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I Have OCD. This Is What It’s Like to Be in My Mind for 3 Minutes.

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By guest blogger Helge Hasselmann

Across the globe, ADHD prevalence is estimated around 5 per cent. It's a figure that's been rising for decades. For example, Sweden saw ADHD diagnoses among 10-year olds increase more than sevenfold from 1990 to 2007. Similar spikes have been reported from other countries, too, including Taiwan and the US, suggesting this may be a universal phenomenon. In fact, looking at dispensed ADHD medication as a proxy measure of ADHD prevalence, studies from the UK show an even steeper increase.

Does this mean that more people today really have ADHD than in the past? Not necessarily. For example, greater awareness by clinicians, teachers or parents could have simply captured more patients who had previously had been "under the radar". Such a shift in awareness or diagnostic behaviour would inflate the rate of ADHD diagnoses without necessarily more people havingclinical ADHD. However, if this is not the true or full explanation, then perhaps ADHD symptoms really have become more frequent or severe over the years. A new study in The Journal of Child Psychology and Psychiatry from Sweden with almost 20,000 participants has now provided a preliminary answer.

The researchers, led by Mina Rydell at Karolinska Institutet, examined data from participants in an ongoing study of all twins in Sweden that started in 2004 and aims to study their physical and mental health, with various measures taken the year that the children turn nine years of age.

Specifically, the researchers analysed A-TAC (Autism-Tics, ADHD and other Comorbidities Inventory) scores from 19,271 children from 9,673 families recorded between 2004 and 2014. The A-TAC is a telephone-based interview in which parents are quizzed about their kids' behaviour and mental health, including sub-scales focused on attention deficits and hyperactivity. The questions are about symptoms with no mention of diagnostic categories and the wording has stayed the same over the years. A typical question is "Does he/she have difficulties keeping his/her hands and feet still or can he/she not stay seated?".

The researchers used the A-TAC scores to classify the proportion of children in different years with diagnostic-level ADHD or subthreshold ADHD or no ADHD. Important to keep in mind here is that instruments like the A-TAC are restricted to assessing the severity of certain symptoms and cannot be used to diagnose children with ADHD (only clinicians and mental health experts can diagnose someone). For example, if a child fell in the diagnostic-level ADHD category, it would mean that the severity of his or her ADHD symptoms would likely result in a diagnosis by a specialist, but this couldn't be known for sure. The authors calculated the changes in these categories, as well as in mean A-TAC scores, over time by comparing results from the parent interviews conducted in 1995-1998, 1992-2002 and 2003-2005.

Across the 10-year study period, 2.1 per cent of all participants (n=406) showed diagnostic-level ADHD and 10.7 per cent (n=2,058) showed subthreshold level ADHD. Interestingly, there was no statistically significant increase in diagnostic-level ADHD prevalence over time, fluctuating around 2 per cent in most years. On the other hand, the prevalence of sub-threshold ADHD increased significantly from 2004 to 2014, when at 14.76 per cent it reached its peak. Mean ADHD scores and inattention/ hyperactivity-impulsivity sub-scale scores also showed a similar increase from 1994 to 2004.

These symptom changes over time are probably not due to changes during the study in the status of the twin families who agreed to take part in the research and those who didn't. The researchers accessed the National Patient Register and this showed that while participants in the twin study differed from non-participants in terms of having fewer ADHD diagnoses, this difference did not change over the years of the study, suggesting that it was unlikely to explain the results. Perhaps most important, the National Patient Register showed that prevalence of clinician-diagnosed ADHD had increased more than fivefold from 2004 to 2014, which is inconsistent with the fact that the twin study found diagnostic-level ADHD prevalence did not see a similar rise.

So while the diagnosis rates of clinical ADHD increased during the period of the study, the findings from the twin study suggest that only milder forms of ADHD-related symptoms became more frequent across the population during the same years. This suggests that the number of people who have such severe ADHD symptoms that it merits a diagnosis has actually remained stable, and that other factors are more probably the driving force behind an increased ADHD prevalence. While speculative, these could be related to changes in awareness among parents, teachers or clinicians; societal or medical norms; or better access to healthcare.

