Wednesday, October 29, 2014

Self-disorders selectively aggregate in the schizophrenia spectrum

Self-disorders, according to the Examination of Anomalous Self-Experience (EASE) which is a semi-structured interview manual published in Psychopathology in 2005 that measures self-disorders both qualitatively and quantitatively, all share in common "a disorder or deficiency in the sense of being a subject, a self-coinciding center of action, thought, and experience" (footnote removed). A link to the manual's full-text can be found here:

Self-disorders include dissociative-like phenomena, disturbances in the stream of consciousness, transitive phenomena, and changes in basic world experience. Studies have shown self-disorders to selectively aggregate in the schizophrenia spectrum:

Basic self-disturbance scores [measured using the EASE] were significantly higher in patients with a schizophrenia spectrum diagnosis (n = 8) compared to patients with other psychotic diagnoses (n = 8).
The findings are consistent with previous work indicating that the disturbance of the basic sense of self is more characteristic of schizophrenia spectrum psychosis than other psychoses. This may have implications for early diagnosis, clinical formulation and intervention.

This shows that people with schizotypal disorder have similar levels of self-disturbance to non-affective psychosis (mostly schizophrenia patients), showing significant differences from other mental illness (which includes patients with bipolar disorder, major depression, OCD, etc.):

Another study with the same result (emphasis added):

Converging evidence indicates that self-disorders (SDs) selectively aggregate in schizophrenia spectrum conditions. The aim of this study was to test the discriminatory power of SDs with respect to schizophrenia and nonschizophrenia spectrum psychosis at first treatment contact. SDs were assessed in 91 patients referred for first treatment through the Examination of Anomalous Self-experience (EASE) instrument. Diagnoses, symptoms severity, and function were assessed using the Structural Clinical Interview for the DSM-IV, Structured Clinical Interview for the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, Young Mania Rating Scale, and Global Assessment of Functioning-Split Version. Most patients found it highly relevant to talk about SDs. EASE total score critically discriminated between schizophrenia, bipolar psychosis, and other psychoses. The EASE total score was the only clinical measure that showed a significant and robust association with the diagnosis of schizophrenia. Systematic exploration of anomalous self-experiences could improve differential diagnosis in first-treatment patients.

Though we don't have the full-text here, another article cites the above article, saying that it shows that when controlling for the "symptomatic PANSS dimensions" self-disorders still aggregated in the schizophrenia spectrum:

The difference in SD between schizophrenia and bipolar psychosis, observed by Haug et al,59 remained significant after controlling for the differences between the groups on the symptomatic PANSS dimensions.

This shows another look at the unity between schizophrenia and schizotypal disorder in terms of self-disorders, again showing their "selective aggregation" in the schizophrenia spectrum:

This study uses a pre-EASE scale of self-disorders and compares them in "residual schizophrenia and psychotic bipolar illness in remission":

Results: Diagnosis of schizophrenia was associated with elevated scores on the scales measuring perplexity (loss of immediate meaning), disorders of perception, disorders of self-awareness, and marginally so, disorders of cognition.

This look at self-disorders is interesting and can possibly bring about greater insight into the schizophrenia spectrum as a whole, showing where and how it differs from other mental illnesses, like psychotic bipolar disorder and OCD, thus bolstering the Kraepelinian dichotomy. Here is a study that looks at a possible relationship between self-disorders and insight in schizophrenia, and actually gives a very good introduction to self-disorders. For example, it mentions that in all the foundational texts on schizophrenia, self-disorders were seen as important:

The notion of disordered self as the core disturbance of schizophrenia appears in all foundational texts on schizophrenia (eg, Kraepelin, Bleuler, Minkowski, Jaspers, and Schneider) but was only recently revived in contemporary psychiatry.

