The author and curator of this site passed away June 2021. In his memory we will keep this site running as long as it brings value.

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~Ken Jr

Sexual deviance is a term that has been both useful and confusing in its application to the human condition. The term sexual deviance has been replaced by the term parafillia, which means the experience of intense atypical sexual arousal to unusual objects, situations, and individuals. The fact is that when applied to mental health, the term becomes very muddled and at times, controversial.
Consider for a moment that we have difficulty discussing typical human sexuality in our normally open and frank discourse. Somehow discussing sex is considered taboo, dirty, or titillating. When Kinsey published his text books on both male and female sexuality in the 1950’s, they were read in secret and could never have been the subject of polite conversation. Even later, Masters and Johnson jointly wrote two classic texts in the field: Human Sexual Response and Human Sexual Inadequacy, published in 1966 and 1970 respectively. Both of these books dispelled long held myths about “normal” and “unusual” sexual behavior. Again, neither made the conversation around the water cooler at work and were relegated to secret reading. And, even more currently, Fifty Shades of Grey, a 2011 erotic romance novel by British author E. L. James is being discussed by the media as a voyeuristic peek at the world of sexual arousal. But, there is no conversation as to how this translates into real life.
Part of the problem of placing parafillia in context with regard to mental health is the cultural divide. For, example, homosexuality was considered deviant as far as mental illness was concerned. It was not removed from the DSM, (Diagnostic Manual of the American Psychiatric Association), until 1973. But, as we look at the culture today, we have civil unions, and gay marriage in several states, and a more liberal cultural view of gays and lesbians. But, if we dig deeper, several parts of the country still consider homosexuals as deviants. There is also a generational divide with regard to the practice. In addition, what may be considered “acceptable sexual practice” for example, oral sex in heterosexual couples is considered abnormal by some segments of society. In fact, some legislators seek to make it a crime. So then, we come to the most problematic aspect of placing parafillias in context; privacy.
If a man is sexually aroused by wearing women’s undergarments, is that a deviant act or simply an expression of individual choice?  Or are any of the sexual acts that we consider “normal” valid across societal norms? These are the questions that perplex mental health professionals as well as the general public. I would submit that the concept of placing the diagnosis of parafillia effectively, we have to consider the impairment factor. If any behavior, sexual or otherwise, impacts the daily life of an individual, then there may be a mental health issue. Without impairment, the desire to label an individual as a deviation is misplaced.

This post entry is a departure from the usual informational attempt on a particular illness to a question for our collective consideration.  The question is whether or not the use of the computer, smart phones and tablets has provided an environment for addiction and a reduced quality of life.
 Many people recognize the word addiction and generally associate the term with abuse of drugs and alcohol, food, shopping, exercise, or other repetitive behavior that may have adverse consequences. Addiction is frequently a component of several mental illnesses. When the illness is accompanied with drugs or alcohol, the condition is referred to as a “dual” diagnosis.
We do know that true addiction is based on anxiety and has a root in obsession and compulsion. But, with computer addiction we may be able to add boredom and distraction. Are these indicators of an underlying problem?
My first questions about computer addiction began with my own use of the computer and asking some basic questions. Was I using the computer and the internet effectively or was I substituting the computer for other productive activities?  And, I believe that this question is a valid one for anyone who uses the computer and the fast-paced world of information. It is a question that is very individual and can best be answered by the reader. Toward that end, I have included a link to HELPGUIDE.org covering computer addiction as an overview here. My hope is that this topic will generate some thought provoking questions for the reader and perhaps, shed some light on how we use our time.