There are several caveats that need to be kept in mind when interpreting these findings. For example, as mentioned, A-TAC relies on parents' reports, which might not be the most adequate source of information. In fact, a diagnosis of ADHD requires symptom impairments in at least two different contexts, such as at school or at home. Because only twins were enrolled in CATSS, it is also not clear whether these results also apply to only children. A similar argument could be made about the age of the participants.

Keeping its limitations in mind, this study highlights an important point by providing an alternative explanation for rising ADHD diagnoses. This demonstrates the effects that shifts in societal, political or medical opinion can have on the "prevalence" of an illness. Considering that more diagnoses are likely to go hand in hand with more (potentially unnecessary) medication, this study provides food for thought to clinical and political decision-makers.

- Has the attention deficit hyperactivity disorder phenotype become more common in children between 2004 and 2014? Trends over 10 years from a Swedish general population sample

Post written for BPS Research Digest by Helge Hasselmann. Helge studied psychology and clinical neurosciences. Since 2014, he is a PhD student in medical neurosciences at Charité University Hospital in Berlin, Germany, with a focus on understanding the role of the immune system in major depression.

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The dramatic increase in the diagnosis of ADHD has not been accompanied by a rise in clinically significant symptoms

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By guest blogger Helge Hasselmann Across the globe, ADHD prevalence is estimated around 5 per cent. It's a figure that's been rising for decades. For example, Sweden saw ADHD diagnoses among 10-year olds increase more than sevenfold from 1990 to 2007.

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It's 03:00. My pillow is soaked with cold sweat, my body tense and shaking after waking from the same nightmare that haunts me every night. I know I'm safe in bed - that's a fact. My life is no longer at risk, but I can't stop replaying the terrifying scene that replayed in my head as I slept, so I remain alert, listening for any sound in the dark.

This is one of the ways I experience post-traumatic stress disorder (PTSD).

PTSD is an anxiety disorder caused by very stressful, frightening or distressing events, which are often relived through flashbacks and nightmares. The condition, formerly known as "shellshock", first came to prominence when men returned from the trenches of World War One having witnessed unimaginable horrors. More than 100 years after the guns of that conflict fell silent, PTSD is still predominantly associated with war and as something largely experienced by men.

You might also like these other stories in the Health Gap:
* Why does dementia hit women harder? * How menstruation changes the brain
* The painful condition that has no cure

But millions of women worldwide develop PTSD not only from fighting on a foreign battlefield - but also from struggling to give birth, as I did. And the symptoms tend to be similar for people no matter the trauma they experienced.

"Women with trauma may feel fear, helplessness or horror about their experience and suffer recurrent, overwhelming memories, flashbacks, thoughts and nightmares about the birth, feel distressed, anxious or panicky when exposed to things which remind them of the event, and avoid anything that reminds them of the trauma, which can include talking about it," says Patrick O'Brien, a maternal mental health expert at University College Hospital and spokesman for the Royal College of Obstetricians and Gynaecologists in the UK.

Despite these potentially debilitating effects, postnatal PTSD was only formally recognised in the 1990s when the American Psychiatry Association changed its description of what constitutes a traumatic event. The association originally considered PTSD to be "something outside the range of usual human experience", but then changed the definition to include an event where a person "witnessed or confronted serious physical threat or injury to themselves or others and in which the person responded with feelings of fear, helplessness or horror".

This effectively implied that before this change, childbirth was deemed too common to be highly traumatic - despite the life-changing injuries, and sometimes deaths, women can suffer as they bring children into the world. According to the World Health Organization, 803 women die from complications related to pregnancy and childbirth every day.

Regardless of the statistics, for the women who go through these experiences, there can be a long-lasting impact on their lives

There are few official figures for how many women suffer from postnatal PTSD, and because of the continued lack of recognition of the condition in mothers, it is difficult to say how common the condition really is. Some studies that have attempted to quantify the problem estimate that 4% of births lead to the condition. One study from 2003 found that around a third of mothers who experience a "traumatic delivery", defined as involving complications, the use of instruments to assist delivery or near death, go on to develop PTSD.

With 130 million babies born around the world every year, that means that a staggering number of women may be trying to cope with the disorder with little or no recognition.

And postnatal PTSD might not only be a problem for mothers. Some research has found evidence that fathers can suffer it too after witnessing their partner go through a traumatic birth.

Regardless of the exact numbers, for those who go through these experiences, there can be a long-lasting impact on their lives. And the symptoms manifest themselves in many different ways.

