رام کردن یک آتشفشان: بیماران مبتلا به اختلال شخصیت مرزی و درک آنان از رنج

Background A substantial proportion of schizophrenia patients deny aspects of their illness to others, which may indicate a deeper disturbance of ‘insight’ and a self-reflection deficit. The present study used a ‘levels-of-processing’ mnemonic paradigm to examine whether such patients engage in particularly brief and shallow self-reflection during mental illness-related self-evaluation. Methods 26 schizophrenia patients with either an overall acceptance or denial of their illness and 25 healthy controls made timed decisions about the self-descriptiveness, other-person-descriptiveness and phonological properties of mental illness traits, negative traits and positive traits, before completing surprise tests of retrieval for these traits. Results The acceptance patients and denial patients were particularly slow in their mental illness-related self-evaluation, indicating that they both found this exercise particularly difficult. Both patient groups displayed intact recognition but particularly reduced recall for self-evaluated traits in general, possibly indicating poor organisational processing during self-reflection. Lower recall for self-evaluated mental illness traits significantly correlated with higher denial of illness and higher illness-severity. Whilst explicit and implicit measures of self-perception corresponded in the healthy controls (who displayed an intact positive > negative ‘self-positivity bias’) and acceptance patients (who displayed a reduced self-positivity bias), the denial patients' self-positivity bias was explicitly intact but implicitly reduced. Conclusions Schizophrenia patients, regardless of their illness-attitudes, have a particular deficit in recalling new self-related information that worsens with increasing denial of illness. This deficit may contribute towards rigid self-perception and disturbed self-awareness and insight in patients with denial of illness.

Results The analysis revealed three comprehensive theme areas: life on the edge, the struggle for health and dignity—a balance act on a slack wire over a volcano, and the good and the bad act of psychiatric care in the drama of suffering. These theme areas at the same time form a movement back and forth—from despair and unbearable suffering to struggle for health and dignity and a life worth living. (Because the interviews were held in Swedish and the biographical material was written in Swedish, citations in the result have been translated by the authors.) Life on the Edge “It's hard climbing this narrow path with precipices on either side.” In the narratives, living and coping with BPD is living a life on the edge, a life of constant falling and climbing—falling into “black holes with slippery walls with something creepy and disgusting crawling around the legs.” In this theme area, three themes occurred: the world of emotional pain and self-hate, the mask of normality, and the Janus face. The World of Emotional Pain and Self-Hate The narratives reveal a life situation overshadowed by intense emotional pain and distress. The pain is a chaos of anxiety, feelings of emptiness, hopelessness, meaninglessness, anger, and powerlessness—feelings that the respondents can neither understand nor control. It is a world of emptiness, darkness, and self-hate with flashes of acute and unendurable emotional pain. “The contours of the surroundings is dissolving, everything is floating together into a grey mist, while twilight is falling behind me.”/“It's hard to believe in light, when you are living in darkness with yourself as enemy number one.”/“I have storms of emotions inside me. I'm angry, sad without really knowing why…It feels like I'm going to explode”/“I get panic from all feelings, it is a fear that spreads like wildfire”/“I'm angry, pissed off, disappointed, ruined, just sad and tired, tired of it all.”/“I hate the one I see in the mirror so much that it's hurting inside.” When the pain gets unendurable, they have to distract themselves by inflicting bodily pain, seeking danger, or just fleeing. Thus, yearning for death as liberator is omnipresent in the narrated life world. “…I thought my life was like shit, and I wanted to kill myself nearly all the time”/“I have lived too long already, but now I'm going to liberate myself. I'm not afraid of the night anymore…”/“…have to continue my wandering into the darkness…If you listen really careful you can here me crying inside.” There is also comfort in having the means of “ending it all” around (collecting pills, always having razors at home, walking near the railroad track, etc.). “I have not cut myself yet, but I'm counting my pills which I collected for possible use in the future—98 sleeping pills, so I'm sure I will sleep well and if I'm lucky never wake up again.” The Mask of Normality Putting on the mask of normality is a way of surviving and showing some kind of dignity. “I'm a clown, a mask with sad eyes and close to tears all the time, but no one notices, or do you notice and keep quiet?”