This is under the section "The Disordered Self in Schizophrenia," a very interesting read into the core of the schizophrenia spectrum. Here is the link to the full text:

This explores those self-disorders in that section (footnote removed):

This basic self-world structure is disturbed in schizophrenia spectrum disorders, ie, it is constantly challengedunstable, and oscillating, resulting in alarming and alienating anomalous self-experiences (also termed “self-disorders”), typically occurring already in childhood or early adolescence. The patients feel ephemeral, lacking core identity, profoundly, yet often ineffably different from others (Anderssein) and alienated from the social world. There is a diminished sense of existing as a bodily subject, distortions of the first-person perspective with a failing sense of “mineness” of the field of awareness (eg, “it feels as if the thoughts aren’t really mine”), and a deficient sense of privacy of the inner world. There is a significant lack of attunement and immersion in the world, inadequate prereflective grasp of self-evident meanings (perplexity), and hyper-reflectivity (eg, “I only live in my head” and “I always observe myself”). Although patients often suffer from self-disorders, the latter are usually lived in an ego-syntonic way, as modes rather than as objects, of the patients’ experience, ie, often affecting more the “how” than the “what” of experience. What is important to emphasize at this point is that the self-disorders, reflecting the unstable basic self-world structure, destabilize the natural ontological attitude and may throw the patient into a new ontological-existential perspective, an often solipsistic framework, no longer ruled by the “natural” certitudes concerning space, time, causality, and noncontradiction. Unconstrained by these certitudes, the world may appear as only apparent or staged, ontologically mind-dependent, prone to noncausal relations, and the patient may experience a unique access to deeper layers of reality, which are inaccessible to others. Often, these experiences evoke a specific sense of grandiosity, leaving others to be seen as oblivious to the true nature of reality and only concerned with everyday trivialities.

Self-disorders seem like they can discriminate between the schizophrenia spectrum and other mental illnesses and seems to show traits present in the schizophrenia spectrum that are typically absent outside of it, even in other psychoses. Even the non-psychotic schizotypal disorder has an aggregation of self-disorders, which suggests that self-disorders are more of a "schizophrenia spectrum thing" than a "psychosis thing."

Sunday, September 28, 2014

Why I hate all the sensationalist news about Bruce Jenner possibly undergoing gender transition

Note: Because I have not seen confirmation that Bruce Jenner actually identifies as a woman and has actually denied that he is undergoing gender transition, I will use male pronouns to refer to him.  This decision is also supported by the current state of his Wikipedia page, which currently uses male pronouns to refer to him.

Bruce Jenner, the former Olympic Track runner, has long been known for exhibiting vanity about his appearance, undergoing plastic surgery at several points in his life, among the latest a tracheal shave because he didn't like his trachea.  Apparently, at that point, a whole bunch of sensationalist new articles were all up in arms about his supposed pending gender transition.  I cringe when I search "sex reassignment" on Google News to try to see our country's (USA's) progress toward making full gender reassignment accessible to all and see that half the results page is filled with articles with rumors about Bruce Jenner.  It really rubs me the wrong way and I'll tell you why.

Bruce Jenner is well known for his vanity, so having so many sensationalist articles saying he is undergoing gender transition poisons the concept of gender transition, making it seem like nothing more than just another vain undertaking, I think.  Not only that, but there's talk of an expensive divorce in the news, so adding to its possibly being viewed as a vain undertaking, gender reassignment may come to be seen as the province of the rich and famous, and more so if it has already come to be seen as that.  Because of the tendency of many people to confuse is and should be, many may come to see that it should be a vain undertaking that is the province of the rich and famous and resist efforts to make full gender reassignment accessible to all people.  This is why the rumors about Bruce Jenner really trouble me.

I don't know if there is anything we can do to stop the sensationalist articles about Bruce Jenner's supposed gender transition, as the guy probably likes all the attention, but when I look with hope for news that coverage of gender reassignment may increase I really hate seeing Bruce Jenner's name come up and take up such a huge portion of the page.

I hope and pray, for my sake (because I really need it) and for others' sake, that we can accelerate the expansion of coverage and access to full gender reassignment in this country.

