It’s been ages since I’ve written here. I figure I’ll do a post on my current situation then do posts on what has happened since I’ve last written.

Employment

We’re both still unemployed and appear no closer to getting a job than when we first moved here. I was reminded the other day that one of the reasons I may not be getting any call backs is the two year gap in my resume. At the same time though, the person recounted her own difficulties with finding a job despite all her volunteer work. In addition, my husband doesn’t have a huge gap in his resume like I do and he’s having as much trouble as I am.

Financial

My mom finally came through and agreed to give me a sizable loan. I had to beg her for it though and she didn’t offer it to me despite my keeping her updated on all the debt I was running up and having to take out a cash advance at a hefty interest rate. She also found a way for the loan to not come out of her pocket at all. It’s from a credit card offer.

My husband’s mom in the meantime has been tapped dry. The money and loans she’s given us have come out of her own pocket. The different between our parents is striking. Then again, it’s my mom who has OCPD, not his.

As part of that OCPD, my mom is suddenly putting restrictions on the loan. Originally, she was going to give us the whole thing at once. When I asked for the loan in stages, she now has an idea of what I’m using it for and has declared it cannot be used on my husband. Huh? Somehow, my credit card bills to pay for his food and rent to pay for his housing is ok but wanting to use the money for his bankruptcy lawyer is not. This happened yesterday. It stressed me out so much that I couldn’t see straight and had a massive headache. We ended up just going to bed because of the stress she’d caused us.

I’m going to try again today, using a lie to get the money to cover my husband’s bankruptcy. I don’t have enough in the bank to pay for it outright, that’s part of the reason I originally asked for the loan!

Eye Strain

I finally have new glasses. Hopefully my eye strain will be less and I won’t need to take naps as often. Damn astigmatism.

My husband says that stress can increase the pressure in my eyes and I’m feeling it even now. I used to be able to read for hours without a problem. Bleh.

Uninsured

We’re still uninsured and see no way of getting around it. Stroger is now where we have to go for health care. We’re not even sure if our Medicaid denial can be successfully appealed without first getting Social Security which can take who knows how many more months. We seriously moved to the wrong state.

Graduate School

I’m researching graduate schools and trying to start the application process. It’s been a very long time since I started on and completed a project. I keep having doubts about whether or not I can actually do the application, never mind do a graduate school program. My self-esteem is shot and that’s all there is to it. Right now, I’m looking at two schools and three programs. The applications are a lot simpler than I expected. When I first started doing research, I was expecting crazy application essay questions like the ones I got for undergrad. Now it’s just simple “Why do you want to attend our program” questions. When I first started looking I was too early, now I fear I’m too late. The graduate schools are already accepting applications. If I don’t try though, I’ll never know.

I have two main hurdles, getting recommendations from people I haven’t talked to in over three years and taking the GRE. I’m terrified of the GRE because of the cost and because I perform so badly on standardized tests. I’m trying to avoid stress and to keep the depression at bay.

When did I become so fucked up? When did I start to see myself as disabled? As intrinsically different and limited? Bleh. I’m hoping that going to grad school will help alter my perception of myself. While most people can get a BA and certainly anyone can be unemployed, not everyone can get a Master’s degree. I need something to make me feel better about myself and my station in life.

We at The Courant considered closing this site recently and in fact did so, for 2 days. Not having posted anything new in months, some of our authors having to take time to heal themselves, and at times feeling disheartened and discouraged in the knowledge that Christopher Hansard and others like him continue to practice, continue to gain credibility and continue to be enabled by fans and followers despite having committed a myriad of abusive acts against clients in their care, former students and workshop participants.

It was also brought to our attention that Christopher Hansard is now counseling and advising others who have been cyber-stalked or harassed online as he claims to have been so “wrongfully” accused and defamed through the internet.

No matter how many people this man has abused, no matter how many ethical and moral boundaries he has crossed, lives he has ruined, Christopher Hansard will always, without fail, present himself as the helpless victim. There will always be those who support him, and there will always be those who believe him because they want to believe.

We cannot change that, nor would we want to attempt to change the minds of those who would choose to believe despite the sheer number of legitimate victims that have come forward, whether online or have simply found the courage to open up to others enough to carry their story, so that others would not share their fate.

Many of us are grateful to those who came forward and shared their stories in an atmosphere of love and healing. Thank you.

There are still ongoing discussions on the Rick Ross Cult Education Forum, and while those discussions are not nearly as frequent, they latter posts are becoming more and more helpful and the site is becoming more a resource and even a comfort to those who were harmed in Christopher’s care, to know they are not alone, and do not have to be alone in their grief, and they CAN have a voice if they wish it.

The Courant wants to take this opportunity to all those who have written in, who have shared, though remained anonymous, and some who simply wanted to tell their stories, and not have them published as well.

We also wish to acknowledge the many great healers and teachers that remain ethical and respectful of personal space, adhere to boundaries, and bring real healing to those in their care. One such teacher is His Holiness the Dalai Lama, and it is a quote by him that brought us to the decision to continue to keep this resource open.

