Letter to my younger self

letter with quill and ink

I’ve seen a few of these on various blogs, but it was one posted recently by Sarah at Sall Good in the End that actually prompted me to give the matter some more thought.  What struck me was that my first thought was to tell my younger self to run.  Run away and join the circus.  Leave it all behind and go live in a yurt.  It took a while to think of anything in addition to the run away theme, but here’s what I eventually came up with.  I picked age 20 because that’s a time when I was at university having loads of fun and starting to discover who I really was.


To Ashley at age 20:

I know you’re having a great time right now, and enjoy it.  Here are a few suggestions I have for along the way:

Travel.  That’s how you will have some of your best experiences ever.

When you get into your first long-term relationship, don’t lose yourself in the relationship.  And if we’re going to get really specific, even though C makes a good friend, skip the boyfriend thing because it just doesn’t work as well, and he turns out to be a jerk in the end.

Bullying can happen to adults.  Know what it is, recognize it when it happens to you, and get the hell outta there.  No one else will care enough to do anything, so you’ve gotta take care of you.

You will get sick.  You will see it, but you will deny it.  When you can no longer deny it, you will think that you can deal with it yourself.  You can’t.  Instead, I want you to grow some lady-balls and reach out for help.

Your illness will affect how you relate to the people around you.  I wish I had some good advice for you, but I don’t.  Try not to beat yourself up over things that don’t work, because guilt is a poison that eats away at you.

Save your money.  You will need it, and it will make life much easier at difficult times.

Love yourself and be true to yourself, and treat your natural introversion with compassion and respect.  There’s nothing wrong with making a brief appearance at a social event to say hi and then heading home to bed.

Don’t get drunk with coworkers.  No matter how good an idea it seems at the time, trust me, it’s just not.

Get furbabies as soon as you live in a place that allows them.  Guinea pigs will offer countless hours of cuteness and comfort.

Life will get a whole lot darker in a few years (at age 27, to be exact).  The flame that was your passion for life won’t burn as brightly after that.  The shadow cast by your illness will never go away.  So live for right now.  Your early 20’s will be some of the most exciting years of your life.  And maybe, just maybe, after you get out of hospital the first time, consider running away to central Asia and living in a yurt.  One final word of advice – save your pelvis some torture and get to the yurt by truck rather than by horseback.


Your 39-year-old self


What would your letter to your younger self say?


Image credit: Bru-nO on Pixabay


More from Quora on mental health

Quora logo

I did a post a while back Gems of Ignorance From Quora with some of the frighteningly ignorant questions asked by people on Quora, a sort of free-for-all website where people can post and answer questions.  Here are some more tidbits I’ve come across.

Some people seem to have a genuine interest in gaining some understanding mental illness.  Some questions I’ve seen that reassured me that not everyone has their head stuck up where the sun doesn’t shine:

  • Can you be depressed without being sad?
  • How do you know the difference between drug-induced psychosis or psychosis from something else?
  • When a depressed person starts taking antidepressants, does he/she start feeling happy or just “not sad”?
  • What does it feel like to have depression or  bipolar disorder?
  • What’s the difference between feeling depressed and having depression?
  • How do people with schizophrenia tell apart real sights/sounds from fake ones?

Other times, the answers people post are even more frightening than the questions:

  • To a question about the maximum number of psychiatric diagnoses a person can have: “When a person enters mental psychosis I’m pretty sure their mind is so fragmented that they’ve pretty much got it all: ocd, npd, psychopath, sociopathy, bpd, anxiety, depression, split personality (definitely) and whatever else you could think of they have a little hint of.  But a number? I’d say 17.”
  • To a question about the use of lamotrigine in bipolar disorder: “You have only to scan back through a few hundred years of “labels” the so-called mental health professionals” have used… “humors”…. “phrenology”… etc..Now they claim there are “microbes” that cause brain disease.. or come up with labels like “bi-polar disorder”?? WHY should anyone place any confidence in such a science? To my understanding, they have very poor results to show for all their claims to be a “mental health science”.  I think you will find results from a minister or group therapist probably as good and likely LESS harmful! I AM NOT A DOCTOR… I am trained in ministerial counselling that has proven very successful for most people!”
  • To a question about the strongest antidepressant: “Meditation is much stronger than any antidepressants you may take.”
  • To a question about whether there is a common mental disorder among mass shooters: “psychotropic drugs”
  • To a question about a non-medication remedy for depression: “Truthfully, when you remove the stagnating, congesting foods like wheat, dairy and dead animals which are filled with anxiety and depression living in horrific factory farms, and fed nasty things, you perk up! You’re not the starched out, sleepy, congested and pale, super tired person you used to be!”
  • To a question about why there’s stigma attached to being hospitalized for psychiatric reasons: “Because the mentally ill were warded with the prisoners in jail. They had no rights. They were stripped of all protections. After the separation, Usually, a lobotomy would be performed. The patient would be basically brain dead and again with no rights, die in a mental aslymn. Sad!”  (My observation: Not to get political, but that sounds kind of like a Donald Trump 3 a.m. tweet)


Yes, this is the world we live in.