"I regularly get vivid images of the birth in my head," says Leonnie Downes, a mother from Lancashire, UK, who developed PTSD after fearing she was going to die when she developed sepsis in labour. "I constantly feel under threat, like I'm in a heightened awareness."

Lucy Webber, another woman who developed PTSD after giving birth to her son in 2016, says she developed obsessive behaviours and become extremely anxious. "I'm not able to let my baby out of my sight or let anyone touch him," she says. "I have intrusive thought of bad things happening to all my loved ones."

Not all women who have difficult births will develop postnatal PTSD. According to Elizabeth Ford of Queen Mary University of London and Susan Ayers of the University of Sussex, it has a lot to do with a woman's perception of what they went through.

"Women who feel lack of control during birth or who have poor care and support are more at risk of developing PTSD," the researchers write.

The stories from women who have developed PTSD after giving birth seem to reflect this.

Women who feel lack of control during birth or who have poor care and support are more at risk of developing PTSD

Stephanie, whose name has been changed to protect her identity, says she was poorly cared for during labour and midwives displayed a lack of empathy and compassion. A particularly difficult labour saw her being physically held down by staff as her son was delivered. "He was born completely blue and taken away to be resuscitated and I was given no information on his condition for hours."

Emma Svanberg, a chartered clinical psychologist who is involved in the Make Births Better Campaign, says this is a common theme from the women she hears from.

"The factor which we hear about time and time again is lack of kindness and compassion from staff," she says.

A study by researcher Jennifer Patterson, at Napier University in Edinburgh, suggests that while midwives are often aware that giving birth can be traumatic for women, they are often so busy they struggle to offer adequate support and information to mothers who may be at risk of PTSD.

Certain groups of women are also more likely to develop postnatal PTSD even before they give birth.

"For women who have a history of prior trauma - perhaps victims of sexual abuse in childhood, those who have previously had PTSD, or depression or anxiety - the risk of developing PTSD is significantly higher. They're five times more likely," says Rebecca Moore, a perinatal psychiatrist working for the NHS in East London.
Postnatal processing
The challenge of PTSD resides in the brain. Usually, memories are filed away in the brain's hippocampus. But if an experience is traumatic, the mind goes into fight-or-flight mode and the part of the brain associated with fear, the amygdala, switches on. This causes memories to become stuck in this primitive part of the brain rather than being safely filed away.

It also means that when something reminds a mother of her experience - such as seeing birth depicted on TV or being in a hospital - the traumatic memories feel less like memories and more like the woman is still in imminent danger, triggering physical reactions like panic attacks or flashbacks.

This broken filing system means "you get a kind of looping of the memory in the mind all the time", Moore explains.

It may cause structural changes in the brain too. Researchers at the University of California studied the brains of 89 current or former members of the military with PTSD using brain scans to measure the volume of various parts of the brain. It showed that the right amygdala in the brains of military-trained individuals with PTSD were 6% larger than their peers. The right-hand part of the amygdala is particularly associated with controlling fear and aversion to unpleasant stimuli.

"We wonder if amygdala size could be used to screen who is most at risk to develop PTSD symptoms after a mild traumatic brain injury," says Joel Pieper of University of California, San Diego, who was one of those who led the study.

Whether similar changes occur in the brains of women with postnatal PTSD is not yet known, but it could offer a way of diagnosing those who are affected. The complex mixture of symptoms experienced by women with PTSD after birth can often lead to delays and even misdiagnosis.

Another issue standing in the way of diagnosis is the stigma attached to the condition. Some women feel uncomfortable speaking openly about it for fear of being seen as a failure as a mother, or of seeming ungrateful for their baby.

Svanberg believes birth trauma is a feminist issue. "There is a huge body of research on the disbelief of women's pain, especially marginalised women, and often women's voices are silenced," she says. Many experts agree that women are simply not listened to or given the information they need to make the best decisions for themselves and their family. (Read more about how women's pain is more likely to be dismissed than men's).

"Giving women the facts about different modes of delivery while they are pregnant isn't scary, it's empowering," adds Moore. "Women are capable of making up their own minds, but rarely are they properly informed about risks and treatment when it comes to birth."

