Identity

Who we are is complex. It incorporates many aspects of where we grew up, how we identify ourselves, how others identify us, actions we have taken in the past and who we would like to grow into. Identity can be fairly solid, it can shift fluidly, or migrate through a series of stages. I turns out that human biological sex is not binary like we were taught.

Once aspect that is a key component to how we see ourselves and how society sees us is biological sex. I was going to write a big thing about it, but then SciShow on Youtube did it for me.

This episode was written by Carly Britton and covers many aspects that are worth listening to.

In short, human biological sex is not binary, it is a spectrum, and it isn’t necesarrily a single spectrum either.

A binary division is where you attempt to divide a thing into 2 parts. Some handy examples that make sense is dividing numbers into numbers that have enlcosed sections (6,8,9,0) and open sections (1,2,3,4,5,7). However some groupings defy easy binary division based on a simple rule, such as trying to binary divide fruit into sweet and sour. While it is easy to identify some fruits that everyone agrees is sweet and some that are sour, there are a number of fruits that either defy easy identification or fit into yet another category of “it depends”.

Every aspect of what we may think of as “male” or “female” is frequently found in various subsections of human populations, but no single aspect is sufficient to describe all humans. For example if we consider chromosomes, the DNA of our sex expression, we were taught in school the simplified version that males have the XY chromosome expression and females have the XX chromosome expression. While it is possible to create a binary divide of XX is female and all others are male, it becomes very awkward when we have the so called sex chromosome be X, or Y, or XXX, or XYY and so on. Many people who appear female and identify as female have a sex chromosome that is not XX.

An image of various sex chromosomes with additional X's, known as Clienfelter Syndrome. Attribute Wikipedia for the image.
Klinefelter syndrome – the presence of additional X chromosomes
By User:Nami-ja – Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=6094574

Additionally when we add in any other sex identifier to the mix we find that a binary division is impossible. There is not even really a spectrum from “female” to “male”.

Another aspect to consider is the difference between assigned sex and chosen sex. While all the traditional markers for categorising someone as a particular sex, the person may not identify themselves as this sex. This person may chose to make no changes in appearance, cosmetic changes, medical changes and or surgical modification to correct this misalignment. Since the definition of who actually fits into the overly simplistic physical definitions of “male” or “female” are poor, it seems odd to then require that someone who fits the physical criteria is then also required to ignore the very important criteria of “self identification”.

It is also odd to try to fix this by just creating a third category of “neither”. If we look at a simple spectrum such as the rainbow of visible light, it is made of either red, blue or “other”. Applying this third category solution means that orange and violet are considered to be the same, when clearly they are not. And where does watermelon and maroon fit?

Sex identity is complex and involved a number of features such as DNA/chromosomes, gene expression, development, hormones, cosmetic appearance, taste and self identity. To lump all of these aspects into a false binary, or stretch it into a false trinary is hurtful to people who find themselves excluded or poorly labelled for no good reason.

To minimise this hurt, it is important to accept when someone identifies other than your initial evaluation of them and if a person is dressing ambiguously, accept that they may not identify as any simplistic label. It is not offensive to ask someone if they have some prefererd pronouns, and accept if the pronouns someone prefers does not align with your assumptions or comfort.

BPD Part 1 – Borderline Personality Disorder – an introduction

BPD is a label given for a set of behaviours combined with a number of personality traits by medical professionals when a person presents with a level of chaotic and sometimes destructive behaviours. The diagnosis carries a significant level of stigma which may lead labelled people finding themselves even more lost and abandoned than they started with. It is unfortunate that BPD is so poorly understood by many health professionals and so poorly supported within the system. Fortunately there are health professionals that are understanding the diagnosis better.

In Part 1 [this one] we will look at what BPD isn’t, and some of the many names that BPD is also known by.

In Part 2 [Link] we will look at some of the diagnostic criteria that is used when giving someone a diagnosis, including a list of aspects that I look for when determining if BPD is an appropriate label for someone’s experience.

In Part 3 [Link] we will look at what is probably going on behind the scenes that leads to the experience and behaviours that meet the criteria in Part 2.