TED Talks on mental health stigma

TED Talks logo

Lately I’ve been sharing some of the TED Talks that I’ve found particularly informative and inspiring.  In this post, I’m focusing on talks that challenge the stigma related to mental illness.


Sangu Delle: There’s No Shame In Taking Care of Your Mental Health

Sangu Delle speaks about the stigma of being an African man with anxiety.  He felt shame when his doctor first suggested that he speak to a mental health professional about his anxiety.  Culturally, the expectation was that emotions were brushed aside and problems were just dealt with.  Among his own group of friends, when one was diagnosed with a mental illness, other friends snickered and made derogatory remarks.  In a study of Nigerians, 34% thought mental illness was due to drug use, 19% thought divine wrath was the cause, and 12% blamed witchcraft.  Delle challenges the stigma that ends up ostracizing and demonizing those who experience mental illness.

Thomas Insel: Toward a New Understanding of Mental Illness

Thomas Insel proposes a different way of looking at mental illness.  He suggests we should refer to mental disorders as brain disorders, since they involve the most complex organ in the body that at this point we still have very little understanding of.  He also frames the scope of the issue, saying that mental illnesses cause more total disability than any other condition.  He suggests that differences in the “connectome”, i.e. connection pathways in the brain, might be a way of identifying illness earlier as opposed to waiting to see behavioural changes.

Michael Botticelli: Addictions Is a Disease. Let’s Treat it Like One.

Michael Botticelli is a former US director of national drug policy under President Obama.    He openly shares his own history of alcohol addiction and subsequent recovery with the aim of changing public opinion and public policy.  He likens the current opioid epidemic to the AIDS epidemic in the 1980’s.  He argues that we can’t arrest our way out of the problem of addiction; instead, we need to view addiction as a chronic medical condition and ensure that people have access to the treatment they need, when they need it.  He says that we need to change the way we view people with addictions, and realize that they are more than their disease.  This is certainly an important and hopeful message to be putting out to the world.

Ruby Wax: What’s so Funny About Mental Illness?

Ruby Wax is a comedian who has depression.  In this passionate, high-energy talk, she uses humour to address common stereotypes and misconceptions about mental illness.  She’s very skillful at doing this in a way that educates and doesn’t make light of mental illness.  Because it’s very engaging and accessible, I think this talk would be particularly good at getting the anti-stigma message across to people who have limited understanding of what mental illness is.

A glossary of psychiatric terms

mental health word cloud

Like any field, psychiatry has its own collection of terminology.  Some of it is self-explanatory, but some of it isn’t.  I believe that knowing the jargon helps to narrow the power gap between health care providers and patients, so I wanted to talk about some of the terminology that’s commonly used.  Some of these terms are a follow-up to yesterday’s post on psychiatric assessment and the mental status exam.

  • Alexithymia: inability to identify and describe one’s emotions
  • Alogia: This refers to an impoverishment of thinking that is inferred from speech.  This can involve a decreased amount of speech (may be referred to as poverty of speech) or a lack  of content (may be referred to as poverty of thought).
  • Anhedonia: an inability to experience pleasure
  • Avolition: an inability to initiate and persist in goal-directed activities
  • Catatonia: markedly decreased physical reactivity to the environment.  Think One Flew Over the Cuckoo’s Nest.
  • Confabulation: This is the unconscious filling in of memory gaps by imagined events; it does not involve intentional lying.  Traumatic brain injury is a good example of a condition that may involve confabulation.
  • Echolalia: imitation of words/sounds
  • Echopraxia: imitation of movements
  • Ego-dystonic: thoughts that are inconsistent with what someone normally believes when they are well (the opposite of this is ego-syntonic)
  • Floridly psychotic: psychosis that is overtly obvious
  • Neologisms: making up new words
  • Overvalued ideas:  a belief that someone is quite fixed on but not to the extent of a delusion
  • Pressured speech: speech that is rapid and very difficult to interrupt
  • Responding to internal stimuli: obviously responding to hallucinations, such as when a person seems to be talking back to auditory hallucinations