“When teachers break the precepts,
behaving in ways that are clearly damaging to themselves and others, students must face the situation,
even though this can be challenging, criticize openly, that’s the only way.”
His Holiness the Dalai Lama

Thank you to the latest poster on Rick Ross by the name of Rudy – rudyh01. We send you ongoing encouragement and support.

Please check out the ongoing discussion at RRCEF and View On Buddhism

The Courant

]]> http://lancashirecare.wordpress.com/2009/11/28/peaks-rampton-clinical-and-risk-characteristics-of-patients-admitted-to-a-secure-hospital-based-dangerous-and-severe-personality-disorder-unit/ Fri, 27 Nov 2009 23:02:58 +0000 sjennings29 http://lancashirecare.wordpress.com/2009/11/28/peaks-rampton-clinical-and-risk-characteristics-of-patients-admitted-to-a-secure-hospital-based-dangerous-and-severe-personality-disorder-unit/

Clinical and risk characteristics of patients admitted to a secure hospital-based Dangerous and Severe Personality Disorder unit, Journal of Forensic Practice , 2009 Sep; 11(3): 19-27

Sheldon K; Krishnan G

The Peaks Academic and Research Unit, Rampton Hospital and Institute of Mental Health, University of Nottingham, UK

Abstract:

This paper describes the clinical and risk characteristics of patients admitted over the first four years of operation of the Dangerous and Severe Personality Disordered (DSPD) NHS pilot at the Peaks Unit, Rampton Secure Hospital. There were 124 referrals, mainly from Category A and B prisons, resulting in 68 DSPD admissions. Clinically, 29% scored 30 or more on the Psychopathy Checklist. The most common personality disorders were antisocial, borderline, paranoid and narcissistic. There is a high risk of violent/sexual recidivism as measured by the Static-99, Violence Risk Scale, and the Historical, Clinical and Risk Management Scale.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Some Animal Facts (in Alphabetical Order)

# Aardvarks have no close relations due to their schizoid personality. They have an order all to themselves and that is how they like it.

# Armadillo “Hoover Hogs” weren’t the only animals eaten out of desperation during the depression– there were also “Roosevelt Remoulades” (Cockroaches with Ketchup), “Churchhill Chimichangas” (Badger Face), and Hitler Berries (Rats Poops).

# Bats are of the order Chiroptera, from the Latin “chirop,” meaning sandal, and “tera,” for cat. Sandal Cat.

Alt. Bats are of the order Chiroptera,from the Latin “chiro,” meaning cinnamon, and “ptera,” for dactyl. Sticky Fingers.

Also Alt. Bats– fuck ‘em.

# Best way to stick it to a Chimp? Thumbwrestling. It is so insecure about its puny thumbs it will shatter your hand like glass.

# Have Some Respect– re: Donkeys: 1. use their Christian names, Jonathan and Jennifer; Mr. & Ms. Ass if you’re nasty, formal.

2. if granted audience with donkey royalty, always use the honorific: Your Donkeyship, Your Anus, or Your Hiney are preferred.

3. “Sir/Madam Butthole” is acceptable when conducting states’ business.

4. staunch anti-miscegenists, never mention any of the following while in court: mules, hinges, zeebrasses, zonkeys, dowse, conkeys, cronks, dabs, domain beings, hunks, Antonio Sabato Jr., underpants, dances, skonks, dittens, conkeys (II), or dodecahedronks.

# Is the Echidna’s cloaca the final step to humano-mammal trans-portal technology? No– but it does taste like fried cake.

# Boeing (BA) expects a big jump in share prices once they clear the last of the Ferret pensions from their books in 2013.

# Dendrobates (poison dart Frogs) practice aposematism, in which outward beauty portends deadly poison. This differs from the practice of afrosemitism, in which outward beauty portends Lenny Kravitz.

# 1688 – Francesco Redi shocks the world when he proves that it’s not meat that spawns Flies, but flies that spawn meat.

# Gibbons‘ syntax judged by zoolinguists to be “more than half, but less than fully illuminating”.

# A Giraffe heart is 6 feet off the ground, allowing a tribe’s tallest man to give them headbutt CPR. Thus was born the Corporal.

# Geese grief is similar to our own: they attend the fallen, wail, pump that shit full of juice, box it, bury it, and split its stuff.

# Hyena poop is bone white as a result of their ghost-rich diet; human singing was invented to ward off these defecated specters.

# The Iguana’s dewlap, or jutesuit, is an unlockable costume you can earn if you “grab the rebound” ten times in a row.

# The Jackalope– neither a playing card, nor a cantaloupe lame.

# The Kangaroo’s three vaginas are or sex, birth, and secrets (in that order).

# Koala means “No water”– a reference to how crucial the marsupials’ patronage was in germinating the masked art.

# Leeches‘ 34 brains are a tribute to their twin loves: Hakeem “The Dream” Olajuwon and strange porn.

“The Admiral had been thoroughly outplayed on the court– embarrassed in his own arena two nights in a row. He thought things couldn’t get any worse. Then he entered the wrong locker room…” And so on.

