsible. you don't have enough money to do more than donate a few dollars, and sometimes you don't even have that. but because of where you live, because of the fact that you have internet access and you're literate enough to read these posts, you know that you have a level of privilege that most people never will. you're aware of that privilege because you're reasonably in-tune with social justice movements and you've probably spent some time dissecting your own privilege to examine your biases. (that's not a bad thing; i'm not here to condemn that. stay with me, if you can.)

there's a thing that can happen if you've lived with ocd like this for a long time where you become kind of incapable of telling what's addressed to you personally and what isn't. everything feels like a personal exhortation. you have trouble saying no, or knowing when you're overextended, because other people have it worse. how dare you enjoy relative comfort when people are being bombed or drowning in a climate change -induced flood or being crushed to death in a crowd panic. how dare you not be aware of it at all times, always, constantly. how dare you look away. don't look away.

i want to tell you about something i went through, if that's okay. a lot of people who follow me will already know this, but i haven't talked about this aspect of it very much publicly. in 2020, while visiting my partner in southern oregon, we had to evacuate from wildfires twice in under 24 hours. that was a really, really bad fire season, caused and perpetuated by a combination of global climate change and colonialization practices that destroyed traditional indigenous fire management strategies across the west coast of north america. fires stretched from bc to california. we wound up fleeing south, and then had to flee back north again, hemmed in on three sides. i flew back home to bc shortly afterwards, and i have this vivid, awful memory of seeing my home mountain range, the cascades, choked out with smoke from the window of an airplane. the woman in front of me sobbed the entire time until we touched down.

i remember thinking at that time that it was insane the entire world wasn't stopping. what i was experiencing was apocalyptic in scale—the fire we ran from the first time was part of a complex that chewed up entire towns. it wasn't the first fire season, nor the worst for the continent, nor the world. but all i could think in the moment was why aren't we doing anything, this is going to be all of us in a decade, why are people looking away.

if i had gone online and posted that, it would not have been morally wrong of me. there's no ascribing morality to a reaction like that. i mean, if i'd gone to someone who suffered in the years prior in australia or california and told them that ours was So Much Worse, that would have made me an asshole, but i didn't do that. i made some upset facebook posts targeted at the trump voters in my family, but i had no way to express at the time the sort of clawing panic of WHY AREN'T PEOPLE DOING ANYTHING??

the answer to that, which you probably know, is: what would they have done? we were sheltered by friends we evacuated with, but what power did a mutual in new york or wales or singapore have to affect a wildfire in oregon?

so, come back to the present day with me again, if you will. i said above that posts worded like this used to make me really, really anxious. in the span of time after the fire, i developed ptsd, and my ocd ruined my life. i took an extra year to graduate after i'd finished all my coursework because i could not send in the forms required. i was too busy spending 10-16 hours a day rearranging furniture in my room, or lying in bed, full-body tense, until it felt like my teeth would crack from the pressure. i'm medicated now. i'm grateful for it. i have more tolerance for these posts because i've been there. i know the op isn't doing anything wrong, because they're not wrong. why isn't the world stopping to look at a natural disaster, or a genocide? the world should not be like this.

you are not the world. you are someone with a brain that will torture you to death given the chance. you know how learning to reckon with your privileges, whatever they may be, requires you to not try and escape them? you need to be able to hold in your head that yes, you benefit from something that isn't fair; yes, other people should have that benefit, and that they don't is unjust. but you need to, for example, not try and weasel your way out of being white because you're uncomfortable with the guilt that it produces. you need to not go online and say well not ALL americans because you can't sit with the idea of being complicit in american imperialism. if you have ocd, you need to apply that to your own brain, too. you need to apply it to every post that you see. you need to know that people are not speaking directly to you, they are crying out in pain and fear. they are not doing anything wrong. they are scared and hurting.

they do not benefit from you taking on all the guilt of that fear and pain. i am not saying this to absolve you of the guilt. i am saying that you need to be able to exist with that level of guilt without allowing it to paralyze and destroy you. if you can't do that right now, i'm not here to cast judgement on you. blacklist phrases. i had "wildfire" blacklisted for a long time. i'm sure i missed aid posts because of it. the alternative was me being nonfunctional. for a long time, i had donation posts blacklisted across the board, because the way my ocd worked meant that i was neurologically incapable of knowing where my own limits were, and i would give money i did not have. if you need to do that, this is me giving you permission. doing this does not make you evil. it does not make you morally bankrupt. it makes you someone whose brain is trying to fucking kill them, and the world needs you to not let that happen.