The pain of no SRS: Why it won't go away

When my insurance company earlier this year denied prior authorization for SRS, though it was expected, hit me like a barrel of bricks.  I lost the ability to work consistently, so I've had to go on leave twice, one month the first time, and two months the second time: I remain on my current leave for a couple more weeks.  But now as my mental health professionals are trying to prepare me to return to work, they ask, It looks like SRS isn't coming any time soon, so why don't you let that be?  I told them, this, it is too important to let that be.  I may be to return to work consistently, but this will always haunt me.

The reason is simple, no SRS is something you must continue to endure.  As I shower, I avert my eyes not to see the thing; as I lie down, I try to keep it in a position where I don't feel it; as I walk, I try to keep it in the correct position in my boxers so as not to hug my leg; and, if I tuck, I can feel that thing the whole way through.  A lot of reminders there are for a part so small.

No SRS is something, if it goes on long enough, will continue to erode me.  It is absolutely vital that I get SRS someway or somehow, and I move desperately for the way.  I've appealed the insurance's denial with help from a lawyer and I've reached out to my company's diversity department to add SRS coverage.

I hope I don't have to save it up.  After returning to work, I don't know if I will have other interruptions as I fall under the weight of no SRS, so saving up money for the whole thing, enough to pay for the SRS and to pay for the food, lodging, and travel while I am away, may be a pipe dream.

The stress of no SRS has worsened my mental state these past couple years.  It started with panic and rage in October 2012 that led to a suicide attempt and hospitalization.  Two more hospitalizations quickly followed.  Now I am $5000+ in medical debt.  Then came the wait and the denial for the pre-authorization that made me so anxious, depressed, and obsessive that I could hardly work at all and I've had to go on two leaves of absence.  Obviously, none of this is amenable to saving up for SRS.

My self-care has also declined, as I've taken to wearing the same clothes day after day, even while showering several times a day.  I've been forgetting to brush my teeth many a night and morning  My motivation to care for myself has declined as no SRS has born down upon me.  I see my failings, but I have no motivation to deal with them.

Now I live on in fear.  I fear that before I can get SRS, I will have a relapse of the psychotic episode I had when I was 14.  I believe the functional declines I've experienced recently have made me more vulnerable to this outcome.  My official diagnoses are autism spectrum disorder and gender dysphoria, but I wonder if there isn't a third more severe disorder lurking underneath it all, biding its time.

To try to reassure me of this, to reduce my obsessive worrying about this, my doctor has placed me on Prozac and states he intends to go to a high dose, but ironically a high dose of Prozac in addition to a high dose of Zyprexa were the medicines I was taking when I became psychotic at age 14.  What fixed the psychosis was getting me off the Prozac and putting me on at least the maximum dose of Zyprexa.  I wonder if the Prozac wouldn't rekindle my vulnerability again.

Such a relapse would mean placement with the men again.  I do not look forward to it.

Sunday, September 14, 2014

Highly genetically based schizotypy answers

These are considered genetically based based on a twin concordance study:

My answers:

Unusual Experiences (12 items)

When in the dark do you often see shapes and forms even thoughYES1
there is nothing there?

Are your thoughts sometimes so strong that you can almost hearYES1

Have you ever thought that you had special, almost magicalYES1

Have you sometimes sensed an evil presence around you, evenYES1
though you could not see it?

Do you think that you could learn to read other’s minds if youNO0
wanted to?

When you look in the mirror does your face sometimes seem quiteYES1
different from usual?

Do ideas and insights sometimes come to you so fast that youYES1
cannot express them all?

Can some people make you aware of them just by thinking aboutNO0

Does a passing thought ever seem so real it frightens you?YES1
Do you feel that your accidents are caused by mysterious forces?NO0
Do you ever have a sense of vague danger or sudden dread forYES1
reasons that you do not understand?

Does your sense of smell sometimes become unusually strong?YES1

Cognitive Disorganisation (11 items)

Are you easily confused if too much happens at the sameYES1

Do you frequently have difficulty in starting to do things?YES1
Are you a person whose mood goes up and down easily?YES1
Do you dread going into a room by yourself where other peopleYES1
have already gathered and are talking?

