What is the meaning of my life?

Things people say

If you struggle with mental health issues, aren’t you sometimes annoyed by things people say to you? Stop wallowing? Pull yourself out of it Go for a run?

There are many things people say to me about my mental health – and that of others – that annoy me. I am sure they may have the best intentions in mind. They usually mean well. They think they’re helping. Speaking to others, I know that I am not alone in feeling that normal, healthy, happy people should be more guarded. All my life people have been saying things like the following to me.

“You should stop wallowing in your misery and snap out of it and pull yourself together.” As though I have a choice. I find this the most annoying thing people sometimes say.

“But you are so successful …”. I am often told that and it is clearly given as a reason as to why I can’t be mad, or be on the spectrum, or have ADHD. I don’t think it’s unreasonable to say that by most measures I have been relatively successful in my career, but that doesn’t mean it hasn’t been very hard work, or that I haven’t just been very lucky. (Yes, I have “impostor syndrome” too.) Or that I couldn’t have done even better with a more normal brain.

“You should just go for a run.” It helps, I know, but when you are severely depressed you just can’t. And it will not cure a seriously depressed person.

“I know you’ve had mental health problems but …” People have actually said this to me. Bring on the equality, diversity, and discrimination training in the workplace! Would they have said something similar to someone in a wheelchair?

If only people would stop before they say anything personal to someone struggling with mental health problems and ask themselves “would I say this thing to someone with cancer?”. Of course the person might think that mental illness and physical illness are different, and that the former is a person’s fault, while the latter isn’t. Changing that outlook is the most important task in the fight against stigmatising mental illness.

Don’t let people say any old rubbish to you.

(I am sorry about the brevity of this post, but a post is better than no post. I have been “wallowing” a great deal lately.)

Weird

All my life, people have been calling me weird, so many that I have at last accepted that they are probably right.
“Weird” is a statistical label; people are weird if they’re out there on the extreme of some behavioural dimension … be free, be yourself, indeed rejoice in your weirdness. And if you don’t think that you’re weird, please don’t judge anyone else.

All my life, people have been calling me weird, so many that I have at last accepted that they are probably right.

“Weird” is a statistical label; people are weird if they’re out there on the extreme of some behavioural dimension, or more likely dimensions. A dictionary definition is:

“Very strange and unusual, unexpected, or not natural.”

That definition doesn’t capture the usually pejorative way in which “weird” is used as a label. Also, it’s not simply being extreme on any behavioural measure. You can be very clever, or very extravert, and I doubt anyone would call you weird. No, weirdness implies a special sort of unusualness. It’s thinking or behaving in some unusual way that catches the attention of most people and makes them want to pass some slightly negative judgement. Looking odd, having an unusual hobby that is considered esoteric (or “boring”, as though the activities of most people have some inherent meaning that makes them worthwhile), saying inappropriate things, or repeatedly breaking social norms, are all likely to get you called a weirdo.

Being weird obviously troubles many individuals because the internet is awash with worried weird people looking for reassurance. My favourite question is “Is being weird normal?” – to which the answer was, surprisingly, “yes”. There is apparently, no normal. But while no one might be exactly average, I don’t think that really lets me off the weird hook.

There are even apparently benefits to being weird. Weird people tend to be more creative. Many scientists and mathematicians are distinctly odd. This finding shouldn’t be too surprising because people who achieve great things must be very unusual in some way.

I think my weirdness is a consequence of my neurodivergence, one of those increasingly fashionable terms that I think does have some value.

Neurodivergent people think and behave in atypical ways, and go against social norms, because our brains are different, either through genetics or upbringing or most likely both.

I have previously listed all my psychological symptoms, and here is a recap: depression, anxiety, obsessive-compulsive disorder, phobias, general phonological disorder, and autistic spectrum disorder (not to mention noise sensitivity, task avoidance disorder and completion anxiety and completeness obsession). Is it likely I have all of these independently? Of course not. They all stem from an underlying brain that’s significantly different from normal; my brain is sufficiently different from others to warrant a label.

You can be neurodivergent without it being a problem for anyone. It’s only difficult if it causes you pain or distress: in my case the depression, anxiety, and occasionally OCD do. I hesitate about adding “or if it causes other people distress” because people are sometimes upset by the behaviour of another when it is questionable whether they should be. A psychopath might not suffer but can hurt others, but is the naked rambler recalling doing anyone any harm?
There are even some people who seem weird to me. There is a chap who wanders around town with no shoes on, whatever the weather. But doubtless he has his reasons, and it’s none of my business. The world would be a happier place if people stopped telling others what to do so much.

So to all you self-confessed weirdos and freaks out there, with the caveat about being or causing psychological or physical pain: be free, be yourself, indeed rejoice in your weirdness. And if you don’t think that you’re weird, please don’t judge anyone else.

