Today is a more clinical post. While this blog explores the nature of living with mental health issues on a personal, anecdotal level, I thought I would take one post and share the diagnostic criteria behind my specific mental health issues (in order of diagnosis): generalised anxiety disorder, social anxiety disorder, panic disorder, obsessive-compulsive personality disorder, and illness anxiety disorder.
I have received five mental health diagnoses in my life, and one will undoubtedly see some relation among them. It’s also important to note that these are somewhat contextual with each being somewhere unique in terms of severity – I might be at a point where I have one relatively well managed while another poses almost daily challenges, for example.
The best way to discuss them seems to be in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Addition (DSM-V) as it was the diagnostic guide used by professionals to determine each of these applied to me.
The first and largest grouping of diagnoses (three of the five) is in the anxiety disorders category. An introduction to anxiety disorders in general requires two principal distinctions. First, the difference between fear, the emotional response to a real or perceived threat, and anxiety, which is the state of preparedness that precedes a real or perceived future threat. Second, anxiety (which is not fear) is a rational response in people. The issue at hand is that the response occurs in neurotypically inappropriate situations or, more importantly, for a protracted period.
300.23 (F40.10) Social Anxiety Disorder (Social Phobia)
A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g. having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g. giving a speech).
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
I consider this my most pronounced disorder aside from the OCPD. People make me incredibly anxious, often including those who are familiar to me because of the scrutiny aspect. This is discussed further in the final section, but I believe the OCPD exacerbated this condition in me if it’s not directly responsible for it appearing.
300.01 (F41.0) Panic Disorder
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur (asterisks on the ones I experience):
Note: The abrupt surge can occur from a calm state or an anxious state.
- Palpitations, pounding heart, or accelerated heart rate.*
- Trembling or shaking.*
- Sensations of shortness of breath or smothering.*
- Feelings of choking.
- Chest pain or discomfort.*
- Nausea or abdominal distress.*
- Feeling dizzy, unsteady, light-headed, or faint.*
- Chills or heat sensations.*
- Paraesthesia (numbness or tingling sensations).
- Derealization (feelings of unreality) or depersonalization (being detached from oneself).*
- Fear of losing control or “going crazy.”*
- Fear of dying.*
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming, or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
B. At least one of the attacks has been following by 1 month (or more) of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
- A significant maladaptive change in behaviour related to the attacks (e.g., behaviours designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).
This seems like the sort of thing that ought to be explained better by another mental disorder in my case, but my panic attacks do not occur only in response to specific phenomena like outlined above. In fact, it seems that I am so amped up in those situations they are the only times I am immune from panic attacks. Mine tend to hit out of the blue when I least expect anxiety, heightening the fear that they will return because I have been unable to identify or predict triggers.
300.02 (F41.1) Generalised Anxiety Disorder
A. Excessive anxiety and worry (apprehensive expectations), occurring more days than not for at least 6 months about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
- Restlessness or feeling keyed up or on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Muscle tension.
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functionintg.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
I will explain this more at the end, but the mental health professionals explained a GAD diagnosis as still relevant despite the final criteria because I have so much anxiety left over after accounting for social anxiety disorder, panic disorder, and illness anxiety disorder that I still meet the diagnostic criteria for this. Fun, eh?
Somatic Symptom and Related Disorders
300.7 (F45.21) Illness Anxiety Disorder
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
D. The individual performs excessive health-related behaviours (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used.
Care-avoidant type: Medical care is rarely used.
I avoid doctors unless I deem it critical, and then I pursue medical care with extreme anxiety, often to the point of triggering panic attacks in the days leading up to the appointment, during the appointment, or as I am calming down after the appointment. The idea that something serious and/or preventable is going undiagnosed because of this seems to be the cause behind my illness anxiety disorder.
The DSM currently identifies ten distinct personality disorders that it organises into three clusters. Cluster A are the paranoid, schizoid, and schizotypal disorders, which the DSM refers to colloquially as appearing “odd or eccentric.” Cluster B are the antisocial, borderline, histrionic, and narcissistic disorders, which might be considered the most “challenging” personality disorders. Cluster C are the avoidant, dependent, and obsessive-compulsive disorders, which typically present as fearful or anxious.
