Borderline personality disorder (BPD) is defined by instability in relationships, emotion, and sense of self (APA, 2013). Dialectical behavior therapy (DBT) is often recommended to those who suffer from BPD. While DBT offers a very helpful set of tools for those who struggle with BPD, significant symptoms of the disorder often persist even when these tools are fully embraced and used effectively. Understanding the limitations of DBT in treating BPD and the need for these techniques to be integrated with other approaches to treatment will lead to the optimization of treatment outcomes.

Many individuals diagnosed with BPD are referred for DBT in outpatient and inpatient settings. These individuals often have great hope that this set of behavioral techniques will bring them relief from the suffering associated with the instability they suffer daily. Many find that even though the DBT techniques are helpful in many ways, they do not stop their suffering. This often leads to an abandonment of the DBT techniques and a sense of hopelessness regarding the efficacy of treatment.

What DBT Does Well

The target of behavior therapy is to change behavior, and this is what DBT is best at. Individuals with symptoms of BPD who use DBT effectively generally experience more stable behavior. DBT targets impulsivity and offers tools for making more thoughtful, or mindful, decisions that are generally associated with better outcomes.

This is likely to reduce the angry lashing out at others that is very common with this disorder. The reduction in lashing out at others increases the stability of relationships and improves social functioning.

DBT also offers benefits by teaching methods of coping with strong emotions, especially anger. This decreases emotional dysregulation, including anxiety, and offers a greater sense of self-control. This is likely to increase confidence and improve social functioning.

DBT is most helpful in stabilizing behavior and significantly helpful in stabilizing some emotional dysregulation. For many individuals with symptoms of BPD, this is not sufficiently motivating to sustain optimal use of these tools, and the benefit can wane or disappear altogether.

Where DBT Needs Supplementation

Behavior therapy does not target the integration of an unstable sense of self. Many individuals with symptoms of BPD experience frequent and painful shifts in their perception of themselves. For example, perceived slights by others can result in feelings of worthlessness and associated impulsive or even reckless behavior. Related to their tendency to view others in black-and-white terms, they also view themselves in either ideal terms or devalued terms. Feelings of worthlessness interfere with the optimal use of DBT tools because they are emotionally overstimulating and overwhelm the cognitive mediation of emotion that DBT offers. This is accentuated by the emotional dysregulation that many individuals with symptoms of BPD suffer. Further adding to the inhibition of the use of DBT skills is the loss of motivation toward self-help/self-improvement that comes with self-devaluation.

Self-Integration

Stabilization of the self starts with self-definition. This involves taking a personal inventory of which aspects of character are most important to you. Examples of desirable character traits include kindness, thoughtfulness, genuineness, generosity, gentleness, etc. Once having identified character traits that are desirable, you must exercise every opportunity to express these characteristics. For example, if you aspire to be a kind person, then you must be kind in all circumstances, not just when things are in your favor or you feel like it. You must be kind to people who you don’t like and to people who might not be kind to you. This does not mean that you sacrifice the need to protect yourself—just do so with kindness.

Stabilization requires consistency in behavior and attitude.

Source: John Hain/Pixabay

Corey’s Story*

Corey is a 48-year-old single person. She sees herself as a good person who is kind, empathic, honest, and highly ethical. She struggles every day to feel well. Dark moods always hover around her. When things don’t go her way, she has very dark thoughts about hurting herself and getting even with others that have hurt her. When things do go her way, she feels better, but things don’t seem real. It always feels like something bad will happen. She took two different courses of DBT and uses the techniques when she is not angry or upset, but she does not feel well most of the time.

“Each morning I wake up wondering what the day will bring and how I can feel OK. I don’t know what I am looking for but usually within the first hour, something goes wrong and kills the day. It could be anything: a bad dream, the way someone looks at me in the elevator, or a line at Starbucks, and I feel worthless. It seems like the sun shines on everyone but me.”

Despite seeing herself as kind and empathic, she tended to respond aggressively to circumstances that displease her. When she does not like the way someone looks at her, she calls them out: “What are you looking at?” When the line at Starbucks is long, she cuts the line by claiming that she was in the line but had to handle an emergency before she could order her beverage. These persistent departures from her view of herself as kind and empathic leave her feeling unstable and empty.

Finally, Corey committed to herself that she would be kind, empathic, honest, and ethical in all aspects of her life. She learned to use her DBT skills to respond differently in uncomfortable social situations. When others look at her on elevators, she still feels like calling them out, but instead smiles at them and wishes them a nice day. She welcomes this as an opportunity to strengthen her good qualities and no longer feels victimized by a stranger’s wandering eye. She no longer cuts the line at Starbucks, although she feels the desire to do so. She rather uses this as an opportunity to express her commitment to ethics and an opportunity for self-improvement.

Consistent utilization of DBT skills to inhibit impulses in conjunction with directed self-definition will gradually increase her sense of stability as she gets better feedback from others (they don’t get annoyed with her), which then starts the process of stabilizing her mood.

*Case study is a composite from clinical practice.

To find a therapist, please visit the Psychology Today Therapy Directory.

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As human beings, we traverse many emotions, thoughts, and perceptions, each contributing to our unique experiences. Occasionally, one may encounter periods of disconnect, where reality feels elusive, and the world appears distant and unfamiliar. These transient moments of detachment can be perplexing, leaving individuals to wonder if they are the only ones experiencing such sensations. 

For some, this can also be much more than just an experience. It can also denote a mental health disorder named depersonalization disorder. 

What is Depersonalization Disorder?

Depersonalization disorder, often referred to as DPD, is a complex and less commonly known mental health condition categorized under dissociative disorders. It is characterised by a persistent feeling of detachment from oneself as if one is observing their own thoughts, emotions, and actions from a distance. This sense of unreality can extend to the external world, leading to a secondary phenomenon known as derealization, where the surroundings feel strange, dreamlike, or artificial.