I have always been concerned about how the media has portrayed mental illness. Specifically, I fail to see the reality when I watch TV or watch a movie that has mental illness in the content. It seems that the majority of us learn about mental illness by observing these “entertaining” visual offerings. The programs that seem to be the greatest advocates of fallacy are the police shows like CSI, Criminal Minds, and others of that genre. They frequently characterize the perpetrator as dangerous, unpredictable, and often with bizarre behavior to be feared by the public. And, while this passes for harmless entertainment, there is a subtle “teaching” of little real value. We do not always recognize that even FBI profilers are not trained psychiatrists and have no credibility when they say that they are searching for a psychopath or a sociopath.  They use the terms almost interchangeably, and although there are similarities, the differences are significant in behavior. This post considers the differences between the psychopath and the sociopath as well as some similarities.
Psychopathy and sociopathy are both anti-social personality disorders. And, while both are conditions are the result of heredity and environment, psychopathy seems more controlled by genetics and sociopathy by environment. Psychopaths are born with temperamental differences which include impulsivity, brain underarousal, and a lack of fear that may lead to behavior that is risky. They are also less likely to recognize social norms and fail to measure their role in society. Sociopaths have more typical temperament but their anti-social behavior has been an effect of poverty, abuse, and being influenced by negative peer pressure.
Although there is no “typical” psychopath or sociopath, there are clusters of behavior that distinguish each of these anti-social personality disorders. Behavioral tendencies in the psychopath include erratic behavior, impulsivity, violence, disorganization and willingness to disregard risk, and poor to no social interaction and interest. They would not actively plan and execute a crime with the expectation of not being caught. They would leave evidence of their behavior and not be concerned with consequences.
Sociopaths on the other hand are much more controlled and would not take the risk of being caught. They tend to be schemers and are frequently involved in fraud and deceit. They can appear to have normal social relationships and can use these skills to their own ends. Sociopaths are often social predators and seem to fit in with society.
Treatment is possible with medications and therapy but diagnosing anti-social personality disorder is a process that is time consuming and involves as much ruling out behavior as well as ruling in risky or anti-social activities. But, the real message in this post is that it is important to question the labels used by the media. Ask yourself if the source of the information is reliable and qualified to determine the attached label.

Due to the most recent shootings and ongoing gun violence it seems apparent that there are two divergent paths being considered to "solve" the problem. One seems to be limit the guns, and the second is to find the mentally ill among us. I used solve in quotes as it is not possible to solve this problem with legislation about guns or rounding up the mentally ill. All that we will see is further entrenchment on the part of the second amendment proponents and a fight from the ACLU about privacy for the mentally ill.
The United States already has more guns than most of the free world including assault rifles, high capacity magazines, and body armor. So, the only way to limit guns now would be to confiscate them which would impact second amendment rights. And, then what about knives, bombs, poisons, and alternate means of causing death? Focusing on weapons seems to be the least productive of the possibilities of minimizing or mitigating acts of violence.
But, in the parlance of the FBI, we do have some profiles that could be helpful in identifying those individuals who are determined to harm others. We know that there are crimes of passion, acts of seemingly random killing, and premeditated death. We find after the fact that the killer was withdrawn, a loner, felt left out or disenfranchised, and spoke openly of acts of aggression. Are these signs of mental illness? Maybe, but probably not a diagnosed mental illness. Remember that early on in these post I wrote  about mental illness meeting some criteria according to the DSM manual. So, are these cases of "falling through the cracks"? Again maybe, but more than likely it is someone who has demonstrated change in behavior or clear signs of disillusionment. And, it will not be Big Brother monitoring Facebook posts or other issues of privacy but someone who take the time to notice a change in a neighbor, friend, family member, fellow worker, or partner who can make a difference between another senseless death and constructive help. The phrase " our brother's keeper" seems relevant to this end. Someone knows the next aggressor, and it is up to us to intervene safely.  

Bipolar disorder is a mood disorder much like depression. But, depression is unipolar and as previously discussed, has a depressed mood as its primary feature. A bipolar mood disorder has two poles; the first is depression, and the second is either mania or hypomania.  Historically this disorder has been called manic-depressive disorder. Mania in this case is a hyper alert, rapid and excitable mood, and can sometimes be associated with psychosis or unreasonable thoughts. Bipolarity is also frequently cyclic in nature with either depression or mania being the dominant mood. The cycle can take days or weeks to change, or it can change many times in one day. Some bipolar patients have hypomania, which is less extreme than full-blown manic episodes. Hypomania can actually be a productive state of mood and is generally characterized as “life in overdrive”. Problem solving, task accomplishment, and organizational skills can be enhanced, until the other end of the pole, depression dominates. 
Bipolar mood disorder as a label, has been used very freely in our society, and I have heard it used in public discourse inaccurately. It is not uncommon to hear a reference to someone acting like they are bipolar.  The truth is that this mood disorder is difficult to diagnose and requires treatment and sometimes collaterally, hospitalization.  The causes are poorly understood but there is good evidence for a genetic component as well as environmental factors. There is additionally a link between thyroid function and bipolar mood disorder.
I have had the opportunity to work with bipolar patients but due to the complexity of this disorder, I have no composite vignette. I will instead, provide a link to the National Institute for Mental Health information file here.