Sometimes I almost feel sorry for all you neurotypicals out there.

Please visit my website at www.trevorharley.com for much more. I am Emeritus Professor of Psychology at the University of Dundee, contact me on trevor.harley@mac.com.

How to help recovery from depression

How can we help ourselves to recover from depression? There are several things we can do.

I have been overwhelmed by responses to my previous post on the experience of being anxious and depressed.
The comments fell into four broad categories:

1. Commiseration and agreement. The most common response, and I thank you all. It helps to feel supported and that others feel similarly.
2. I should turn to God. I realise this works for some people, but it is not for me. I am not though going to talk people out of it, or try to persuade them that they are wrong (even if I think they are). If you have faith, and it helps you, I am pleased for you.
3. You should choose to make yourself feel better. This sort of comment is fortunately rare, but the underlying belief is unfortunately quite common in society more widely, and misunderstands the nature of mental illness. It essentially says we are choosing to be ill; to use my favourite analogy, would you say that to someone with cancer? Pull yourself together and snap out of it? It is the sort of belief that stigmatises depression because it’s essentially saying that we are weak and can’t be bothered to help ourselves. It’s all our own fault. It just makes me annoyed.
4. It’s depressing. What did you do to feel better?

I’m going to focus on the final point. I’ve covered many of these things before but I’m putting them altogether here. This list covers how, with much help, I’ve made myself better from the nightmare described in my previous post. Note I say better, not well. Rather like an alcoholic, I fear I always be on the edge.

1. Seek help. There is no need to suffer alone. Call your GP or other health professional, call NHS Direct, or, if you are desperate and thinking about suicide, call the Samaritans. They are wonderful.
2. Remember that there should be no stigma attached to mental illness. You might meet the odd person who tells you to pull your trousers up, or that you brought it on yourself, or whatever, but they are wrong (see above). It’s not easy, but just ignore them.
3. Take medication. You’d take medication for flu, or TB, or cancer, wouldn’t you? Yes, many psychoactive drugs have side effects. You might have to experiment, and go back to your GP and psychiatrist, but remember it takes time for some medication takes time to work and for side-effects to settle down. A bit of constipation is a price worth paying for not feeling suicidal, but remember the extent and severity of side-effects varies from person to person. Consult your GP or psychiatrist if you are worried.
4. All things must pass. You will feel better, eventually. When I am bad I always remind myself of this fact.
5. Exercise as much as possible. I know it’s what everyone says (“when I feel down I just go out for a run”, a doctor once helpfully told me), and when you’re really depressed it’s one of the last things you’d rather do, but it does help. Even a brief walk will make a difference.
6. Go outside as much as possible. Nature makes you feel better.
7. Get as much natural light as possible in the morning. If necessary get a SAD light box.
8. Eat well. Eat for the brain, heart, and against inflammation. See below for some links
9. Stick to a routine you have worked out in advance. Routine might be a bit dull, but it helps mental health, minimises stress, and helps you sleep properly. Talking of which …
10. Get enough sleep at all costs, but not too much. Find a schedule that works for you. I swear by an afternoon nap.
11. Avoid toxic people like the plague. Do not make the mistake I have made many times of believing that you can reason with them or get them to change. Do not perseverate about what they say and just do not engage with them.
12. Consider getting a dog. A dog increases your lifespan by over a year. You have to go outside and exercise ever day. And it releases so much oxytocin. Beau (above) has been a lifesaver for me, perhaps literally.

I should say that of course I don’t have any magic bullet for depression, or any form of mental illness. If I did I’d be well myself, and probably rich. These things have helped me though. I apologise if it all sounds a bit trite and simple.

About me

I am Emeritus Professor of Psychology at the University of Dundee. There is much more information on mental health and other things on my website, http://www.trevorharley.com. Please pass details of this blog on to anyone who might find it useful. There is no need for anyone to suffer in silence. If you are depressed or anxious contact your GP, or NHS 111, or a psychology or medical practitioner, or call Samaritans or Samaritans USA.

Links to healthy eating sites

The Mediterranean diet for general good health and increased longevity.

The DASH diet for hypertension.

The MIND diet for a healthy brain and reducing risk of Alzheimer’s.

What does it feel like to be depressed?

What to does it actually feel like to be severely depressed? To be very anxious? To suffer from OCD?

People who don’t suffer from mental illness often think that being depressed is a bit like being sad, that being anxious is like having a touch of nerves before an exam, and that having a compulsion is simply an urge to do something. They’re all much worse.