Do you find it difficult to keep interested in the same thing for aNO0
long time?

Do you often have difficulties in controlling your thoughts?YES1
Are you easily distracted from work by daydreams?YES1
Do you ever feel that your speech is difficult to understand becauseNO0
the words are all mixed up and don’t make sense?

Are you easily distracted when you read or talk to someone?YES1
Is it hard for you to make decisions?NO0
When in a crowded room, do you often have difficulty in followingYES1
a conversation?


Introvertive Anhedonia (10 items)

Are there very few things that you have ever enjoyed doing?YES1
Are you much too independent to get involved with other people?YES1
Do you love having your back massaged?aYES0
Do you find the bright lights of a city exciting to look at?aNO1
Do you feel very close to your friends?aNO1
Has dancing or the idea of it always seemed dull to you?YES1
Do you like mixing with people?aNO1
Is trying new foods something you have always enjoyed?aNO1
Have you often felt uncomfortable when your friends touch you?YES1
Do you prefer watching television to going out with people?YES1

Impulsive Nonconformity (10 items)

Do you consider yourself to be pretty much an average sort ofNO1

Would you like other people to be afraid of you?YES1
Do you often feel the impulse to spend money which you know youNO0
can’t afford?

Are you usually in an average kind of mood, not too high and notNO1
too low?a

Do you at times have an urge to do something harmful or shocking?YES1
Do you stop to think things over before doing anything?aYES0
Do you often overindulge in alcohol or food?YES1
Do you ever have the urge to break or smash things?YES1
Have you ever felt the urge to injure yourself?YES1
Do you often feel like doing the opposite of what other peopleYES1
suggest even though you know they are right?


a means score 1 for no, 0 for yes

My totals:

Unusual experiences: 9 out of 12 (mean 3.39 sd 2.92)
Cognitive disorganization: 8 out of 11 (mean 4.44 sd 2.88)
Introvertive anhedonia: 9 out of 10 (mean 2.40 sd 1.98)
Impulsive nonconformity: 8 out of 10 (mean 2.59 sd 1.99)

(Statistics of mean and standard deviation are given in the article above.)

Thursday, September 11, 2014

USA: Expansion of SRS coverage: The catch

As I'm certain many are aware, most Canadian provinces cover SRS (comprising as many as 95% of the national population), and as far as I can tell the surgeon Canadians are sent to under their public health plans is one man: Dr. Brassard of Montreal.  Coverage of SRS is something that has been in place for quite a while in many Canadian provinces.  Reading anecdotal reports from Canadians, they generally don't have to wait very long, generally less than a year from when their SRS is approved.  They also don't have to pay upfront in full for the surgery.  According to the CIA World Factbook, the Canadian population is almost 35 million.

Now, let's look at the USA.  Currently, most insurance and public health plans categorically exclude SRS, but what would happen if and when coverage is expanded?  According to the CIA World Factbook the U.S. population is nearly 320 million, almost 10 times that of the Canadian population.

I have researched multiple surgeons and only two surgeons will accept insurance upfront without requiring full payment for SRS beforehand, Dr. Bowers and Dr. Kuzon of the University of Michigan at Ann Arbor.  Dr. Bowers appears to be the more popular of the two and already has yearlong waiting lists, even with the paltry level of coverage we have currently.  Dr. Kuzon unfortunately is not well-known or popular in the community, evidenced when I asked on Reddit about Dr. Kuzon and I received warnings that the quality of his work is poor.  Very few people, it seems, have gone or are willing to go to him.

Another surgeon, Dr. Kathy Rumer, had also accepted insurance upfront without requiring full payment beforehand, but according to her office she ceased accepting insurance at the end of last year and started requiring full payment for the procedures ahead of time.  (That news was a big blow to me.)  I have researched all other surgeons in this country that I could find (about half-a-dozen or so) and they are all the same: Full payment beforehand, submit to insurance later.