She believes the problem is more of a societal one. "Women are often treated like princesses when they are pregnant, but once the baby is born, it's all about the baby," she says. "It's not uncommon for new mothers suffering with mental illness to hear 'You've got a healthy baby, why are you complaining?' And it's then even more difficult for women to pluck up the courage to ask for help."

It's thought that half of women with perinatal mental health problems won't be treated.

"There's still shame in seeking help and women struggling often fear they will be judged and criticised," says Moore.

Attempting to keep her condition hidden in this way started to harm Stephanie's relationships with her husband and her older daughter. Her own PTSD manifested as hyper-vigilance, leaving her in a permanent and exhausting state of being alert and expecting the worst.

"I knew I wasn't OK but kept it hidden for months," says Stephanie. "I wasn't eating or sleeping. I refused to let anyone look after my son. My other children relied on their dad as I was too focused on my baby.

"My relationship suffered with my daughter, who was just two. I lost all my confidence in my parenting ability when I was always calm and went with the flow before. I pushed my husband and family away."

Nearly all women involved in the research reported initial feelings of rejection towards their baby

A study led by the University of Sussex confirmed women with postnatal PTSD reported negative effects on their relationship with their partner, including sexual dysfunction, disagreements and blame for the events surrounding the birth. The mother-baby bond was also seriously affected.

Nearly all women involved in the research reported initial feelings of rejection towards their baby and while this changed over time, the study concluded that childbirth-related PTSD can have "severe and lasting" effects on women and their relationships.

For others, it is their career that suffers.

"PTSD has changed my whole life," says Leonnie Downes, who used to work for the North West Ambulance Service. "I had a good career, and I've had to leave my job to become self-employed just so I can work from home. My wife has had to leave her job too and has become my registered carer. I'm now registered disabled and for the first time ever, we now have to live off disability benefits."

Moore says she regularly meets women who are too traumatised to return to work, including paramedics and midwives.

Lucy Webber is one such midwife. "I quit because I couldn't cope with not being able to give women the support they need," she explains.

But there is help available for women who are struggling with postnatal PTSD, provided they are able to access it. Treatment typically takes the form of medication or cognitive behavioural therapy (CBT) - a talking therapy designed to change the way someone thinks and behaves. Eye movement desensitisation and reprocessing (EMDR) can also be used, which sometimes involves tapping or music to help a patient's brain remember they are in the present, not trapped in the moment of their flashback. Research also has shown that transcendental meditation can help war veterans with PTSD.

Birth trauma is not that difficult to treat, but it is very difficult for women and partners to access appropriate support - Emma Svanberg

"Birth trauma is not that difficult to treat, but it is very difficult for women and partners to access appropriate support," Svanberg says, warning that many women are misdiagnosed as having post-natal depression (PND) - another debilitating condition that can follow the birth of a child, but one with a different set of symptoms. In the UK, it can be hard to access treatment in some areas on the NHS, while in other countries, including the US, it can be prohibitively expensive.

But many people believe that mitigation is the answer and that better training for midwives and obstetricians could prevent women developing PTSD in the first place.

"The whole system contributes to trauma," Moore says. "Often women are being cared for by frontline staff, who are doing their job but not with much compassion, because they are burnt out." The Make Births Better campaign focuses on offering training to medical professionals in an attempt to tackle this. Small changes that cost nothing, such as using kind language and less jargon, can make all the difference in stopping women developing physical and mental problems as a result of giving birth.

Most women would agree that giving birth is a defining and transformative event. And with the right support, good can even come from the most traumatic of births.

Lucy Webber says her experience has helped her become a gentler parent and Stephanie has even decided to become a midwife.

Almost two years on, my own life is gradually getting easier, but I approach my daughter's birthday with a mixture of excitement and trepidation because of the memories and physical reactions it will undoubtedly trigger. She is the best gift I could ever hope for and her birthday will also be a celebration of how far we have come since her arrival.

Besides the little toy guitar we will be giving her, perhaps the best gift I can offer is to play my own small part in challenging the norms of what it is to give birth and be a mother, so birth trauma and postnatal PTSD can be dealt with in the open.
-- This story is part of the Join one million Future fans by liking us on Facebook, or follow us on Twitter or Instagram. , a special series about how men and women experience the medical system - and their own health - in starkly different ways. Do you have an experience to share? Or are you just interested in sharing information about women's health and wellbeing? Join our Facebook group Future Woman and be a part of the conversation about the day-to-day issues that affect women's lives.
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The effect of childbirth no-one talks about

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It's 03:00. My pillow is soaked with cold sweat, my body tense and shaking after waking from the same nightmare that haunts me every night. I know I'm safe in bed - that's a fact.