this is not a post about how you're exempt from caring about the world if you're mentally ill, it's about how you cannot apply that care to anything useful if you're having massive panic spirals every other day about the guilt that you feel. your guilt should not rule your life. if it does, i say this kindly, but you very likely need medication. i'm sorry if you don't have access to that right now. you cannot think your way out of ocd. you cannot think your way into stopping neural activity. you cannot guilt your way into being a good person; you have to be able to exist with the guilt and not let it rule you in order to do that. nobody benefits from your brain trying to martyr you in the name of solving the world's suffering.

you need to be able to function, free of crushing and paralyzing guilt, before you can help anyone. you are not an effective ally like this just because your brain tells you that it's necessary.

#bark bark #ocd tag #actually ocd #also i want to say this now: if you do not experience ocd i do not want your 'well actually' takes on this. #again. this is not a site-wide thing i think everyone should do #do not mistake this for me saying that it's ~okay~ to be wilfully ignorant about genocide or climate disaster #i am speaking to a very specific clinical population whose brains do not work in a way that people outside of that population understand #the guilt you experience with ocd is not the same guilt that everyone has just turned up #it warps your entire personality. it warps your sense of right and wrong #you will deal with it for your entire life unfortunately #(even medicated i still absolutely have Intense White Guilt episodes lol #i just try not to make them my loved ones' problem #because part of handling pathological guilt has to be responsibility without overresponsibility)

[studyingbymylonesome]

Like Moliere’s bourgeois who was surprised to speak in prose, the clinician may discover they are constantly faced with iatrogenic comorbidity. In pharmacological terms, let us just think of the case of switch into mania of a patient with allegedly unipolar depression treated with antidepressant drugs. You are faced with a modification of illness that is largely drug-induced and that is likely to affect treatment. Or, in psychotherapeutic terms, let us think of a patient who has been unsuccessfully in analysis for many years and is offered a course of cognitive behavioral therapy (CBT): their response is likely to be affected by the previous psychotherapeutic experience in terms of expectation, adherence, and motivation. The concept of iatrogenic comorbidity is simply an attempt to conceptualize the problem in a practical way.

Regrettably, psychiatrists, unlike other specialists, have been taught to consider comorbidity only in terms of diagnoses, and not as problems and treatment experiences. And they are unable to think “iatrogenic” in interpreting clinical problems, simply because they have not been exposed to the concept, which has been submitted to tight censorship by mainstream psychiatry.

Clinicians and researchers have been taught and/or have learned to ignore and misunderstand antidepressant discontinuation symptoms, such that in many instances, withdrawal symptoms are interpreted as indicators of impending relapse. In fact, the vast majority of psychopharmacological maintenance randomized controlled trials appear to conflate withdrawal reactions with illness relapse to justify superiority of maintenance treatment over discontinuation. How can psychiatrists better differentiate between withdrawal and illness relapse, and how can maintenance studies be better designed to parse out this issue?

Psychopathology, the basic neglected method of psychiatry, allows differentiation of withdrawal syndromes from relapse. Specific diagnostic criteria have been developed by Guy Chouinard, MD, and Virginie-Ann Chouinard, MD, in 2015.5 These criteria allow differentiation of withdrawal syndromes from relapse, recurrence, rebound, and persistent post-withdrawal disorders. Maintenance studies with antidepressants are likely to confound withdrawal and relapse unless specific criteria are used. We need new studies with these criteria.

It has been interesting that the psychiatric establishment insists on using the term antidepressant discontinuation syndrome, while researchers such as yourself and critics in the general public favor antidepressant withdrawal. Does this battle of terminology have any larger significance?

The term discontinuation syndrome applied to antidepressants, versus withdrawal syndromes with benzodiazepines, was a very smart method of the pharmaceutical industry to deny the problem. It is sad that most academic psychiatrists followed these leads. The evidence, based on systematic reviews and a large body of literature, is now pretty clear and the tide is turning.2 Selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors may cause withdrawal reactions (ie, new symptoms that were not present before) despite slow tapering; these reactions may be severe and do not necessarily subside in a few weeks. When I see a patient whose symptoms have been treated with paroxetine or venlafaxine, I am always looking for manifestations of iatrogenic comorbidity, which, unfortunately, I am very likely to find.