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What are the symptoms of depersonalization disorder?

The symptoms of depersonalization disorder can vary from person to person, but common experiences include:

Persistent Feelings of Detachment

The hallmark symptom of DPD is a persistent sense of detachment from oneself. Individuals may describe feeling like an outside observer of their thoughts, emotions, and actions. A study published in the journal “Psychiatry Research” (Sierra & Berrios, 2000) found that individuals with DPD experienced reduced self-awareness and felt detached from their own identity and physical self.  

Emotional Numbness and Reduced Affect

People with DPD often report feeling emotionally numb, as if their emotions are muted or distant. A study by Michal et al. (2013) published in the “Journal of Affective Disorders” found that individuals with DPD showed reduced emotional reactivity compared to healthy controls, supporting the notion of emotional detachment in the disorder.

Altered Perception of Reality (Derealization)

DPD is frequently accompanied by derealization, where the external world appears strange, dream-like, or lacking in depth. A study published in the “Journal of Trauma & Dissociation” (Simeon, Guralnik, Knutelska, Hollander, & Schmeidler, 2001) found that derealization was a common feature in individuals with DPD. 

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Time Distortion

Individuals with DPD may experience an altered perception of time. Time may feel distorted, elongated, or compressed. A study published in the “Journal of Anxiety Disorders” (Hunter et al., 2004) reported that individuals with DPD showed altered time perception during specific tasks.

Depersonalization and Derealization Frequency

Studies have indicated that individuals with DPD may experience depersonalization and derealization episodes frequently, often daily or even continuously for extended periods (Simeon et al., 2001). 

Cognitive Impairments

Some studies have suggested that individuals with DPD may experience cognitive impairments, such as difficulties with attention, concentration, and memory (Hunter et al., 2004).

It Is associated with other mental disorders

Depersonalization disorder is frequently associated with other mental health conditions, such as anxiety disorders, mood disorders, and post-traumatic stress disorder (PTSD). A study published in “The Journal of Clinical Psychiatry” (Simeon, 2004) found high rates of comorbid anxiety disorders in individuals with DPD.

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What causes Depersonalization Disorder?

Here are some potential factors that have been hypothesized to contribute to the development of DPD:

Due to stress and trauma

High levels of stress, trauma, or adverse life events are often associated with the onset or exacerbation of depersonalization disorder. Traumatic experiences, such as physical or emotional abuse, accidents, or witnessing violence, can trigger dissociative symptoms, including depersonalization, as a coping mechanism to detach from overwhelming emotions. A study published in the “Journal of Nervous and Mental Disease” (Lipsanen et al., 2003) found that childhood trauma was associated with an increased risk of depersonalization symptoms.

Due to anxiety and depression

Depersonalization disorder frequently co-occurs with anxiety disorders and depression. There is evidence suggesting that depersonalization can be a defence mechanism in response to overwhelming anxiety or depression, allowing individuals to distance themselves from distressing emotions. A study published in the “Journal of Anxiety Disorders” (Hunter et al., 2004) reported a high prevalence of anxiety and depressive disorders in individuals with DPD.

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Neurobiological Factors

Some research has suggested that alterations in brain function and neurotransmitter systems may be involved in the development of DPD. Studies using functional magnetic resonance imaging (fMRI) have shown differences in brain activity patterns in individuals with DPD compared to healthy controls (Phillips et al., 2001).  

Psychological Vulnerability

Individuals with a history of emotional dysregulation, difficulties in emotional processing, or problems with self-identity may be more susceptible to experiencing depersonalization symptoms. 

Substance Use

Depersonalization episodes can be triggered or exacerbated by the use of certain substances, particularly hallucinogenic drugs or dissociative anaesthetics. Substance-induced depersonalization is generally temporary but can be distressing during its duration.

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What are the treatments for Depersonalization Disorder?

Here are some treatment options commonly used for Depersonalization Disorder:

Cognitive-Behavioural Therapy (CBT)

CBT is considered the most effective psychotherapy for depersonalization disorder. It aims to help individuals recognize and challenge negative thought patterns and beliefs related to depersonalization. CBT can also teach coping strategies to manage anxiety and stress associated with DPD. A study published in the “Journal of Clinical Psychiatry” (Simeon et al., 2011) demonstrated the effectiveness of CBT in reducing depersonalization symptoms. 

Exposure Therapy

In some cases, exposure therapy may be used to gradually confront triggers or situations that elicit depersonalization episodes. This approach helps individuals desensitize to their triggers and reduce the avoidance of anxiety-provoking situations. 

Mindfulness-Based Therapy

Mindfulness techniques, such as mindfulness-based cognitive therapy (MBCT), can help individuals stay present and focused, reducing ruminations about depersonalization experiences.

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Self-Help Techniques

Self-help techniques, such as grounding exercises and relaxation techniques, can help individuals stay connected to the present moment and manage feelings of detachment. Engaging in activities that promote a sense of self-awareness and grounding can be beneficial.

Avoidance of Triggers

Identifying and avoiding triggers that provoke depersonalization episodes can be helpful. This may include avoiding excessive stress, sleep deprivation, or the use of substances that may exacerbate symptoms.

Psychoeducation

Psychoeducation about depersonalization disorder can help individuals understand their symptoms and normalize their experiences. Education about the disorder can also reduce anxiety and provide a sense of validation.  

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Treatment outcomes may vary, and some individuals may experience significant improvement with appropriate interventions. 

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This story discusses suicide. If you or someone you know is in crisis, call or text 988 to reach the Suicide and Crisis Lifeline. You can also text HOME to 741741 or visit SpeakingOfSuicide.com/resources for additional resources.

After a successful career that spanned multiple decades, Sinéad O’Connor has passed away at the age of 56.

News of the musician’s death broke on Wednesday, but an official cause of death has not been released yet.