Adolescent girls who have borderline personality disorder (BPD) pay more attention to negative facial expressions when they’re in a bad mood, according to this study from Germany. Mood-dependent therapy focusing on attentional issues might well be studied in addition to other interventions for BPD, the authors suggest.

RESULT: Attentional Bias in Later Stages of Emotional Information Processing in Female Adolescents with Borderline Personality Disorder
Psychopathology | Nov 6, 2009

Search: personality disorder

Results of a 134-patient trial showing that mentalization-based treatment (MBT) has superior results for outcomes such as self-harm when compared with the structured therapy for BPD recommended by the UK’s National Institute for Clinical Excellence. MBT requires less training for clinicians, according to the authors of this study, and is easier to implement in an outpatient setting.

RESULT: Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder
American Journal of Psychiatry | Oct 15, 2009

Search: borderline personality disorder

This new single-blind trial from the University of Toronto suggests that psychiatrists with expertise in BPD can achieve results just as good as those from therapists trained in dialectical behavior therapy, which has been shown to be effective in previous trials.

RESULT: A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder
American Journal of Psychiatry | Sep 15, 2009

Search: dialectical behavior therapy

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SEARCH TIP: Related concepts

All three of these related searches, using different terms, occurred on the same day last week.

To be sure you’ve caught everything new on a topic in question, it makes sense to do separate searches using related terms from articles relevant to your topic.

It may also help to look at the list of Related Concepts in the left column.

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OTHER RECENT SEARCHES ON SEARCHMEDICA

Search: Tourette’s syndrome

RESULT: Thalamic deep brain stimulation for treatment-refractory Tourette syndrome: Two-year outcome
Neurology | Oct 27, 2009

A prospective multicenter study from Italy and the UK shows that deep-brain stimulation significantly reduces obsessive-compulsive, anxiety, and depressive symptoms among patients with intractable Tourette syndrome. Also, there was a marked reduction in the severity of tics and (perhaps not surprisingly) quality of life improved.

Search: bipolar disorder and crime

RESULT: A Psychiatrist’s Worst Nightmare? Psychiatrist Stabbing Raises Concerns
Psychiatric Times | Nov 2, 2009

A stabbing by a patient at Massachusetts General Hospital’s bipolar clinic late last month renews concern about the growing problem of violent attacks on psychiatrists. This article includes resources to help you defend yourself against the risk.

Search: alzheimer dementia

RESULT: JAD Volume 18, Number 2
Journal of Alzheimer’s Disease | Oct 2, 2009

There may be some articles on Alzheimer dementia in the collection of abstracts behind this uninformative link title. Unfortunately, you can’t identify them at a glance.

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SEARCH TIP: Journals that complicate your search

Most major journals (including those below) make it easy for a search engine to locate article abstracts individually. Each abstract appears on a separate Web page, with a convenient link to full text.

But some journals behave differently, complicating searches.

Journal of Alzheimer’s Disease is one of the few journals that includes all abstracts for each new issue on a single Web page. Because all of its abstracts contain several instances of the word “Alzheimer,” new pages from this journal will always rise to the top of the list in any search that includes that word. (Regrettably, the software interprets them as both recent and highly relevant.)

To find relevant articles, you need to click on the link and scroll down looking for articles about dementia, much as you would scan the contents page of a print journal. The only solution to this technical problem would be for SearchMedica to exclude journals with this formatting entirely.

But scroll on, and you’ll see:

RESULT: Association of Muscle Strength With the Risk of Alzheimer Disease and the Rate of Cognitive Decline in Community-Dwelling Older Persons
Archives of Neurology | Nov 1, 2009

RESULT: CSF biomarkers predict rate of cognitive decline in Alzheimer disease
Neurology | Oct 27, 2009

RESULT: Effects of Family History and Apolipoprotein E(varepsilon)4 Status on Cognitive Decline in the Absence of Alzheimer Dementia
Archives of Neurology | Nov 1, 2009

Risk typologies of serious harm offenders managed under MAPPA: Mental health, personality disorders, and self-harm as distinguishing risk factors, Journal of Forensic Psychiatry & Psychology, Volume 18, Issue 4 December 2007 , pages 470 – 481

Joanne Wood,   MAPPA Support Unit, Manchester, UK

Abstract:

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

A descriptive evaluation of patients and prisoners assessed for dangerous and severe personality disorder, Journal of Forensic Psychiatry & Psychology, 2009

Tim Kirkpatrick;  Simon Draycott;  Mark Freestone;  Sylvia Cooper;  Karen Twiselton;  Neil Watson;  Jacquie Evans;  Val Hawes;  Lawrence Jones;  Claire Moore;  Kathryn Andrews; Tony Maden

WLMHT, The Paddock, Broadmoor Hospital, Crowthorne, Berks, UK …

Abstract:

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Interview granted to Samantha Cleaver for YourTango.com

Q. What are some common ways that a mother’s narcissism can affect her daughter’s relationships?

A. Depends on how narcissistic the mother is. Narcissistic parents fail to recognize and accept the personal autonomy and boundaries of their offspring. They treat them as instruments of gratification or extensions of themselves. Their love is conditioned on the “performance” of their children and on how well they cater to the needs, wishes, and priorities of the parent.

