I have written in a couple of places over the last two years in tentative ways about ‘what it is like’ to live as someone with a bipolar disorder diagnosis (see here and here). I continue to be happy with the idea of representing myself to others as falling under this category in writing, and do so in day to day conversations with people in my more immediate vicinity. But there is always a serious concern in the back of my mind about the crudeness of the criteria that are used to lump people together under this heading. It is manifest in the fact that one of the ways of breaking the ice in those conversations is to allow a slightly uncomfortable joking about some of the more traditional conceptions of manic behaviour: “No, you don’t need to worry about whether I will take my clothes off and dance on the table in the middle of the next faculty meeting – however preferable that might be to the in which such meetings usually unfold.”

I found a way to conceptualise another of the background concerns in the wake of reading a series of papers by Louis Sass and Elizabeth Pienkos, in which they discuss differences between what it is like to be bipolar and schizophrenic. The issue here was that my status as bipolar left me falling into the schizophrenic camp far more often than Sass’ and Pienkos’ analyses should have allowed.

Interesting as the bipolar vs schizophrenia issue is in itself, I want to focus here on something else, though the relationship to this realization should be readily apparent. A couple of weeks ago, I discovered that a person working in another faculty has taken on a central role in the University’s strategy for equality and diversity issues. I’ve worked with this person from time to time over the last fifteen years or so and always found them sympathetic. I put this mainly down to the fact that they speak with a strong northern regional accent (as I did before my years living in the US), and have been involved in the efforts to increase the representation of students from state-funded schools in Oxford (something which has been central to the identity of the college in Oxford of which I am a member). However, it is also because they say what they think without seeming to care too much about the ramifications.

Too cut a potentially long digression short, we agreed to meet up to talk about the ways in which ‘mental disability’ might be more of a focus as the strategy moves forward. Not unsurprisingly to me, it was a really enjoyable, long, and lively conversation, of the kind I find relatively easy with one, but no more than one, other person. It was perhaps easier than usual, given that we both disclosed our diagnoses very early on, and it is here that we get to the focus of this post. They told me that they had received an autistic-spectrum diagnosis very recently. And, as we talked about how that related to the struggles they have navigated, and performed into the shadows, on their journey to becoming a Full Professor, I heard many things that resonated. We discussed various social difficulties that I had thought were best bundled under the bipolar label, or treated as a function of poor socialization, egotism, or simply a result of growing up in Yorkshire.

The meeting was enough to get me thinking. But it was followed the very next day by attending the first event organized by Neurodiversity at Oxford which is aimed at anyone, students or staff, who are looking for community. The event was centred around readings by writer poet and Joanne Limburg, another person who received an autism diagnosis later in life. As she read a selection from her beautiful writings and talked about her experiences growing up as a child and fashioning a life as an academically high achieving individual, I found myself very emotional (as I do even now while reflecting on it) holding back the floods of tears that wanted to emerge. It was like watching Elsa singing ‘Let It Go’ for the first time all over again. I was also very moved to hear of how Joanne’s life has been transformed by finding spaces in which she can meet with others who have the same diagnosis, where she can be herself without feeling social anxiety and the constant fear of performing the ‘wrong’ version of what it is to be a person. And I was also intrigued by her discussion of the way in which she has reconstructed her sense of self in the wake of the diagnosis.

Afterward the event I talked to another of the late autism academics who was there, and asked in more detail about how the diagnosis had changed her life and how she got the diagnosis in the first place. The next day I called my local doctors’ surgery and passed the initial screening required for a referral, doubtless aided by the fact that they already have me down as someone with a mental health problem. All this will happen on the NHS, and it seems the wait will be around 6 months.

So now I am waiting. I’m not quite sure for what. The colleague I mentioned first (I think I really can, and should, say ‘friend’ at this point) warned me that she initially ‘failed’ at the first step of the diagnostic testing – which is a very long questionnaire – because she showed up as too empathetic. It seems it was only her capacity to articulate the reasons for this that got her through to the next stage. I’m not sure whether I will fall at that hurdle too, or others. I’m also not sure how it will feel if I don’t come out with a diagnosis, though I know part of me would like to have the chance to find out what it is spend time with people who find community with those who are autistic. And, as a someone who has spent so much time in academic philosophy, I’m already thinking in that kind of way about what it might be to be in a position to use lots of new concepts to understand my past, present and future self and its actions and relations with other selves. It’s exciting and daunting. But mainly it’s just a messy thing waiting to fall out one way or another.