O’Connor’s family shared the following statement with The BBC and Irish broadcaster RTE: “It is with great sadness that we announce the passing of our beloved Sinéad. Her family and friends are devastated and have requested privacy at this very difficult time.”

Sinead O’Connor, 1992 (Crispin Rodwell / Shutterstock)

Throughout her career, the “Nothing Compares 2 U” singer was open about the various health struggles she experienced, many of which were related to mental health.

O’Connor had bipolar disorder

In 2007, the star spoke about her bipolar disorder during an appearance on “The Oprah Winfrey Show” and said she experienced thoughts of suicide and overwhelming fear before her diagnosis nearly four years beforehand.

“It’s like being a bucket with holes in it. Just leaking tears from every pore,” she said.

At the time, O’Connor was taking mood stabilizing and antidepressant medications. She told Winfrey they helped, but added that she was a “work in progress.”

“I’m not going to sit here and claim that I’m kind of perfect or anything. Anything is an improvement when you’ve been in desolation … to be out of that place is brilliant. It doesn’t mean you don’t have lumps and bumps,” she said.

Over the years, O’Connor was forthcoming about the effect her condition had on her career. In 2012, she canceled her tour, explaining that she was “very unwell due to bipolar disorder.” The same year, she sought treatment for depression.

In 2017, the Irish singer spoke openly about her mental health and suicidal thoughts in an emotional video, claiming that her family had abandoned her.

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“Why are we alone?” she said. “People who suffer from mental illness are the most vulnerable people on Earth. You’ve got to take care of us. We’re not like everybody.”

The star also encouraged her fans to check in on anyone in their lives who might be struggling.

“If you have a family member that suffers from mental illness, care for them, tenderness, love, care for them. Visit them in the hospital, don’t dump them in the hospital and bugger off,” she said.

O’Connor was hospitalized last year after her son died

In January 2022, O’Connor was hospitalized just days after her 17-year-old son Shane died. As reported by CNN at the time, the singer sought medical care after posting a series of alarming Twitter posts claiming that she planned to die by suicide.

“I’ve decided to follow my son. There is no point living without him. Everything I touch, I ruin. I only stayed for him. And now he’s gone,” O’Connor shared via an unverified Twitter account that was linked to her account.

Later on, the star added to her tweets and apologized, admitting that she “shouldn’t have said that.”

“I am with cops now on way to hospital. I’m sorry I upset everyone,” she wrote. “I am lost without my kid and I hate myself. Hospital will help a while. But I’m going to find Shane. This is just a delay.”

O’Connor experienced PTSD from childhood abuse

O’Connor’s memoir, “Rememberings,” published in 2021, dives into the physical abuse she endured from her mother as a child.

“I won the prize in kindergarten for being able to curl up into the smallest ball, but my teacher never knew why I could do it so well,” she wrote in the book.

In a 2021 interview with the New York Times, O’Connor offered the following insight into her experience as a child.

“Child abuse is an identity crisis and fame is an identity crisis, so I went straight from one identity crisis into another,” she said.

In an interview with TODAY’s Carson Daly in 2021, O’Connor explained how she still lived with the trauma of her childhood.

“I suffer from a condition called complex post-traumatic stress disorder, from things that I went through growing up,” she said.

While talking with Carson, O’Connor recalled an iconic moment when she tore up a photo of Pope John Paul II in 1992 while appearing on “Saturday Night Live.” The photo belonged to the star’s mother, and she explained that it was a therapeutic experience since she had been so abusive during her childhood.

“It was a way of ripping her up, as well, I guess,” she said.

O’Connor spoke out about the challenges she faced following a hysterectomy

In 2015, O’Connor underwent a radical hysterectomy in an attempt to manage her endometriosis. While speaking with People in 2021, the star said the procedure and the subsequent menopause that came afterwards was very challenging to experience.

“When I had the surgery, I was terribly triggered,” she said.

The star visited several psychiatric facilities in the years following the procedure, and she opened up to People about her mental health struggles.

“You can never predict what might trigger the (PTSD). I describe myself as a rescue dog: I’m fine until you put me in a situation that even slightly smells like any of the trauma I went through, then I flip my lid,” she said. “I manage very well because I’ve been taught brilliant skills. There was a lot of therapy. It’s about focusing on the things that bring you peace as opposed to what makes you feel unstable.”

This article was originally published on TODAY.com

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Data analysis for the three stakeholder groups revealed a variety of barriers, facilitators, and needs in the healthcare of autistic adults in Germany, focusing on medical and psychotherapeutic care. In addition, recommendations for improving healthcare were identified. This resulted into six group-overarching themes with several subthemes that are outlined below: (1) lack of knowledge about autism, (2) a need for increased participation/ involvement, (3) consideration of autism-specific needs in treatment, (4) lack of services, (5) limited access to services, (6) improvement of stakeholder collaboration (see Table 2). The majority of themes and subthemes were reported equally across the three stakeholder groups. Differences are reported within the description of the themes.

Table 2 Overview of themes and subthemes

Although interviews and focus groups were structured to assess barriers and needs per level (individual, professional, structural) across groups, the resulting themes were not selective to a single level but overarching in nature and were not perfectly equal across groups. Figure 1 provides a simplified visualization of the main findings, clustering the themes (shown in circles) by relevant stakeholder group (x-axis) and respective level (y-axis).

Fig. 1

Simplified visualization of themes related to level and group of stakeholders

The following sections give a detailed overview about the separate themes. Participant identification numbers are used below to indicate direct quotations in accordance with the consolidated criteria for reporting qualitative research (COREQ) [48].

Lack of knowledge about autism

The theme “lack of knowledge about autism” in adulthood was mentioned by all participants as an important barrier in healthcare of autistic adults at all three levels (individual, professional and structural; see Fig. 1). For this theme, several subthemes were identified in the data: (i) stigma about ASD in society, (ii) lack of knowledge among healthcare providers, (iii) research about ASD in adulthood and in women.

