It's the time of year when many employers hold holiday parties for their employees. Some of these parties will be held in venues that serve alcohol, despite the fact that approximately 10 percent of people are alcoholics or have the disposition to become alcoholic.
I've had at least one patient who was fired from a job due to alcohol-related behavior at an office party. Why would employers create situations that facilitate problematic behavior and raise liability risk for the company? Because often managers are people without common sense.
Even without alcohol, office parties may be problematic, because co-workers aren't necessarily friends. People choose their friends, but they rarely choose their co-workers.
The office party may be an attempt by the management to create an image of bonhomie among workers, an image that may not correspond to reality.
If employers choose to hold holiday parties, they should be optional events and in no circumstance should alcohol be served.
Increased diversity in the workplace in recent decades has not always meant increased harmony in the workplace. Many male or white employees have not made the mental transition to a diverse workplace.
Free-form banter among persons who have nothing in common except their place of employment is likely to lead to disharmony. In what may go down in history as the worst possible outcome of this type of disharmony, the recent San Bernardino shooter may have been involved in a heated conversation with co-workers prior to the attack. (Although the couple was planning a terrorist attack for some time, it's not clear that the office party was the original intended target). One newspaper report I read indicated the conversation may have been about "Israel." Why on earth would someone initiate or continue a conversation about a controversial foreign policy subject with a co-worker he or she isn't friends with and especially, if it's likely the co-worker will disagree? In fact it looks like a deliberate attempt at provocation. I've observed, over the course of my life, that many people enjoy provoking others with whom they disagree. This isn't smart behavior, but many people do not use good judgment in social situations.
Having lived and traveled around the world, I've observed that many issues that are life-or-death to persons in foreign countries are viewed as abstractions and appropriate topics for social conversations among Americans. There used to be a commonly-repeated dictum in American social etiquette, "don't discuss religion or politics," but this dictum has fallen by the wayside.
If you don't know your co-workers well, it's best to avoid any controversial topics of conversation.
Tuesday, December 8, 2015
Friday, December 4, 2015
What Questions Should You Ask A Prospective Therapist?
The most common question people ask when they contact me is "Are you taking new patients?" In most cases, the person is seeking to make an appointment, so it would save time if the person just said 'I'd like to make an appointment." This would result in my saying "do you need an evening slot or can you come during the day?" or "I have a time available at 6 p.m. Monday" or "I'm not taking new patients right now." All of those responses answer the question of whether I am taking new patients or not, as I would never enter a conversation about scheduling unless I was taking new patients. If I am taking new patients, we can get right down to the details of scheduling.
What type of questions should people ask when they contact a therapist? First of all, people should ask whether I take their insurance or what type of fees I charge. I am often surprised how many people ask for an appointment without asking first for this information. When I tell some people that I don't take their insurance, they are surprised. I'm often not sure where the misinformation has come from. I am on some HMO panels and not on others. Many times people have found me through their insurance directory, but sometimes people find me through the internet or personal referrals.
A few people pay cash for their sessions. I have a sliding scale fee based on income/net worth. On a few (thankfully rare) occasions, a patient who reports a high income has tried to "negotiate" a lower fee. I offer lower fees for people with low incomes, not for people with high incomes.
I sometimes I get a question along the lines of: "What is your orientation?" People aren't asking about my sexual orientation. They're asking about my theoretical orientation. I'm never sure how to answer this question. If I gave a complete answer, it would sound like gibberish to most people. It would sound something like this: "I believe Object Relations Theory, Self Psychology and Ego Psychology are all important. I sometimes use DBT techniques for anxiety disorders and borderline personality disorder. I've been trained in Family Systems Therapy, but when I do couples counseling I mostly just take a problem-solving approach." (that isn't even a totally complete answer). If you understood all of that, you are probably a therapist yourself.
What I usually say instead is "I'm mostly an insight-oriented therapist, but I sometimes use DBT and other techniques as appropriate." But I don't think most people understand that either.
There are some questions on subjects other than payment and scheduling that someone might want to ask a prospective therapist:
1. Do you have experience treating (name of problem)?
2. What are the typical types of patients you work with?
3. Are there any types of patients you don't work with?
4. How many years have you been practicing psychotherapy?
The answers to these questions are more important than the theoretical orientation to which a therapist subscribes.
Newspapers, TV and the internet are full of articles about new types of therapy, often accompanied by claims that the new treatment works miracles. Never forget that today's miracle cure is tomorrow's debunked failure. Almost all of these articles are written by people who aren't mental health professionals. Some of these articles may give a false impression that one can understand different types of therapy by reading articles in the media.
All types of psychotherapy adhere to some basic principles and most therapists today use a variety of techniques. In fact, if you come across a therapist who is wedded to a particular theory or technique, you should be suspicious. That type of specialization only works if the therapist is willing to refer out all patients who need a different type of therapy, and in today's economy, most therapists need more patients, not fewer patients. I do refer out people who need a type of therapy I don't do. But mostly I have a general practice that allows me to see a wide variety of patients. Most of them get better.
What type of questions should people ask when they contact a therapist? First of all, people should ask whether I take their insurance or what type of fees I charge. I am often surprised how many people ask for an appointment without asking first for this information. When I tell some people that I don't take their insurance, they are surprised. I'm often not sure where the misinformation has come from. I am on some HMO panels and not on others. Many times people have found me through their insurance directory, but sometimes people find me through the internet or personal referrals.
A few people pay cash for their sessions. I have a sliding scale fee based on income/net worth. On a few (thankfully rare) occasions, a patient who reports a high income has tried to "negotiate" a lower fee. I offer lower fees for people with low incomes, not for people with high incomes.
I sometimes I get a question along the lines of: "What is your orientation?" People aren't asking about my sexual orientation. They're asking about my theoretical orientation. I'm never sure how to answer this question. If I gave a complete answer, it would sound like gibberish to most people. It would sound something like this: "I believe Object Relations Theory, Self Psychology and Ego Psychology are all important. I sometimes use DBT techniques for anxiety disorders and borderline personality disorder. I've been trained in Family Systems Therapy, but when I do couples counseling I mostly just take a problem-solving approach." (that isn't even a totally complete answer). If you understood all of that, you are probably a therapist yourself.
What I usually say instead is "I'm mostly an insight-oriented therapist, but I sometimes use DBT and other techniques as appropriate." But I don't think most people understand that either.
There are some questions on subjects other than payment and scheduling that someone might want to ask a prospective therapist:
1. Do you have experience treating (name of problem)?
2. What are the typical types of patients you work with?
3. Are there any types of patients you don't work with?
4. How many years have you been practicing psychotherapy?
The answers to these questions are more important than the theoretical orientation to which a therapist subscribes.