In Part 4 (yet to come) we will look at how to tell if something needs to be done about your experience of BPD, and if so, what that might be.

BPD has a few different names. It can be called EUPD (Emotionally Unstable Personality Disorder), CPTSD (Complex Post Traumatic Stress Disorder – although there is a version of CPTSD that isn’t BPD) and PD-Bt (Personality Disorder, Borderline type). None of these labels are a good description of what is going on or how the diagnosed person experiences the label. We’ll get into that a bit later.

Frequently BPD is misdiagnosed as anxiety, depression, bipolar or schizoaffective disorder. People frequently fly under the radar (often at great personal expense and discomfort) until something occurs (often traumatic) or the ability to manage fails and the person comes into the awareness of health services. By the time someone with BPD is elevated to health services the person frequently has at least one or more of these secondary traits and is thus misdiagnosed with the trait as dominant instead of secondary. A good clue that these are secondary to BPD are a failure to actually bring real relief to the person when only using the recommended treatment plans for these conditions and not realising the proper diagnosis should be BPD.

BPD has a great deal of stigma attached to it. There are three primary reasons for this stigma. Firstly, in the counselling side it seems that the secondary traits (or misdiagnosed traits) seem easier to address first, but the standard treatment plan for anxiety and depression via medication and CBT are only mildly effective. This results in frustration for the clinician and a transference of failure to the client. The clinician failed, but can’t find fault in their treatment plan (as it is for the wrong condition). The second stigma comes from the effects of the personality disorder on staff as staff become confused about who they are dealing with and often struggle with infighting as the person’s inner chaos becomes manifest in the staff. If you have found your staff lost and chaotic and find that frustrating, imagine what it is like to live with this every day. Stigmatising the person with the BPD diagnosis is personally cheaper than realising the staff need more training in BPD staff splitting. The third most common reason for stigma is the dramatic violence often associated with BPD. This can take the form of destruction of the environment, destruction of the person’s social connections and or destruction of the person’s self in the form of self harm or suicide.

Project Semicolon is an American nonprofit organization known for its advocacy of mental health wellness and its focus as an anti-suicide initiative.
Attribute: By Kencf0618 – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=52641091

Many hospitals and facilities are ill equipped to manage people with BPD and thus try to avoid admitting people with any of the various forms of BPD unless they really have to. Unfortunately and ironically this can feed the abandonment issues that often accompany BPD leading to greater demonstrations of destruction. I very well understand why many hospitals have gone this way and the complexities of addressing this issue. It still sucks. A way to think about it is that BPD requires a certain specialisation to manage well, and not managing well is basically managing poorly. If there was a hospital or department that specialised in BPD, the hospitals would on refer patients there, but very few such hospitals exist and often hospital is just the wrong environment irregardless of specialisation. Consider the optics part of your hospital deciding they could manage your heart condition – this seems foolish, just get transferred to the cardiac ward. However there is no BPD ward, so where should the hospital refer you? Often to private therapy, away from the hospital environment.

Well that all seems kind of scary. Wrong diagnosis, lots of stigma, too hard for hospitals to handle, destructive nature of the diagnosis… While that feeds some of the issues with BPD, this is a more extreme end of BPD that gets the attention and drives the aversion and quite frankly a different recognition and management would ease a great deal of the problems. 

Part of the stigma attached to the diagnosis feeds the misdiagnosis of the condition. As many diagnositians are of the opinion that BPD is chronic and untreatable, they are reluctant to attribute a person’s experience to a condition that has little hope. While these diagnosticians (GP’s, psychiatrists and clinical psychologists) are wrong on this perception, let us pretend for a moment they are right. It is much better to treat someone for anxiety and depression, which have known frequently effective treatment plans, than to diagnose someone with BPD which doesn’t (remember, we are pretending there isn’t here). If you are wrong about BPD diagnosis, you have failed to treat someone who could have got help. If you are right about it being anxiety and depression, you fixed it. With this faulty assumption, the lesser evil is to diagnose with anxiety and depression and get some positive results when wrong than doom the person with a terrible condition. The avoidance of the diagnosticians is understandable. But wrong.