Depression is very different from feeling a bit down, or having a moment of passing sadness. It’s an extraordinary “pain in the mind”. Imagine feeling sad, but much, much sadder than you’ve ever felt before. Imagine all the lights being turned off in your head. Imagine your mind turning black; black is the colour of depression. You’re living in a monochrome world where all feelings except pain have been turned right down. Imagine a dark ball at the centre of your being that is so cold it hurts. It’s like an icy knife in your soul; it’s worse than any physical pain. You just want to go to bed and cry, to fall asleep, or even die. Death would be a relief, because death is an end to the misery. In any case, who cares: alive or dead, what’s the difference in the end? And who would miss you anyway? You hate yourself and your life. The idea of doing anything is impossible to contemplate. There’s nothing to look forward to, and nothing gives you pleasure, not even the things that in better mental states you can rely upon to excite you. Your despair is utter. Everything is hopeless; and you are sure you’re never going to get better. You feel a terrible sense of doom, foreboding, and fear, not just that you’re never going to get better, but that the universe is a threatening, mysterious, evil place. And everything is such a fight; everyday life is exhausting. You can’t concentrate long enough to be able to complete simple tasks, and in any case you forget what you were going to do nearly as soon as you form the intention to do it.

Managing to do the little things can wipe you out after you’ve used up so much energy making yourself do them. You feel exhausted all the time; deep fatigue goes with severe depression. You make mistakes in the simplest tasks. You have no motivation do to do anything anyway, and no interest in anything. You feel nothing other than total despair, and feeling amazingly, incredibly guilty about everything, as though you’re lazy, incompetent and everything wrong with the world is your fault. So you deserve to suffer so much. Everything is overwhelming, and you are paralysed. You don’t just have very low self-esteem, you are also full of self-hatred. You are the lowest of the low and completely worthless; the world would be a better place without you. If you‘re depressed for any period of time self care tends to go out of the window: what is the point of shaving? Can you really be bothered to wash your face? Who cares if the kitchen sink is filthy? You overeat and overeat convenience food, because that’s all you can be bothered to cook. You sit, finding yourself in tears, and you’re not sure why. You feel completely alone; no one can possibly understand how you feel just now. You can’t bring yourself to speak to other people anyway. And in one final little trick of the mind, time slows down to prolong the agony. Every second is torture. So you try to sleep for as much of the day as possible, and you drink wine and take pills to try to ensure that you can sleep. You feel physically ill as well, with aches and pains exaggerated to distraction. There’s a tickle and lump in your throat. You perpetually tug at your eyebrows, and occasionally pull them out so that they contain strange bald patches. And the ear-worms – those annoying tunes stuck in your head – drive you even madder. You also worry that you’re a black hole of misery, sucking in joy around you, ruining the lives of others – so it’s fortunate that you prefer to suffer in isolation. It is paradoxical that you are lonely and yet want to be alone at the same time, but depression is full of paradoxes. When you’re severely depressed you can’t do anything. You just want to sit still and let the pain wash over you. Some people kill themselves because they can’t take the pain any more; and some people are so ill they can’t even initiate the act of suicide. You have contemplated suicide many times because everyday life hurts too much, and often you really don’t care if you wake up tomorrow morning or not.

That’s what it’s like for me at its worse, but fortunately therapy and medication has helped me enormously. It’s been a while since I’ve felt that bad, but I still get occasional relapses, occasional inklings of those feelings.

I find severe anxiety more difficult to describe. It is a bit like being anxious before an exam, or giving an important presentation or wedding speech, but much more intense and persistent. It is also highly visceral; it gets to your gut. You can’t concentrate on anything, but instead worry about everything. You’re completely on autopilot.

Anxiety often goes with depression, giving a condition imaginatively known as “anxious depression”. There is also agitated depression, which is similar but with more activity – of a bad sort.

It is my misfortune to suffer from obsessive-compulsive disorder (OCD) as well (which is occasionally co-morbid with depression). An obsession is not just like a pre-occupation; it is all-consuming, and you can think of nothing else. A compulsion isn’t simply an urge to do something, or check that you really did lock the door; you must do it, usually many times. My OCD started when I was about 11. I would repeatedly get up in the night to check that my bus pass was in my jacket pocket, and go downstairs to check that the front door was shut. I think it was about fifty times a night, possibly more. Why didn’t anybody notice? Then when a passenger in the back seat of my uncles’ cars I would worry that passing drivers would be able to read my thoughts (even though I knew that was impossible), and might be insulted by them, so I had to apologise to them by saying “sorry” mentally – in powers of three. Occasionally I would reach 243 sub-vocalisations. I suffered greatly performing these compulsions, but the prospect of not doing them filled me with even greater pain. Performing these compulsions also releases the mental pressure somewhat, perhaps in a similar way that self-harm makes some people feel a little better. Eventually the compulsions faded away, to be placed with slightly less compulsive compulsions, such as hand-washing (but much less excessively). I still tend to do things in multiples of three (such as checking the front door is locked behind me nine times), and I am still a very obsessive person, with curious obsessions like having to have complete sets of things such as books all in the same format.
That’s what it’s like when it’s bad, but even then perhaps I have failed to capture the full horror. I am sure that for some people it is even worse.