Newspapers, TV and the internet are full of articles about new types of therapy, often accompanied by claims that the new treatment works miracles. Never forget that today's miracle cure is tomorrow's debunked failure. Almost all of these articles are written by people who aren't mental health professionals. Some of these articles may give a false impression that one can understand different types of therapy by reading articles in the media.
All types of psychotherapy adhere to some basic principles and most therapists today use a variety of techniques. In fact, if you come across a therapist who is wedded to a particular theory or technique, you should be suspicious. That type of specialization only works if the therapist is willing to refer out all patients who need a different type of therapy, and in today's economy, most therapists need more patients, not fewer patients. I do refer out people who need a type of therapy I don't do. But mostly I have a general practice that allows me to see a wide variety of patients. Most of them get better.
Sunday, November 1, 2015
Narcissistic Personality Disorder--Diagnosis and Treatment
NOTE: This post has been edited since originally published. I've noticed that Narcissistic Personality Disorder is increasingly being used as an epithet in the media and by the general public. It is actually a serious disorder with a lack of effective treatment protocols, and it is on the increase.
The Diagnostic and Statistical Manual of Mental Disorders' checklist of NPD symptoms for diagnosis is the following. Only five symptoms need be present to diagnose the disorder:
1. Has a grandiose sense of self-importance.
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love.
3. Believes that he or she is "special" and unique and can only understood by or should associate with, other special or high-status people or institutions.
4. Requires excessive admiration.
5. Has a sense of entitlement.
6. Is interpersonally exploitative.
7. Lacks empathy, is unwilling to recognize or identify with the needs of others.
8. If often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
Many people with NPD do not have the stereotypical presentation of being overtly arrogant or haughty. I believe the DSM model has been based on treatment experiences with white American males. I work with a diverse population and I've noticed that some people, especially women from cultures in which deference and politeness are valued, can have NPD that is only revealed through an examination of their mental content, not their social behavior.
No one has ever come to my practice for treatment of their Narcissistic Personality Disorder. As I mentioned in my previous post, personality disorders are created by the use of pathological ego defenses that are unconscious. People with NPD are unaware that they have the disorder. Most people with NPD whom I've seen have come to therapy because of dissatisfaction with careers, depression, addictions, or problems managing anger. I will confess that I do not believe I have ever cured anyone's NPD, nor am I aware of any therapist who has done so. Most clinicians and theorists believe that NPD is barely treatable and probably not cureable. However, people with NPD can be helped to develop insight and better judgment, and their symptoms of depression and anxiety generally improve with therapy.
Psychoanalytic theorists became very interested in NPD between the 1970s and the 1990s, but the disorder has received little attention in recent years, in terms of treatment protocols. Yet some research has shown that NPD is on the increase, and it can be a dangerous disorder when it involves lack of empathy. It cannot be resolved with medication, and I believe there's a possibility anti-depressants may make it worse, because they increase self-esteem without increasing insight, which could result in a spike in feelings of grandiosity. Perhaps research will eventually suggest mood stabilizers should be used to treat NPD, but these would not cure the underlying disorder.
Two main theorists have written about NPD: Otto Kernberg, who I mentioned in my previous post, and Heinz Kohut, another psychoanalyst. Kernberg describes a developmental process in which unempathic caregivers give a child the message he or she cannot emotionally depend on anyone. The child may be used for the parent(s)' own purposes, for example, as someone to show off. This interferes with the normal development of the superego. In normal development, the superego includes a component called the ego ideal, which one might describe as the "carrot" whereas the punitive aspects of the superego are the "stick." In normal development, the ego ideal is a psychic structure based on internalizations of persons, systems or values that are admired and desired to be emulated. Without a healthy ego ideal, the child develops "pathological grandiosity" in which he or she become his or her own ego ideal, in a sense worshiping him/herself. This self-worship in lieu of healthy internalizations often leads to a feeling of being hollow, because humans are social animals who depend not only on others in the external world, but also on our internalized representations of others. Kohut developed a slightly different theory that holds that although the ego ideal is necessary for ambition, people with NPD are likely to suffer from a disordered sense of self that is due to a lack of "mirroring" in childhood. His branch of psychoanalytic theory is known as "Self Psychology" and clinicians who follow Kohut's theories tend to believe that therapy that validates a patient's accomplishments as well as emotions, and tolerates a natural idealization of the therapist, is curative.
I've worked with many patients with narcissistic traits, but probably only a few who have had full-blown NPD. What I have experienced in my treatment of persons with NPD and of people with the traits, is that they often improve a lot in the first six months of therapy. Their depression decreases, and if they have had problems managing anger, that usually gets better. They often enjoy therapy. But I've also noticed that after a certain point, the therapy stalls. This can be from a number of reasons, including the difficulty in giving up grandiosity and sometimes, the patient's envy of the therapist, which leads him or her to subtly sabotage the therapy. Here are some examples of how therapy can be only partially effective for people with narcissistic problems:
1. A woman came to see me for career dissatisfaction among other concerns. Although some of her problems cleared up after awhile in therapy, she did not resolve her career dissatisfaction. We discussed various possibilities for modifying her career, but I began to notice that if I suggested an avenue to explore, she gave me a reason why she couldn't do it or wasn't interested in it. No type of work or activity really appeals to people with NPD unless it involves attention from others, or what could be called fame or glory. The normal reasons why people value their work, such as pride in achieving certain skills or helping others, are meaningless to the NPD. Sadly, many jobs and activities don't result in praise and attention, and the NPD is therefore chronically dissatisfied. This chronic dissatisfaction is why NPD is so often implicated in substance abuse and in chronic depression.
2. A man came to see me because of career dissatisfaction and some interpersonal events. He had had a traumatic break-up and I hoped that he could find a happy relationship that would help him get over the traumatic break-up. But as he described his dating activities, it became quite evident that he had no empathy for the people he dated and was sometimes quite critical of how a person looked, (even though he was willing to have sex with them regardless of whether he found them attractive). It turned out he'd pursued his career because he thought it would give him a sense of importance, but the reality is that few jobs change the world or make one famous, just as few romantic partners are beautiful or dramatically exciting. I couldn't think of any realistic career path that would give this man what he craved, and he seemed to come to the realization eventually that he wasn't interested in a committed romantic partnership--at which point he left therapy.
There may be a treatment program that is effective for NPD, even though it wasn't, at least not overtly, designed to treat NPD at all. The 12-step program was designed to treat addictions, but as I have studied it over the years, it has struck me how much of it might actually be targeted toward the symptoms of NPD: The 12-step program insists that its members "deal with life on life's terms," and "turn it over" to a "higher power." It has occurred to me that the "higher power," when internalized, could create a healthy ego ideal. The group norms of the 12-step program, such an anonymity, help to stifle grandiosity and instead provide emotional nurturance through group support. Slogans such as "Easy Does It" and "Live and Let Live" may help temper the rage, envy and other problems that plague people with NPD. Although the 12-step program may not totally "cure" NPD it may control and ameliorate it.