Consequently, narcissistic parents oscillate between clingy emotional blackmail when they seek the child’s attention, adulation, and compliance (known as “narcissistic supply”) and steely devaluation and silent treatment when they wish to punish the child for refusing to toe the line.

Such inconstancy and unpredictability render the child insecure and codependent. When in relationships as adults, these children feel that they have to “earn” each and every morsel of love; that they will be instantly and facilely abandoned if they “underperform”; that their primary role is to “take care” of their spouse, mate, partner, or friend; and that they are less important, less endowed, less skilled, and less deserving than their significant others.

Q. What are the top concerns when daughters of narcissistic mothers start relationships? When their relationships move
forward? When their relationships end?

A. Children of narcissistic parents are ill-adapted; their personality is rigid and they are prone to deploy psychological defense mechanisms. Consequently, they display the same behaviors throughout the relationship, from start to finish and irrespective of changing circumstances.

As adults, offspring of narcissists tend to perpetuate the pathological primary relationship (with their narcissistic parents). They depend on other people for their emotional gratification and the performance of Ego or daily functions. They are needy,  demanding, and submissive. They fear abandonment, cling and display immature behaviours in their effort to maintain the “relationship” with their companion or mate upon whom they depend. No matter what abuse is inflicted upon them – they remain in the relationship. By eagerly becoming victims, codependents seek to control their abusers.

Some of them end up as inverted narcissists.

Also called “covert narcissist”, this is a co-dependent who depends exclusively on narcissists (narcissist-co-dependent). If you are living with a narcissist, have a relationship with one, if you are married to one, if you are working with a narcissist, etc. – it does NOT mean that you are an inverted narcissist.

To “qualify” as an inverted narcissist, you must CRAVE to be in a relationship with a narcissist, regardless of any abuse inflicted on you by him/her. You must ACTIVELY seek relationships with narcissists and ONLY with narcissists, no matter what your (bitter and traumatic) past experience has been. You must feel EMPTY and UNHAPPY in relationships with ANY OTHER kind of person. Only then, and if you satisfy the other diagnostic criteria of a Dependent Personality Disorder, can you be safely labelled an “inverted narcissist”.

A small minority end up being counterdependent and narcissistic, emulating and imitating their parents traits and conduct. The emotions of these children of narcissists emotions and needs are buried under “scar tissue” which had formed, coalesced, and hardened during years of one form of abuse or another. Grandiosity, a sense of entitlement, a lack of empathy, and overweening haughtiness usually hide gnawing insecurity and a fluctuating sense of self-worth.

Counterdependents are contumacious (reject and despise authority), fiercely independent, controlling, self-centered, and aggressive. They fear intimacy and are locked into cycles of hesitant approach followed by avoidance of commitment. They are “lone wolves” and bad team players.

Counterdependence is a reaction formation. The counterdependent dreads his own weaknesses. He seeks to overcome them by projecting an image of omnipotence, omniscience, success, self-sufficiency, and superiority.

Q. How do narcissistic mothers interfere (or get involved) with their daughters’ love/dating lives? How does this compare to typical mothers?

A. The narcissistic mother is a control freak and does not easily relinquish good and reliable sources of “narcissistic supply” (admiration, adulation, attention of any kind). It is the role of her children to replenish this supply, the children owe it to her. To make sure that the child does not develop boundaries, and does not become independent, or autonomous, the narcissistic parent micromanages the child’s life and encourages dependent and infantile behaviors in her offspring.

Such a parent bribes the child (by offering free lodging or financial support or “help” with daily tasks) or emotionally blackmails the child (by constantly demanding help and imposing chores, claiming to be ill or disabled) or even threatens the child (for instance: to disinherit her if she does not comply with the parent’s wishes). The narcissistic mother also does her best to scare away anyone who may upset this symbiotic relationship or otherwise threaten the delicate, unspoken contract. She sabotages any budding relationship her child develops with lies, deceit, and scorn.

Q. Are there any statistics that you know of that would shed light on how many people are dealing with either narcissism or a parent with narcissism?

A. According to the DSM IV-TR, Narcissistic Personality Disorder (NPD) is diagnosed in between 2% and 16% of the population in clinical settings (between 0.5-1% of the general population). The DSM-IV-TR proceeds to tell us that most narcissists (50-75% of all patients) are men.

“The lifetime prevalence rate of NPD is approximately 0.5-1 percent; however, the estimated prevalence in clinical settings is approximately 2-16 percent. Almost 75 percent of individuals diagnosed with NPD are male (APA, DSM IV-TR 2000).”

From the Abstract of Psychotherapeutic Assessment and Treatment of Narcissistic Personality Disorder By Robert C. Schwartz,Ph.D., DAPA and Shannon D. Smith, Ph.D., DAPA (American Psychotherapy Association, Article #3004 Annals July/August 2002)

Narcissistic Injury

An occasional or circumstantial threat (real or imagined) to the narcissist’s grandiose and fantastic self-perception (False Self) as perfect, omnipotent, omniscient, and entitled to special treatment and recognition, regardless of his actual accomplishments (or lack thereof).