I am Emeritus Professor of Psychology at the University of Dundee. There is much more information on mental health and other things on my website, www.trevorharley.com. Please pass details of this blog on to anyone who might find it useful. There is no need for anyone to suffer in silence. If you are depressed, anxious, or suffer from OCD, contact your GP, or NHS 111, or a psychology or medical practitioner, or call Samaritans or Samaritans USA.

Sing if you’re glad to be mad, sing if you’re happy that way

As I write it’s World Mental Health Day. Should we take pride in being mad? Is it indeed something to celebrate? How do remove the stigma surrounding mental health problems?

As I start writing this entry, today, Monday 10 October, is World Mental Health Day, so I thought I’d write an entry to celebrate it.

“Mad Pride” is a movement of people who argue that individuals with mental health issues should be proud of their “mad” identity. According to its Wikipedia entry, the movement started in 1993 in Toronto in response to local prejudice towards people with a psychiatric history, and grew from there. Mad Pride seeks to educate people about mental illness, and also to “reclaim” terms of abuse such as “nutter”. I have mixed feelings about this idea. On the one hand educating people is obviously good, as is identifying and preventing psychiatric abuse. We also need to be wary about what is labelled as “ill” or “mad”. In 1860 Elizabeth Packard was committed by her husband to Jacksonville Insane asylum for three years by her husband because she disagreed with her his religious and political beliefs and with the way he treated her. Most people have heard of the misuse of psychiatry in the USSR, with the hospitalisation and enforced treatment of people with anti-state and anti-communist views, a “disorder” that was charmingly called “delusion of reformism”. There was also Walter Freeman’s use of lobotomy, performing several thousand lobotomies across the USA spanning decades, including one on a child of just four. Virtually everyone would agree that these sorts of things are wrong, but on the other hand, being anxious or depressed is utterly miserable. Would anyone say they’re glad to have cancer? I doubt it very much. We can have pride in coping, pride in surviving, definitely, but pride and joy in being mad?

Perhaps I’m misinterpreting the idea of the movement. Of course some mental health conditions have positives as well as negatives, such as the bursts of energy and creativity that go with bipolar disorder, but whether people think the ups are worth the downs is highly debatable, and the suicide rate in this group suggests many don’t. I don’t also mind – indeed I quite enjoy – being neurodivergent. There is nothing “wrong” with me just because I’m very introverted, and don’t much care for social activity, or am “on the spectrum”, but these things don’t cause me suffering, apart from when other people tell me I shouldn’t be this way, and in that respect I am right behind “difference pride” movement. There is also some vagueness associated with the term “mad”; people say so-and-so is mad because of their unusual behaviour, but they don’t really mean that person is suffering from a mental illness. The key word here is “suffering”: the suffering mental illness can cause is horrible, and definitely not to be celebrated.

It is extremely important to be able to say that you have mental health difficulties without feeling shame or with there being any stigma attached. The situation used to be much worse, and still many people feel embarrassed about being mentally unwell. They shouldn’t. To take my favourite analogy, people don’t feel stigmatised and ashamed because they have cancer (although admittedly once there was some stigma attached to it, because it was so poorly understood and usually a death sentence; my mother would never refer to it by name, simply calling it “tthe c-word”””, which was often confusing for the young me just learning a few swear words). The brain is an organ like any others, and mental illness is a brain disorder (albeit a complex one, involving genes and upbringing). You wouldn’t feel embarrassed to say you had a pancreatic disorder; so why should you feel shame about your brain going wrong? My mother, yet again, though often very ill with depression and OCD, would refuse to do anything about it, because, she thought, she should be able to control it; if only she were strong enough the depression would go. I am not saying that attitude and taking some responsibility aren’t important, simply that we should accept mental illness has some physical basis and that we should not feel shame because we are ill. Neither am I saying that there are not psychological influences on physical health and illness, when there clearly are, but there are limits to what we can do.

If I could excise mental illness from my health, would I? It is so difficult to imagine life with just the bad bits cut out, and the bad bits influence the good too. Would I be able to write and be a scientist without any OCD, for example? It makes me think of that episode of Dr Who, The genesis of the Daleks, when the Doctor decides against killing all the Daleks at their inception because he concludes they have done more good in uniting the universe than they did harm. I wouldn’t be me without my mental health problems. It has shaped my personality, and given me a degree of resilience I probably wouldn’t otherwise have. “That which does not kill us makes us stronger”, as Nietzsche said in his Twilight of the Idols.