The therapeutic dyad sometimes sets up a power struggle for the person with NPD by making him/her feel vulnerable. Kohut's idea that the therapist can be idealized and that this is curative I find to be somewhat ridiculous--adults don't idealize people the way children do, or if they do, they set themselves up for a quick disappointment. It's well known that people with NPD often idealize, then devalue others. Only abstractions--such as a "Higher Power"--can be truly idealized and internalized in adulthood.
The Diagnostic and Statistical Manual of Mental Disorders' checklist of NPD symptoms for diagnosis is the following. Only five symptoms need be present to diagnose the disorder:
1. Has a grandiose sense of self-importance.
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love.
3. Believes that he or she is "special" and unique and can only understood by or should associate with, other special or high-status people or institutions.
4. Requires excessive admiration.
5. Has a sense of entitlement.
6. Is interpersonally exploitative.
7. Lacks empathy, is unwilling to recognize or identify with the needs of others.
8. If often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
Many people with NPD do not have the stereotypical presentation of being overtly arrogant or haughty. I believe the DSM model has been based on treatment experiences with white American males. I work with a diverse population and I've noticed that some people, especially women from cultures in which deference and politeness are valued, can have NPD that is only revealed through an examination of their mental content, not their social behavior.
No one has ever come to my practice for treatment of their Narcissistic Personality Disorder. As I mentioned in my previous post, personality disorders are created by the use of pathological ego defenses that are unconscious. People with NPD are unaware that they have the disorder. Most people with NPD whom I've seen have come to therapy because of dissatisfaction with careers, depression, addictions, or problems managing anger. I will confess that I do not believe I have ever cured anyone's NPD, nor am I aware of any therapist who has done so. Most clinicians and theorists believe that NPD is barely treatable and probably not cureable. However, people with NPD can be helped to develop insight and better judgment, and their symptoms of depression and anxiety generally improve with therapy.
Psychoanalytic theorists became very interested in NPD between the 1970s and the 1990s, but the disorder has received little attention in recent years, in terms of treatment protocols. Yet some research has shown that NPD is on the increase, and it can be a dangerous disorder when it involves lack of empathy. It cannot be resolved with medication, and I believe there's a possibility anti-depressants may make it worse, because they increase self-esteem without increasing insight, which could result in a spike in feelings of grandiosity. Perhaps research will eventually suggest mood stabilizers should be used to treat NPD, but these would not cure the underlying disorder.
Two main theorists have written about NPD: Otto Kernberg, who I mentioned in my previous post, and Heinz Kohut, another psychoanalyst. Kernberg describes a developmental process in which unempathic caregivers give a child the message he or she cannot emotionally depend on anyone. The child may be used for the parent(s)' own purposes, for example, as someone to show off. This interferes with the normal development of the superego. In normal development, the superego includes a component called the ego ideal, which one might describe as the "carrot" whereas the punitive aspects of the superego are the "stick." In normal development, the ego ideal is a psychic structure based on internalizations of persons, systems or values that are admired and desired to be emulated. Without a healthy ego ideal, the child develops "pathological grandiosity" in which he or she become his or her own ego ideal, in a sense worshiping him/herself. This self-worship in lieu of healthy internalizations often leads to a feeling of being hollow, because humans are social animals who depend not only on others in the external world, but also on our internalized representations of others. Kohut developed a slightly different theory that holds that although the ego ideal is necessary for ambition, people with NPD are likely to suffer from a disordered sense of self that is due to a lack of "mirroring" in childhood. His branch of psychoanalytic theory is known as "Self Psychology" and clinicians who follow Kohut's theories tend to believe that therapy that validates a patient's accomplishments as well as emotions, and tolerates a natural idealization of the therapist, is curative.
I've worked with many patients with narcissistic traits, but probably only a few who have had full-blown NPD. What I have experienced in my treatment of persons with NPD and of people with the traits, is that they often improve a lot in the first six months of therapy. Their depression decreases, and if they have had problems managing anger, that usually gets better. They often enjoy therapy. But I've also noticed that after a certain point, the therapy stalls. This can be from a number of reasons, including the difficulty in giving up grandiosity and sometimes, the patient's envy of the therapist, which leads him or her to subtly sabotage the therapy. Here are some examples of how therapy can be only partially effective for people with narcissistic problems:
1. A woman came to see me for career dissatisfaction among other concerns. Although some of her problems cleared up after awhile in therapy, she did not resolve her career dissatisfaction. We discussed various possibilities for modifying her career, but I began to notice that if I suggested an avenue to explore, she gave me a reason why she couldn't do it or wasn't interested in it. No type of work or activity really appeals to people with NPD unless it involves attention from others, or what could be called fame or glory. The normal reasons why people value their work, such as pride in achieving certain skills or helping others, are meaningless to the NPD. Sadly, many jobs and activities don't result in praise and attention, and the NPD is therefore chronically dissatisfied. This chronic dissatisfaction is why NPD is so often implicated in substance abuse and in chronic depression.
2. A man came to see me because of career dissatisfaction and some interpersonal events. He had had a traumatic break-up and I hoped that he could find a happy relationship that would help him get over the traumatic break-up. But as he described his dating activities, it became quite evident that he had no empathy for the people he dated and was sometimes quite critical of how a person looked, (even though he was willing to have sex with them regardless of whether he found them attractive). It turned out he'd pursued his career because he thought it would give him a sense of importance, but the reality is that few jobs change the world or make one famous, just as few romantic partners are beautiful or dramatically exciting. I couldn't think of any realistic career path that would give this man what he craved, and he seemed to come to the realization eventually that he wasn't interested in a committed romantic partnership--at which point he left therapy.
There may be a treatment program that is effective for NPD, even though it wasn't, at least not overtly, designed to treat NPD at all. The 12-step program was designed to treat addictions, but as I have studied it over the years, it has struck me how much of it might actually be targeted toward the symptoms of NPD: The 12-step program insists that its members "deal with life on life's terms," and "turn it over" to a "higher power." It has occurred to me that the "higher power," when internalized, could create a healthy ego ideal. The group norms of the 12-step program, such an anonymity, help to stifle grandiosity and instead provide emotional nurturance through group support. Slogans such as "Easy Does It" and "Live and Let Live" may help temper the rage, envy and other problems that plague people with NPD. Although the 12-step program may not totally "cure" NPD it may control and ameliorate it.