Narcissistic Wound

A repeated or recurrent identical or similar threat (real or imagined) to the narcissist’s grandiose and fantastic self-perception (False Self) as perfect, omnipotent, omniscient, and entitled to special treatment and recognition, regardless of his actual accomplishments (or lack thereof).

Narcissistic Scar

A repeated or recurrent psychological defence against a narcissistic wound. Such a narcissistic defence is intended to sustain and preserve the narcissist’s grandiose and fantastic self-perception (False Self) as perfect, omnipotent, omniscient, and entitled to special treatment and recognition, regardless of his actual accomplishments (or lack thereof).

Narcissists invariably react with narcissistic rage to narcissistic injury.

These two terms bear clarification (also see note):

Narcissistic Injury

Any threat (real or imagined) to the narcissist’s grandiose and fantastic self-perception (False Self) as perfect, omnipotent, omniscient, and entitled to special treatment and recognition, regardless of his actual accomplishments (or lack thereof).

The narcissist actively solicits Narcissistic Supply – adulation, compliments, admiration, subservience, attention, being feared – from others in order to sustain his fragile and dysfunctional Ego. Thus, he constantly courts possible rejection, criticism, disagreement, and even mockery.

The narcissist is, therefore, dependent on other people. He is aware of the risks associated with such all-pervasive and essential dependence. He resents his weakness and dreads possible disruptions in the flow of his drug: Narcissistic Supply. He is caught between the rock of his habit and the hard place of his frustration. No wonder he is prone to raging, lashing and acting out, and to pathological, all-consuming envy (all expressions of pent-up aggression).

The narcissist’s thinking is magical. In his own mind, the narcissist is brilliant, perfect, omnipotent, omniscient, and unique. Compliments and observations that accord with this inflated self-image (“The False Self“) are taken for granted and as a matter of course.

Having anticipated the praise as fully justified and in accordance with (his) “reality”, the narcissist feels that his traits, behavior, and “accomplishments” have made the accolades and kudos happen, have generated them, and have brought them into being. He “annexes” positive input and feels, irrationally, that its source is internal, not external; that it is emanating from inside himself, not from outside, independent sources. He, therefore, takes positive narcissistic supply lightly.

The narcissist treats disharmonious input – criticism, or disagreement, or data that negate the his self-perception – completely differently. He accords a far greater weight to these types of countervailing, challenging, and destabilizing information because they are felt by him to be “more real” and coming verily from the outside. Obviously, the narcissist cannot cast himself as the cause and source of opprobrium, castigation, and mockery.

This sourcing and weighing asymmetry is the reason for the narcissist’s disproportionate reactions to perceived insults. He simply takes them as more “real” and more “serious”. The narcissist is constantly on the lookout for slights. He is hypervigilant. He perceives every disagreement as criticism and every critical remark as complete and humiliating rejection: nothing short of a threat. Gradually, his mind turns into a chaotic battlefield of paranoia and ideas of reference.

Most narcissists react defensively. They become conspicuously indignant, aggressive, and cold. They detach emotionally for fear of yet another (narcissistic) injury. They devalue the person who made the disparaging remark, the critical comment, the unflattering observation, the innocuous joke at the narcissist’s expense.

By holding the critic in contempt, by diminishing the stature of the discordant conversant – the narcissist minimises the impact of the disagreement or criticism on himself. This is a defence mechanism known as cognitive dissonance.

Narcissistic Rage

Narcissists can be imperturbable, resilient to stress, and sangfroid. Narcissistic rage is not a reaction to stress – it is a reaction to a perceived slight, insult, criticism, or disagreement (in other words, to narcissistic injury). It is intense and disproportional to the “offence”.

Raging narcissists usually perceive their reaction to have been triggered by an intentional provocation with a hostile purpose. Their targets, on the other hand, invariably regard raging narcissists as incoherent, unjust, and arbitrary.

Narcissistic rage should not be confused with anger, though they have many things in common.

It is not clear whether action diminishes anger or anger is used up in action – but anger in healthy persons is diminished through action and expression. It is an aversive, unpleasant emotion. It is intended to generate action in order to reduce frustration. Anger is coupled with physiological arousal.

Another enigma is:

Do we become angry because we say that we are angry, thus identifying the anger and capturing it – or do we say that we are angry because we are angry to begin with?

Anger is provoked by adverse treatment, deliberately or unintentionally inflicted. Such treatment must violate either prevailing conventions regarding social interactions or some otherwise a deeply ingrained sense of what is fair and what is just. The judgement of fairness or justice is a cognitive function impaired in the narcissist.

Anger is induced by numerous factors. It is almost a universal reaction. Any threat to one’s welfare (physical, emotional, social, financial, or mental) is met with anger. So are threats to one’s affiliates, nearest, dearest, nation, favourite football club, pet and so on. The territory of anger includes not only the angry person himself, but also his real and perceived environment and social milieu.

Threats are not the only situations to incite anger. Anger is also the reaction to injustice (perceived or real), to disagreements, and to inconvenience (discomfort) caused by dysfunction.