Joanne Limburg is a very impressive person and a wonderful writer. No doubt aware of the fact that she was talking to a room of people self-identifying as neurodivergent in various ways, she pulled away on occasion from her own identity as autistic. At those times she spoke to something else, her sense of the way in which being autistic allowed her a kind of freedom that went beyond the freedom engendered by her new-found sense of explicit solidarity, a freedom to feel more comfortable with her sense of being ‘weird’. Even if I don’t end up being autistic, I’m grateful to her and to my new friend for already feeling more comfortable with some of the bits of my weirdness that I could never squeeze into my bipolar diagnosis. And, of course, that is really a matter of already feeling just a little bit less weird and less alone in that weirdness after so many years.

As I noted in an earlier post, I have been suffering from illness anxiety disorder, formerly known as “hypochondria” for about twenty years. Five days ago, I had my last therapy session. The reason is that I reached the main goal of the therapy, that is: being able to live with uncertainty. Since I had so many kind reactions to my last post on this issue, I thought it would be nice to post an update and say a little bit about the therapy and how it helped. It was what is called cognitive behavioural therapy, and I received treatment for about eight months. On the whole, I think that the therapeutic devices are so straightforwardly mechanical that they might help with other troubles, too. At the same time, I am still struck by the rationalist thought patterns that might be responsible for part of my anxiety. Let me try and put some order into my thoughts now.

The worst of all possible worlds. – Imagine you notice something, for instance some unusual sensation like a spot on your arm that wasn’t there the evening before. You might think, “oh, a spot” and move on. The fact that I can think that, too, now is perhaps one of the greatest successes of my therapy. Usually, I would think that this is probably the symptom of an incurable disease. If you don’t believe this, it’s easy to shrug it off, but if you do believe it… But how did I get out of this structure of catastrophic beliefs? It’s helpful to break down this question into two parts: (1) What sort of belief made me enter catastrophic thought cycles? (2) How did I block them? Question (1) has a number of answers. Let me focus on the most surprising aspect. One of the most problematic thoughts I tend to have is that there is an explanation for the “symptom”. Now you might think that this is indeed a plausible thought to have. And indeed, as someone trained in the history of philosophy I know I am not alone in recognising this as a variation of the rationalist principle of sufficient reason (PSR).  There is an explanation for everything. Fine. Problems start if you actually expect that you or your doctor or the internet can provide an explanation. For if you’re like I’ve been and there is no obvious or reassuring explanation available, you think, “hey, this might have a sinister or rare cause”. So the PSR keeps the search going until you either find reassurance or an even worse “symptom” to worry about. The thought I didn’t ever entertain is that there might be no explanation available.* So when my therapist suggested this idea I just gave him a blank stare. This leads us to question (2). A common approach in behavioural therapy is to “challenge” such thought cycles. So how do you challenge the PSR? Well, first you try to figure out and write down your precise thoughts. Then you raise challenging questions. The most successful question was this: “Is it actually helpful to worry about this symptom or search for an explanation now?” If you’re honest and not in an actual emergency, you’ll end up having to answer this question with “no”, again and again. What I learned to accept is that it is often more helpful to resign to the fact that no explanation is available rather than keep searching for one. This is, for me, a very concrete way of learning to live with uncertainty.

Magical thinking. – Observing my thought processes, I often wondered why I was so glued to certain patterns. One miserable day I was lucky enough to catch one of the culprits in the act. I thought something like the following: “If I don’t take this symptom seriously, it will turn out even worse.” The thought was so elusive that I had trouble ‘catching it’. But even when I got hold of it, I had trouble seeing what it meant. But suddenly it struck me: This is a variation of the magical thoughts I had as child. Magical thinking is the assumption that your thoughts or some neglect in thinking will cause bad events, like “if I think badly of my parents, they’ll have an accident.” I’m told this is fairly common in children, while adults grow out of it. And of course, I wouldn’t dream of ascribing such assumptions to myself. But here I was! I realised that my thought “if I don’t take this symptom seriously, it will turn out even worse” could most plausibly be rendered as a magical thought like “if I don’t keep fretting over this symptom, I will deserve the illness I ignore right now.” The causal assumptions in the magical thought are closely tied to a moral judgment of deserving or being guilty of my threatening fate, if I neglect it. Of course, it’s hard to be sure, but I’m pretty convinced that it’s this childish superstition that glued me to my anxiety variant of the PSR. While I was shocked and somewhat ashamed to discover this in me, I was equally relieved, because seeing this pattern greatly helped distancing myself from my obsessive search for explanations.