First, (i) stigma about ASD in the society and “that public and media often have a very distorted picture of what autism actually is, and especially the area of high-functioningFootnote 2 is extremely difficult” (autistic adult; ibew6). According to participants, the portrayal of autism in the media has a negative impact on the healthcare of autistic adults because of misconceptions developed by stakeholders in the healthcare system.

Second, all stakeholder groups saw (ii) a lack of expertise among healthcare providers in adult autism as another major barrier. This “cluelessness” (autistic adult; ibew10) about autism would affect all professions in the healthcare system, e.g., physicians, psychotherapists, occupational therapists, and assistance providers. For example, autistic adults reported to hesitate sharing their diagnosis with healthcare providers because they feared discrimination. Participants considered the lack of education and training programs about autism to be the primary reason for this. It was “not easy at all” (healthcare provider; B1) to gain expertise in this field because healthcare providers “do not come in contact with any autism spectrum disorder treatment or even diagnostic theoretical idea, such as with anxiety disorder, personality disorder, etc.” (healthcare provider; B1). A psychotherapist described:

From my experience in advanced training in behavioral therapy, I can say that I certainly did not gain my knowledge about autism from advanced training in psychotherapy, so after six hundred hours of theory or something, I have already stopped counting and I have not had a single autism seminar, not a single one. […] I haven’t had a single teaching unit in my whole education on this, which is from my current perspective, absolutely devastating […]. (B4)

Participants described that healthcare providers frequently refused treatment based on lack of knowledge. For example, responses included “oh, you are autistic, no, I don’t have any experience with that, better contact someone else” (autistic adult; ibew11). Another autistic adult reported that “with Asperger’s and Attention deficit hyperactivity disorder [ADHD] in particular, I found that I had to make a lot of phone calls to find a therapist. I think nineteen out of twenty said, ‘we have no idea about that’” (ibew15). Autistic adults reported experiences like this and the subsequent burden. In addition, knowledge gaps were suggested as a reason for the high rate of misdiagnosis and resulting mistreatment of autistic adults. This was a prominent theme across all three stakeholder groups, but autistic adults and family/partners in particular reported stories of misdiagnosis, years of mistreatment, and resulting negative impact on a personal and emotional level. A man described his autistic wife’s diagnostic path:

Third, all three groups emphasized the need of further (iii) research on ASD in adulthood and in women. Participants demanded better screening and diagnostic tools for adults in general and especially for women, as it would allow sooner diagnoses and “filtering of waiting lists” (healthcare provider; B2). Furthermore, “girls fall through the cracks” (relative, I5) in mental healthcare because characterization and manifestations of symptoms often differ in women and they tend to be more adapted than male autistic persons:

In addition, healthcare providers identified the lack of valid measurements for severity assessment to be another field to be researched: “severity is poorly operationalized and therefore it is not possible to say in a very general way what the individual person needs in terms of support” (healthcare provider, B2).

A need for increased participation/ involvement

The theme “a need for increased participation/ involvement” refers to both the autistic adults and the relatives which should become more involved and participate in different areas of the healthcare system, according to most participants. This theme is classified at both the individual and professional level (see Fig. 1).

On the one hand, autistic adults and relatives postulated to become better involved in examinations and treatment in general. They demanded to be directly involved in decisions and to be informed about fundamental issues, such as medication, diagnoses and interventions and recommended treatment to be as transparent as possible.

Moreover, autistic adults recommended to systematically involve autistic adults into knowledge dissemination and research on ASD:

What is very important to me is bringing education about autism into the broad field. […] This is about medicine, care, and that must be brought into the broad area, and definitely in participation with autistic people. Only from the view inside it can be explained what autism is. (Autistic adult; ibew11)

In addition, all groups highlighted that “it is important trying to have a stronger exchange with family members” (autistic adult; ibew8). Support of relatives and partners, e.g., in planning and/ or accompanying appointments or activities of daily living was essential according to the participants. Without this support, many autistic adults would not be able to participate in the mental healthcare system. Nevertheless, they acknowledged barriers in involvement of relatives and demanded to “take a supporting person with you without being ridiculed” (autistic adult; ibew 2). Healthcare providers described that relatives also have a great impact on diagnostics and therapy, but are rarely involved at the moment:

And the family is not involved, it is not even implemented by the insurance company. There are always a few sessions with relatives, but the family is not really involved. And I also find that totally difficult when adults from the spectrum then end up in such an ordinary behavioral therapy. (Healthcare provider; T4)

Consideration of autism-specific needs in treatment

This theme describes challenges in accessing or participating healthcare services due to specific characteristics of autism itself. It addresses all relevant levels and was mentioned by all of the three stakeholder groups but was predominantly represented in the group of autistic adults. Following subthemes were identified in the data: (i) difficulties in executive functions and self-management, (ii) need for consistency and transparency, (iii) autism-specific sensory sensitivities, (iv) difficulties in verbal and nonverbal communication.

Participants reported (i) difficulties in executive functions and self-management on healthcare seeking behaviors affecting access to healthcare services, for example, when “completing very simple paperwork” (healthcare provider; B4), adhering to medication, navigating in the healthcare system, or planning/ attending appointments:

So, something like making an appointment, but also attending the appointment if I don’t know the place yet. That means estimating how long it will take me to get there, even with public transportation, because I don’t drive a car. So to organize something like that. Or, in general, not to take on too much for one day and to estimate how long I have to plan for this appointment. (Autistic adult; ibew2)

Furthermore, the (ii) need for consistency and transparency in treatment and healthcare settings was emphasized. “New situations are difficult” (autistic adult; ibew 14), including changes in staff, appointments or environment. An autistic adult described:

The biggest challenge is when I go to a new physician where I don’t know the environment, the practice, everything. To get used to it is a big challenge for me, for which there is not really a solution apart from doing it. (Autistic adult, ibew5)

Autistic adults said that it would be difficult not to be involved in treatment and not to obtain “background information”, for example about physical examinations (autistic adult; ibew11). Some said it was helpful if providers “explained [treatment] step by step”, if they involved in medication adjustments, and informed about diagnoses.