Still, all manner of angry people – narcissists or not – suffer from a cognitive deficit and are worried and anxious. They are unable to conceptualise, to design effective strategies, and to execute them. They dedicate all their attention to the here and now and ignore the future consequences of their actions. Recent events are judged more relevant and weighted more heavily than any earlier ones. Anger impairs cognition, including the proper perception of time and space.

In all people, narcissists and normal, anger is associated with a suspension of empathy. Irritated people cannot empathise. Actually, “counter-empathy” develops in a state of aggravated anger. The faculties of judgement and risk evaluation are also altered by anger. Later provocative acts are judged to be more serious than earlier ones – just by “virtue” of their chronological position.

Yet, normal anger results in taking some action regarding the source of frustration (or, at the very least, the planning or contemplation of such action). In contrast, pathological rage is mostly directed at oneself, displaced, or even lacks a target altogether.

Narcissists often vent their anger at “insignificant” people. They yell at a waitress, berate a taxi driver, or publicly chide an underling. Alternatively, they sulk, feel anhedonic or pathologically bored, drink, or do drugs – all forms of self-directed aggression.

From time to time, no longer able to pretend and to suppress their rage, they have it out with the real source of their anger. Then they lose all vestiges of self-control and rave like lunatics. They shout incoherently, make absurd accusations, distort facts, and air long-suppressed grievances, allegations and suspicions.

These episodes are followed by periods of saccharine sentimentality and excessive flattering and submissiveness towards the victim of the latest rage attack. Driven by the mortal fear of being abandoned or ignored, the narcissist repulsively debases and demeans himself.

Most narcissists are prone to be angry. Their anger is always sudden, raging, frightening and without an apparent provocation by an outside agent. It would seem that narcissists are in a CONSTANT state of rage, which is effectively controlled most of the time. It manifests itself only when the narcissist’s defences are down, incapacitated, or adversely affected by circumstances, inner or external.

Pathological anger is neither coherent, not externally induced. It emanates from the inside and it is diffuse, directed at the “world” and at “injustice” in general. The narcissist is capable of identifying the IMMEDIATE cause of his fury. Still, upon closer scrutiny, the cause is likely to be found lacking and the anger excessive, disproportionate, and incoherent.

It might be more accurate to say that the narcissist is expressing (and experiencing) TWO layers of anger, simultaneously and always. The first layer, of superficial ire, is indeed directed at an identified target, the alleged cause of the eruption. The second layer, however, incorporates the narcissist’s self-aimed wrath.

Narcissistic rage has two forms:

I. Explosive – The narcissist flares up, attacks everyone in his immediate vicinity, causes damage to objects or people, and is verbally and psychologically abusive.

II. Pernicious or Passive-Aggressive (P/A) – The narcissist sulks, gives the silent treatment, and is plotting how to punish the transgressor and put her in her proper place. These narcissists are vindictive and often become stalkers. They harass and haunt the objects of their frustration. They sabotage and damage the work and possessions of people whom they regard to be the sources of their mounting wrath.

A Dream (Night of May 8/9, 2009)

Throughout my dream life, Nazism (the regime, its operatives, and its visual manifestations) represented my mental health disorder, the rot that is my being.

In my dream, a squadron of high-ranking Nazis invades my rented apartment with the aim of confiscating my collections (mainly books I had packed in cardboard boxes and stashed in what passed for storage space in my real abode in Israel many years ago). The physical premises in the dream are a combination between my parents’ house and the apartment I shared with my first wife. In other words: they represent the entirety of my life.

As they roam my home, fingering objects and evaluating them, I desperately try to explain to the them that I have abstained from other expenses to be able to afford my prized possessions. They ignore my pleas as they boisterously participate in the hustle and bustle, climbing up and down stairs and calling to each other. It then occurs to me that I envy Hitler who remains untouchable despite his vast library. Despite the dire circumstances, I am still hopeful that my things will be returned to me, unmolested, once the misunderstanding that is at the base of these ominous proceedings is cleared up.

Thus, even in my dream, I realize how my disease is set dead against everything I love and cherish: my privacy, my person, my learning, and the accumulated goods that make an existence. My narcissism is all-pervasive, hideously energetic, tyrannical, and unfair. It is a malignant manifestation of my self-destructive and self-defeating urges.

A senior Nazi orders me to join an SS doctor-officer in his rounds as he compiles an inventory of tangibles in the neighborhood. There are two of us detailed to this ostensibly pedestrian mission: myself and a street-wise and resourceful child whose face I never see, but whose presence is clear. His cheer and acumen immediately render him my competitor. It is clear that only one of us will survive.

This impish child is my True Self and to outlive my disorder (my Nazi tormentors), I have to eliminate him. The only way to come on top is to demonstrate to our indifferent slavemaster how profoundly and overwhelmingly more intelligent I am. I want to make it worth the SS officer’s while to keep me alive, even as he sacrifices my co-worker. In other words: terrified by my sickness, I choose to become the False Self.

I have a stomach-churning four-pronged epiphany right there and then: (1) This ordeal is not going to end soon; (2) I have to make it to the end of the War (another 2 years, as the dream inexplicably takes place in 1943); (3) As death is administered randomly and off-handedly by the Nazis, my chances to survive are not good; (4) I am ill-equipped to cope in an environment that values practical, or somatic skills above intellectual achievements and capacities.