The therapeutic dyad sometimes sets up a power struggle for the person with NPD by making him/her feel vulnerable. Kohut's idea that the therapist can be idealized and that this is curative I find to be somewhat ridiculous--adults don't idealize people the way children do, or if they do, they set themselves up for a quick disappointment. It's well known that people with NPD often idealize, then devalue others. Only abstractions--such as a "Higher Power"--can be truly idealized and internalized in adulthood.
Wednesday, October 14, 2015
Diagnosing and Treating Borderline and Narcissistic Personality Disorders, Part One: Borderline Personality Disorder
Over the past 10 or 20 years there have been increased mentions of Borderline Personality Disorder and Narcissistic Personality Disorder in the media, including newspapers, self-help books and even feature films. These disorders are complex and manifest differently in different individuals. Many times clinicians can't diagnose, or won't diagnose, these
disorders in the first session or the first several sessions, especially
if the person is initially depressed.
How to diagnose personality disorders remains controversial in the mental health field. The Diagnostic and Statistical Manual of Mental Disorders, the main reference book for diagnosis, uses checklists of symptoms. Is a checklist of symptoms really the most accurate way to diagnose a disorder? A checklist does not describe causes or underlying psychological processes.
The current checklist for Borderline Personality Disorder in the DSM-V, is the following ( only 5 of these symptoms need be present to make the diagnosis). One can see that there might be significant overlap with other diagnoses, such as depression and PTSD:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation.
3. Identity disturbance: markely and persistenly unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentialy self-damaging.
5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
6. Affective (emotional) instability.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Starting in the 1970s, a psychoanalyst and researcher named Otto Kernberg began studying borderline personality disorder, a condition that had begun to be identified after the time of Sigmund Freud. Prior to the development of the term "borderline personality disorder," clinicians sometimes came across patients with what they called "ambulatory schizophrenia" or the "As If" personality. What they were trying to describe was a syndrome in which the person functioned mostly normally, and had no obvious evidence of psychosis, but under psychoanalysis or even just persistent questioning, revealed themselves to have highly distorted thought processes. Kernberg came up with a type of initial evaluation to diagnose this condition. He also developed a theory that remains controversial today. He believes that all personality disorders are subsets of borderline personality disorder, because the disorder isn't really a syndrome at all but a type of personality organization--"Borderline" refers to the border between neurosis and psychosis. "Normal" people have a neurotic level of organization (no one is completely mentally healthy), psychotic people have lost the ability to distinguish reality from fantasy, and borderlines, in the middle, remain in touch with physical reality but distort perceptions based on pathological psychological defenses. These distorted perceptions can lead to problems in interpersonal relationships and other issues. Other personality disorders, such as narcissistic personality disorder, function on the same level, but simply manifest differently due to slightly different personality development.
The subject of psychological defense mechanisms is complex. However, this explanation, taken from Wikipedia, is generally correct:
A defence mechanism...reduces anxiety arising from unacceptable or potentially harmful impulses. Defence mechanisms are unconscious and are not to be confused with conscious coping strategies "
... In psychoanalytic theory, defence mechanisms...are psychological strategies brought into play by the unconscious mind to manipulate, deny, or distort reality in order to defend against feelings of anxiety and unacceptable impulses
....Healthy persons normally use different defences throughout life. An ego defence mechanism becomes pathological only when its persistent use leads to maladaptive behaviour such that the physical or mental health of the individual is adversely affected.
Kernberg and others have found that people with borderline personality disorder often extensively use the defenses of idealization, devaluation (often combined in "splitting"), grandiosity, and types of projection. But use of these defenses often are not apparent to the casual observer, and, because defenses are unconscious, the borderline person remains unaware of their own use of these defenses.
Although I believe Kernberg's theories to be mostly correct and especially helpful in terms of formulating a prognosis, like many psychoanalytic theories, it doesn't really address the issue of later environmental factors (Kernberg believes that early environmental factors combined with genetics are at the root of personality disorders). Starting about 20 years ago, theorists began to notice that the typical symptoms of persons with borderline p.d. were quite similar to those of trauma survivors and suggested that some borderlines might actually have PTSD and had been misdiagnosed. But one could say that this is the very reason why Kernberg's perspective is important, because it emphasizes the underlying defenses rather than the overt symptoms.
Earlier this year I went to a talk by Dr. Michael Stone, the forensic psychiatrist, in which he suggested clinicians decide whether the borderlines with whom they were working had primarily a trauma-based condition or primarily a genetic condition. I've begun to believe that there are different types of borderline p.d. Perhaps eventually diagnostic manuals will reflect what clinicians have been seeing for many years.
How is borderline personality disorder treated? Some would answer, not well. The general consensus is that the disorder is resistant to change. However, there are a multitude of treatments that may help. Traditionally the disorder has been treated with intensive psychotherapy to address the pathological defenses. The underlying premise of this treatment is that human personality is malleable, is developed in an early dyadic relationship, and can be altered by the patient/therapist dyadic relationship even in later life. I believe this to be somewhat true. In the 1990s, a psychologist named Marsha Linehan developed a treatment protocol called Dialectical Behavior Therapy to help borderlines learn to cope with their emotions and interpersonal relations. DBT is now used to help people with other disorders as well. I occasionally use DBT techniques, as they help people learn assertiveness as well as distraction techniques, especially "mindfulness," to relieve overwhelming emotions. I have found people with anxiety disorders often benefit from DBT. The DBT program does not really alter the underlying personality structure, however.
I've treated a number of people with borderline personality disorder, and have found them to be quite different from each other. A childhood marked by invalidating remarks by parents is common, but not everyone subjected to such an environment will develop BPD. Psychotherapy that combines validation with confrontation of unhelpful defenses seems to be useful for my personality-disordered patients. In a few cases, I've seen patients with borderline personality disorder benefit from a mood stabilizing medication called Lamictal, which moderates their unstable emotions.
How to diagnose personality disorders remains controversial in the mental health field. The Diagnostic and Statistical Manual of Mental Disorders, the main reference book for diagnosis, uses checklists of symptoms. Is a checklist of symptoms really the most accurate way to diagnose a disorder? A checklist does not describe causes or underlying psychological processes.
The current checklist for Borderline Personality Disorder in the DSM-V, is the following ( only 5 of these symptoms need be present to make the diagnosis). One can see that there might be significant overlap with other diagnoses, such as depression and PTSD:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation.
3. Identity disturbance: markely and persistenly unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentialy self-damaging.