My personal case, perhaps unsurprisingly at this point, falls into the Cluster C group.
301.4 (F60.5) Obsessive-Compulsive Personality Disorder
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
- Is preoccupied with details, rules, lists, order, organisation, or schedules to the extent that the major point of the activity is lost.
- Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
- Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
- Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
- Is unable to discard worn-out or worthless objects even when they have no sentimental value.
- Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
- Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
- Shows rigidity and stubbornness.
I write extensively about this disorder because it’s comparatively rare by mental health standards, but I find it easy to relate with other personality disorders (especially Cluster B; my nature seems to make me amenable to people with Cluster B disorders and we can discuss things calmly at length). This is also the only disorder of the five that I sometimes feel compelled not to address beyond it’s tendency to make the other disorders worse.
One last thing worth discussing here is the notion of comorbidity – the coexistence of multiple diagnoses.
Anyone familiar with the DSM or taking the time to read the diagnostic criteria of my conditions above knows that the manual goes to explicit lengths to eliminate unnecessary diagnoses. My anxiety about personal health, for example, specifically calls out panic disorder and generalised anxiety disorder as alternate conditions that might better explain my symptoms. In such a case, illness anxiety disorder does not apply.
How could I have a diagnosis of generalised anxiety disorder alongside specifics such as social anxiety disorder, panic disorder, and illness anxiety disorder? Would not one of them eliminate the others?
The way mental health professionals explained my parallel diagnoses was as a sort of Venn diagram. If we take all of the diagnostic criteria that applies specifically to concerns about my health, I meet the criteria for illness anxiety disorder. If I could snap my fingers tomorrow and eliminate that disorder completely, I would still meet the diagnostic criteria for all the others. Vice versa, if I were to eliminate the diagnostic criteria for the other four disorders, I would still meet the criteria for illness anxiety disorder.
In short, I have more than enough worry to go around.
I tend to view my five diagnoses in two broad camps: anxiety and personality. It’s not a scientific perspective on my struggles, but mental health clinicians and I find it useful in treatment to examine my mental health holistically.
Anxiously, I have my social anxiety (those geared towards social situations), my illness anxiety (geared towards my personal health), and my generalised anxiety (geared towards literally everything else – though we increasingly consider this diagnosis wrong because many of these worries also relate to people in some way). Years of severe anxiety lead to panic attacks not associated with any particular event, which gave way to panic disorder.
Personality-wise, my OCPD seems to explain (or at least exacerbate) all of the anxiety issues. See, I’m not anti-social. I’m an introvert with social anxiety, but I am not anti-social. Along with the OCPD, I am conflict-averse and desperate to keep people happy – even though having people around stresses me.
With the social anxiety in particular, this amplifies everything. My constant concern that others are judging me, that I am being rude, stupid, bizarre, or any number of other disagreeable things stresses me to a problematic degree.
While I have anxiety about my personal health (regular worry that I am developing or already have a serious condition), I avoid medical professionals (fear of their tools and procedures; social anxiety about the medical staff judging my anxiety, nervousness, inability to care for my health…). The social anxiety in medical situations is almost as severe as the illness anxiety that keeps me away from them.
With the myriad other constant worries that plague my mind, I connect most (all) of them back to people. I worry about the environmental health of the planet, which I see as exacerbated by people. I worry about public safety (shootings, extremism, etc.), which is obviously people. I worry about the state of education and public health, both of which people administer. And while I have opinions about how we should address those worries, so too do I have anxiety about how others will take my opinions. The idea that the only path forward on any of my anxieties is conflict only leads to more anxiety!
A solution here would be to work on caring less or trying to focus the energy into one particular area – except that I have OCPD. To ignore the other areas is, according to my value system, just as bad as perpetrating the problems in those areas. If one is not part of the solution, one is part of the problem. It’s only a matter of time before my resolve to step away from a subject weakens and I recommit myself.