Most participants highlighted the impact of (iii) autism-specific sensory sensitivities on seeking or receiving mental healthcare for autistic adults. Healthcare facilities would cause stress and overload because they are not tailored to autistic peoples’ needs. For example, it was described that “physical contact is unpleasant” (autistic adult; ibew8), “smells can be very disturbing and irritating” (autistic adult; ibew4), “noises are very unpleasant and hardly bearable” (autistic adult; ibew2), “sensitivity to light leads to distraction” (autistic adult; ibew4), and overall “chaos reigns in the practices” (autistic adult; ibew 14). In addition, difficulties in body awareness and pain perception were mentioned:

On the one hand, being very sensitive during examinations and being unable to handle and endure a lot of situations, but on the other hand, not always noticing when there is pain or symptoms. In any case, these are also major barriers. (Autistic adult; ibew2)

Autism-related (iv) difficulties in verbal and nonverbal communication with medical staff also were a prominent topic, such as difficulties in making appointments by phone or miscommunications with healthcare providers during treatment or examinations. Autistic adults reported to struggle in following spoken instructions or answering open-ended questions. For example, an autistic participant described the following interaction with a physician:

“‘Where exactly does it hurt?’” – I always feel very stupid when I can’t answer that. It would be better to ask, “Is this a pain in the whole abdomen or specifically in one spot?“ Then it would be easier for me to understand that it may just hurt in the whole abdomen and that this is okay as a description. (Autistic adult; ibew12)

In addition, autistic participants described problems in communicating symptoms because “they like to be on the matter level and tend to communicate information and the emotional stuff doesn’t get carried along” (autistic adult; ibew3). This would cause that “many symptoms are not even recognized properly or are dismissed as incidental […]” (autistic adult; ibew4). Autistic adults also described difficulties with typically very brief clinical appointments: “I feel rushed under time pressure and then I forget a lot of what I actually wanted to discuss. The appointments are often too short” (autistic adult, ibew9).

As mentioned before, this theme was predominately represented in the group of autistic adults. In general, they emphasized individualization of treatment of autistic adults as a facilitating factor to cross barriers in these autism-related difficulties.

Lack of services

All stakeholder groups commonly agreed upon a lack of mental healthcare services for adults with autism: “The whole system is not intended for autistic adults. It seems as autism is seen as a children’s disease […]” (autistic adult; ibew6). Especially “the high-functioning are not acknowledged or are not seen as a relevant group” (autistic adult; ibew6). Following subthemes were identified, referring to the professional and structural level: (i) transition, (ii) diagnostic services, (iii) psychotherapeutic services, (iv) inpatient services, (v) low-threshold services, (vi) assistance services.

Participants criticized the lack of adequate support systems for (i) transition from youth into adulthood. Mental healthcare would be provided during childhood and adolescence, but collapses once autistic individuals reach adulthood. An autistic adult reported:

The main problem is that the areas are separated from each other. The area of child and adolescent psychiatry and the area of adult psychiatry, not only in psychiatry, but also in medical care. Then you have to go from one to the other and are and treated completely differently. (Autistic adult, ibew2)

Participants demanded transitioning being adjusted in regard to the development of the individual rather than to the age and to “install a support system at least temporarily” (healthcare provider; B4).

Another prominent topic, particularly discussed by healthcare providers, was limited (ii) diagnostic services for adults seeking an ASD diagnosis as expressed by long waiting times for obtaining diagnostic assessment:

In [city name], healthcare is, I would say horrible, waiting times at the [name of hospital] for the autism consultation two and a half years, only a handful psychiatrists in practice, completely overloaded and waiting times about three years. (Healthcare provider; B2)

This was explained by a limited amount and limited capacity of specialized services: “there are not enough diagnostic and therapeutic centers at all” (healthcare provider; T5), especially in rural areas. Furthermore, it was expressed that psychometrically valid and specific screening and diagnostic instruments for autistic adults, also suitable for use in primary care, need to be developed which could shorten or optimize the diagnostic process.

After ASD diagnosis, participants reported “being left completely alone” (autistic adult; ibew13) with insufficient availability of subsequent (iii) psychotherapeutic services. Participants also described limited and scattered specialized services (“in the country side, very very few therapy options for older autistics or Asperger’s autistics […]. I would have to drive 100 kilometers to get anything, any help at all.“ (relative; I4)). Autistic adults and relatives remarked to put up with long-distance therapy because there were no services close to their residence or waiting lists were at maximum capacity. Reported waiting times for psychotherapy ranged from nine months to one and a half years. Even when successfully accessed therapy, a few autistic adults highlighted their need for individually tailored support and personalized treatment: “The needs are very individual. And even in the high-functioning area, if you compare two people, then the needs or the level of suffering, etc. and the living situation might be very different (healthcare provider; B3).”

With respect to (iv) inpatient services, including psychiatric or rehabilitation services, all stakeholder groups agreed upon the need for increased specialized and personalized services. “In inpatient healthcare of people with autism spectrum disorders, […] there are very, very few offers” (healthcare provider; B2), and “shared rooms in hospital are just not acceptable. I think if you are autistic, you should have the opportunity, at least if it is possible, to get a single room” (relative; I2).

Furthermore, all groups of stakeholders criticized a lack of (v) low-threshold services, suggesting, for example, to expand self-help groups for autistic adults as well as for relatives:

Very little attention is paid to the fact that not only the affected person is impacted, but also a large number of people around them. I think it would be very, very good and very important if more counselling were created, for example get relatives informed or they can also experience support for themselves. (Autistic adult; ibew15)

Relatives/ partners described stress and burden due to the support of the autistic relative. Therefore, they “would really like to have support also as a relative. That you are taken by the hand in order to understand conflicts better, to accept peculiarities better and to spend a good and stress-free life together with the affected person” (relative; I2).