Moving on. – Catching precise formulations and what they mean is actually quite crucial for moving on. I know that I cannot be straightforwardly cured of anxiety, but I can aid the cure by “learning to live with uncertainty”. The reformulation of my therapeutic goals alone already helped me embracing them as something positive rather than as negative. Being interested in social philosophy, you can imagine that I often annoyed my therapist by venting about the missing social aspects in therapy, though. What you (or at least I) need is not just overcoming my mental habits. What I need is a social infrastructure that is understanding and able to deal with conditions like mine. It makes a hell of a difference how a doctor or indeed anyone articulates their diagnosis or suspicions. But you can support your social environment in this. To achieve this, I began to force myself to apply the question “is it actually helpful to worry about this now” not only to my “symptoms” but to all sorts of issues my interlocutors confront me with. Pushing back against concerns of others like this did not make everyone around me happy… But despite some misgivings here and there, this change in my conduct seems to have overall positive effects. What helps is taking the time to explain how and why I attempt to respond and challenge requests with this question now.

The upshot is that, despite my initial scepticism, I would really recommend this therapeutic approach. It is not a magical cure, but that might be for the better.

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* I think this “anxiety PSR” is also an epistemic variation of what is known as the just world fallacy, but I might go into this another time.

Relatedly, I just came across a nice piece on the epistemic merits of CBT: “A common idea about CBT is that it does not contribute to the person’s understanding of reality (validity) but encourages ways of thinking that boost the person’s wellbeing (utility). In our brief commentary, we argue that CBT can also contribute to some of the person’s epistemic goals.”

It was around the time of finishing my PhD, so well over twenty years ago, when bouts of my anxiety disorder manifested themselves so clearly that I sought professional help. The reason I want to write about my condition today is that, for the first time, I am hopeful to have found a way of curing it, to a considerable degree at least. I’ll begin by saying a bit about the condition and then move on to what I consider a potential step towards a cure. Since I don’t really understand my condition and the cure very well, I’m not sure that this will be of help to others. But perhaps adding my voice to the people who talk about such things openly can’t do harm. However, before you read on please note that I am not in any way an expert in these matters. All I have to offer is a personal story.

Being a hypochondriac. – Although I have some special anxieties like a fear of hights and fear of flights, my main problem is a more general disorder that goes by the name of “illness anxiety disorder”, formerly known as “hypochondria”. There is a lot I could say about this condition. The main issue is that, often following a perception of what I classify as a “symptom”, I assume to have some rather threatening illness. The kind of illness changes; what’s crucial is that I consider the worst-case scenario. The drama then typically unfolds as follows: I will first heighten the anxiety by paying selective attention to the “symptom” and indulging in refined self-monitoring. “Is it still there? Is it getting worse?” But now it’s not merely the object of my anxiety but knowledge of the anxiety itself that plays into the cycle: Knowing that I have the anxiety disorder suggests to me that my fears are overblown. But if they are overblown, I go on to think, it must be possible to find reassurance. Thus, I seek reassurance either by “investigating via google” or from people close to me, who will often confirm this and allow me to avoid seeking proper medical advice. This is my avoidance strategy. However, knowing that this is an avoidance pattern suggests to me that I am avoiding confronting the initial “symptoms”. Thus, reassurance amplifies the initial fear. This tangle works best in tandem with anxiety-induced symptoms such as an increased heart rate, but believe me it works with just about any kind of “symptom”. While proper panic attacks never last longer than 30 to 45 minutes, such anxiety cycles can go on for as much as five days. Often such cycles run for a couple of days. Then I have some days of gradual relief before they start again, often with a new perception of a different “symptom”. Since I have developed coping strategies that allow me to function well, I can go through these cycles without people around me noticing, unless I ask for reassurance. This means that the anxiety is often present at the back of my head, like an unpleasant noise in the background that sometimes spirals to very high volumes and then feels more like a disability.

For a long time, I didn’t realise that I had what people formerly called hypochondria. Simply because I sought reassurance, not through pestering doctors, but through other means. When I finished my PhD and lived on social security, the disorder worsened considerably. Among the “best of” of my worries was fearing to fall over in the street or during talks, job talks in particular. At the time, I had three meetings with a behavioural therapist. After understanding how anxiety works (especially understanding that its symptoms disappear after a certain amount of time), I felt relieved and got better again. But anxiety works in mysterious ways: Getting a permanent job in 2012 cured me of many existential worries. It’s been a game changer for sure. But something inside of me resisted the good news and clung to the strange belief that bad things will happen to me inevitably. Self-identifying as an optimist, I refused to embrace that belief consciously, but it seems to have worked its way up nevertheless. Having witnessed a number of troubles, illnesses and deaths in the family, I guess that this belief could take hold despite my avowals to the contrary. For quite a number of years, avoidance was my main coping strategy. Let’s look at some things I think were particularly unhelpful.