Finally some explanation. I let my subscription to WordPress lapse because it costs money and like most others I am trying to cut back. I tried hosting this blog on my website, but it’s clear that many people prefer this way of reading the material, and I can see why, so I have renewed my subscription. Please do check out my website though because there is a lot of material there:

www.trevorharley.com.

Anyway, stay healthy, stay proud, don’t feel shame or embarrassment about mental health, and seek help if you need it. There is no point in suffering in silence. And the best of luck to Mad Pride; the only way we will overcome stigma about mental health issues is by being honest.

Ups and downs

It is some time since I have written about mental health and after comments and questions from several people have decided that I should add something to this blog.

Things have been up and down, and I fear that is the best I can hope for. I noted some time ago that no matter how bad I feel, I will always feel better, eventually.

I have noticed two sorts of variation in mood over time.

The least surprising is variation over days. There are periods of many days, even weeks, when I feel depressed, or very depressed, and then I recover and feel normal or even better than normal for a while. A bad phase typically happens for two to four weeks once or twice year. The curious thing is that although I am very depressed for weeks, there is the odd day in which I feel fine.

Then there is the second sort of variation, which is that within a day. Broadly I have identified the following pattern. Immediately on waking (typically 7.15 – 7.30) I feel fine, as though I don’t yet know what I think or how I feel, or perhaps just haven’t had time to think about it yet. Then within ten or fifteen minutes I realise I feel very, very depressed. This period is usually the worst of the day. Generally it lifts a great deal around 11 am, and as lunch time approaches I can feel quite good. By mid-afternoon my mood can be quite reasonable. Then in early evening it’s though I collapse, and feel bad again, but usually now as bad as first thing. I then improve and by the time I go to bed might be really good. It amazes me that I can fall asleep very happy and wake up and within a few minutes extremely depressed.

Doubtless there are good biological reasons for this short-term variation, but I can find little research on the topic and I can only speculate that it has something to do with the interactions of several factors, including neurotransmitter levels, hormone levels, the sleep-wake cycle, and even blood sugar levels.

Of course when we talk about major swings of mood we must think about bipolar disorder. With bipolar, how order, each extreme lasts weeks, maybe longer, and I don’t experience mania (I think). I swing between depressed and normal. There is a phenomenon in bipolar disorder called rapid cycling, but even then we are talking about several swings a year; it’s defined as four distinct mood episodes a year. I can experience four distinct episodes a day, so I don’t think what I have is rapid cycling, at least as not normally conceived.
I have found this online:

“Borderline personality disorder (BPD): BPD is a personality disorder characterized by difficulties regulating emotions, as well as extreme mood swings. These mood episodes are easily triggered and can last from minutes to hours.”

(See:
https://www.verywellhealth.com/rapid-and-extreme-mood-swings-5193418
A personality disorder as well! That’s all I need.)

My advice is to keep a diary of how you feel. I just score every day between 1 and 7. It enables me to test ideas like “I always feel bad n a Sunday” (I don’t, in fact).

Am I normal?

I have always been troubled by labels such as “normal”, and its opposite, “abnormal”, particularly when applied to mental health and personality. I am glad that it is no longer fashionable to talk about “abnormal psychology”, the preferred term being “psychopathology”. (You wouldn’t call someone with cancer “abnormal”, would you?) Normality is defined statistically, and just means the typical, or average behaviour or personality. If you’re some way from the mean on some personality trait it doesn’t mean, usually, that there is anything wrong with you. There is nothing wrong with being very introverted, and something very right about being highly creative. But we do like labelling people, and sometimes the labels take on a life of their own.

Here is a list of the disorders or syndrome with which I have been officially and unofficially diagnosed – the labels I have been given.

1. Moderate to severe depression. No arguing about this one. Yes.

2. Bipolar disorder. Yes my moods go up and down but I don’t think I have ever been manic. The moods also change quickly, even for rapid cycling. But perhaps bipolar and unipolar disorder are on a continuum, and I am just a little away from the unipolar end?

3. Anxiety disorder. Another obvious yes.

4. Phobias. I do have some mild phobias, particularly arachnophobia and trypophobia, but they’re mild. More troubling are claustrophobia and social phobia.

5. Obsessive-compulsive disorder (OCD). Definitely, particularly obsessiveness, and I should have been treated for compulsive behaviour when young. But hey, it was the early 70s, and no one knew anything then.

6. Attention deficit hyperactivity disorder (ADHD). I made the grade for a psychiatric diagnosis, but my blood pressure is too high for Ritalin.

7. Autistic spectrum disorder (ASD) definitely. I score 40 on the AQ.

8. Developmental prosopagnosia. I have never been able to remember or recognise faces, and when I imagine them, only face-shaped blankness comes to mind, although I can remember the hair.