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t secondary school, they become the "leftover girls", drifting, alienated and often miserably lonely because the other teenage girls won't accept them. It's not that autistic girls don't want friends - they are as desperate for friends as any teenager - but in a world which denies, rejects and ignores them, they are simply not wired to understand the only social role available to them: that of a neurotypical girl living an ordinary life.

Dr Sarah Bargiela wants to reach these girls. With illustrator Sophie Standing, she has written Camouflage: The Hidden Lives of Autistic Women, a graphic novel that transforms the growing mass of dry, scholarly research on autism and women into intriguing science facts and moving personal accounts.

"There's loads of autistic research on women, but it's written exclusively for research communities," says Bargiela, a clinical psychologist and design researcher who completed her doctoral research at University College London, specialising in the study of Autism Spectrum Condition (ASC) in women. "My interest is encapsulated in a single experience: meeting a 10-year-old girl who didn't tick enough criteria for diagnosis, but was clearly autistic," she says. "I felt a huge sense of injustice. What opportunity was this little girl going to have to tell her stories other than in a clinician's room - and she wasn't believed there. She'd just have to go through life believing she was what other people called 'weird' but without knowing why. I want to celebrate autism," she continues. "Some of the autistic women I interviewed are incredibly successful in their professional life because of their dedication to a special interest they've pursued, be it in academia, the arts or athletics. We need to appreciate what neurodiversity can offer."

The easily digestible book explains why doctors identify autism in women so much less frequently than they do men. Studies, Bargiela shows, don't focus enough on the differences between men's and women's cognitive skills, such as women's generally greater talent for "social mimicry" - or masking - and so miss the ways autism manifests in women. Society, she says, gives autistic people who want to fit in one option and one option only: "Pretending to be normal."

Making sense of it all: 'The easily digestible book explains why doctors identify autism in women so much less frequently than they do men.' Illustration: Sophie Standing/The Observer

In her book, Laura, an autistic teenager, says, "There's a lot more pressure on girls in general to be a certain way, but I think that especially affects girls on the autistic spectrum because we are more different anyway so it's more difficult for us to be just the same as everyone else."

It's only in the past five years that specialists in neurodevelopmental disorders have widely accepted that autism is not limited to boys and men. "There's a concerted effort to find out what's happening with women who are getting missed or misdiagnosed." While a "hot topic" in research circles, the fact that women and girls can even be autistic is still a surprise to many non-specialists. Not just in the playground but - crucially - to the gatekeepers of services for those with autism, such as teachers and GPs. Elaine, a girl quoted in another study, says, "I'll always remember my special needs teacher saying I was too poor at maths to be autistic."

"Many people still think autistic people are either non-verbal or have an exceptional skill, like in . And, of course, that they're almost all men, says Bargiela. "The idea that women can't be autistic is really pervasive."

The idea that women can't be autistic is really pervasive

Experts now agree that the ratio male:female autism is as close as 3:1, which, the researchers say, "may not change very much across the spectrum or intellectual ability range". Richard Mills, director of research at the National Autistic Society (NAS), says he "would not be surprised" if the true ratio was one woman on the spectrum for every two men. Dr Judith Gould, lead consultant of the NAS's Lorna Wing Centre, thinks the ratio could be even narrower, with 1.5 women and girls on the spectrum for every man and boy. Sarah Wild, head of Limpsfield Grange school, Surrey, a state residential and day secondary school for girls with interaction and communication difficulties, including autism and Asperger's, goes even further. "I genuinely think there are equal numbers," she says.

Under-diagnosing autism in females matters. According to the NAS 2012 survey, 42% of females had been wrongly told they suffered psychiatric, personality or eating disorders, compared with 30% of males. The survey also found that just 8% of girls with Asperger syndrome were diagnosed before the age of six, compared with 25% of boys. Only 21% of girls with Asperger's were diagnosed by the age of 11, compared with 52% of boys. Many adult women who took part in the survey didn't have a diagnosis at all: 10% compared with 5% of males. Many of those adult women had only received a diagnosis because they had analysed themselves and then paid for a private opinion: 14% of females, compared with 9% of males. Even when women are diagnosed, however, their life doesn't necessarily get any easier. There is virtually no specialist support, academic or otherwise, for girls.