The three of us proceed from one backyard to another, taking stock of all the physical objects in them. As we progress, I commit a mistake and the SS man notices it. Endowed with the gifts of gab and blarney, I assure him that it was intentional and that he has nothing to worry about, he can leave it all to me. “If this happens again, feel free to torture me!” – I protest to his bemusement. He seems skeptical, but doesn’t put a bullet through the back of my skull, as I dreaded he would.

The tour ends at a familiar site: the lane of semi-detacheds, among which is my grandparents’. The entire row of dilapidated houses (in reality, long demolished) is enclosed within a wire fence. The objects strewn in the weed-grown backyards are borrowed from my childhood. The door to my grandparents’ unit is ajar. The great commotion inside indicates that this is the Headquarters of the Nazis (read: where my disease originated). My streetwise and resourceful colleague enters it and at first I can hear his voice, but then it ceases. I know that he is dead.

The SS-officer turns to me and says: “It’s time to complete the ethics chapter of our report”. I seethe inside: “The hypocrite! What do the Nazis have to do with ethics?” Something in me, a sliver of sanity, rebels against the inane demands of my disorder and is revolted by its confabulated fakery. I flip through the notepad that we have used to take the inventory and mutely indicate that it has run out of empty pages. The officer dives into an inner vest pocket and emerges with a cheap, blue plastic-bound diary. He searches for an empty leaf. As he turns the pages, I notice handwritten comments about the genocidal activities of various “gangs”.

Next I know, the SS doctor is holding a baby in his arms, examining it in a clinically-aloof but thorough manner. The boy is deformed: the skin on the right side of his face is covered with a patchwork of purplish scales; his lips are bumpy; his eyes wander aimlessly, unfocused and dim.

The doctor takes meticulous notes and then rises from his crouch, the baby cooing, still in his embrace. He enters my grandparents’ house, I hear a shot and the baby’s pale body is hurled on top of a heap of still corpses in the garden.

Two Dreams (Night of November 6/7, 2006)

I dreamt that I am a child. I am surrounded by family members who pay scant attention to me. They go about their bustling daily lives and I merely exist on the fringes of their awareness. Suddenly I notice a pure white bird, a cross between a seagull and a quail or a magpie. It is strutting on a cabinet shelf, turning itself into an impeccably shaped ball and rolling with brio among the statuettes and vases. I finally succeed to draw attention to myself by pointing to this magical bird and its nigh-impossible exploits. The fowl does nothing of value or utility – but it still garners narcissistic supply for me. This bird is my pathological narcissism.

Seamlessly and gradually, the bird metamorphoses into a swallow – plain, grey, small, and inconspicuous. Still, it is far more clever and useful than its erstwhile transformation. It fulfills functions: it cleans the house, it turns electrical appliances on and off, it even communicates, perhaps via telepathy.

Despite the fact that the sparrow – the drab adult incarnation of the flamboyant seagull-quail – is helpful and charitable, the adults around me reject it cruelly and consign it to the weather-beaten porch, behind a glass partition. The swallow is baffled; why is it being so punished? It tries to prove its merit by sweeping clean with a broom the entire balcony. To no avail.

I point out to the adults how incredible this tiny bird is and how productive. “See how it has scrubbed the verandah sparkling shine!” – I implore. But they are uninterested. I stare at my hyper-intelligent bird, deeply pained and sad. I know that I will never ever have a bird like this again: so clever, so industrious, so functional. I can communicate with it from now on only through a glass darkly. And one day she surely would be gone.

When narcissists grow old, society forces them to let go of major facets of their hitherto unbridled pathological narcissism. This coerced transfiguration makes them very sad, angry and bitter. Narcissists find it difficult to give up their narcissism. They are shocked by the fact that they no are no longer able to attract attention and adulation to themselves (to their magic birds). They then realize that their True Self (the child) is immature and helpless and their False Self (the bird) is a social outcast.

In my second dream, there was a black kid. He inhabited a tiny cubicle, crammed to the ceiling with books, amongst them, prominently displayed, my tome, “Malignant Self Love – Narcissism Revisited”. This leads me to believe that this child is I, the author. But why black? And why a child? I am a white, middle-aged male.

Blacks were discriminated against, excommunicated, and persecuted throughout their sad history as slaves in the Americas and as natives under colonial administrations. I feel like that: a freak, shunned by one and all and victimized by “normal people“. My True Self (that does the dreaming) is an immature child.

The child is despondent and depressed. He shuts himself in his room and refuses to eat or drink and, most alarmingly, won’t even touch his precious books. A procession of adults gently force themselves into his living space in order to cheer him up. Among them is a white cheerleader (adolescent girl), beating a drum and blowing a trumpet and a colored magician with a top hat. They represent my defense mechanisms: narcissism (the cheerleader) and magical thinking (the magician).

