#Fundamental Health

[xtruss]

Many Mental-Health Conditions Have Bodily Triggers! Psychiatrists Are At Long Last Starting To Connect The Dots

— April 24th, 2024

Illustration: The Economist/Getty Images

The tics started when Jessica Huitson was only 12 years old. Over time her condition worsened until she was having whole-body fits and being rushed to hospital. But her local hospital, in Durham, England, was dismissive, suggesting she had anxiety, a mental-health condition, and that she was probably spending too much time watching videos on TikTok. Her mother describes the experience as “belittling”. In fact, Jessica had an autoimmune condition brought on by a bacterial infection with Streptococcus. The condition is known as Paediatric Autoimmune-Neuropsychiatric Disorders Associated with Streptococcus (pandas). When the infection was identified and treated, her symptoms finally began to improve.

Ms Huitson is not alone in having a dysfunction in the brain mistaken for one in the mind. Evidence is accumulating that an array of infections can, in some cases, trigger conditions such as obsessive-compulsive disorder, tics, anxiety, depression and even psychosis. And infections are one small piece of the puzzle. It is increasingly clear that inflammatory disorders and metabolic conditions can also have sizeable effects on mental health, though psychiatrists rarely look for them. All this is symptomatic of large problems in psychiatry.

A revised understanding could have profound consequences for the millions of people with mental-health conditions that are currently poorly treated. For example, over 90% of patients with bipolar disorder will have recurrent illness during their lives; and in children with obsessive-compulsive disorder (ocd) over 46% do not achieve remission. Some 50-60% of patients with depression eventually respond after trying many different drugs.

For some in the profession, a deeper understanding of the biology of mental health, tied to clear biological fingerprints of the kind that might come from a laboratory test, will lead to more accurate diagnoses and better targeted treatments.

Shrinks, Rapped

The field of psychiatry has historically been focused around the description and classification of symptoms, rather than on underlying causes. The Diagnostic and Statistical Manual of Mental Disorders (dsm), sometimes known as the bible of psychiatry, emerged in 1952 and contains descriptions, symptoms and diagnostic criteria. On the one hand, it has brought helpful consistency to diagnosis. But on the other, it has grouped patients into cohorts without any sense of the underlying mechanisms behind their conditions. There is so much overlap between the symptoms of depression and anxiety, for example, that some wonder if these are actually even separate categories of illness. At the same time, depression and anxiety come in many different subtypes—panic disorder with and without agoraphobia, for example, are distinct diagnoses—not all of which may be meaningfully distinct. This can lead to patient groups in drug trials being so diverse that drugs and therapies fail simply because the cohort being studied has too little in common.

Previous attempts to find causal mechanisms for mental-health conditions have run into difficulty. In 2013 the National Institute of Mental Health, an American government agency, made a heroic gamble to move away from research based on the dsm’s symptom-based categories. Money was funnelled into basic research on disease processes of the brain, hoping to directly connect genes to behaviours. Some $20bn of new research was funded but the idea failed spectacularly—most of the genes uncovered had tiny effects. Allen Frances, a professor of psychiatry at Duke University, calls the search for such biomarkers “a fascinating intellectual adventure, but a complete clinical flop”.

Genes alone are clearly not the answer. Ludger Tebartz van Elst, a professor of psychiatry and psychotherapy at the University Hospital Freiburg, in Germany, says that many different conditions such as schizophrenia, attention deficit hyperactivity disorder (adhd), anxiety and autism can be triggered by the same genetic disorder, 22q11.2, caused by the loss of a small piece of chromosome 22.

Despite this counsel of misery, a shift in psychiatry is potentially on the horizon. Some of this is coming from a revived interest in finding neurological biomarkers with ever-more sophisticated technology. In addition, there is a greater understanding that some mental-health conditions actually have triggers or roots which need to be treated as medical conditions rather than psychiatric ones.

Fundamental Health

A key moment came in 2007, when work at the University of Pennsylvania showed that 100 patients with rapidly progressing psychiatric symptoms or cognitive impairments actually had an autoimmune disease. Their bodies were creating antibodies against key receptors in nerve cells known as nmda receptors. These lead to brain swelling and can trigger a range of symptoms including paranoia, hallucinations and aggression. The disease was dubbed “anti-nmda-receptor encephalitis”. Most important of all, in many cases it was treatable by removing the antibodies, or using immunotherapy drugs or steroids. Studies of patients having a first episode of psychosis have found that between 5% and 10% also have brain-attacking antibodies.