5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
6. Affective (emotional) instability.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Starting in the 1970s, a psychoanalyst and researcher named Otto Kernberg began studying borderline personality disorder, a condition that had begun to be identified after the time of Sigmund Freud. Prior to the development of the term "borderline personality disorder," clinicians sometimes came across patients with what they called "ambulatory schizophrenia" or the "As If" personality. What they were trying to describe was a syndrome in which the person functioned mostly normally, and had no obvious evidence of psychosis, but under psychoanalysis or even just persistent questioning, revealed themselves to have highly distorted thought processes. Kernberg came up with a type of initial evaluation to diagnose this condition. He also developed a theory that remains controversial today. He believes that all personality disorders are subsets of borderline personality disorder, because the disorder isn't really a syndrome at all but a type of personality organization--"Borderline" refers to the border between neurosis and psychosis. "Normal" people have a neurotic level of organization (no one is completely mentally healthy), psychotic people have lost the ability to distinguish reality from fantasy, and borderlines, in the middle, remain in touch with physical reality but distort perceptions based on pathological psychological defenses. These distorted perceptions can lead to problems in interpersonal relationships and other issues. Other personality disorders, such as narcissistic personality disorder, function on the same level, but simply manifest differently due to slightly different personality development.
The subject of psychological defense mechanisms is complex. However, this explanation, taken from Wikipedia, is generally correct:
A defence mechanism...reduces anxiety arising from unacceptable or potentially harmful impulses. Defence mechanisms are unconscious and are not to be confused with conscious coping strategies "
... In psychoanalytic theory, defence mechanisms...are psychological strategies brought into play by the unconscious mind to manipulate, deny, or distort reality in order to defend against feelings of anxiety and unacceptable impulses
....Healthy persons normally use different defences throughout life. An ego defence mechanism becomes pathological only when its persistent use leads to maladaptive behaviour such that the physical or mental health of the individual is adversely affected.
Kernberg and others have found that people with borderline personality disorder often extensively use the defenses of idealization, devaluation (often combined in "splitting"), grandiosity, and types of projection. But use of these defenses often are not apparent to the casual observer, and, because defenses are unconscious, the borderline person remains unaware of their own use of these defenses.
Although I believe Kernberg's theories to be mostly correct and especially helpful in terms of formulating a prognosis, like many psychoanalytic theories, it doesn't really address the issue of later environmental factors (Kernberg believes that early environmental factors combined with genetics are at the root of personality disorders). Starting about 20 years ago, theorists began to notice that the typical symptoms of persons with borderline p.d. were quite similar to those of trauma survivors and suggested that some borderlines might actually have PTSD and had been misdiagnosed. But one could say that this is the very reason why Kernberg's perspective is important, because it emphasizes the underlying defenses rather than the overt symptoms.
Earlier this year I went to a talk by Dr. Michael Stone, the forensic psychiatrist, in which he suggested clinicians decide whether the borderlines with whom they were working had primarily a trauma-based condition or primarily a genetic condition. I've begun to believe that there are different types of borderline p.d. Perhaps eventually diagnostic manuals will reflect what clinicians have been seeing for many years.
How is borderline personality disorder treated? Some would answer, not well. The general consensus is that the disorder is resistant to change. However, there are a multitude of treatments that may help. Traditionally the disorder has been treated with intensive psychotherapy to address the pathological defenses. The underlying premise of this treatment is that human personality is malleable, is developed in an early dyadic relationship, and can be altered by the patient/therapist dyadic relationship even in later life. I believe this to be somewhat true. In the 1990s, a psychologist named Marsha Linehan developed a treatment protocol called Dialectical Behavior Therapy to help borderlines learn to cope with their emotions and interpersonal relations. DBT is now used to help people with other disorders as well. I occasionally use DBT techniques, as they help people learn assertiveness as well as distraction techniques, especially "mindfulness," to relieve overwhelming emotions. I have found people with anxiety disorders often benefit from DBT. The DBT program does not really alter the underlying personality structure, however.
I've treated a number of people with borderline personality disorder, and have found them to be quite different from each other. A childhood marked by invalidating remarks by parents is common, but not everyone subjected to such an environment will develop BPD. Psychotherapy that combines validation with confrontation of unhelpful defenses seems to be useful for my personality-disordered patients. In a few cases, I've seen patients with borderline personality disorder benefit from a mood stabilizing medication called Lamictal, which moderates their unstable emotions.
Wednesday, September 30, 2015
"Trigger Warnings"
After writing my last post, on PTSD, I started thinking about the current controversy over "Trigger Warnings," labels that are being placed on some class materials by some college professors. This term misappropriates a concept from mental health treatment. A content warning label is not a "trigger warning."The so-called "trigger warnings" are not really trigger warnings at all, as I will explain:
The concept of a "trigger" that incites symptoms has been used for some time in the study of PTSD (post traumatic stress disorder). For example, it has been observed for many decades that some combat veterans are triggered by the sound of explosions to re-experience combat experiences in a dissociative state. People who have been raped and who have PTSD as a result may experience a triggering of symptoms by a wide variety of stimuli: Some may experience anxiety when alone with a man, during sex, or when exposed to something only tangentially related to the rape--this could be anything from a song that was playing while they were being raped to a particular smell. Clinicians who work with people with PTSD, and researchers who study PTSD, know that a traumatized individual may have very individual, specific, triggers. Thus, it's impossible to predict in advance what might trigger PTSD symptoms in a person with PTSD without knowing that person.
Content warning labels have been used for a long time for movies, and more recently, for record albums. All movies are given a rating for content, the purpose of which is to alert parents that some content might not be appropriate for children. Warning labels on music, which began in the 1980s, perform a similar function. Content warning labels were not designed to help people with PTSD, but to provide information for the general public, especially parents. Are such warning labels appropriate for college reading materials? College students aren't children and college reading assignments aren't entertainment, but may in fact be designed to provoke or challenge.
A college professor doesn't know individual students at the start of the semester, and can't possibly know whether the class will include students with PTSD, and in any case, what their triggers would be. Many students with PTSD can often figure out, by looking at synopses of books, films or other material that they will have to view for class, whether the materials might contain triggering material. But depending on the individual's triggers, it might also be impossible to predict. What is absolutely certain, however, is that it would be impossible for the professor to predict what material might be triggering to any particular student. And even if it was possible for the professor to know in advance that particular material would be triggering to a particular student, is it the professor's responsibility to warn the student? This puts the professor in the role of mental health clinician, a role most college professors are not qualified or licensed to fulfill.