/“The anxiety and depression is inside me, but I don't show it on the outside. It is tormenting me all the time. Sometimes it feels as if I'm going to explode”/“You have never seen me, not with my feelings, just the mask. I'm tough but rather small and scared as hell.”/“Sometimes I wished that the shell would fall off, jangle into a heap like an old armour, and then maybe someone would have understood.” The mask of normality is also a gesture of compassion toward people around the informants. It is a will to not upset and harm others by showing their pain and distress. “When I'm with H I'm collected and controlled. I always am when I'm together with other people. Inside I'm not one dammed bit controlled, just have such anxiety”/“I'm not happy it is just a mask I used to hide all my real feelings. They hurt so damn much. I look happy because others wanted me to look happy.” The mask of normality is also narrated as some kind of invocation—representing a will and a struggle to be normal—if I act normal I may be regarded as normal and then I may become normal. “I can't show who I really am. I have some kind of delusion that if I act normal I can change my personality perfectly; become calm, happy and receptive and all those things probably everybody dreams about.” The Janus Face This theme refers to the rapid mood swings that are narrated and sometimes even shown in the texts. On one side, it is the tormented face of emotional pain; on the other, the mask of normality. It seems like the mask of normality often comes on and off very quickly. “After supper I phoned P and J. Then I and E (staff on the ward) were out walking. Still feel fat. I know that I'm not. I cut my wrist again.” The struggle to act normal is defeated by “the world of pain and self-hate.” On the other hand, in some diaries, informants have barely recovered from a suicide attempt before it is “mask on” and business as usual. “Had to go by ambulance to the emergency room…I had taken an overdose of antidepressants…Then I was given oxygen by mask because I had trouble breathing. Got to the observation ward at about three o'clock am. There I met a drop dead beautiful guy called M, who was working on the ward.” The Struggle for Health and Dignity—A Balance Act on a Slack Wire Over a Volcano The struggle for health, dignity, and a life worth living is for the informants “a balance act on a slack wire over a volcano,” the volcano being the rapidly shifting feelings and mood swings—the world of emotional pain and self-hate that always is bubbling underneath the surface. Under the outbursts of anxiety and emotional pain, they have nothing much to defend themselves with. The patients' entire life situation turns into a hellhole of despair and hopelessness; thus, they become easy victims of impulses—getting away from it all. The struggle for health and dignity revealed three themes, which at the same time are dialectical pairs of opposites: fear of life, longing for death–fear of death, longing for life; hopelessness and helplessness–will to struggle for a change; solitude, fearing relations–longing for love and fellowship. Fear of Life, Longing for Death–Fear of Death, Longing for Life The informants narrate a profound ambivalence—fearing life and longing for death and yet longing and struggling for life. “Hope I'm dead when I wake up. Please, help me what shall I do”/“I'm so damned angry with myself because I don't handle to cut myself properly—yet. I don't dare to close the door, please help me close the door”/“What happened? Why did I take these pills, when I really want to live? This feels like a failure that I'm alive. At the same time I felt scared, I could have died.”/“To dare being someone who shall live, who has a life, who shall work in the future”/“I cannot live but don't want to die. I live even if I don't”/I'm balancing between wanting to be here and just get away.”/“It's not small thoughts, they are big and are about life, my existence, about the calm and harmony I wish for above all, about my fears not coming away from the dark and destructive thoughts which have followed me through life.” Hopelessness and Helplessness–Will to Struggle for a Change Because the informants often are overwhelmed by the darkness and pain inside, they are easy victims of impulses that in turn make them feel powerless, small, and helpless. At the same time, there is a strong will to struggle for a change toward being competent and in control and using more adaptive coping strategies. “I poured a whole bottle of wine in me last night after a conversation on the phone with B, to sleep off the anxiety. I don't really want to do that but how else shall I cope”/“I can't love myself, can't even give myself credit for anything good. I'm sure you did what you could…I can't do no more”/“…then I just want to lie in bed in hospital being taken care of. Being surrounded by strong and secure people…”/“I shall go on struggling and get so well that I can be discharged. So what can I do when I'm worried and anxious…Go for a walk…Talk to the staff…instead of getting an outburst or cutting my wrist, visiting friends…”/“It's hard climbing this narrow path with precipices on either side. I wish there was