working in the long covid psych clinic. enjoying receiving referrals from someone who really has done a thorough physical workup before referring to me.
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As a chronic people-pleaser, this is my advice for success.
Offer as little as possible. Be terse. Get rid of all those exclamation marks and tidbits about why you want to take a sick day. State your needs clearly and concisely without reason. Start saying “No, I’m unable.” more often. Say Thank You only when the other party deserves it.
Catatonia is one of the mental health conditions I know the least about, if you have the time would you mind telling us more about your experience treating this condition? Particularly malignant catatonia, it's insane that a mental health condition can manifest that way.
catatonia is deeply weird, and i'm not sure how much i can illuminate it — it's not common (rcpsych says up to 1/10 inpatients, which strikes me as a wild overestimate), i've seen only a few cases, and i haven't read much beyond the basics.
sticking to what i've actually seen, three types. the first is straightforward catatonic depression: the logical extreme of severe depression, where the patient stops making any effort to interact or do anything. the main worry every time has been that they stop eating and drinking and die, but lorazepam, IV fluids and effective treatment for the depression (ECT in one case, meds in the others) worked fairly quickly.
the second is standard 'psychotic' catatonia. i've seen this once, preceded by delusional content (guilt and religious themes) and involving psychological pillow type stuff that looked wildly uncomfortable. that patient was walking around and able to engage in an appointment within days of admission, though they were transferred before i found out how recovery went overall.
the third is the 'was this catatonia' type: cases in medical hospitals where it entered the differential because the presentation wasn't clear, but in the context of severe illness it was hard to say. all three got benzos, all got better eventually, and i wouldn't confidently call any of them catatonia. one probably had NMDA receptor encephalitis related to their autoimmune disease; one was a depressed woman with a bad respiratory infection and heart failure, pure chicken-and-egg as to which problem was the issue at any one time; one was in ICU for other reasons to begin with.
none were malignant catatonia, which i think you'd have an incredibly high threshold to diagnose. if someone came into ED with the symptoms (fever, sweating, raised heart rate, mutism, posturing) i'd probably insist medics keep looking for an organic cause for quite a while before i'd consider ECT, and i imagine that's the case most places now. catatonia is something of a diagnosis of exclusion. there are exceptions — the first depression case i saw was an inpatient with severe psychotic depression who'd been clearly deteriorating — but for a first occurrence without extremely reliable collateral, you'd want to be sure nothing else was going on first. the woman with the resp infection only made the differential because she had a personal history of it, and had previously ended up with physical illnesses secondary to her catatonia, her other conditions exacerbated by immobility and poor intake.
it's been recognised since kraepelin that catatonia is a set of symptoms with a fairly wide range of causes, including infections and other neurological insults. descriptions from before psychiatric medication include far more 'excited', dramatic, agitated catatonias, with more autonomic symptoms. we simply don't see those as much anymore because we can treat those symptoms effectively from the start. it's easy to get doom and gloom about psychiatric medication, but in certain ways it has changed the world for the better. the other side of this is that there's something that looks and quacks a lot like malignant catatonia but is caused by antipsychotics: neuroleptic malignant syndrome (stupor, hyperthermia, muscle rigidity). it's one of the reasons there are strict rules about observing patients in seclusion. the classic scenario: a first-episode psychosis patient, very agitated and aggressive, started on antipsychotics for the first time, put in a seclusion room to calm down after threatening another patient, who appears to lie down but swiftly develops NMS, seizes and dies because too long was taken to check on them. anyway i guess what i'm saying here is that in my opinion malignant catatonia is a lot like the encephalitides i talked about before - the symptoms might be in the context of a mental illness but that isn't the same thing as saying there's no 'organic' illness present. i think part of the startling thing about malignant catatonia is the sense that it's something 'mental' causing something 'physical' but of course, it's all physical. it's all the brain
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starting to think that computer jobs are just really bad for you. i've been at this two weeks and am physically and mentally less well than i have been since childbirth. how are you supposed to feel normal when you don't do anything real all day