The misdiagnosing of people with anxiety, depression, bipolar or schizoaffective disorder is instead of BPD does great harm to far too many people who could have got effective help earlier. It is important to point out that being diagnosed with any of the above conditions does not mean you have been misdiagnosed. GAD (Generalised anxiety disorder) is a very specific condition, and the subtypes of anxiety disorders are definitely specific conditions that frequently have very effective treatment plans (which should be tailored for each individual). The same is true for the other diagnoses. Being given one of these does not mean you have been misdiagnosed. It just might, especially if you are finding the recommended treatment paths ineffective.

All of that and we haven’t even said what BPD is. Stay tuned for next time to find out – because it is complicated.

Collaboration isn’t a dirty word

I would seem weird if we had a hospital visit and the doctors and the nurses didn’t communicate with each other and tried to treat you for different things. While each has specific and different duties, one will guide the other which will guide the first. That is, the doctor’s diagnosis will guide the care the nurses give you, and the nurses observations will guide the doctor’s diagnosis.

Our podiatrist and dentist almost never need to talk to each other because they are working on very different parts or our health. However our Ears Nose Throat (ENT) specialist may need to talk to our dentist, or our GP may have to if we have certain blood conditions as they do have an overlap in our health. Frequently, though, we just tell our dentist the basic gist of why we might have an ENT or what blood condition we have that may affect dentistry and never the two specialists will speak.

It seems odd to me that when it comes to mental health, people are very reluctant to talk to their specialists openly or allow them to talk to each other. Confidentiality means that if you are my client, then I can’t talk to other professionals about you without your express permission. If a doctor has referred you to see me, built into my treatment contract is permission to send them progress reports. However that doesn’t cover other professionals that may be in your treatment team.

When I worked in hospitals it was clear that there was a treatment team. The confidentiality contract was with the hospital, so if it was relevant to your health, I would go to the OT (occupational therapist) and ask for them to support you with X, or let your doctor know they should check out Y, or ask the nurses to remind you to do Z and report back to me how that went. We worked as a therapeutic team to help you get out of hospital fastest. Once a week we professionals would all meet up and discuss your case and compare notes on progress. One of us (usually me) would come and talk to you about progress and your goals. Sometimes there would be an incidental meet up with professionals to discuss a thing, or with you and a few professionals. Every couple of weeks there would be a team meeting with you to discuss what is needed and what goals need to be hit to get you home and how we would get you there. (I appreciate that not all people get this holistic experience from hospitals, but that is how my team worked).

For some reason, once you are out of hospital, that all changes. We professionals don’t tend to talk to each other. There is no longer a “case manager” ensuring that your treatment is a cohesive holistic whole. And the fault isn’t just with the professionals not talking to each other – often you, the client, will hoard information and not tell relevant professionals relevant information. This can lead to two or more professionals trying to fix the same problem in non-compatible ways, or aspects about your health being missed because no one knew it wasn’t being taken care of.

I guess we kind of expect that you, the client, will be the case manager and get us all to do our bits. But how on earth can we reasonably expect you to be an expert in case management? Don’t get me wrong – some people become that expert and do a pretty good job at it, but that is often through lots of trial and error.

Frequently in therapy, I’ll ask my clients (who have just disclosed a thing to me) “Have you informed X about this?” where X is the relevant expert in that aspect. Frequently the answer I receive back is “no”, generally in a tone of “of course not”. I will ask the client to do so, then ask if they will do so and if not, what is holding them back and do they need support (it can be scary to be the one to initiate certain conversations).

What I want is that holistic care you get with a hospital allied health team, where we all know what the goals are, have a rough plan of how we are all going to get you there and a list of which bit each professional is going to work on. We then have accountability for doing our jobs and you get the benefit of that. Naturally you are involved with the creation of that plan and the goals and have a say about who and how those things are done.