Types of delusions:

  • Capgras: believing that people have been replaced by imposters
  • Erotomanic: an example would be believing that one is in a romantic relationship with a famous person
  • Grandiose: an example might be a person believing they are a key advisor to a major political figure
  • Ideas of reference: interpreting messages as being particularly directed at oneself, including things on billboards, tv, or radio
  • Paranoid/persecutory: This is probably what first comes to mind when many people think of delusions.  These delusions that one is or will be harmed may be further described as non-bizarre (within the realm of possibility, like being monitored by the government) or bizarre (aliens trying to enter their home via the cat door to steal their right foot).
  • Somatic: false beliefs about things that are happening in one’s body, ranging from something like cancer to something bizarre like believing one’s stomach is filled with dancing turtles
  • Delusions of control: belief that one’s thoughts are controlled by outside forces
    • Thought broadcasting: believing that one’s thoughts can be heard by other people
    • Thought insertion/thought withdrawal: believing that thoughts are being put into or taken out of one’s head
  • “Delusional proportions”: things like guilt or obsessions may become so intense they’re considered to have become delusional in nature, aka reached delusional proportions


Thought form/thought process descriptors:

  • circumstantiality: wandering away from the original idea, but eventually returning to it
  • clanging: grouping unrelated words based on sound (such as rhyming)
  • concrete: interpreting things very literally, often tested by asking a patient to interpret proverbs; eg “it ain’t over til the fat lady sings” might be interpreted as an obese woman would have to sing a song before something could be finished
  • loose associations: connecting ideas that seem to be totally unrelated
  • overinclusive: including excessive amounts of detail
  • perseveration: repeatedly returning to the same topic
  • poverty of thought: an easy way to describe this might be that the lights are on but nobody’s home
  • tangentiality: going off on a tangent, and losing the original idea


Descriptors of affect (facial expression of emotion):

  • euthymic: neutral, “normal”
  • expansive: unrestrained expression of feelings
  • incongruent: does not match the reported mood
  • labile: rapidly changing
  • restricted/blunted/flat: These all refer to decreased facial expressiveness.  Restricted is the mildest term, and flat refers to almost no emotional expression.


Some of these terms may sound rather judge-y, but like jargon in any field, when terms are used routinely they start to lose the connotations they might have outside that particular field.  Having a set of relatively standardized terms is useful in helping health care providers understand what is being referred to in a patient’s chart, but it’s easy to forget that these terms may mean something very different to the patient who ends up reading their own chart.

Have you ever had psychiatric jargon applied to you in some way that felt wrong or judgmental?


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The Mental Status Exam (MSE) in psychiatry

assess written in Scrabble tiles

The mental status exam (MSE) is a framework for assessment that’s used widely in the field of psychiatry.  Rather than being a one-time assessment, it is used on an ongoing basis to capture how a patient is doing on any given encounter (and I use the term patient to describe the role and not the person as a whole).  This is what it covers:

Appearance, attitude, and behaviour:  This isn’t supposed to be about passing judgment; instead, the purpose is to identify clues that could potentially give information about someone’s mental health.

  • Apparent vs stated (i.e. actual) age: When I’m depressed, I tend to appear older than my stated age. While it sounds odd, “stated age” is just the usual terminology and isn’t intended to imply that someone is lying about their age.
  • Grooming: If someone is depressed or struggling with negative symptoms of schizophrenia their hygiene may be poor, while someone who’s manic may be wearing heavy makeup and revealing clothing.  This is most useful when the clinician knows the patient’s baseline for comparison, or can refer back to MSEs documented in the past.  Another factor is whether the person is dressed appropriately for the weather.  For example, if someone is dressed for a polar expedition on the hottest day of the summer, that may be an indicator of a psychotic illness.
  • Eye contact: This is another area where it’s useful to be aware of the patient’s baseline as well as relevant cultural norms.  When I’m very depressed, I make minimal eye contact.
  • Cooperation with interviewer: Someone may be “guarded” (reluctant to reveal information) due to paranoia, or rapport may be “tenuous” (weak) because the interviewer is a pompous jerk, and this can mean the information gathered through the interview isn’t necessarily reliable and therefore the assessment may not accurate capture the entire clinical picture.
  • Motor behaviour: There are a variety of ways in which mental illness can affect people’s physical activity.  For example, mania may speed up people’s movements (psychomotor agitation), while depression may slow it down (psychomotor retardation).  Catatonia refers to extreme disruptions in motor behaviour.
  • Speech: This includes rate, rhythm and volume.  If someone is slow to give answers to basic questions they may be described as having “latency of response”

Mood and affect: Mood is how the patient describes their emotional state, and affect is the emotional expression visible on the patient’s face.  Affect may be referred  to as incongruent if, for example, a person was laughing while speaking about a very sad topic.