From a clinical perspective, this type of discussion might be beside the point. Therapists don't counsel PTSD patients to avoid triggers. We don't tell rape survivors to avoid men, or tell Iraq combat veterans to avoid driving so that they won't think about roadside bombs. We help people develop coping skills, tell them that their symptoms are likely to subside over time, and encourage them to NOT avoid triggers, because to do so can increase the fear and create a phobia. This is precisely why the area of PTSD triggers is best left to mental health clinicians and not college professors from unrelated fields. I read a comment from a philosophy professor, in The New York Times, that she gives "trigger warnings" so that students with PTSD can meditate or take medication before exposing themselves to difficult material. As a therapist, I encourage meditation for people who can benefit, but I would never counsel anyone to take an anti-anxiety medication prior to reading a book. This could set the stage for a bad habit. This is not the purpose for which anti-anxiety medication is prescribed.
If a college student had such severe PTSD that she or he was unable to read or view triggering material without experiencing disabling symptoms for hours or without having a suicidal, homicidal or psychotic episode, that person should not be in college at all. College is a stressful environment and persons who are severely psychiatrically ill do not belong in college. However, few PTSD sufferers fall into this category. For most students with PTSD, attending therapy to improve coping skills and process the trauma in a safe environment is enough to be able to attend classes and complete all assignments. There is also the fact that some people with PTSD may have to acknowledge that for the rest of their lives, they are going to experience some discomfort from certain stimuli that would have no affect on most people. Many people learn to live with symptoms from medical or psychiatric problems, because treatment often doesn't mean a 100 percent cure.
As I thought about this topic, it occurred to me that perhaps what I'm saying here is obvious, and maybe I am missing the point: Maybe the point isn't to help PTSD sufferers at all. Maybe the point of these so-called "trigger warnings" is to alert students to the professor's opinion about the material. Maybe what these "trigger warnings" really do is alert students to the fact that the professor finds the material troubling, and to suggest that the students should also find it troubling. I hope this isn't what's really going on, because it would be a violation of the basic principle of a liberal arts education, which is to teach students independent critical thinking.
The concept of a "trigger" that incites symptoms has been used for some time in the study of PTSD (post traumatic stress disorder). For example, it has been observed for many decades that some combat veterans are triggered by the sound of explosions to re-experience combat experiences in a dissociative state. People who have been raped and who have PTSD as a result may experience a triggering of symptoms by a wide variety of stimuli: Some may experience anxiety when alone with a man, during sex, or when exposed to something only tangentially related to the rape--this could be anything from a song that was playing while they were being raped to a particular smell. Clinicians who work with people with PTSD, and researchers who study PTSD, know that a traumatized individual may have very individual, specific, triggers. Thus, it's impossible to predict in advance what might trigger PTSD symptoms in a person with PTSD without knowing that person.
Content warning labels have been used for a long time for movies, and more recently, for record albums. All movies are given a rating for content, the purpose of which is to alert parents that some content might not be appropriate for children. Warning labels on music, which began in the 1980s, perform a similar function. Content warning labels were not designed to help people with PTSD, but to provide information for the general public, especially parents. Are such warning labels appropriate for college reading materials? College students aren't children and college reading assignments aren't entertainment, but may in fact be designed to provoke or challenge.
A college professor doesn't know individual students at the start of the semester, and can't possibly know whether the class will include students with PTSD, and in any case, what their triggers would be. Many students with PTSD can often figure out, by looking at synopses of books, films or other material that they will have to view for class, whether the materials might contain triggering material. But depending on the individual's triggers, it might also be impossible to predict. What is absolutely certain, however, is that it would be impossible for the professor to predict what material might be triggering to any particular student. And even if it was possible for the professor to know in advance that particular material would be triggering to a particular student, is it the professor's responsibility to warn the student? This puts the professor in the role of mental health clinician, a role most college professors are not qualified or licensed to fulfill.
From a clinical perspective, this type of discussion might be beside the point. Therapists don't counsel PTSD patients to avoid triggers. We don't tell rape survivors to avoid men, or tell Iraq combat veterans to avoid driving so that they won't think about roadside bombs. We help people develop coping skills, tell them that their symptoms are likely to subside over time, and encourage them to NOT avoid triggers, because to do so can increase the fear and create a phobia. This is precisely why the area of PTSD triggers is best left to mental health clinicians and not college professors from unrelated fields. I read a comment from a philosophy professor, in The New York Times, that she gives "trigger warnings" so that students with PTSD can meditate or take medication before exposing themselves to difficult material. As a therapist, I encourage meditation for people who can benefit, but I would never counsel anyone to take an anti-anxiety medication prior to reading a book. This could set the stage for a bad habit. This is not the purpose for which anti-anxiety medication is prescribed.
If a college student had such severe PTSD that she or he was unable to read or view triggering material without experiencing disabling symptoms for hours or without having a suicidal, homicidal or psychotic episode, that person should not be in college at all. College is a stressful environment and persons who are severely psychiatrically ill do not belong in college. However, few PTSD sufferers fall into this category. For most students with PTSD, attending therapy to improve coping skills and process the trauma in a safe environment is enough to be able to attend classes and complete all assignments. There is also the fact that some people with PTSD may have to acknowledge that for the rest of their lives, they are going to experience some discomfort from certain stimuli that would have no affect on most people. Many people learn to live with symptoms from medical or psychiatric problems, because treatment often doesn't mean a 100 percent cure.
As I thought about this topic, it occurred to me that perhaps what I'm saying here is obvious, and maybe I am missing the point: Maybe the point isn't to help PTSD sufferers at all. Maybe the point of these so-called "trigger warnings" is to alert students to the professor's opinion about the material. Maybe what these "trigger warnings" really do is alert students to the fact that the professor finds the material troubling, and to suggest that the students should also find it troubling. I hope this isn't what's really going on, because it would be a violation of the basic principle of a liberal arts education, which is to teach students independent critical thinking.
Wednesday, September 23, 2015
Taking a Closer Look at PTSD
I wrote a previous post about PTSD (post-traumatic stress disorder), but I decided the subject could use more elaboration. There seems to be misinformation about PTSD floating around. In addition, there is some dispute in the mental health field about how to categorize PTSD patients who've had different experiences.
PTSD can result from a wide range of traumatic experiences. The Diagnostic and Statistical Manual of Mental Disorders states that PTSD can result from exposure to "actual or threatened death, serious injury, or sexual violence." This covers many types of situations.
It's normal for people exposed to one of the above situations to have symptoms including fears, flashbacks and intrusive memories, for up to one month following the incident. If symptoms last only one month or less, the syndrome is called "Acute Stress Disorder," but in my opinion it is not a disorder at all, but a normal reaction. Most people who have witnessed an accident or a crime that involved serious injury or death to another person will have some of these symptoms. For example, I counseled someone who, while working at a bank, witnessed the bank's armed robbery. In another case, the patient witnessed the sudden death of a co-worker from natural causes. These individuals had some symptoms, but they were not serious. These types of patients might not need long term treatment and may only need support. If the incident happened at a workplace, sometimes it is helpful for employees to meet as a group for support. I have facilitated some groups for this purpose.