someone to hold my hand supporting me over the obstacles.” Solitude, Fearing Relations–Longing for Love and Fellowship There is also ambivalence between the wish for love and fellowship and the self-hate that tells patients that they are not worthy to be loved. The fear of being rejected puts them in a position of “the strong solitaire” or testing if another person really can be trusted. “I don't need anybody because I am nobody”/“I want to have relationships with people but when I feel down it doesn't matter, I don't take contact because I'm about to die anyway”/“Don't touch me! I don't like anybody and nobody are allowed to like me. Do you hear me, but the little girl inside is still striving to be loved”/“To trust others I have to test the relationship very much, and who ever can cope with that in the long run?” The Good and the Bad Act of Psychiatric Care in the Drama of Suffering The narratives revealed a double role of psychiatric care in the informants' drama of suffering. On one hand, personnel can add to the suffering by not understanding and being disrespectful; on the other, they can be helpful and relieve suffering by being respectful, understanding, and validating. “I can't do it without help, so help me someone…It hurts to walk here alone. I promise to accept you as company on my way, but I don't want to be hurt or rushed. Just be there and dare to hold my hand, then I will dare to hold out mine.” Under this theme area, five themes were found: not being understood and disrespectful attitudes, discontinuity and betrayal, respect and confirmation—the foundation of being helpful, getting help to accept is the beginning of change, and getting help being responsible. Not Being Understood and Disrespectful Attitudes The informants described experiences of not being understood and meeting disrespectful and condemning attitudes from personnel. In the first case, the informants felt that there were personnel at hand trying to meet them but not succeeding very well. In the second case, the informants felt that either no one seemed to care or listen at all or the personnel at hand were hostile and condemning in their comments. “…and I never felt that anyone really understood, everybody said they understood but then nothing at all happened.”/“Everybody thinks that we are harming ourselves to get attention, but we are not, we are harming ourselves because life hurts so damned much.”/“There was no respect for me as a human being. I had no value as a human whatsoever”/“…and if I felt bad, they just poured medicines into me, so they could have peace and quiet on the ward and they didn't do anything else like talking or so.” The statements on meeting disrespectful attitudes also contained feelings of not being a part of the decisions concerning themselves. “They have always taken over the decision-making and responsibility, all of them, they never asked what I thought or wanted.”/“No one cared about what I said”/“She didn't talk to me, she talked right over my head.” Discontinuity and Betrayal Some of the informants stress that the experience of discontinuity has added to their suffering, when for different reasons therapists and attendants have ended contact with them, leaving them with feelings of betrayal. “…but lots of times it happened that they handed me over to someone else, because they felt it was trying and tough, and that feels like betrayal, and then you don't dare to open up anymore.” Understanding, Respect, and Validation—The Foundation of Being Helpful In the narratives, understanding, respect, and validation appear as the very foundation of being helpful and relieving suffering. “…it's the understanding, to be taken seriously, met with respect…”/“…I have never met the kind of validation I get here…here they are more calm and more as…: Maybe that wasn't the best solution, what could you have done differently?”/“…and they understand that you are going through hell sometimes, and just that makes you grow a little…”/“Number one is to get respected, being treated like an equal…” Getting Help to Accept is the Beginning of Change The informants' pattern of self-hate and the tendency of always condemning their own thoughts, feelings, and efforts as bad or not good enough play a large role in their suffering. Getting help accepting the feelings and enduring the suffering appears as a beginning of change. “…being able to accept that life can feel like shit for one day, without cutting myself to pieces…”/“…you can't always reach the stars, it's just the way it is, and I don't have to condemn myself because of that…”/“I'm trying to accept that life is like it is and some days are good and some are like hell, but I couldn't accept that before, just through accepting it's easier to live with.” Getting Help Being Responsible Getting help to see themselves as responsible for their own lives as well as their treatment was narrated by the patients as another helpful component in the struggle for health. “…here you really have to work with your problems, trying to change things”/“…I have got a responsibility; it's me that has to change things with support from my therapist…”