Illustration: The Economist/Getty Images

It seems likely that, in rare cases, ocd can be caused by the immune system, too. This is seen in the childhood condition pandas, with which Ms Huitson was diagnosed in 2021. But it is also sometimes found in adults. One 64-year-old man reported spending an extraordinary amount of time obsessively trimming his lawn only to look back on this behaviour the next day with feelings of regret and guilt. Researchers found these symptoms were being caused by antibodies attacking the neurons in his brain.

More recently, Belinda Lennox, head of psychiatry at the University of Oxford, has conducted tests on thousands of patients with psychosis. She has found increased rates of antibodies in the blood samples of about 6% of patients, mostly targeting the nmda receptors. She says it remains unknown how a single set of antibodies is capable of producing clinical presentations ranging from seizures to psychosis and encephalitis. Nor is it known why these antibodies are made, or if they can cross the blood-brain barrier, a membrane that controls access to the brain. She assumes, though, that they do—preferentially sticking to the hippocampus, which would explain how they affect memory and lead to delusions and hallucinations.

Dr Lennox says a shift in medical thinking is needed to appreciate the damage the immune system can do to the brain. The “million dollar question”, she says, is whether these conditions are treatable. She is now running trials to find out more. Work on patients with immune-driven psychosis suggests that a range of strategies including removing antibodies and taking immunotherapy drugs or steroids can be effective treatments.

Another important discovery is that metabolic disturbances can also affect mental health. The brain is an energy-hungry organ, and metabolic alterations related to energy pathways have been implicated in a diverse range of conditions, including schizophrenia, bipolar disorder, psychosis, eating disorders and major depressive disorder. At Stanford University there is a metabolic psychiatry clinic where patients are treated with diet and lifestyle changes, along with medication. One active area of research at the clinic is the potential benefits of the ketogenic diet, in which carbohydrate intake is limited. This diet forces the body to burn fat for energy, thereby creating chemicals known as ketones which can act as a fuel source for the brain when glucose is in limited supply.

Kirk Nylen, head of neuroscience for Baszucki Group, an American charity that funds brain research, says 13 trials are under way worldwide looking at the effects of metabolic therapies on serious mental illness. Preliminary results have shown a “large group of people responding in an incredibly meaningful way. These are people that have failed drugs, talk therapy, trans-cranial stimulation and maybe electroconvulsive-shock therapy.” He says that he keeps meeting psychiatrists who have come to the metabolic field because of patients whose low-carb diets were followed by huge improvements in mood. Results from randomised controlled trials are expected in the next year or so.

It is not only understanding of the immune and metabolic systems that is improving. Vast quantities of data are now being parsed with unprecedented speed, sometimes with the help of artificial intelligence (ai), to uncover connections previously hidden in plain sight.

Dr Jung, Tear Down This Wall

This could at long last bring biology more centrally into the diagnosis of mental health, potentially leading to more individualised treatments, as well as better ones. In early October 2023, uk Biobank, a biomedical database, published data revealing that people with depressive episodes had significantly higher levels of inflammatory proteins, such as cytokines, in the blood. A study last year also found about a quarter of depressed patients had evidence of low-grade inflammation. This could be useful to know as other work suggests patients with inflammation respond poorly to antidepressants.

Illustration: The Economist/Getty Images

More innovation is under way. A number of researchers are exploring different ways of improving the diagnosis of adhd, for example, classifying patients into a number of different subgroups, some of which may have been previously unknown. In three separate announcements in February 2024, different groups announced the discovery of biomarkers that could predict the risks of dementia, autism and psychosis. The search for better diagnostic tools is also likely to be accelerated by the use of ai. One firm, Cognoa, is already using ai to diagnose autism in children by analysing footage of their behaviour—side-stepping the long waits for clinicians. Another outfit, the Quantitative Biosciences Institute (qbi) in California, has used ai to create an entirely new map of the protein-protein interactions (and the molecular networks) involved in autism. This will greatly facilitate further explorations of diagnostic tools and treatments.