If you teach a psychiatric resident that symptoms that occur during tapering cannot be due to withdrawal, they are likely to interpret them as signs of relapse and to go back to treatment (exactly what “Big Pharma” likes). In the United Kingdom, the National Institute for Health and Care Excellence (NICE) guidelines are changing to reflect the potentially malignant outcome with SSRI and SNRI discontinuation. I do not see anything similar happening in the United States.

Many clinicians seem to hold the view, implicitly or explicitly, that it is better to identify and treat depression when it is mild or even subthreshold because untreated depression will progress in severity. This is coupled with the assumption that at worst, the medication may not help but it certainly won’t cause disease progression. Do such clinicians have an unfairly malignant view of the natural history of untreated depression and an unfairly benign view of psychopharmacological treatment?

These clinicians perceive a state of distress in their patients but have been taught only to think in terms of harmless medications. They are often unaware of the major advances that have been made in psychotherapy in the past decades, which are far superior to the pharmacological ones. Mild or subthreshold depression should be primarily addressed with effective and short-term psychotherapies, such as CBT. Unfortunately, the prescribing clinician is driven by an overestimated consideration of potential benefits, paying little attention to the likelihood of responsiveness and to potential vulnerabilities in relations to the adverse effects of treatment, one of the spectacular achievements of “evidence-based medicine,” which has been transformed into the marketing arm of the pharmaceutical industry. These latter components outweigh potential benefits of antidepressants in mild depression.

(...)

In the long run, antidepressants may increase chronicity, vulnerability to depressive disorders, and comorbidity. There is now extensive literature supporting this mechanism. In practice, you may encounter patients whose symptoms have been treated with a number of psychotropic drugs, particularly in combination, and who end up as in the STAR*D. What to do is a big problem. You can blame the illness and the patient, it is easy, but you should also think iatrogenic.

You wrote, “Current diagnostic methods in psychiatry, both DSM-5 and the forthcoming ICD-11, refer to patients who are drug-free and do not take the issue of iatrogenic comorbidity into adequate consideration. They are suited for a patient who no longer exists.”4 How do you think the diagnostic manuals can take iatrogenic comorbidity into account?

Most of the patients we see in practice are already taking psychotropic drugs. If a primary care physician refers a patient to me, it is because the patient’s symptoms did not respond to the pharmacological treatment (generally an SSRI or SNRI) that had been started. Medications may affect clinical presentation of symptoms. In a naïve implicit formulation that runs counter to any modern insights into the plasticity of the brain, we may believe that after discontinuing an antidepressant everything goes back to the pre-treatment state. It does not, as any physician in the real world knows.

It is very common for psychiatrists to encounter patients with complex presentations of multiple psychiatric comorbidities who are on multiple psychotropic medications but remain symptomatic with a mix of symptoms that does not fit into diagnostic categories and their psychopharmacological treatment history is a mess of one trial after another, consisting of medications that once worked but no more, medications that never worked, and medications poorly tolerated. Do you have any general clinical recommendations regarding how to approach evaluation and treatment in such cases?

These are exactly the patients who do not fit into any DSM category. You need to take the issue of iatrogenic comorbidity into account and spend a good deal of time for a full clinimetric assessment and use diagnoses only as temporary transfer stations that can be verified in the course of time. There is almost no research on these issues, as it happens with most of the truly important matters in psychiatry.

What percentage of patients prescribed antidepressants would you say experience clinically significant effects related to oppositional tolerance? Why is there so much variability in how individuals are impacted by these medications?

It very much depends on the type of practice. In my practice, which is very much shifted to treatment resistant, difficult, unusual cases, the percentage of cases who present with the various manifestations of tolerance (eg, loss of clinical effects, paradoxical reactions, switching, persistent post-withdrawal disorders, refractoriness) is very high and may approach 1 case out of 2. But you do not have the same crowd, the percentage may be much lower. We need studies addressing these issues in a comprehensive manner in outpatient populations.