The PTSD cases I've treated have been diverse. At least two patients I've seen had PTSD from terrible accidents. One case resulted from a construction accident in which one person was killed and another seriously injured. Another patient was a driver in a car accident that killed several people--his friends. These individuals had severe PTSD that included hallucinations. In these hallucinations, they saw their dead friends sitting next to them on the sofa and in some cases were able to "touch" the dead friend. The presence of such symptoms does not indicate a chronic psychotic disorder. In fact, visual hallucinations are not uncommon in PTSD, whereas chronic psychotic disorders such as schizophrenia are more likely to involve auditory hallucinations ("hearing voices"). Both patients got somewhat better over time with treatment, but unfortunately one of them developed a drug addiction, which complicated matters.
I've also worked with combat veterans from conflicts including Vietnam, Lebanon, Kosovo, Iraq and Afghanistan. It is normal for any combat veteran to have some stress disorder symptoms. In some cases, however, symptoms persist long after the person leaves the combat zone. Why does this happen with some individuals and not others? There can be many factors, including the severity of combat experienced, and, as I mentioned in my previous post, guilt feelings. The guilt can be either irrational or rational. Irrational guilt feelings can be treated in psychotherapy through examining the irrational thoughts and how they developed. Helping someone who feels guilty about doing something that was actually wrong is a bit more complicated. In those cases the treatment might involve helping the person to make amends in some way or helping the person to put actions in a context. In some cases, when a person has voiced religious views, I have suggested that he speak with clergy from his denomination. I can't answer the question "am I going to Hell?"
Exposure to wartime combat may change views on life and prompt philosophical questions. In my opinion dealing with such issues can be an important part of therapy, but unfortunately, there is a trend in the field to emphasize behavioral approaches to PTSD that may be helpful in symptom management but ultimately fail to address the roots of the disorder. Many people who have been exposed to trauma suffer a loss of a previous, idealized view of the world that is common but also inaccurate. I believe that trauma survivors, far from being merely damaged individuals, often have wisdom that should be appreciated.
About 20 years ago, a psychiatrist named Judith Lewis Herman proposed a new diagnosis called "Complex PTSD" for people who have survived long-term captivity in an abusive situation. This category includes survivors of childhood abuse, as children have no power to leave their abusive situations. This diagnosis has never been formally accepted by the American Psychiatric Association, which is a puzzle to me, because PTSD from long-term childhood abuse is going to result in a different symptom profile than PTSD from a one-time incident or even PTSD from wartime combat. Long-term exposure to trauma, especially if it starts during childhood, can cause personality changes.
In short, there are many factors to consider when evaluating stress disorder symptoms. These include whether the trauma was a one-time incident or a prolonged series of incidents, whether or not the patient feels guilt about the trauma, and if so, is the guilt rational or irrational, at what age was the trauma experienced and for how long, and also the identity of the perpetrator if there was one (or more than one). There are probably more factors that I can't think of at the moment. Treatment for PTSD in my opinion should involve a combination of insight-oriented and cognitive or behavioral interventions and in some cases medication may be necessary. Group therapy can sometimes be helpful, perhaps especially for combat veterans and for survivors of childhood sexual abuse.
PTSD can result from a wide range of traumatic experiences. The Diagnostic and Statistical Manual of Mental Disorders states that PTSD can result from exposure to "actual or threatened death, serious injury, or sexual violence." This covers many types of situations.
It's normal for people exposed to one of the above situations to have symptoms including fears, flashbacks and intrusive memories, for up to one month following the incident. If symptoms last only one month or less, the syndrome is called "Acute Stress Disorder," but in my opinion it is not a disorder at all, but a normal reaction. Most people who have witnessed an accident or a crime that involved serious injury or death to another person will have some of these symptoms. For example, I counseled someone who, while working at a bank, witnessed the bank's armed robbery. In another case, the patient witnessed the sudden death of a co-worker from natural causes. These individuals had some symptoms, but they were not serious. These types of patients might not need long term treatment and may only need support. If the incident happened at a workplace, sometimes it is helpful for employees to meet as a group for support. I have facilitated some groups for this purpose.
The PTSD cases I've treated have been diverse. At least two patients I've seen had PTSD from terrible accidents. One case resulted from a construction accident in which one person was killed and another seriously injured. Another patient was a driver in a car accident that killed several people--his friends. These individuals had severe PTSD that included hallucinations. In these hallucinations, they saw their dead friends sitting next to them on the sofa and in some cases were able to "touch" the dead friend. The presence of such symptoms does not indicate a chronic psychotic disorder. In fact, visual hallucinations are not uncommon in PTSD, whereas chronic psychotic disorders such as schizophrenia are more likely to involve auditory hallucinations ("hearing voices"). Both patients got somewhat better over time with treatment, but unfortunately one of them developed a drug addiction, which complicated matters.
I've also worked with combat veterans from conflicts including Vietnam, Lebanon, Kosovo, Iraq and Afghanistan. It is normal for any combat veteran to have some stress disorder symptoms. In some cases, however, symptoms persist long after the person leaves the combat zone. Why does this happen with some individuals and not others? There can be many factors, including the severity of combat experienced, and, as I mentioned in my previous post, guilt feelings. The guilt can be either irrational or rational. Irrational guilt feelings can be treated in psychotherapy through examining the irrational thoughts and how they developed. Helping someone who feels guilty about doing something that was actually wrong is a bit more complicated. In those cases the treatment might involve helping the person to make amends in some way or helping the person to put actions in a context. In some cases, when a person has voiced religious views, I have suggested that he speak with clergy from his denomination. I can't answer the question "am I going to Hell?"
Exposure to wartime combat may change views on life and prompt philosophical questions. In my opinion dealing with such issues can be an important part of therapy, but unfortunately, there is a trend in the field to emphasize behavioral approaches to PTSD that may be helpful in symptom management but ultimately fail to address the roots of the disorder. Many people who have been exposed to trauma suffer a loss of a previous, idealized view of the world that is common but also inaccurate. I believe that trauma survivors, far from being merely damaged individuals, often have wisdom that should be appreciated.
About 20 years ago, a psychiatrist named Judith Lewis Herman proposed a new diagnosis called "Complex PTSD" for people who have survived long-term captivity in an abusive situation. This category includes survivors of childhood abuse, as children have no power to leave their abusive situations. This diagnosis has never been formally accepted by the American Psychiatric Association, which is a puzzle to me, because PTSD from long-term childhood abuse is going to result in a different symptom profile than PTSD from a one-time incident or even PTSD from wartime combat. Long-term exposure to trauma, especially if it starts during childhood, can cause personality changes.