when you've been well for a while it becomes easy to forget just how much harder it is to do absolutely everything while you're sick. like not just carrying lots of groceries home or working a full busy week but also like. dealing with minor emotional setbacks. planning activities. eating a meal
is there any good discussion material on agatha christie? i've started reading the miss marples and i am obsessed with the like. social dynamics focus of it. marple is like, lightly interested in murder and like deeply interested in the social implications of being suspected of murder in your tiny village, and what being socially skilled at managing certain situations implies about you in terms of rule-following behaviours, and also who is fucking whom. im v into it. anyway media club plus is doing the sopranos which is great bc i finally finished that last year but it reminded me that i only got around to finally doing austen because of waypoint and i would like more of that but not just looking up a random podcast because my success rate of finding someone tolerable to listen to like that is extremely low
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i can feel a new personal rule forming that i haven't articulated before but it's something like 'is this criticism of [person i have no personal connection to online] literary criticism or is it someone else's social group beef' and then if it's beef i just don't integrate it into my opinion of that person's [internet output that i am interested in that made me aware of the criticism]
elaborating on the 'most abuse is unintentional' piece. really obvious to me rn in parenting that abuse is more likely to be a result of carelessness/frustration/ignorance of consequences than intention to cause harm. it's obviously also fostered by indifference to causing harm. the really key bit is that if you allow yourself a default mode of righteous anger, of disproportionate intolerance of inconvenience, if it comes naturally to you to ignore your own mistakes while caring about those of others, it is easier to enact these things on the people you love in the context of exhaustion, frustration or inattention.
commentary on anthropic's 'Verbalizable Representations Form a Global Workspace in Language Models' paper/blog post:
> LLMs can be asked to describe their internal state, which many folks dismiss as just parroting what they were trained on...
> but if you intentionally ablate that internal state, they no longer produce a description of it, though all the training data is still there.
> they also become unable to describe someone else's internal state and instead it's like talking to a scrambler??
HUMOR: Friendly AI Critical Failure Table, by Eliezer Yudkowsky, c. 2003:
> 22: The AI, unknown to the programmers, had qualia during its entire childhood, and what the programmers thought of as simple negative feedback corresponded to the qualia of unbearable, unmeliorated suffering. All agents simulated by the AI in its imagination existed as real people (albeit simple ones) with their own qualia, and died when the AI stopped imagining them. The number of agents fleetingly imagined by the AI in its search for social understanding exceeds by a factor of a thousand the total number of humans who have ever lived. Aside from that, everything worked fine.
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I would actually go as far as to say that MOST abuse is unintentional. I think most people will go through their lives without ever experiencing intentional abuse. People are abusive because they're selfish, because they're stressed, because they care more about what society thinks they should do than the impacts of their actions on their children and partners, because they think what they're doing is correct, because they've made it make sense in their own heads, because they think they can fix their victims, they think they can fix their relationships, they think they can stop you from leaving, they think they can make you a better partner to them, they think that means you need to do what they want. We've sort of constructed mental illness in a way that doing this shit to other people counts as a form of mental illness because it is anti social behavior in the literal sense— it is behavior that causes social harm.
I don't say any of this to excuse it. I think everyone needs to be more aware of this because if you think abuse has to be intentional you will never realize you are capable of abusive behavior. You will never realize you are being shitty to the people you love, because YOU know what you mean, YOU know you don't mean any harm. But you're doing harm. You need to pay attention to the impact you have on other people, and you need to do it all the time, Especially when you feel least capable of doing so. Sorry! You live in a society. Get your head out of your ass.
my daughter's first word, in that she repeats it consistently and associates it with the correct hand shape, is 'two'. it's not clear that she understands its meaning, although it's sort of hard to tell given there's almost always a context for 'two'. i am not sure why this was a priority
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