9. Depersonalisation and derealisation. Funny turns. Yes, occasionally.

10. General phonological deficit (GPD). Trouble processing novel speech sounds. Definitely: I have trouble learning and remembering new words, learning nonwords, learning new languages, and recognising speech, particularly against a background of other speech sounds (although my general hearing is fine).

11. Personality disorder. Borderline personality disorder. Or narcissistic personality disorder. Or obsessive-compulsive personality disorder. I disagree with this one, but perhaps I would.

12. Authority defiance disorder. Who likes to be told what to do? (From the research on authoritarianism and compliance, quite a lot of people, actually). Are we starting to get silly?

13. Task avoidance disorder. Now I fear I am guilty of pathologising normal behaviour. Who doesn’t procrastinate occasionally?

Is it likely that I would suffer from all of these things independently? That’s 13 labels for me, and let’s suppose that each condition occurs in 5% of the population, which is almost certainly an over-estimate. That means the probability of them co-occurring if they are independent is about 10 to the power of -18 – that’s extraordinarily small. I am special, but not so special as to think I’m the only person who has ever lived that has these problems. That means the conditions can’t be independent. That makes sense, because we know anxiety and depression usually go together, as do some neurodevelopmental disorders.

And so is it likely that these “peculiarities” of mine are explained by a single faulty gene? Of course not. Like our physical appearance, our brains and mental life are determined by the interaction of many genes with our upbringing. And just as some people are considered more physically attractive, and some of us less so, some people have more adaptive or happier personalities, and some of us struggle.

I like the terms (labels) neurotypical and neurodivergent for just the reason that we can talk about people as being very different from the population norm without implying that there is necessarily anything wrong with them. Neurodivergence is a cluster of semi-related characteristics, including primarily what used to be known as Asperger’s syndrome.

The labels clarify my thinking a bit, but do the conditions marked by the labels map on to clearly identifiable brain states? Although there are genetic markers of depression, some brain abnormalities have been observed, there may be neurotransmitter differences, and some differences in fMRIs between the brains of depressed and non-depressed people, we cannot yet reliably identify a depressed person by their brain alone. And, if you are in doubt, if you had a brain scan which came back completely normal, what kind of psychiatrist would say that you are wrong about your suicidal ideation, that you can’t really be experiencing it because your brain looks normal?

When does unusual behaviour cross over into becoming illness? Very simply, when it causes you distress. You might argue that we should also include when someone’s behaviour causes others distress, but that is a risky path to take.

Of course our mental states are related to our brain states, but our understanding of the nature of the relationship is still rudimentary, and that is part of the problem with treatment: we don’t really understand what we’re treating. We have to rely on how our symptoms are changed by some treatment, and have only a basic understanding in some cases of how (see for example the recent and misunderstood fuss about SSRIs and serotonin levels).

The brain and the mind that works in it is among most complex structures in the universe, so please be patient with your psychiatrist or psychologist if sorting things out takes time.

Withdrawal: Duloxetine discontinuation syndrome

I am not sure how long I had been taking Duloxetine. I think about it was about ten years at a daily dose of 120 mg. I thought I wasn’t getting the benefit I used to. Now I know it’s complicated, many things can change, and so on, but one hypothesis was that the antidepressant had stopped working, or was no longer as effective as it had been. Others have noted a decline in the efficacy of anti-depressants with time: antidepressant treatment tachyphylaxis is the name given to the problem. (It’s been reported with at least SSRIs and MAO anti-depressants, and doesn’t appear to affect everybody.) There’s a limit to how much you can increase the dose to overcome this tolerance, so the main method of dealing with it is switching to a different drug. With my psychiatrist I decided to move to Venlafaxine. You can’t just stop taking one and start the other; you need to stop taking the Duloxetine gradually, wait a bit, and then start Venlafaxine on a relatively low dose. We agreed on a programme of a relatively slow taper, as this method is called.

I am not sure how long I had been taking Duloxetine (Cymbalta). I think about it was about ten years at a daily dose of 120 mg.

I thought I wasn’t getting the benefit I used to. Now I know it’s complicated, many things can change, and so on, but one hypothesis was that the antidepressant had stopped working, or was no longer as effective as it had been. Others have noted a decline in the efficacy of anti-depressants with time: antidepressant treatment tachyphylaxis is the name given to the problem. (It’s been reported with at least SSRIs and MAO anti-depressants, and doesn’t appear to affect everybody.) There’s a limit to how much you can increase the dose to overcome this tolerance, so the main method of dealing with it is switching to a different drug. With my psychiatrist I decided to move to Venlafaxine. You can’t just stop taking one and start the other; you need to stop taking the Duloxetine gradually, wait a bit, and then start Venlafaxine on a relatively low dose. We agreed on a programme of a relatively slow taper, as this method is called. Things were then delayed by my being hospitalised with pneumonia. I knew that stopping anti-depressants is not something to be suddenly or lightly, and I knew that Duloxetine is widely regarded as one of the more problematic, so didn’t think it was wise to start in a period of serious ill-health.