This basically makes our surgeon situation not much different from Canada: Dr. Bowers is our only Dr. Brassard.  Unfortunately, as stated previously, our population is nearly 10 times that of Canada's and, unlike in Canada, there is likely a lot of pent-up demand for SRS, because many poor and working-class people can't afford paying for it upfront.  Were full coverage of SRS provided to all trans people who need it in this country, we could be looking at multiple year-long waiting lists with the one to two surgeons who bill to insurance without expecting full payment upfront.

I've heard Dr. Bowers discuss this issue before in a video on transgender health care earlier this year, but it doesn't seem to be getting the attention that it needs.  Expansion of coverage for the poor and working class is futile unless and until we get more competent surgeons that bill to insurance and don't require full payment upfront.

Unfortunately, I don't see any sign of that happening any time soon, even with Dr. Bowers discussing it.  We simply don't have the number of surgeons billing to insurance without requiring full payment upfront needed to make nationwide coverage of SRS feasible.

I find it sad that surgeons like Dr. McGinn, Dr. Nguyen of Oregon, and Dr. Rumer don't seem to give a flip about providing access to poor and working-class trans people through insurance.

Writing this essay has depressed my mood quite a bit.

tl;dr: Here I discuss the problem with the low supply of SRS surgeons in the U.S. who accept insurance and don't require full payment of SRS upfront and how expanding to nationwide SRS coverage is not feasible while that supply of surgeons is low.

Clarification: By SRS, I'm referring to bottom surgery.

Saturday, August 30, 2014

USA: Misleading headlines in the news on the ACA ("Obamacare") and coverage of transition-related care.

There are some misleading headlines regarding the ACA and sex reassignment surgery, saying that Obamacare now provides for sex reassignment, when that isn't the case at all.  Nothing in the law brought about a requirement to cover sex reassignment surgery.

In reality, what's going on is that Oregon decided to cover hormones and sex reassignment surgery on its state Medicaid program.  ACA has nothing to do with it other than Oregon expanded Medicaid.  You can get an accurate picture here:

Now as for this article with the misleading headline:

I really wish the headline were true, because I'd be signed up and scheduled by this point, as it is medically indicated in my case per my doctors with finances being my only hurdles.  Everything but the finances has been a go.

So, yeah, jeez, thanks a lot, Obama. (rolls eyes)

And thanks a lot, too, for conservatives lying about Obama himself making sex reassignment surgery available, when he didn't do a thing to directly bring any increase in such coverage about, which credit is actually owed to state health insurance and medical review boards and the independent review board of the HHS, and coverage is still kept from me and most trans people in this country.  Their ignorant bloviating is like rubbing salt in my wound.

Some more misleading info from the usual suspects:
Keep in mind that according to, this welfare program does not cover (for the most part, though there are a few tiny exceptions here and there) custodial care, dental care, acupuncture, hearing aids and eye examinations. But it does cover gender reassignment surgery, because apparently, the Obama administration considers this surgery to be a priority. Note also that the national debt continues to trickle toward $18 billion and that according to the Daily Caller, the Obamacare website itself (this doesn’t even include the many subsidies) is slated to cost over $1.7 billion.

Uh, no, it was the independent review board of HHS, the Departmental Appeals Board, none of whose board members was appointed by a Democratic administration, that made this decision.  A case went before the Board regarding coverage of sex reassignment surgery and the Board ruled on it.  You can find the ruling here:

While others may mention priorities, they have to keep in mind that the priorities of the Departmental Appeals Board are the cases that actually come before it.

More from the article:
Regardless, yes, Obamacare does provide some degree of coverage for gender reassignment surgery via Medicare. Furthermore, it’s on its way to providing coverage via both the private market and Medicaid. All this is occurring because the Obama administration fervently believes that this desire to be another gender stems from some sort of legitimate medical condition that mandates physical (and some mental) healthcare.
"Obamacare" had nothing to do with the Medicare decision, neither has HHS or Obama been involved in extending coverage for sex reassignment in any state health plans.