In short, there are many factors to consider when evaluating stress disorder symptoms. These include whether the trauma was a one-time incident or a prolonged series of incidents, whether or not the patient feels guilt about the trauma, and if so, is the guilt rational or irrational, at what age was the trauma experienced and for how long, and also the identity of the perpetrator if there was one (or more than one). There are probably more factors that I can't think of at the moment. Treatment for PTSD in my opinion should involve a combination of insight-oriented and cognitive or behavioral interventions and in some cases medication may be necessary. Group therapy can sometimes be helpful, perhaps especially for combat veterans and for survivors of childhood sexual abuse.
Tuesday, September 1, 2015
Diagnosis and Prognosis in the Information Age
Recently I read a quote from a celebrity, I think on Facebook, saying that he has been "struggling" with anxiety and depression for at least 7 years. I was puzzled by this, because there's no reason for anyone to struggle with anxiety or depression for that length of time. There are numerous treatments for depression and for anxiety disorders. Most people with depressive or anxiety disorders are able to resolve their symptoms or at least tolerate them, if they get the appropriate treatment.
I wondered whether the celebrity had really been diagnosed with bipolar disorder or borderline personality disorder, but was afraid to say so, because these conditions are far more serious and he thought it would be too stigmatizing to admit he had them. It's also possible that his treatment professionals told him that he had "anxiety and depression" when in reality they had diagnosed him with borderline personality disorder or possibly even with bipolar disorder, without telling him. In other words, it's possible his treatment professionals lied to him, to avoid upsetting him (and potentially losing a high-paying patient). It's also possible the celebrity was misdiagnosed or was receiving inappropriate or inadequate treatment, or that he has been noncompliant with treatment. All I know is that something was missing from the picture.
This scenario and its possible behind-the-scenes factors illustrate some of the pitfalls of our "Information Age" in which people are inundated with "information" from the internet and especially from social media. It also may illustrate the continuing stigma relating to mental health conditions, as well as the general difficulties people may encounter getting correct diagnoses, information and treatment for their conditions.
I have learned that it is important to tell people what their diagnoses are. When I was in graduate school, some of my professors minimized this educative component of treatment. Many colleagues I've had believe that patients can fixate on diagnosis, or that diagnoses are controversial or often inaccurate. Although I agree with those colleagues that there are many potential problems involved in telling patients that they have a condition such as borderline personality disorder, antisocial personality disorder, or another stigmatizing condition, I now believe patients have a right to know and I feel comfortable making such diagnoses when I have the required evidence.
I saw numerous comments on the actor's Facebook page from fans stating they too had been struggling with depression or anxiety and depression for years. I didn't see any comments from people speaking about how they recovered from their conditions. No one seemed to be questioning whether they had been given the correct diagnosis or the right treatment. This is sad. With only a couple of exceptions that I can think of, every patient I've worked with who had a depressive disorder or an anxiety disorder as their primary diagnosis got much better, sometimes with therapy alone and sometimes with a combination of therapy and medication. In the two cases that spring to mind in which the person did not get better, I strongly suspected the patients were not compliant with their medication and in one case, the person was using drugs. I also had one patient who didn't recover from severe depression until she had treatment with a brain stimulation method that at the time was only available in Canada ( I believe it is now approved in the US). The medications she'd previously tried had been ineffective. It may take some time to find the correct treatment regimen for someone's condition. But there is no question that depression and anxiety can usually be resolved. The treatment of a condition such as borderline personality disorder is far more difficult and perhaps I'll discuss this in a later post. Bipolar disorder is incurable but can be managed with medication.
I commend public figures for speaking about their personal problems in an attempt to destigmatize those problems, but this is only useful if what they are saying is the truth. It's sad that both patients and their treatment professionals are still sometimes victims of the fear of stigmatization. Perhaps one day our society will acknowledge that there's no such thing as perfect mental health and that we all have problems.
I wondered whether the celebrity had really been diagnosed with bipolar disorder or borderline personality disorder, but was afraid to say so, because these conditions are far more serious and he thought it would be too stigmatizing to admit he had them. It's also possible that his treatment professionals told him that he had "anxiety and depression" when in reality they had diagnosed him with borderline personality disorder or possibly even with bipolar disorder, without telling him. In other words, it's possible his treatment professionals lied to him, to avoid upsetting him (and potentially losing a high-paying patient). It's also possible the celebrity was misdiagnosed or was receiving inappropriate or inadequate treatment, or that he has been noncompliant with treatment. All I know is that something was missing from the picture.
This scenario and its possible behind-the-scenes factors illustrate some of the pitfalls of our "Information Age" in which people are inundated with "information" from the internet and especially from social media. It also may illustrate the continuing stigma relating to mental health conditions, as well as the general difficulties people may encounter getting correct diagnoses, information and treatment for their conditions.
I have learned that it is important to tell people what their diagnoses are. When I was in graduate school, some of my professors minimized this educative component of treatment. Many colleagues I've had believe that patients can fixate on diagnosis, or that diagnoses are controversial or often inaccurate. Although I agree with those colleagues that there are many potential problems involved in telling patients that they have a condition such as borderline personality disorder, antisocial personality disorder, or another stigmatizing condition, I now believe patients have a right to know and I feel comfortable making such diagnoses when I have the required evidence.
I saw numerous comments on the actor's Facebook page from fans stating they too had been struggling with depression or anxiety and depression for years. I didn't see any comments from people speaking about how they recovered from their conditions. No one seemed to be questioning whether they had been given the correct diagnosis or the right treatment. This is sad. With only a couple of exceptions that I can think of, every patient I've worked with who had a depressive disorder or an anxiety disorder as their primary diagnosis got much better, sometimes with therapy alone and sometimes with a combination of therapy and medication. In the two cases that spring to mind in which the person did not get better, I strongly suspected the patients were not compliant with their medication and in one case, the person was using drugs. I also had one patient who didn't recover from severe depression until she had treatment with a brain stimulation method that at the time was only available in Canada ( I believe it is now approved in the US). The medications she'd previously tried had been ineffective. It may take some time to find the correct treatment regimen for someone's condition. But there is no question that depression and anxiety can usually be resolved. The treatment of a condition such as borderline personality disorder is far more difficult and perhaps I'll discuss this in a later post. Bipolar disorder is incurable but can be managed with medication.
I commend public figures for speaking about their personal problems in an attempt to destigmatize those problems, but this is only useful if what they are saying is the truth. It's sad that both patients and their treatment professionals are still sometimes victims of the fear of stigmatization. Perhaps one day our society will acknowledge that there's no such thing as perfect mental health and that we all have problems.
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