Things that didn’t really help. – (1) Being “reasonable”: For someone who enjoys – to some degree at least – things like thinking, understanding, and animated discourse, I found living with bouts of hightend anxiety or panic particularly frustrating, because understanding my own condition often did not help or even made it worse. Of course, understanding how anxiety plays out physically and knowing that I have the condition, for example, helped me seeing why things unfold the way they do. But at least my type of anxiety can get heightened through knowing that it might be partly irresponsive to reasons. Knowledge about anxieties can work like a self-fulfilling prophecy: If you know that your heart rate will go up with your next bout of panic, that very knowledge might actually increase the fear of your heart rate going up, and, as a result of this, increase your heart rate. (2) There is a common dualism according to which conditions like anxiety disorders are only or mainly “in your head”. Even if such claims are meant as a reassurance to someone worrying about their physical health, they don’t help in the long run. Apart from the fact that superficial reassurance can backfire quickly by initiating problematic cycles of seeking ever more reassurance, they underestimate the fact that anxiety comes in many physical manifestations. (3) Reassurance or confrontation? Reasonable reassurance that everything is fine (for good reasons) or confronting your fears, for instance, by going to the doctor can certainly help in singular instances. If a friend points out a good reason why a particular worry is unfounded or if I go to the doctor to get a proper check up, these are good things. The problem is that they are useless once they are turned into general coping strategies. Why? Well, it seems to me at least that anxieties will absorb any coping strategy into the anxiety cycle itself. – I’m not saying, then, that these ways of approaching things don’t ever help anyone. Rather, I wish to stress that they might not help in case you have an anxiety disorder. Of course, if you discover something about yourself that makes you worry, any of these approaches might help very well, but they can fail if they are turned into coping strategies. Why? I guess because using them as strategies makes them part of an anxiety cycle. The toxic thing about anxiety is that anything, even something perfectly helpful, can be turned into part of a cycle that ends up feeding the anxiety.

Moving forward. ­– Last year was particularly bad for most of us. Strangely enough, the threat of coronavirus did not overtly add to my anxieties. Rather, I learned to “embrace fatalism” a bit and became a bit more confrontational about my condition. Thanks to the suggestions of a good friend, I also managed to catch up with some medical check ups that I had avoided for about ten years. Worrying that my daughter Hannah might pick up my behavioural patterns, I also considered starting therapy again. Living in two different places during what is called lockdown, the fairly recent death of my father and some work-related pressures made this seem an even more appropriate consideration. I started behavioural therapy again now. But while I don’t want to pass judgement on this, what eventually made me take a good leap is something else.

What helped me, after all these years, is so strikingly simple that I still don’t know what to make of it, except that it definitely does help greatly. So what happened? After a conversation about a recent bout of anxieties, a dear friend sent me a video explaining a simple thing: to slow down my breathing (like in yoga), and providing an image to think about when doing so. Whenever I experience anxiety, I now take a few deep breaths and most of the problematic anxiety symptoms disappear. The heart rate slows down and I feel good. That’s it.

Why does it work? Don’t get me wrong. I have known that this kind of thing might help for a long time. I’ve been doing a lot of physical exercise for many years. In moments of hightend anxiety I instinctively took to slowing down my breathing anyway. There is nothing fancy about the breathing technique as such. Nothing I do is special; most of it isn’t even new to me. So why does it have such a great effect? I think there are two main aspects: First, the image I am thinking of when inhaling absorbs my attention, away from anxiety symptoms, to the positive impact of inhaling. Second, the fact that this video was presented to me as a personal response and gift turns the exercise into a relational act. Both aspects, simple as they may be, strike me as indispensable in explaining the effect it has on me. I am not saying that this has cured me of my anxiety, not least because I ultimately think that at least some of this disorder is the dark side of my personality, inevitably triggered in a certain kind of context. So I’m not saying I’m cured, but what seems to make a difference, for the time being, is that I can accept this, and yet break the cycle effectively. Even if it only works for certain situations, it restores a sense of agency that many of my coping strategies seem to have deprived me of. – I’m not sure this carries over or can help you. But perhaps a bit of hopefulness will inspire trying to look for unexpected resources.

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PS. It goes without saying that I am immensely grateful to many friends who helped along the way. You know who you are.