Depression has been defined using many words over time but is currently called Major Depressive Disorder (MDD). It has also been referred to as clinical depression, major depression, unipolar depression, recurrent depression, and in the early 20th century was known as melancholy.
Depression is classified as a mood disorder and is characterized as a cluster of symptoms, (syndrome) that includes low mood, low self-esteem, lack of interest in anything usually pleasurable, (anhedonia), and in general, a feeling of lethargy and low energy.
Major depressive disorder has an often disabling effect on a person’s life with trouble sleeping, working, eating, and impairs life to a large extent. But, as in the case of anxiety, depression occurs along a continuum, from simply “feeling down” to totally disabling. And, although anyone can have a low day with no clinical significance, someone who has MDD has a difficult time negotiating life. The following vignette may help to illustrate the complexities of depression:
I first met Ann, a 35 year old woman, when I became her case manager as she was seeking continued treatment after a long problem with major depression. She had been hospitalized for 3 months but was doing well with medication and therapy. My task was to support her at home with paperwork, and personal organization of her day to day life. She lived in a very rural location but had a car and a part-time job and was managing her illness with excellent results. My home visits were generally every two weeks, and she also met with me when receiving therapy in our office setting.
For the first six months, all went very well; her apartment was always clean, she dressed appropriately, was consistent with her medication and therapy, and kept appointments as scheduled.
Upon arrival for a usual scheduled home visit, there was no answer at the door, but her car was in the usual parking space. I called her on the cell phone several times and received no answer. Her landlady lived in an adjacent apartment and I asked her if she had seen Ann but was advised that it had been two or three days since she had been seen going to work. I called the office to determine if she had called to cancel the appointment but that had not happened. I then spoke to her psychiatrist and he suggested that I have the landlady open the door and make a visual check. And, this is the difficult choice as I have no intention of invading individual privacy, but concern for Ann’s safety was the determining factor. The landlady and I entered the apartment as I knew immediately that there was a problem. The apartment was a mess and the heat was off. With reluctance, the landlady accompanied me to the bedroom and we found Ann barely conscious and in extreme distress. An ambulance was called and she was transported to a local hospital where life-saving efforts were performed. Ann had taken most of her medication in an attempt to commit suicide but had failed to understand that the medications were not lethal. But the attempt raises many questions.
Most importantly, what causes a person who is managing her illness so well to resort to a suicide attempt? Despite what we do know about MDD we still do not know what triggers the desire to give up on mental health management. We do know that there is an interplay between the biology of the brain and the environmental issues. But, we have no way of knowing what was in Ann’s mind when the decision was made. I spoke to her in the hospital and she cannot explain what happened. We are aware that between 3 and 4 % of patients with MDD do commit suicide, and that some 60% of all suicides have some mood disorder associated with them. Ann continues to be in treatment but will have to struggle with the symptoms for a long time to come.

The last of the major anxiety disorders to be discussed in this series is Post Traumatic Stress Disorder or PTSD. It is another one of the combination of emotional and neurological disorders that remains without complete understanding. As with other mental health problems, it occurs along a continuum and has varying degrees of disabling symptoms. Generally speaking, PTSD is a reaction to a traumatic event like, fire, flood, natural disasters, assault, domestic abuse, rape, terrorism, and war. This can also be triggered by seeing a traumatic event, not just having it happen personally.
Although this illness has been known for centuries, the first recognized classification came about during World War I. Soldiers who were under constant fire and barrage of enemy shells suffered reactions that at first were considered a form of cowardice. But, over time it was determined to be an emotional and physical reaction to the fear and unpredictability of combat. At that time is was called “shell shock”, and later “combat stress reaction”, and is now called PTSD.
There are three main categories of the symptoms of PTSD:

1.     Reliving the event which causes day-to-day activities to be disturbed. This may include flashbacks of the event, repeated memories of the event, and nightmares and dreams of the event.

2.     Avoidance of the event, causing a numbing of the senses, feeling detached, lack of interest in life, avoiding places and people that may be reminders of the event, and feeling that there is no real future.

3.     Physical manifestations, like difficulty in concentration, being startled easily, hyper-vigilance, irritability, and difficulty falling asleep or staying asleep.