Autistic adults highlighted the need for further low-threshold services, such as music, sports, or occupational therapy, specialized for autistic adults or low-threshold crisis counselling: “there is only one telephone emergency service for autistic people in Germany and that is a voluntary one. And that’s also relatively small given such a high suicide prevalence” (healthcare provider; T3). Counselling services for different purposes were mentioned. Healthcare providers described the need especially for social therapeutic services in particular: “because often it’s not about psychotherapy or processing the experiences from the past, but supporting, in order to somehow cope with the daily challenges, for Asperger’s, […] with the social challenges” (healthcare provider; B2). The need for peer counseling and information about existing services was also emphasized. Lastly, the lack of services for those who are not able to get manifest therapy or are waiting for it was expressed:

I think a larger network of counselling centers would be helpful, because I think that many affected people, many relatives experience greater barriers finding information at a clinic, a therapy center, than going to a counselling center or to a regulars’ table and seeking advice and exchange there. So, I think that would be a practical way to facilitate initial contact. (Autistic adult; ibew5)

Furthermore, participants across all groups highlighted the lack of (vi) assistance services for autistic adults without ID “because autism doesn’t mean therapy will be done and then everything will be okay again” (relative; T6). It was emphasized that case management (i.e. services to provide adequate healthcare for autistic adults according to their individual needs) needs to be implemented to relieve the burden on autistic adults, but also on relatives who often provide care and assistance. An autistic adult responded to the question how relatives and partners could be supported: “others who provide required assistance. In other words, assistance for autistic people across the whole lifespan. In my opinion, even a high-functioning autistic person like me needs some kind of lifelong assistance service” (autistic adult; ibew 11).

Limited access to services

Not only the lack of services was described, but also barriers in accessing the available services were highlighted in most interviews and focus groups. Two subthemes were identified in the data, which are loading on the professional and structural level: (i) lack of transparency about healthcare services, (ii) funding.

On the one hand, the (i) lack of transparency about healthcare services was described. Neither autistic adults nor relatives or healthcare providers were fully informed about available services. A healthcare provider described: “That’s the problem, caregivers don’t have an overview of available services, including myself. It’s not easy to find one’s way in this network, but that’s actually the most important thing” (healthcare provider; B1). For example, patients often do not receive adequate care after diagnosis and have to obtain information on their own or with the support of relatives. Those who found services reported to have problems with the complex application process that could not be managed without external support. Healthcare providers reported regularly assisting autistic people with application forms, even though they are not responsible to provide assistance services. Furthermore, autistic adults reported that, based on the division of healthcare services among different social systems, navigating the healthcare system would be difficult:

Access to services is so massively divided among the various social systems by law that it is incredibly difficult for me to even find out who is responsible for me and from whom I have to apply for what. Yes, the fact that the individual social systems are always trying to pass the buck to each other is also not conducive. (Autistic adult; ibew4)

In relation to this, it was criticized that (ii) funding of autism therapy is not provided by health insurance. An autistic adult shared her opinion on this topic:

Because at the moment autism therapy and psychotherapy are separated from each other. And a classic autism therapy is also not funded by the health insurance, because with health insurance financing, this healing aspect is always included, which is a wrong approach, in my opinion. (Autistic adult; ibew2)

Regular psychotherapy, on the other hand, is not funded by health insurance when only ASD is diagnosed. To be approved for psychotherapy, a mental disorder such as depression or anxiety disorder must be present. A healthcare provider mentioned “almost three-quarters have a relevant co-morbidity, so the largest group finds access” (healthcare provider; T5) to psychotherapeutic services, but it would be a problem anyway. In addition, it was criticized that statutory health insurance companies do not enable rapid support in case of crisis situations.

Improvement of stakeholder collaboration

This theme includes the collaboration of relevant stakeholders in the healthcare of autistic adults on a professional and structural level, which were mentioned to be healthcare providers from various professions. Primarily healthcare providers, but also few autistic adults emphasized the need for collaboration between different groups of professions and “multi-professional teams work[ing] with affected people” (autistic adult, ibew7). Many participants described that this could allow for simplification of healthcare processes, as all providers can be on the same level of knowledge about the patient – as long as the autistic adult consents. Some participants mentioned that collaboration would also facilitate the transition between pediatric and adult healthcare providers:

That the new doctor can also call the old doctor if there are any questions until the autistic person is really back at home with the new one, where he or she is again in safe hands during this transition phase. (Autistic adult; ibew11)

Few healthcare providers also highlighted that exchange with other providers also contributes to increase knowledge about autism: “there should actually be more networking and more exchange of experiences” (healthcare provider; B2).

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A few weeks ago, Pasadena Humane rescued 38 cats and kittens from a cramped trailer. Many of these cats have now recovered and are ready to find new homes. For more information, pasadenahumane.org/adopt. (Photos courtesy of Pasadena Humane)

Hoarding cases are some of the most challenging situations we encounter at Pasadena Humane.

Imagine entering a home with an overpowering smell of ammonia and seeing urine, feces and moldy pet food cans covering the floor.

Then, imagine discovering dozens of suffering animals, with an owner who has no insight into the danger of the situation for the animals or themselves.

Animal hoarding is animal cruelty, but it is also a mental-health disorder. That’s what makes it so complex to address.

The two most common forms of hoarding we deal with are: overwhelmed caregivers who start with a handful of unaltered pets that multiply, or “rescuers” who want to “save” animals and actively attempt to acquire more.

Many people who hoard animals are strongly attached and believe they are helping the animals, despite evidence to the contrary.

A few weeks ago, our team rescued 38 cats living in a small trailer. As you can imagine, the conditions inside were cramped and highly unsanitary.

Most adult cats were healthy, but many of the kittens were sick and emaciated. One kitten tested positive for a highly contagious and often deadly virus, necessitating a quarantine for the entire group once they reached the shelter.