One of the key problems in diagnosing females with autism is that they can present very differently to males with autism. In the words of a research paper on the issue: they pretend to be normal. One of the biggest misconceptions, Bargiela says, is that if you're autistic, you can't empathise. "That's rubbish. A complete fallacy. A lot of autistic women are incredibly sensitive to social situations and the fact that they know they have to mask suggests that they are very sensitive to people's cues."

This "masking" or "camouflaging" of their condition involves mimicking (an unconscious attempt) or learning (a conscious effort) socially acceptable behaviour, such as making eye contact in conversation, using pre-prepared phrases or jokes in conversation, copying other's social behaviour and imitating facial expressions or gestures. People may also learn to consciously speak more quietly or not to stand too close to another person or not to make personal remarks.

Not enough research has been done to determine whether masking is a protective or a harmful technique. It has led to a huge amount of missed and wrong diagnoses of female autism. Added to which, females who mask report difficulties ranging from exhaustion to losing their sense of identity, and camouflaging behaviours have been linked to stress, anxiety, mental health problems and increased risk of suicide.

"I really, really tried [to appear normal] and I kept imitating and copying," says Jenny, a young woman. "But it's very draining trying to figure out everything all the time, everything is more like on a manual."

There is virtually no specialist support for girls with autism

Gwen, an older woman, agrees: "I was so scared [of socialising] because I didn't know what to do, so everything I had to learn by observing. It's kind of like a duck on water. You know it's calm on the surface but sort of paddling really hard underneath."

Girls and women with autism are far more at risk of sexual exploitation than boys and men. In one study there was a shockingly high incidence (nine of 14 participants) of sexual abuse, half of which had happened in a relationship. "There's potential for you copying a guy's flirtatious behaviour without realising that's what you're doing," says Annalise, one participant. Many women in the study also reported finding it difficult to "read" other people's intentions and so struggled to understand if a man was just being friendly or was sexually attracted to them.

Some women also reported that their experiences of peer rejection left them "desperate" for acceptance, which in turn made them more vulnerable to exploitation.

And finally, young women's uncertainty regarding social rules also contributed to risk of abuse: some women in the study had not known that they could say "no" when they had wanted to refuse sex or other people's advances. One girl abused by an older boyfriend said that she didn't know she could refuse because she had been told to be polite to her elders.

Society has to change, not autistic people, says Bargiela. "Autism isn't a disease: there's no cure and nor should there be. If you're autistic, you're wired differently. You can't change. The dialogue around autism focuses too much on the deficits, but we need people who think differently. We can't all be extroverts."
Camouflage: The Hidden Lives of Autistic Women (Jessica Kingsley, £12.99) from guardianbookshop.com

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Different for girls: understanding autism

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t secondary school, they become the "leftover girls", drifting, alienated and often miserably lonely because the other teenage girls won't accept them. It's not that autistic girls don't want friends - they are as desperate for friends as any teenager - but in a world which denies, rejects and ignores them, they are simply not wired to understand the only social role available to them: that of a neurotypical girl living an ordinary life.

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The new proposal - part of the psychiatric association's effort of many years to update its influential diagnostic manual - is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it's allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: "All I can say is that personality disorders were one of the first things we tackled, but that doesn't make it the easiest."

The entire exercise has forced psychiatrists to confront one of the field's most elementary, yet still unresolved, questions: What, exactly, is a personality problem?
Habits of Thought
It wasn't supposed to be this difficult.

Personality problems aren't exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues' gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of "confounded identities" that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling - in who they were.

"These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired," said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. "They had problems that were neither psychotic nor neurotic. They represented something else altogether."

Several prototypes soon began to emerge. "A pedantic sense of order is typical of the compulsive character," wrote the Freudian analyst Wilhelm Reich in his 1933 book, " Character Analysis," a groundbreaking text. "In both big and small things, he lives his life according to a preconceived, irrevocable pattern."

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association's third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. "Personality Disorder-Not Otherwise Specified," a catchall label meaning little more than "this person has problems" became the most common of the diagnoses.

It's a murky area, and in recent years many therapists didn't have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

"The diagnoses simply weren't being used very much, and there was a real need to make the whole system much more accessible," Dr. Lenzenweger said.