As with other anxiety based disorders there may be other physical concerns. Rapid heartbeat, dizziness, sweating, fainting, and chest pressure may occur.
Although as a case manager, I have had several patients with PTSD, there is not an easy way to construct a vignette to further clarify this disabling condition. There is however a great deal of information about PTSD on the web and I would suggest a search to learn more. The fact that this disorder presents in so many different scenarios speaks to the complexity and understanding of this illness.

This post deviates from the overall direction of this blog page in that it does not follow the concept of covering the major mental illnesses and relevant information. Instead, this post is a response to the most recent mass murder of both adults and children at the Sandy Hook Elementary School. Everybody has had some reaction to this level of violence, perhaps due to the ages of the victims, or to the occurrence of another senseless shooting. But, as part of the mental health community, I hear the voices from many sources that have a great deal of noise and very little balanced consideration for the complexity of the issue of mass murder. It may be a completely valid visceral reaction that I hear, but many of the loudest voices are not qualified as professionals to guide a meaningful discussion of the issues. In some cases, the comments are from vested interests; in others, it is a reflection of the complicated time in which we live. In the hope of tempering this conversation I offer the following thoughts, recognizing that there is no single solution, and that we will experience the death of innocent victims again. Whether or not there is a mental illness involved, I count myself among many others that do not have an answer. But, there are some insights that may be helpful in clarifying the murders that are becoming more commonplace, and more of an expected event.
Shortly after all of the most recent shootings, there has been a constant barrage of conversation about guns and gun violence. Both sides of the issue are fierce, with the second amendment proponents being concerned about losing their right to bear arms, and the detractors fearing that more guns will lead to more violence. But, as a nation, we already have more guns per capita than any other civilized country. And, most gun owners are responsible with weapons and are not committing mass murder. Certainly there should be a debate about assault guns with high capacity clips and magazines, but again, we have millions of these weapons in circulation already. The federal law concerning background checks is another area for consideration. We know that about 40% of all guns sold occur in the secondary market, gun shows and private sales and these sales require no background check. And, in addition, there are the guns stolen from residential burglary. So, although there is a lot of gun commentary, there is very little that can actually be done with “more control”.
The next most loudly trumpeted reason for the mass murders is the violence in movies, TV, and video games. And clearly, we have become somewhat desensitized to the violence that we see in these venues and on the news program. It seems as if every day there is a shooting, stabbing, or other violent act in many communities. The only difference is in the level of numbers. Only the high body count murders make national news. We will have to leave it to the sociologists to decide if the violence in entertainment is a reflection of reality, or if the reality is being driven by the entertainment industry. But, we also run squarely into the first amendment when we try to control free speech.
The one aspect that seems most perplexing is the discussion of the shooter themselves. As citizens, we have only limited information with regard to the information harvested from each of these incidents. But we do have some general guidelines about the individuals involved. Many are solo shooters with the most recent exception being the Columbine murders. But the profile offered is that the event has been considered for some period of time, that the weapons required are obtained, there is a plan for implementation, and there is an end game; the shooter dies by a self-inflicted gunshot. So, the act is organized, premeditated, and there is an exit strategy. Additionally, the shooter is often described as a loner, somewhat socially ill at ease, and at times, either writes about or talks about his/her intentions and seeks notoriety. (As a thought, it might be helpful to not even report the shooters name or plaster his image on the news to take away the 15 minutes of interest in him). But this profile does not necessarily describe a mental illness but rather a skewed state of mind. And, this is the most problematic concern with regard to identifying a potential killer.
This is what I consider the truly grey area of our mental health system. For those patients who have demonstrated a valid mental illness, there is treatment. Most are identified by parents, teachers, or others in the patient’s life and help is available. But, we have laws that protect an individual from being forced into treatment unless they have demonstrated the desire to harm themselves or others. And, that is the case with many of the shooters that we have seen recently. They simply do not fit the criteria for “forced treatment”. It is very similar for dealing with addiction in that we cannot force an addict to seek treatment unless there is a threat involved. Can we, or should we change the laws protecting our right to free choice? This is a prime example of those “falling between the cracks” and there is no easy answer. But, someone knows the next shooter and they are really at a loss when it comes to intervening unless there is a demonstrable threat.
Perhaps the Vice Presidential task force that was recently named by the president will have some concrete recommendations and constructive dialog to offer a very weary public. I think that we are all tired of hearing that we must do something so that “this never happens again”. But, we all know that it will…