All such developments are promising. But many of the field’s problems could be resolved by relaxing the distinctions that exist today between neurology, which studies and treats physical, structural and functional disorders of the brain, and psychiatry, which deals with mental, emotional and behavioural disorders. Dr Lennox finds it extraordinary that the treatment options differ so completely if a patient ends up on a neurology ward or a psychiatric ward. She wants antibody testing to be more routine in Britain when someone presents with a sudden post-viral mental illness that does not get better with standard treatments. Thomas Pollak, a senior clinical lecturer and consultant neuropsychiatrist at King’s College London, says mri scans should probably be used on patients after their first episode of psychosis as, in 5% to 6% of patients, it would change the way they are treated.

This rift between neurology and psychiatry is greater in Anglo-Saxon countries, says Dr Tebartz van Elst. (These are countries including America, Britain, Canada, and New Zealand.) In Germany, psychiatry and neurology are more integrated, with neurologists training in psychiatry, and psychiatrists doing a year of neurology as part of their training. That makes it easier for investigational work to be done. He says he offers most patients with first-time psychosis or other severe psychiatric syndromes an mri of the brain, an electroencephalogram, lab tests for inflammation, and a lumbar puncture to find evidence to support different treatments in some patients. The price tag, around €1,000 ($1,070), is no more than the cost of hospitalising a patient for three or four days, says Dr Tebartz van Elst, so may be good value for money.

What’s The Diagnosis?

All this work will one day put psychiatry, and its patients, on a firmer footing. It is already offering validation for some of those for whom the field has failed.

Jessica Huitson is only one of them. Diagnosed and treated too late, she still struggles with her condition and her future is uncertain. Those with me/cfs, a post-infectious condition which comes with a series of cognitive problems such as attention and concentration deficits, were once dismissed as malingering or diagnosed with “yuppie flu”. New work suggests it is associated with both immune and metabolic dysfunction.

Some wonder whether these conditions are the tip of a much larger iceberg. The prize in finding out more will be better patient care and outcomes. Biology is coming, whether psychiatry is ready or not.■

— This Article Appeared in the Science & Technology Section of the Print Edition Under the Headline "Psychiatry’s Blind Spots"

[girlfriendline]

claude giroux gets the helmet after scoring the OT winner

preds @ sens || 29.1.24

+ bonus Extra Large Versions under the read more (highly recommended)

[faeriekit]

Health and Hybrids (XIV)👽👻💚

[I can't remember the original prompt posters  for the life of me but here's a mashup between a cryptid!Danny, presumed-alien!Danny, dp x dc, and the prompt made the one body horror meat grinder fic.]

PART ONE is here PART TWOis here PART THREE is here PART FOUR is here and PART FIVE is here PART SIX is here and PART SEVEN is here PART EIGHT is here PART NINE is here PART TEN is here PART ELEVEN is here PART TWELVE is here PART THIRTEEN is here and this is part fourteen! Yes I messed it up this morning yes I had to wait all day to correct it it's all goooood

💚 Ao3 Is here for all parts

Where we last left off... Bart is a good egg who is having a Bad Time waiting for his friend :(

Trigger warnings for this story:  body horror | gore | post-dissection fic | dehumanization (probably) |  my nonexistent attempts at following DC canon. On with the show.

💚👻👽👻💚

Danny wakes up with a gasp.

He’s—where is he? Everything hurts. He can barely think. Danny groans, long and loud, and lifts up an aching hand to his temple.

His fingers come away green. Aw, fuck. What happened to him? What’s going on? Why is his hand…blurry? Is he concussed? Is something wrong with his eyes, or with his head??

(He hopes it’s not his head. It’s waaay easier to heal from one than the other.)

Danny tries to sit up, and— NOPE. Ow. Bad idea. Suuuuuch a bad idea. His arms and hands and his neck and his back are screaming at him, now that he’s awake enough to pay attention. Ughhhhhhhhhhh.

He lays back down. His eyes don’t—well, they don’t shut all the way, which part of his brain labels as very bad, actually, but the world does turn darker and greener as he tries to shut his eyes, and that’s close enough to closing his eyes that Danny can mostly zone out past the pain.

He licks his sore lips. They taste like copper. And battery acid. …And Pixie Sticks.

Ugh, ecto-blood. His own, he assumes.

Everything is blurry and everything kind of hurts and he doesn’t know how he got here or what’s going on. Danny tries to roll over, tries to get more comfortable, but something starts dragging on the inside of his arm, which means intravenous lines.