Resisting Simplification

It was easier said than done.

The most central, memorable, and knowable element of any person - personality - still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to "develop a coherent sense of self or identity." Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

For example, an interim proposal for narcissistic personality disorder involved rating a person on four traits, including "manipulativeness," "histrionism," and "callousness," and the final proposal relied on just two, "grandiosity" and "attention-seeking." The current definition includes nine possible elements.

The proposed diagnostic system would be simpler, as well as "responsive to the array of diverse and sometimes contradictory suggestions made by other" personality disorders experts, wrote Dr. Andrew Skodol, a psychiatrist at the University of Arizona and chairman of the group proposing the new system, in a paper published last spring.

But since then the outcry against the proposed changes has only grown louder.

Some experts argued that throwing out existing definitions was premature and reckless. Others insisted that the diagnoses could not be simplified so much. And some complained that the effort to anchor the disorders in traits had not gone far enough.

"You simply don't have adequate coverage of personality disorders with just a few traits," said Thomas Widiger, a professor of psychology at the University of Kentucky.

Dr. Widiger compares the process of reaching a consensus on personality to the parable of the six blind men from Hindustan, each touching different parts of the elephant. "Everyone's working independently, and each has their perspective, their own theory," he said. "It's a mess."

"It's embarrassing to see where we're at. We've been caught up in digression after digression, and nobody can agree," Dr. Millon said. "It's time to go back to the beginning, to Darwin, and build a logical structure based on universal principles of evolution."

At least for now, then, the misfits will remain in their colony, part of mainstream psychiatry but still in the back country.

And if a unified theory can be devised to explain them, most agree that it will be some time in the making - perhaps requiring the efforts of an obsessive-compulsive narcissist with some political skills.

Correction: November 30, 2012

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diagnostic and statistical manual of mental disorders (book)

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Clearing the Fog Around Personality Disorders

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The new proposal - part of the psychiatric association's effort of many years to update its influential diagnostic manual - is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment.

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MENTAL HEALTH & RACE - DUAL DISCRIMINATION

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MENTAL HEALTH & RACE - DUAL DISCRIMINATION

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Mental health and race - the blight of dual discrimination | Mary O'Hara

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Mary O'Hara: Black and minority ethnic people living with mental illness face a double dose of prejudice, says a new report from the anti-stigma organisation Time to Change

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The latest lifestyle, fashion and travel trends

The latest lifestyle, fashion and travel trends

It is estimated that 1.2% of the population suffers from OCD, which equates to 12 out of every 1000 people. Obsessive compulsive disorder focuses on the need for order and control of your environment, which can be challenging within the panicked nature of the city.

This third film in our Mental Health in the Metropolis series looks at a commonly misunderstood and misrepresented mental health condition: obsessive compulsive disorder.

36-year-old Alex Crawford has suffered from OCD for last 30 years.

Alex suffers from a form of OCD called 'pure-o' which means she experiences an overwhelming amount of intrusive thoughts.

Far from the stereotypical belief that OCD is purely centred on hygiene concerns, a person with 'pure-o' will still have compulsions which mainly manifest as unseen mental rituals.

Her obsessive beliefs can manifest in compulsive behaviours, something that resulted in her developing anorexia.

What it's like to live with an anxiety disorder in the city

One aspect Alex struggles with is the fear of hurting children, which makes the closed proximity of public transport exceptionally difficult for her.

Despite battling with her condition on a daily basis, Alex works as a chef in Peckham. She finds this allows her to find focus and clarity away from her hectic thoughts.

Watch the video about Alex to find out more about her moving story.
If you or anyone you know are concerned about obsessive compulsive disorder contact OCD Action, OCD UK or alternatively contact the Samaritans on 116, 123.

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What it's like to live with OCD in the city

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It is estimated that 1.2% of the population suffers from OCD, which equates to 12 out of every 1000 people. Obsessive compulsive disorder focuses on the need for order and control of your environment, which can be challenging within the panicked nature of the city.

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Are sexual abuse victims being diagnosed with a mental disorder they don't have?