I appreciate that it is hard to get all of the professionals together in one place when you live in the community and those professionals are your GP at one medical centre, a counsellor somewhere else, maybe a support worker from that agency etc and maybe a few more besides. Sometimes it has to be a phone in, or communications via paperwork. But mostly it comes down to you – start opening up to each of your team and tell them what is going on, what the other professionals are doing and what you want and need. Also give them permission to talk to each other.

There are three major levels of community need when it comes to mental health. 

  • Entry level – two to three professionals – eg: GP and therapist (and maybe psychiatrist)
  • Middle level – four or five professionals – eg: GP, therapist, psychiatrist, support worker
  • Pre-acute level – six or more professionals – eg: GP, therapist, psychiatrist, support worker, domestic agency, community nurse, Guardian, Administrator … etc

(After pre-acute, you are in hospital, which is no longer community)

At the Entry level, all you generally need is for your professionals to send reports to each other. Ask for “Release of Information” forms (or similar) to be signed by you for them to talk to each other. Ask them to send reports and updates to all participants.

At the Middle level, beyond “Release of Information” forms, it is important for one of the professionals to start taking on more of a coordinator role. Likely that will be the therapist, but may be another.

At the Pre-acute level you have reasonable grounds to have a dedicated Case Manager, who will coordinate the goals, care and outcomes of your team. Several of your team should be able to meet up monthly or 3 monthly (depending on your needs) with a few call ins via phone/video to have an allied health team meeting. The odds are that you are being considered for or are already on NDIS, so try to factor this role into your NDIS budget.

I’ve said that this is fairly rare, that most of my clients do not have this. I suspect that this is because of a few factors. Either my clients are a bit embarrassed that they need help and don’t want to fully admit to how complex their situation is, or they don’t trust one or more of their professionals. Sometimes there just isn’t budget (time or money) to make this happen.

Embarrassment is connected to public perception. It is time to see past the attempt of the ignorant public to try to blame you for what you are going through. We don’t stigmatise eye sight, diabetes or heart conditions. Why do we stigmatise mental health? Don’t fall for their ignorance and please, talk to your therapist about why you find it hard to open up to your other professionals. If it isn’t embarrassment, it could be denial about how complex your situation is, and again, your therapist is a good person to talk to about getting over that. You are too important to let a thought error get in the way of good care.

Trust can be a major problem. If there is a professional that you don’t trust, or feel good opening up to, that can be an indication that you need to swap that person out for someone you do trust. Almost all of your team can be swapped (unless you are under community treatment orders, where you can request for a change – and sometimes you just have to work with the least bad person assigned to you). Remember that they are your employees. They have to do what you say (within their code of professional ethics), and if you don’t like or trust them, you can fire them and get another. If you are not sure about this section, talk to your therapist. If your therapist is one of the people on that list, talk to your GP about getting a new therapist. If your GP is also on that list, go to a new GP and if you like the new GP, ask for your records to be transferred.

Many hands in the team will help lift your load

It is your health, and the best way to look after it is for the relevant professionals to have a more complete picture about what is going on for you and for a coordinated plan to be made and implemented to sort out the problem that you are experiencing. It is time to take the power back and push for this to be done. Get those documents signed so they can talk to each other, push for that coordination, and push to be central and involved in the plan.

This week in what fills me with awe: Brains

Ever wondered why snowflakes are symmetrical? How does the water molecule adhering to the snow flake know where to land and which orientation to point so that it is symmetrical with the the far side? It comes down to electric charges. Water has an electric charge that is not balanced. The shape of a water molecule is kind of like a boomerang, with the hydrogen atoms at the far ends and the oxygen in the bend. The oxygen has a strong negative charge which equals and cancels out the positive charge of the two hydrogen atoms. But that equal is only at a distance. Close up one side of the boomerang is negative, the other side is positive, so long as you are coming in from the right view. This makes the water molecule susceptible to electrical and magnetic fields, kind of like how iron filings will fall into an interesting pattern when sprinkled around a magnet. The snowflake is basically a water version of that.

As each water molecule joins the snowflake, the shape of the field shifts a bit to factor in this new particle. It is a dynamic system, ever changing as bits join the snow flake. Snowflakes are mostly water, but they also capture bits of dust, pollen and other pollutants. This can radically change the way the snow flake “grows”.