Ugggghhhh. He hopes it’s got pain meds at least.

Awake him can deal with this later. Danny zones out, his labored breathing evens.

He’s asleep before he knows it.

*

Danny wakes up next to quiet murmuring, and to weird sensation of something moving in his arm.

He yawns—and his jaw cracks apart farther than usual, with more clicking noises than his jaw usually makes. Weird. His arms come up, his eyes unblur…

The tugging sensation doesn’t go away. Danny sniffs blearily. Blinks.

Two white-coated humans(…?) in PPE pause at his bedside, a half-dissembled IV shared between them.

Danny stops breathing. He can’t—is he—

His eyes go to the ceiling. The floor. He doesn’t recognize the room he’s in. He doesn’t understand. Is this the Guys in White again? Is he— Did he never leave? Is he trapped? Danny doesn’t—he can’t—

—One of the white coats starts making worried noises, which. Danny’s never heard that before. It’s usually threats. They raise both their arms, and Danny flinches back—

…And so do they. Huh. Hm. Are the Guys hiring scaredy cats now? That would be a change of pace, if they were as scared of Danny as Danny is of them.

The second person clicks the new IV bag into place. Danny stops focusing on number one and starts focusing on number two.

They don’t make any overt tells either. The IV line is already in him, and the bag is… Well. It’s not red and Danny’s not in any pain, and it’s not green either. It’s just. Kinda opaque? Milky? The person doesn’t start cackling evilly or telling Danny how screwed he is, either. They both just sort of…tidy up?

The first one doesn’t get closer, either, but Danny can mostly tell that they’re scanning him visually. Their attention goes from his face, to Danny’s visible arm, to the puncture point in his elbow for the IV needle.

Danny also eyes his IV point. Well. It looks like a needle. Doesn’t hurt all that much.

Someone says something he doesn’t catch. But the tone isn’t…mean, or anything. If anything, it sounds quiet, and low, like they’re trying to keep him calm.

Danny doesn’t understand.

He moves as far out of the way of them as possible. It only has the effect of a few inches and it's so painfully slow. If that. He— he remembers. He’s supposed to be scared of— something. No, he knows it—

The labs. He’s supposed to be scared of the labs. The smell is rank there and there’s always screaming and Danny had been hurt there; really, really hurt.

He’s still hurt. He’s still in a lab. In a room. In some sort of too-small prison, and now his barely-sewn together lungs are trying too hard to keep air in his body and it’s not working, and—

Danny barely pays attention when the first doctor leaves. He sees the other back into the door and reach for the phone line, and he can’t stop breathing and he can’t calm down because that means that they’re calling for help and they’re going to hurt him all over again. Tie him down. Cut him open. Shock him, until he can’t breathe without screaming—

Someone new comes in. They look— rushed. Danny can see her actively tying up long black hair, threading a mask up over her face, pulling on one of those paper shifts the doctors wear. The only difference is that she doesn’t put boot covers on.

She has big, bright boots that go all the way up her legs. With his green vision, they look kind of…greyish? (Maybe they’re pink..?)

Either way. They look…ridiculous. Danny doesn’t exactly forget to be scared, but also…what the fuck.

The woman sees that Danny can see her. She waves.

Danny presses back against his— cot. Bed.

That doesn’t stop her. She pulls latex gloves from out of the paper slip she’s wearing and snaps them on, revealing a thin layer of something shiny underneath her elastic-bound sleeves. Once that’s on, she does a visible body checkup of herself: boots, gown, gloves, mask, hair.

…No hair net, though. Or goggles. The Docs in White always wanted to be fully covered when they saw their victims. Being able to see her eyes is a lot…friendlier.

She figures herself out. Straightens. Gives a double thumbs up.

…Danny's eyes roam around. There’s no one nearby. There's only a wall behind him. Is she looking at…him? Is that directed to him?

She doesn’t move immediately— and once she’s in, the second doctor leaves the room entirely.

…The new person takes over. She goes from monitor to monitor, getting closer, but with none of the focus on Danny, per se. She reads his stats, verbalizes them out loud, which, doesn’t sound like…English? But enough to confuse him? It’s kind of like trying to discern Esperanto when he's not thinking about how it's not English.

Ancients. The pounding in his head is getting worse. Maybe Danny has a concussion or something.