Eventually I started, and went down from 120 mg to 90 mg for a week, and then 60 mg. Things were OK. I don’t remember any obvious symptoms, and my mood held up well. And then I went down to 30, and the withdrawal side-effects began, first when the famous brain zaps kicked in. It’s difficult to describe these to someone who hasn’t experienced them. It is as though you’re brain is sneezing, or you experience a big mental shiver – it’s most unpleasant. Sometimes you feel as though you’ve been moved against your will. I also had an upset gut, but still I didn’t feel any different, mentally: I wasn’t depressed, or at least I wasn’t noticeably more depressed. So after anger two weeks or so I went down to 15 mg. (This point is where cutting tablets up and slicing capsules open comes into play). After two weeks, maybe a bit more, or I went down to 0 mg.

My records show that withdrawal was worst after going down to a quarter of my original dose and lower for about eight to ten weeks. It was really bad: brain zaps, upset stomach, frequent migraines, extremely vivid dreams starting early in the night, a feeling that I was still dreaming when awake. Even after three months or more I didn’t feel right. My gut hadn’t returned to anywhere normal. Most noticeably after a couple of weeks at zero my mood started plummeting. Low mood, anhedonia, no energy, recurring thoughts of suicide – all of course classic symptoms of depression. It’s interesting my mood took so long to fall, and that the lowering of mood correlated with the discontinuation side-effects starting to fade. The half-life of duloxetine (the time if takes for the body to process half the dose) is about 12 hours, but it must cause longer lasting changes to the brain’s neurochemistry (or perhaps the brain itself). Looking at the research literature I don’t think these things are very well understood.

I know there was a class action started against Eli Lilly in the States about what is called duloxetine discontinuation syndrome (DCS), but it was dropped because there was no evidence that Eli Lilly knew about the possible problem before they marketed the drug. I don’t blame anyone. I started taking it on consultation with my psychiatrist and I was aware that there might be withdrawal problems, as there are with many medications. I suppose I thought it wouldn’t be that bad, having come off other anti-depressants before. Even now I think there must have been many people worse off than me.

Fear of death

When I was three or four I was afraid of television aerials, dogs (particularly black ones), plugs, painters, thunder, and pneumatic drills. As I grew up these specific fears resolved into more general anxiety disorders, but I still have mild arachnophobia (I bear spiders no ill will, but they have far too many legs and move much too quickly for their size), and thanatophobia, a profound fear of death.

When I was three or four I was afraid of television aerials, dogs (particularly black ones), electrical plugs, outdoors painters, thunder, and pneumatic drills. As I grew up these specific fears resolved into more general anxiety disorders, but I still have mild arachnophobia (I bear spiders no ill will, but they have far too many legs and move much too quickly for their size) and thanatophobia, a profound fear of death.

Most people don’t want to die, but I am surprised how casual most people are about their eventual demise. Why isn’t everyone raging against the dying of the light from the moment they first realise that the light will some day die? I think that in twenty-five years or so I could well be dead, and I think back twenty-five years from now and that doesn’t seem to be any time at all. Even if I die peacefully in my sleep, which seems to be most people’s goal, I won’t be happy. When I reflect on my fear I’m particularly afraid of not being conscious ever again. The universe will roll on perfectly well without me. A few people will grieve, but that will fade, and the ripples of the effects of my life will soon die down and I will be forgotten. Just writing that makes me very, very miserable. And angry, as does thinking about the unfairness of having to get old.

Mental illness requires consciousness. Your computer can’t be depressed, but a dog can be; we know from Martin Seligman’s studies on learned helplessness that dogs can show symptoms akin to depression, and of course other animals can suffer mentally too. Social outcasts in groups of social primates also give the appearance of being depressed. But can a wasp be depressed? We can’t know for sure, but it doesn’t seem likely. A wasp has very little consciousness, not enough to feel depressed. I explore animal consciousness in my new book, The Science of Consciousness.

Some forms of mental illness require more than consciousness: they require self-consciousness: thanatophobia is one example, and illnesses to do with the meaning of life are another. I am pretty certain Beau, my poodle, is not afraid of his death. Of course (non-human) animals are capable of fear and other negative emotions, but not of concepts that require self-reflection. I don’t think he has any concept of death, so he can’t be afraid of it. I’m not saying that if something happened to me he wouldn’t be very upset, but that he can no more appreciate the meaning of mortality than he can understand quantum mechanics. These concepts are utterly beyond his comprehension because he doesn’t have the mental capacity for them. It isn’t simply that the concepts are too complicated for him, it’s that reflecting on the death of his self requires a complex concept of his self, and for that he requires self-awareness. Awareness and self-awareness are very different things. Many animals are (probably) aware, but few are self-aware. I’m not sure it’s right to talk about awareness and self-awareness as if they are a dichotomy – he might possess a bit of self-awareness, but not enough to worry about his death.