Perceptual disturbances: Alterations in perception could include hallucinations (which may occur in any of the five senses) and illusions (skewed perceptions of “real” environmental stimuli)

Thought form/thought process: This considers the “how” of a person’s thinking.  Is it logical?  Is it disorganized?  I’ll talk more about this in tomorrow’s post on terminology.  Thought form isn’t assessed based on asking the patient specific questions, but rather is evaluated based on the entirety of the interview.

Thought content: This considers the “what” of a person’s thinking, and includes delusions (which I’ll break down further in tomorrow’s post), obsessions, and suicidal or homicidal ideation (commonly abbreviated as SI/HI).

Cognition and sensorium: This includes things like orientation, concentration, and memory.  Further formal testing may sometimes be required.  A brief test like the mini mental state exam or MMSE (despite what it sounds like, no relation to the MSE) might cover questions like what day/month/year it is, spell “world” backwards, subtract by 7’s (“serial sevens”), remember 3 objects, and copy a geographic design.  Baseline intelligence and education is relevant here; if someone with no formal education can’t subtract by 7’s that doesn’t necessarily indicate there’s a problem, but if an astrophysicist can’t do that task it’s a pretty good indicator of significant impairment.

Insight and judgment:  Insight refers to the patient’s level of awareness of the symptoms they’re experiencing and the impact those symptoms are having on their functioning.  Insight tends to be poorer with some illnesses compared to others, and may fluctuate depending on the severity of the symptoms someone’s having at any particular time.  Someone may have good insight into their symptoms without necessarily agreeing with the clinician on the cause of those symptoms.  Judgment refers to the extent to which a person’s judgment, particularly with regards to behaviour, is influenced by the symptoms they’re currently experiencing.  An obvious example of poor judgment would be someone who was manic blowing a bunch of money at a casino.

So there you have it, the basic pieces of a mental status exam (MSE).  In tomorrow’s post, I’ll explain some more of the terminology that’s commonly used in assessing mental health.


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Trigger management

lightning strike

We’ve all got things in our lives, past or present, that cause us pain.  And we’ve also got triggers that bring that pain back up to the surface.  This has been on my mind lately because I’ve been getting triggered by something that’s seemingly innocuous.

In my last job I became quite close to a male coworker, B.  I trusted him, but was never sure exactly what kind of relationship we had, and both at work and outside of work it always felt like he alternated between pulling me in and then pushing me away.  He became psychologically abusive and ended up causing a great deal of harm in my life.  One quirk of speech he happened to have was frequent use of the word “cheers”.  It was also a word he would often use to shut down conversation on topics that were a little too personal.  I might say I wanted his input on something because his opinion mattered to me.  “Cheers”, on to another topic.

Fast forward to the present.  There is a male coworker, A, who I am quite close to.  I trust him.  I’m not entirely sure where our relationship is going, but it feels slow and steady rather than game-y.  He is very kind, accepting, and open; a completely different person from B.  Just in the last week or two A has used the word “cheers” several times in text messages and emails, including in response to an email I sent thanking him for always being willing to listen to me.  Each time I got that response I felt a lightning bolt of pain, followed by the thought that he is going to harm me the same way that B did.  I recognize right away that logically this is completely insane.  It’s just an innocent word.  Yet that doesn’t stop the pain.

If I told A that this was happening, I know he would be very receptive and try very hard not to let that word slip out.  I’m reluctant to bring it up, though, and I guess there are a few reasons for that.  One is that I feel kind of ridiculous asking him not to use such a neutral word; this is my problem, and I shouldn’t make it his problem too.  Two, I don’t really want to talk about my experience with B.  And three, this is a word that I’m going to encounter people using on a fairly regular basis, and I feel like I should be able to gain control over my own reactions.

I just don’t know how to desensitize that trigger.  I suspect I probably will end up talking to A about it, and that will go fine, but trigger management is something that I’m going to need to put some thought into.

Have you found strategies that help you manage your own triggers?