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The lack of recognition for complex PTSD by the psychiatric establishment means it is difficult for sexual abuse victims who might suffer from it to receive the right diagnosis

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BRITISH PSYCHOLOGICAL SOCIETY CURRENT RESEARCH SUMMARIES

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BRITISH PSYCHOLOGICAL SOCIETY CURRENT RESEARCH SUMMARIES

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By guest blogger Helge Hasselmann

Across the globe, ADHD prevalence is estimated around 5 per cent. It's a figure that's been rising for decades. For example, Sweden saw ADHD diagnoses among 10-year olds increase more than sevenfold from 1990 to 2007. Similar spikes have been reported from other countries, too, including Taiwan and the US, suggesting this may be a universal phenomenon. In fact, looking at dispensed ADHD medication as a proxy measure of ADHD prevalence, studies from the UK show an even steeper increase.

Does this mean that more people today really have ADHD than in the past? Not necessarily. For example, greater awareness by clinicians, teachers or parents could have simply captured more patients who had previously had been "under the radar". Such a shift in awareness or diagnostic behaviour would inflate the rate of ADHD diagnoses without necessarily more people havingclinical ADHD. However, if this is not the true or full explanation, then perhaps ADHD symptoms really have become more frequent or severe over the years. A new study in The Journal of Child Psychology and Psychiatry from Sweden with almost 20,000 participants has now provided a preliminary answer.

Some researchers hope that focusing on the cognitive, neural, genetic and social processes that contribute to symptom dimensions - like anxiety-depression or social withdrawal - may be more fruitful than trying to understand the causes of different diagnostic categories, like "schizophrenia" or "major depression". It's in this vein that a new paper in Biological Psychiatry has used a simple perceptual task to investigate how judgment confidence, judgment accuracy and metacognition (judgment insight) are related to various trans-diagnostic symptom dimensions in the general public.

There's a stereotype that mental distress is an almost inevitable part of being highly creative. But is there any substance to this idea, or have we been misled - by biographers drawn to artists with colourful and chaotic lives, and the conceits of cultural movements like the romantics?

Scientific attempts to resolve this question, which have mainly focused on disorders of mood, have so far struggled to reach a definitive answer. However, in a new review in Perspectives on Psychological Science, Christa Taylor of Albany State University has applied surgical precision to open up the existing body of research and lay out what we currently know.

At the heart of obsessive-compulsive disorder (OCD) are the intrusive, often distressing, thoughts. My skin is dirty... I must have left the gas on and my house will burn down... But why do some obsessive thoughts compel the person to act on them, while others don't? And how are some people with OCD able to control the compulsion to act - to repeatedly wash their hands, or to go home to check appliances, for example - while others can't?

As the authors of a new study on OCD, published in Clinical Psychological Psychotherapy, point out: "A single negative intrusive thought may result in an avalanche of compulsive behaviour, whereas even hours of intrusive thought may prompt little or no compulsive behaviour in some individuals."

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By guest blogger Helge Hasselmann Across the globe, ADHD prevalence is estimated around 5 per cent. It's a figure that's been rising for decades. For example, Sweden saw ADHD diagnoses among 10-year olds increase more than sevenfold from 1990 to 2007.

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We improve the lives of people severely affected by mental illness through our network of local groups and services, expert information and successful campaigning. Our goal is to make sure everyone severely affected by mental illness has a good quality of life.

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About mental illness

1 in 4 people will experience a mental illness in their lifetime. People can, and often do, recover with the right treatment and support. Our advice and information pages can help you learn more about conditions, symptoms and diagnoses, so you or a loved one can get the help you need.

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Living with a mental illness should not be a barrier to a good quality of life. Our advice and information pages contain all you need to know about getting the proper treatment and support for you or a loved one and what you can do if you feel the help you are getting is not right.

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No matter how bad things are, we can help.

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1 in 4 people will be affected by a mental health problem in their lifetime - we are here to support them when they do.

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PERSONAL STORIES ABOUT MENTAL HEALTH & STIGMA

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PERSONAL STORIES ABOUT MENTAL HEALTH & STIGMA

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Copyright © 2023 Time To Change. Time to Change is led by Mind and Rethink Mental Illness.

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Mental health problems are very common. We have interviewed a wide range of people with personal experience of mental health conditions, so that you can share in their stories. All of the topics covered in this section are listed below and in the menu on the left.

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Some people have a legitimate reason to feel depressed, but not me. I just woke up one day feeling sad and helpless for absolutely no reason...