The woman doesn’t…get. Him. In fact, he seems to be the least interesting thing in the room to her. Her time is spent on reading the charts and the machines waiting around him, putting something into a…fridge? A Cabinet? In the corner of his room? And otherwise, she leaves him alone.

Until. She does get up and look at him, and all of Danny tenses up painfully. He can’t move. Something’s holding down his legs, his body’s stiff, and all of him is so tired that he genuinely can’t tell if his waist is tied down or if he’s just that exhausted.

He can hear his heart rate monitor kick up. He can’t move, not really. He tries to go intangible but his core just throbs with misery, and—

She mostly just pats his sheets. Not his person, even. Apparently the torture is being held off for now. “Eow eart wel?”

…Danny squints. That is almost English.

“Eom hebbjan yift,” she adds, leadingly, as if Danny is a friend she can tease and not a subject under threat of the knife. He doesn't like it. It hurts. Nothing is real and everyone hates him and all he wants to do is leave but his body is rejecting him and—

Something light and plastic thumps down onto the bed.

Danny blinks. He looks—down. (His neck makes him regret that.)

Is that a…is that a space shuttle? No, ‘cause Danny thinks he recognizes it. It’s Discovery? Isn’t it? That’s the one they just retired. He tries to grab it, but— ouch, oof, his fingers can’t even stretch, bad idea—

The woman gently guides the shuttle into his hand. It doesn’t even hurt. And.

It’s cold to the touch. The model is plastic, it shouldn’t be so cold, but the sensation is distinctly cool and kind of familiar.

…Oh. Danny struggles to flex his fingers around the thing.

It’s him.

Or. Well. The shuttle is his. It has his ectoplasm imbued all throughout it. He can even sort of feel the sensation of carefulplayingcareful he’d have felt while near it. The feeling is weak, and timid, but it’s still there.

So. Then. When did he get it? And…why? Why was it allowed to him? How did he get it?

Is this how they’re feeding him now? Instead of showering him with poorly filtered ectoplasm every time he gets rowdy, are they actually trying to feed his Obsession? For real?? That’s—that’s brand new behavior from the—

Danny blinks. Wait. That’s not it either. Because there’s an IV in him. So…they know he’s getting human food.

So. Uh.

Hm.

Danny doesn’t want to get his hopes up. But this…might not be the Guys in White.

Of course, they might not be better than the GIW either; it’s a total possibility that Danny’s getting suckered into some scheme where every gentle permission and soft voice is a debt he owes…some new reason to take…

His eyelids twitch as they try to shut. He’s so tired. Fear kept him mobile, but now…everything is so heavy.

The lady carefully shushes him, ever so gently. She pulls up his blanket for him. Pats it down.

Danny shivers. He’s so, so scared.

“Ræste þiht,” the woman whispers. The words sound fond. Danny’s so scared, but he’s so tired. His heart is beating so fast. “An freond becymþ hraðe.”

It’s reassuring.

Danny doesn’t want it to be.

He falls asleep the way the desperate do—clawing at the last traces of wakefulness, only to have his consciousness ripped from him.

[uncanny-tranny]

The frustrating part about conversations like "should people with self-harm scars warn others before showing off their body?" and conversations like it is how nobody would tell me that my scars are obscene or should be hidden despite, literally, being self-harm scars. They just do not know because people literally do not know what self-harm scars are and what self-harm is.

Our bodies are not vulgar or gross. We deserve to live our lives, and if our scars make you uncomfortable, we can be compassionate about that, but that doesn't mean that our bodies are Bad and should be Locked Away. Treat us like we belong, because we do.

[tin-can-iron-man]

I'm just gonna say it again real quick:

Yes!! Iron Man is a tragedy! It has and always has been since the very first appearance in 1963 which describes itself, Tony's life, and legacy, as such.

Tony causes most of his issues himself, he is his biggest villain, a majority of his rogues gallery are caricatures of the worst versions of himself brought to life (when they're not just being racist cuz...60s...). The worst thing about being Tony Stark is that he can't stop being Tony Stark (he tried!!) That is the point.

The majority of pain Tony goes through, is pain he inflicts on himself, whether intentionally or inadvertently. That is the point.

He is not A villain (at least. Not usually. There are...some rough moments and arcs that are. Not great. As there is with any character as old as he is). But he is his own main antagonist.