I’m happy to report that most of the cats are now recovered and ready to find loving homes, although sadly, two kittens did not survive.

Unfortunately, more animals are at risk. Our team is actively working on multiple other suspected hoarding cases.

The most up-to-date Diagnostic and Statistical Manual of Mental Disorders defines animal hoarding as the accumulation of a large number of animals and a failure to provide minimal standards of nutrition, sanitation and veterinary care and to act on the deteriorating condition of the animals (including disease, starvation or death) and the environment (e.g., severe overcrowding, extremely unsanitary conditions).

Research indicates that people who hoard are most commonly women over the age of 60. Also, the most commonly hoarded animals are cats. Pasadena Humane’s experience is in line with these statistics.

In a hoarding situation, our primary goal is to gain the trust of the animals’ owner and attempt to get the owner to turn over the animals voluntarily. Working with the hoarder — rather than against them — is usually the best solution for the animals.

When the animals are voluntarily surrendered, they can quickly be made available for adoption. This avoids lengthy and costly legal proceedings which can prevent the animals from finding new homes for months or even years.

Research has also shown that involuntary seizures of the animals are both traumatic to the person who hoards them and ineffective in preventing hoarding in the long run due to a higher rate of recidivism.

Because recidivism is so common (even when animals are voluntarily surrendered), we attempt to maintain an ongoing relationship with hoarders to help keep the situation from spiraling out of control again. Without regular check-ins by our staff, the hoarder will most likely acquire more animals.

In addition to working to keep animals safe, we also try to work with the public health department and/or adult protective services to help the humans involved. Often, we see that toilets, showers and tubs are not in working order. Depression, isolation and other mental illness may also play a role.

For some cases, we work in conjunction with the police department to help us protect the animals involved. Many hoarders are not receptive to help and may even become violent toward our staff members.

If you suspect hoarding in your neighborhood, you can help. Contact Pasadena Humane or your local animal control agency. You can reach us at 626-792-7151.

Dia DuVernet is president and CEO of Pasadena Humane. pasadenahumane.org

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A Danish study involving over six million participants found that cannabis use disorder significantly increases the risk of developing depression and bipolar disorder. Despite the link, researchers stress that the study doesn’t conclusively prove that cannabis use causes these mental health conditions, advising caution in use and consideration in legalization debates.

A new study suggests that cannabis use disorder leads to an increased risk of developing bipolar disorder and depression.

Cannabis is one of the world’s most commonly used illegal drugs. New Danish research suggests that cannabis use disorder is more strongly linked with the development of mental disorders than previously assumed.

The study includes register data from more than six million Danes and its findings indicate that cannabis use disorder increases the risk of both psychotic and non-psychotic depression and bipolar disorder.

“When we take differences in gender, age, socioeconomics, and family history, and more into account, we see that cannabis use disorder is associated with almost twice the risk of developing depression and a two-to-three-times higher risk of developing bipolar disorder in both men and women,” says Oskar Hougaard Jefsen, a PhD student from the Department of Clinical Medicine at

“As far as we know, we’ve conducted the world’s largest study of the link between cannabis use disorder and affective disorders,” says Oskar Hougaard Jefsen, a PhD student from the Department of Clinical Medicine at Aarhus University. He is the first author of the study, which includes register data from more than six million Danes. Credit: Simon Byrial Fischel

According to the Danish Health Authority, one in three Danes under the age of 25 has smoked cannabis. However, the new study only focuses on people with a significant consumption of cannabis such that they have been registered with a substance use disorder – e.g. because they have been in contact with the substance abuse treatment system or other parts of the healthcare system.

More countries are legalizing cannabis

Several studies have supported the hypothesis that extensive cannabis use is not harmless to human mental health. For example, previous studies suggest that cannabis use disorder can increase the risk of developing schizophrenia. But until now, the risk of other mental disorders has been sparsely studied.

In this study, researchers from Aarhus University and the University of Copenhagen have analyzed data from Danish nationwide registers such as the National Patient Register, the Danish Psychiatric Central Research Register, and the Danish Register of Pharmaceutical Sales.

“The study is the largest of its kind in the world, and our findings suggest that cannabis use disorder is also associated with an increased risk of developing depression and bipolar disorder. The results recommend caution when it comes to using cannabis. This applies to people with an increased risk of developing mental illness, and to politicians and other decision-makers who are discussing the possibilities of legalizing cannabis,” says Oskar Hougaard Jefsen.

An increasing number of countries are legalizing the production and sale of cannabis for medicinal and recreational use. Since 2018, general practitioners in Denmark have been able to write prescriptions for drugs based on cannabis for patients as part of a trial scheme that also gives companies and individuals the opportunity to produce cannabis for medicinal or industrial use.

Oskar Hougaard Jefsen believes that the results of the study should be considered when it comes to legalizing and controlling cannabis use.

“We should conduct more research into whether there are people for whom cannabis is particularly harmful. This could strengthen preventative measures,” he says, adding that there is a particular need for more knowledge about the dose-dependent effects of cannabis use on the brain, cognition, and behavior, and for identifying risk factors for the transition from cannabis use disorder to psychiatric disorders.

No conclusive evidence

Oskar Hougaard Jefsen points out that, despite the indications in the study, it does not provide conclusive evidence that cannabis causes these mental disorders.

For example, he cannot rule out that undiagnosed depression or bipolar disorder has led some of the people in the register-based study to develop cannabis use disorder – i.e. the disease resulted in the abuse and not the other way around.

“But when we see an increased disease risk – even ten years after the cannabis use disorder has been registered – I don’t think that self-medication can be the only explanation. It seems unlikely that so many people would go undiagnosed for so long,” he says.

“Danish register data really gives us a unique opportunity to take into account many of the crucial factors that could affect the results. However, conclusive evidence would require a randomized controlled trial in which a group of people would have to smoke large amounts of cannabis to see if this increased their risk of developing mental illness in the long term, and such a study would, of course, be unethical,” he says.