After a team of sperm cells break through the outer membrane of an egg and one timely sperm gets in and fertilises the egg, the embryo begins a massive growth and divide cycle, increasing in size manyfold very rapidly. Each of these new cells are basically exact clones of the first egg/sperm hybrid cell. After a short amount of time, the egg/sperm cell division starts to create some different versions, which begin to self sort into clumps of like type cells. Slowly some basic organs and nerves begin to grow. Some differentiate into muscles and blood vessels. Some begin to differentiate into skin. Most of the skin cells form on the outside. As the parent cell divides, if it finds itself unbalanced due to being on the outside, the new cells become skin cells. Sometimes the skin cell forms accidentally on the inside. When this happens, it will try to migrate to the outside, and if it fails, it will self destruct and be recycled – that is, consumed by a nearby cell which then divides into a more useful inner body cell.

There are no brains yet.

The gonad cells appear around 4-5 weeks. Eventually these will become either testes or ovaries. At this point, it is too soon to tell. We don’t know why the gonads appear where they do, but we do know they go on a fantastic journey before settling down in their eventual place in about 59 out of 60 people. 

Around this time, the nerve cells have self organised into a network with a definitive spine and the first preliminary bulge at one end that could be considered the beginnings of a brain. This is not a brain. It is the hint of one.

By Dr. Vilas Gayakwad – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=9582575 – A six-week embryonic age or eight-week gestational age intact human embryo.

Somewhere around week 6 some of the muscle cells have divided into a specialised type that beats in a rhythm. This will eventually become a heart and be part of pumping blood. At this stage those, they just pulse. There is nothing overly special about this. If a doctor were to biopsy some of your heart tissue from your chest and put it in a nutrient bath, it will also pulse, completely separately to any external signal. Add another bit of heart tissue in the nutrient bath and they will beat out of sync from each other. When they get close enough, they self organise and start to beat in sync. Nothing special here, just the nature of that kind of cell.

The embryo at this stage is about 4mm long. The nerves are continuing to network all of the areas of the embryo together. Pre-arms and pre-facial features are starting to develop and the embryo looks like a very strange alien or fish spawn thing. 

At week 7, the growing clustered nerve ganglion at the top of the spine divides into 5 major regions and starts to specialise. This is similar to some of the earlier cells specialising into cell versus muscle. They are all nerve type cells, some are now looking more like synapses but there is no intrinsic control over the body yet per se. That is, each part of the body that was busy self organising into the things that make up a human are continuing to do so without a central instructing organ like a brain. They are working more like the snow flake, but at a much greater complexity. Each cell is emitting hormones and other communicative fluids, which attract other like kind cells. Based on rules, the cells will organise in specific but somewhat random ways similar to how a flock of birds or a school of fish will move together without a specific organiser.

The brain/nerve cells are self organising similar to how heart muscle cells self organise. In petri dishes we have witnessed synaptic cells joining together in networks and starting the rudiments of communication. There isn’t enough to have a thought, or memory or a dream, but there is some kind of organisation occurring. 

This growth keeps going. At about 20 weeks we get the first indication that the proto-brain of the fetus is responding to external stimuli. It is now plugged into enough of the fetus that it receives data from outside of brain for processing and then sends a signals back out to do something about that signal. One might be mistaken into thinking that thought is occurring now. It is possible, but the odds are more likely that it has some stimuli reflex that your lower spine does when you step on something sharp. Your foot lifts off the unexpected sharp thing before the signal can reach your brain. We don’t fight for the rights of our lower spine – it’s just a reflex mechanism with some basic data analysis without actual thought. It is like saying that your knee is capable of thought when you hit it with a reflex hammer and your foot kicks. It isn’t – it’s just a reflex.

Time goes on and the baby is born. Sometimes. Often the embryo grows faultily and is expelled before 4 weeks. Many fertilised eggs self abort because they aren’t viable and many pregnancies are not detected because of this. The uterus just gets ready for the next chance and doesn’t bother to inform the owner of the uterus that an egg was fertilised and rejected.

