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.”

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.

Further reading

Allsopp, Kate, John Read, Rhiannon Corcoran, and Peter Kinderman. (2019). Heterogeneity in Psychiatric Diagnostic Classification. Psychiatry Research, 279, 15–22.