The research results – more information

• The study is a register-based epidemiological cohort study of 6,651,765 people born in Denmark before 2006, and who lived in Denmark between 1995 and 2021. An equal number of men and women appear in the study.
• The partners are Associate Professor Carsten Hjorthøj, Senior Researcher Annette Erlangsen and Clinical Professor Merete Nordentoft – all three from the University of Copenhagen.

Reference: “Cannabis Use Disorder and Subsequent Risk of Psychotic and Nonpsychotic Unipolar Depression and Bipolar Disorder” by Oskar Hougaard Jefsen, MD; Annette Erlangsen, PhD; Merete Nordentoft, DMSc and Carsten Hjorthøj, PhD, 24 May 2023, JAMA Psychiatry.
DOI: 10.1001/jamapsychiatry.2023.1256

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Depression is a mood disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable. It can also cause physical symptoms such as fatigue, changes in appetite, and difficulty sleeping. Depression can be caused by a variety of factors including genetics, environmental stressors, and chemical imbalances in the brain.

Bipolar disorder, on the other hand, is a mood disorder that causes extreme shifts in mood, energy, and activity levels. Individuals with bipolar disorder experience periods of mania or hypomania, characterized by elevated or irritable mood, increased energy and activity levels, and impulsive behaviors. These periods are followed by depressive episodes, similar to those experienced in depression. Bipolar disorder can also cause changes in sleep patterns, appetite, and behavior.

Diagnosing and treating these conditions is crucial in managing symptoms and improving quality of life. A mental health professional, such as a psychiatrist or psychologist, can assess symptoms and provide a diagnosis. Treatment options may include medication, therapy, or a combination of both.

Medications commonly used for depression include antidepressants, which work by balancing chemicals in the brain. For bipolar disorder, mood stabilizers such as lithium or antipsychotic medications may be prescribed to manage manic and depressive episodes.

Therapy, such as cognitive-behavioral therapy or psychotherapy, can also be effective in managing symptoms of depression and bipolar disorder. These therapies can help individuals identify negative thought patterns and behaviors, develop coping skills, and improve relationships.

In addition to medication and therapy, lifestyle changes can also aid in managing symptoms of depression and bipolar disorder. This may include regular exercise, a healthy diet, and establishing a consistent sleep schedule.

It is important for individuals with depression or bipolar disorder to seek professional help and support from loved ones. With proper treatment and support, individuals can manage symptoms, improve quality of life, and lead fulfilling and productive lives.

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Early intervention is crucial in treating mental health disorders, as it can minimize the severity of symptoms and improve the overall prognosis. Unfortunately, many individuals with mental health disorders may not seek help until their symptoms have become severe, leading to prolonged suffering and functional impairment.

Mental health disorder tests can play a vital role in early intervention by identifying symptoms and providing a diagnosis. These tests are designed to assess various aspects of mental health, including mood, anxiety, behavior, and cognitive functioning.

There are several types of mental health disorder tests, including self-report questionnaires, clinician-administered interviews, and objective measures such as neuropsychological tests. Self-report questionnaires are the most commonly used type of test, as they are relatively easy to administer and can be completed by individuals without the need for a clinician.

Self-report questionnaires such as the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) are widely used by healthcare providers to screen for depression and anxiety disorders, respectively. These questionnaires provide a quick and reliable way to identify symptoms of mental health disorders and can be used to guide further evaluation and treatment.

Clinician-administered interviews, such as the Structured Clinical Interview for DSM-5 (SCID-5), are more in-depth assessments that are typically conducted by mental health professionals. These interviews are intended to provide a comprehensive evaluation of symptoms and can be used to diagnose specific mental health disorders.

Objective measures such as neuropsychological tests are designed to assess cognitive functioning and can be used to identify specific deficits that may be associated with mental health disorders. These tests may be used in conjunction with other assessments to provide a more complete picture of an individual’s mental health.

Getting help sooner for mental health disorders is essential, and mental health disorder tests can play a critical role in early intervention. By identifying symptoms and providing a diagnosis, mental health disorder tests can guide treatment and support individuals in achieving better mental health outcomes. If you or someone you know is experiencing symptoms of a mental health disorder, it is essential to seek help from a mental health professional.

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Anxiety is a normal human emotion that everyone experiences at some point in their lives. However, when anxiety becomes excessive or interferes with daily life, it may be a sign of an anxiety disorder. Anxiety disorders are a group of mental health disorders that are characterized by excessive fear or worry about everyday situations. Some of the most common types of anxiety disorders include generalized anxiety disorder, panic disorder, and social anxiety disorder. Symptoms of anxiety disorders can include excessive worry, restlessness, irritability, difficulty sleeping, and sweating.

Bipolar disorder, on the other hand, is a mood disorder that is characterized by extreme mood swings. People with bipolar disorder may experience periods of intense euphoria, or mania, followed by periods of depression. Bipolar disorder is divided into several subtypes, including bipolar I disorder, bipolar II disorder, and cyclothymic disorder. Symptoms of bipolar disorder can include elevated mood, increased energy, impulsivity, sadness, and difficulty concentrating.

While anxiety and bipolar disorder are two very different mental health disorders, they do share some similarities. For example, both disorders are often treated with medication and therapy. Additionally, both disorders can be triggered by environmental factors, such as stress or trauma.

It’s important to note that mental health disorders are not a sign of weakness or personal failing. Rather, they are medical conditions that require treatment and support. If you or someone you know is struggling with a mental health disorder, it’s important to seek help from a mental health professional.

In conclusion, mental health disorders are becoming increasingly common in today’s society. Anxiety and bipolar disorder are two of the most common mental health disorders, and while they are very different, they do share some similarities. It’s important to seek help if you or someone you know is struggling with a mental health disorder, as treatment and support can make a significant difference in improving quality of life.

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