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Cognitive distortions: Getting personal

infographic: brain, thoughts, feelings

Yesterday I outlined some of the common types of cognitive distortions.  It’s one thing to know about them, but actually recognizing them in ourselves can be a lot harder to do.  It’s all well and good to try to look for evidence against a possibly distorted thought, but what if there is a preponderance of evidence that actually supports the negative thoughts?  It’s taken quite a bit of time and reflection to see many my own cognitive distortions for what they are, and understand that even though there may have been some truth underlying some of these thoughts, my mind then grabbed hold and ran off in a distorted direction.  Warning: I don’t have a good synonym for the word shit, so that word is used very liberally.

Always being right:  For the most part I don’t do this when I’m depressed, but when it comes to things to do with my treatment I get very rigidly convinced that what I think is right.  During one hospitalization I was adamant that I was not going to have ECT.  It was stupid, because ECT is helpful for me, but I wasn’t budging; I was always right about what treatment I should have, and the doctor was just plain wrong.

Black and white thinking:  I do this the most in evaluating whether people are safe or unsafe, trustworthy or untrustworthy.  Most people get quickly shuffled into the unsafe/untrustworthy category.

Catastrophizing:  I expect that small shit is going to turn into big shit.  Not an if but a when.  A big factor in this is that there have been multiple occasions in the relatively recent past when what should have been small shit did in fact turn into big shit, so it’s easy to tell myself that no, this isn’t distorted thinking, it’s being realistic.  I’ve done a lot of drowning in shitstorms in the last while, so why shouldn’t I expect it?  Throw me a life raft already!  The reality, though, is that probably most small shit will stay small most of the time.

Disqualifying the positive:  When I’m unwell, the thinking might go: “So I had a decent minute/hour/day… what difference does it make, everything is still just as shitty overall.”  As I start to get a little better, the thinking takes a bit of a turn and it’s more having a hard time trusting that the positive truly is positive rather than just shit in disguise.

Filtering:  I’ll focus on the downpour of negativity, and think that I must have been walking around in a bubble in the past that made me oblivious to the permanent negative downpour.  When in reality it’s probably more like a cartoon character walking around with a little raincloud temporarily following along above his head, and all the while the sun is shining everywhere else.

Emotional reasoning:  The biggest one for me right now is that I feel unloved by my parents, therefore they must not love me.  I know intellectually that this isn’t true, but I still really struggle with it.

Fallacy of fairness:  I have a pretty strong sense of ethics and justice and all that crap, and I tend to assume that everyone else should have the same.  Where I seem to get most caught up in the fallacy of fairness is expecting fairness from people who I don’t have a close personal relationship with.  I guess somehow I expect that distance=objectivity=fairness.  Except the world doesn’t work that way.

Fallacy of control: When I’m depressed I often feel like I have no control over what’s happening to me, and it can be hard to tease apart that a) maybe I do have limited control over what happens around me, and b) maybe I do have limited control over my illness given that it’s not always that responsive to treatment, but c) somewhere in all of that there are still elements of my reactions and choices that I do have control over.

Fortune telling:  So much shit has happened before, my automatic expectation is that the future will follow along in the same direction as the past.  I even run over mock conversations on replay in my mind of some shitty event that I’m imagining will happen.

Mind reading: I must admit, I tend to do this at the best of times, but more so when I’m feeling vulnerable.  A recent recurring theme: “I haven’t heard from X today.  It must be because X is sick of talking to me and doesn’t want to deal with me any more.”

Overgeneralization:  “I hate people” is something I say probably more often than I should.  I have encountered a plethora of stupid and shitty people in my real life, and I’ve expanded that outwards to include pretty much everyone in a 50km radius.  Ok, so maybe I need to admit it’s an overgeneralization to say I hate all people, but if I tone it down to “I hate most people” then perhaps I’m no longer overgeneralizing…

Personalization:  I think I do this more at work, and it tends to go hand in hand with catastrophizing.  I’ll read a team email and be convinced that the message is actually directed at me, and then all of a sudden I’m thinking damn, they’re going to fire me, or do this or that to me…  There have been work situations before when things were not-so-subtly directed at me, so it can be hard to convince myself that it’s not reasonable to expect that to keep happening all the time.

The last time I tried seeing a therapist, she wanted to do CBT with me, and I remember very clearly thinking that I didn’t have cognitive distortions; my negative cognitions were based in reality.  I think that for me personally I’m just not receptive to CBT when I’m at my lowest with my depression.  It’s really just in the last couple of months that I’ve been gradually feeling somewhat better and mentally flexible enough to be able to work on gaining insight into these thought patterns.  It’s an ongoing project that involves finding a balance between challenging the distorted thinking and validating the thoughts, emotions, and experiences that gave rise to those distortions.  Blogging and journalling have been an important part of that.

What are some of your major stumbling blocks?


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