Can we learn anything useful from all this? On the whole I’d say Beau is much happier than me, and he doesn’t spend his life reflecting on canine existential concerns. I think his happiness and restricted self-obsession are related; sometimes humans reflect too much. Of course some thinking is good: it’s good to be aware of our situation; it’s important to prepare for our deaths and leave our affairs in order, and I wouldn’t want to put existential philosophers out of a job, but for many of us too much reflection can be a bad thing. We should look at Beau and realise that it is good to live in the moment, which is essentially what studies of mindfulness and mental illness tell us to do. This obsession with death is also utterly futile because there is nothing I can do to prevent my impending obliteration. And maybe that’s true of much mental illness: we need to learn to stop thinking. Easier said than done of course.

Psychologists occasionally reflect on what makes humans unique. To the list of language, a highly convoluted cortex, and opposable thumbs, I think we should add the ability to suffer mentally in particular ways. Our uniqueness has given us unique ways of being tormented.

Pure O: Obsessing about obsessions

Obsessional thought is a form of OCD. My experience is that obsessional thought goes with compulsive behaviour, and therefore it does make sense to talk about OCD, and the amount of obsession and compulsion is a ratio on a continuum. When I was young I was more compulsive; now I am more obsessional.

Do you just find yourself sometimes obsessed, thinking about the same thing and can’t stop? There was an interesting article in the (UK) Times on 2 September 2020 about George Ezra’s struggle with his “pure obsessional” thought disorder. The article then covered the debate about whether it is a distinct category of mental illness from OCD. As you might know, my view is that diagnostic criteria for mental illness are pretty messed up, and we don’t have much idea about what is going on in terms of brain dysfunction, genetics, and the effects of experience, and one of the best things about psychiatrists is that they can prescribe drugs (although even then some claim some drugs may do more harm than good). I think it’s very hard to disentangle different types of mental illness, and depression and anxiety disorders are one big blob of unwellness that manifests itself in different ways in different people at different times.

I am definitely inclined to “Pure O”, but I still have some compulsions, albeit currently weak ones that are not too dysfunctional (such as checking the door is locked in multiples of three). The key thing is that the compulsions don’t trouble me, but the obsessive thinking is horrible. When I was younger though my compulsions were much worse – going downstairs in the middle of the night when I was 12 or so checking that the front door was locked maybe a hundred times (although it would have been 99, a multiple of 3, or 81, a nice power of 3, and once or twice 243 times). I was also obsessed with the idea that other people could read my thoughts, even though I knew they couldn’t. I sat in the back of my uncles’ cars and worried that a passing driver would misinterpret my hand posture as a V-sign, and would then track me down, so I would mentally say “sorry sorry sorry” (again some power of 3 times). It was the different world then. I’d never heard of mental illness and had no idea what a clinical psychologist or psychiatrist was. There was nothing like a counsellor at school (I think i might be wrong here: there might have been a nurse in case we broke our leg in break – might).

I’m not so bad now, but I am still pretty obsessive, and occasionally something comes along that I just can’t stop thinking about. I know everyone has their worries but talking to other people about worry, obsessional thinking is completely different. It’s all consuming. It can be dangerous. It can be a form of self-harm. Mostly now I just have a “completeness obsession” – the idea that if a read a certain book or hear a particular piece of music I will be a better person. That isn’t unnatural, but then comes the idea that just owning a certain book, or worse all books in a series, or all pieces of music, will do the job. Or having every track on a music programme. That can work out to be quite expensive, and it takes a bit of time, but it doesn’t make me very unhappy. When I was 12-13 I was very, very unhappy about it all.

My experience is that obsessional thought goes with compulsive behaviour, and therefore it does make sense to talk about OCD, and the relative amount of obsession and compulsion is on a continuum. When I was young I was more compulsive; now I am more obsessional.

I wish I could be optimistic about treatment. There are no specific drugs; SSRIs and anxiolytics are usually prescribed, but they don’t seem to do much for me, and neither has CBT (although of course you might argue I’d be even worse without these).

You might also be interested in Rose Cartwright’s book Pure. Personally it didn’t tell me much new, but you might have a different view.

If anyone has come across a reliable way to stop obsessing about something, please let me know. It might be extreme, but sometimes I wonder if giving myself an electric shock every time I had a bad thought would work.

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