[hjartasalt]

Honestly it is a bit crazy to me how at 22 I am at a very typical age for someone seeking an OCD diagnosis despite having spent like half my life in therapy why is this disorder so massively underdiagnosed

[chickensauras]

Its not 'aging' or 'an art style change'- this is just the result of puttin up w this grim dark angry kid for a 11 years

[captain-lovelace]

I’ve said this before but I firmly believe that fatphobia and ableism are intrinsically linked

[dont-offend-the-bees]

Fuck I hate being an adult. I need a more adult adult to help with the volatile emotional situation.

[liesmultixxx]

what’s wrong with me? why am i so fundamentally unlovable?

[jochona]

i will wash my hair tomorrow

[funkytoesart]

you can always tell the people who give social media advice who are naturally or conventionally attractive even without even having to look at a photo of them cause they're always the ones that recommend showing your face in reels or videos to promote your art and it's like,,, talk about pretty/skinny privilege lol

[tennessoui]

I think I really lose braincells each time you post about couples counselling au - because I have never felt a characterization of Obi-Wan and Anakin fit *so much* to my own headcanon that it drives me crazy. The lack of communication? The desperate need to please (Anakin) the delusion of thinking you're giving someone complete access (Obi-Wan) while keeping them out. It is SO perfect, it's literally my favourite obikin fic, I am so invested in this au. The questions you have them answer at the end. When Obi-Wan said he's "happy to make the list as an obligation" because free time means a lot to an enslaved man. Kit. KIT *stick figure gore of me sinking my talons into your shoulders* When Anakin says he has nothing to hide from Obi-Wan but Obi-Wan never asks and he feels like he's getting away with something each time he learns something while Obi-Wan is like. He can ask me anything. KIT *BLOOD IN MY MOUTH*

ahhh thank you so much!!! i really love writing chapters and answering asks about this fic because i'm really attached to these versions of obi-wan and anakin like. their motivations are so interesting to me, especially at this part of the story, in the beginning, when all they are are motivations

anakin absolutely feels this need to please and be loved and the focus of his master's attentions. he also feels helpless in the face of thinking obi-wan will never let him in like that. he also is unhealthily controlling in small ways (checking and rechecking his closed door, for one, trying to have a say in what he eats out of concerns for his health) but he just loves him so much and he really experienced like.d devastation when obi-wan was temporarily dead that i feel like altered his motivations fundamentally, especially because he restarted his heart so.....probably a tiny part of him....illogically feels as if that's his heart now......

and obi-wan absolutely thinks he is so transparent for anakin!! he has let him in!!! more than he's ever let anyone in at all probably, but it's probably not that much. he's so practiced at keeping him out and hiding his real emotions that that's second nature. not to mention he feels betrayed in his own way at anakin marrying padmé --instead of just having an affair with her-- and he's trying to frantically detach himself before anakin leaves the order because he'll be devastated when that happens. not to mention he can also be shit at respecting boundaries (he reads the messages on anakin's phone when he's asleep)

and it's all just so interesting especially because there's so much narrative bias and just narrative inaccuracies where the narrator/POV character completely reads the other's reactions wrong, which makes the little questionnaire at the end have so much more weight because the counselor is 1000% right when she says that that's what's most important--how they feel about each other and their relationship after honest deliberation and reflection

[uncanny-tranny]

If you truly want to do what's best for mentally ill people, you have to learn that you often won't be able to separate the "salvageable" parts of ourselves with our illnesses, and you can't pretend like we are sane people underneath the façade of insanity, like we can flip a switch and magically erase the differences that make us "disordered"

[unopenablebox]

and i'm not in it to cure any diseases or resolve any health problems at all! i just really love biology, the academic field of study, but specifically things that are tissue-size and smaller and not the ones that would involve even a genetic disease that we could pretend to think was curable if everything about gene editing was different. it's just fun to look at because of the shapes, and it's exciting to understand how the shapes work. i'm not going to solve anyone's health problems and i'm not going to document any special animals for anyone! i'm going to develop a series of practical tools for getting a better handle on a fundamental conceptual problem that has for the last 30 years bedeviled the Why Do Cells Arrange Themselves In Shapes community and i have no interest in anyone else!

[suncaptor]

I feel like we need to be more critical of like. health care systems including mental health very actively the same way people are critical of other institutions.