One third of the embryos that make it past 4 weeks don’t make it past 12 weeks. Many of these pass without notice too. 

Those what make it to live birth all have a brain. No two of these brains are the same, much like no two snowflakes are the same (allegedly this saying was tested and found that under certain circumstances you can get a duplicate snowflake around 1 in 100,000 – some people contest this). Humans are not snowflakes (leaving politics out of this). No two brains are the same. They generally look similar to a simple look, but the neurons and synapses do not conform to any rigid model. There are some organisational rules and principles that form specialised regions in similar locations, but the details are different.

For example, the bit of my brain that determines where my left index finger is going to be when I want to press the “a” key on my keyboard is located in a couple of hundred neurons in a part of the motor cortex of my brain. The odds are very high that you have a motor cortex in the same approximate region of your brain, and that the area that controls my left hand is about the same in yours. My left index finger control will be sort of similar to yours but importantly different. The cluster of neurons that allows my finger to strike the “a” key will be tellingly different to yours. And yet I can hit it quite well and the odds are high that you can do the same.

From a little before birth I have been training my brain to do a whole host of human things just as you have yours. But the details of how each of our brains do this is very different in specific, even if it is kind of similar in general. Somehow through all of this we are able to communicate, make art, create computers and send people into space. We are able to learn and teach each other skills.

If I were to take the bit of my brain that does a skill that I have and you don’t, and put it into your brain, it would mean nothing to your brain. It would not give you that skill. If I use that part of my brain to show you how to do the skill, you will form a new part of your brain, often coopting under used parts of your brain that are doing other things, to form a new pattern that is now your new skill, as per how I showed you. It won’t look like mine. It will probably be stored in a similar part of your brain to mine, or it may be in a very different part.

As we become adolescents, our brains switch from dependent child to independent adult over roughly a ten year period. This involves a massive reorganisation of the brain, vastly increasing the complexity as new wrinkles form, new connections are made and new skills are acquired. The hormones in our body trigger massive changes to our muscles, sex organs, height, hair and other bodily systems. 

While certain developmental stages can be predicted, the specific path is unique for all of us. Kind of like if I want to get some chips from the store, I’ll grab my keys, get in the car, drive to the store, find the chips, pay for the chips, drive home and then eat the chips. Assuming you don’t have chips in your reach you’ll go through a similar approximate process. However if you do it exactly the way I do, you’ll probably crash into furniture before you even get to your car, and should you drive exactly the way I did to get to the store, it will be bad. Instead, you’ll adapt the approximate system to your needs and your situation. Generally it will look the same, but specifically it will be different.

This gets interesting when we start looking at how brains work. We know that serotonin is an important neurotransmitter for certain tasks. When you have too much or too little it can look like anxiety and or depression. How much is too much or too little is determined by the individual symptoms of the person. I may be functioning fine, but if you have my levels you might be chronically depressed. We don’t have a set amount you are supposed to have – we have a range of “probably good” (not that we tend to bother measuring the amount, we just treat the symptoms). If the amount is a little out for you, then you’ll show a bit of behaviour that reflects that outness. If you are a lot out, you’ll exhibit strong symptoms. If you are very far out, you’ll have other problems.

This also makes it tricky when we are trying to define rules. Some people pick up implicit rules easily. Most pick them up easily enough. Some struggle a bit and some struggle a great deal. This is because all of our brains are different. There is no faulty neuron causing this, and probably no specific neurotransmitter. The odds are it is a shaping of the brain from birth (that’s what the science is currently telling us), which has the most likely origin in the DNA that the combination from the beginning formed – the sperm/egg cell. If your parents found it easy to pick up implicit (not clearly stated) rules, then you probably will too. If your parents struggled, you probably will too.

Basically, brains are awesome. I love that we all have different brains. I also find it kind of surprising how well we humans interrelate and interact considering these differences.

I also find it interesting when some people don’t accept that humans are a grouping of very different brains, or when people think there is something fundamentally wrong with their brain.

Different isn’t wrong as no two brains are the same.