The child in the dream is instantly reassured and uplifted by their presence. He says to himself: How wonderful for any kid to be surrounded by such support and love. My defense mechanisms, including my pathological narcissism, keep me alive. I need them in order to survive and function. By ignoring them or trying to suppress them, I place myself at risk.

The Sad Dreams of the Narcissst

I dream of my childhood. And in my dreams we are again one big unhappy family. I sob in my dreams, I never do when I am awake. When I am awake, I am dry, I am hollow, mechanically bent upon the maximization of Narcissistic Supply. When asleep, I am sad. The all-pervasive, engulfing melancholy of somnolence. I wake up sinking, converging on a black hole of screams and pain. I withdraw in horror. I don’t want to go there. I cannot go there.

People often mistake depression for emotion. They say: “But you are sad” and they mean: “But you are human”, “But you have emotions”. And this is wrong.

True, depression is a big component in a narcissist’s emotional make-up. But it mostly has to do with the absence of Narcissistic Supply.

It mostly has to do with nostalgia to more plentiful days, full of adoration and attention and applause. It mostly occurs after the narcissist has depleted his Secondary Source of Narcissistic Supply (spouse, mate, girlfriend, colleagues) for a “replay” of his days of glory. Some narcissists even cry – but they cry exclusively for themselves and for their lost paradise. And they do so conspicuously and publicly – to attract attention.

The narcissist is a human pendulum hanging by the thread of the void that is his False Self. He swings between brutal and vicious abrasiveness – and mellifluous, saccharine sentimentality. It is all a simulacrum. A verisimilitude. A facsimile. Enough to fool the casual observer. Enough to extract the drug – other people’s glances – the reflection that sustains this house of cards somehow.

But the stronger and more rigid the defences – and nothing is more resilient than narcissism – the bigger and deeper the hurt they aim to compensate for.

One’s narcissism stands in direct relation to the seething abyss and the devouring vacuum that one harbours in one’s True Self.

I know it’s there. I catch glimpses of it when I am tired, when I hear music, when reminded of an old friend, a scene, a sight, a smell. I know it is awake when I am asleep. I know that it subsists of pain – diffuse and inescapable. I know my sadness. I have lived with it and I have encountered it full force.

Perhaps I choose narcissism, as I have been “accused”. And if I do, it is a rational choice of self-preservation and survival. The paradox is that being a self-loathing narcissist may be the only act of self-love I have ever committed.

The Narcissist’s Clarion Call

Background

This dream was related to me by a male, 46 years old, who claims to be in the throes of a major personal transformation. Whether he is a narcissist (as he believes himself to be) or not is quite irrelevant. Narcissism is a language. A person can choose to express himself in it, even if he is not possessed by the disorder. The dreamer made this choice.

Henceforth, I will treat him as a narcissist, though insufficient information renders a “real” diagnosis impossible. Moreover, the subject feels that he is confronting his disorder and that this could be a significant turning point on his way to being healed. It is in this context that this dream should be interpreted. Evidently, if he chose to write to me, he is very preoccupied with his internal processes. There is every reason to believe that such conscious content invaded his dream.

The Dream

“I was in a run-down restaurant/bar with two friends sitting at a table in a large open area with a few other tables and a bar. I did not like the music or the smoky atmosphere or other customers or greasy food, but we were travelling and were hungry and it was open and the only place we could find.

There was a woman with other people at a table about 10 feet in front of me that I found attractive, and noticed she was noticing me as well. There was also another woman with other people at a table about 30 feet to my right, old with heavy make-up and poorly dyed hair, loud, obnoxious, drunk who noticed me. She started saying negative things to me, and I tried to ignore her. She just got louder and more derogatory, with horrible rude and jabbing comments. I tried to ignore her, but my other friends looked at me with raised eyebrows, as if to ask: ‘How much more are you going to take before you stand up for yourself?’ I felt sick to my stomach, and did not want to confront her, but everyone in the place was now noticing her confrontation of me, and she was almost screaming at me. I couldn’t believe no one was telling her to stop it, to be civil, to be nice.

I finally looked over at her and raised my voice and told her to shut up. She looked at me and seemed to get even angrier, and then looked at her plate and picked up a piece of food and threw it at me! I couldn’t believe it. I told her I wasn’t going to take one more thing, and to stop it now or I would call the police. She got up, walked towards me, picking up a plate of popcorn from another table, and upended it flat upon the top of my head. I stood up and said: ‘That’s it! That’s assault! You’re going to jail!’ and went to the cash register area by the door and called the police.

The police instantly appeared and took her away, with her resisting arrest the whole time. I sat down and someone at the table next to me said: ‘Now you can open up the dam gate.’ I said: ‘What?’, and he explained how the woman was actually pretty powerful and owned a dam and had shut the gate down years ago, but that now she was locked up we could go open it up.

We piled into a truck and I was led into a cavernous room and shown a small room with a glass wall in it and a big wheel, a control valve. I was told that I could turn it whenever I wanted. So I started to turn it and the water started flowing. I could easily see it through the glass, and the level on the glass rose higher the more I turned the wheel. Soon there was a torrent, and it was thrilling. I had never seen such an incredible roar of water. It was like the Niagara falls flowing through the huge room. I got frightened along with being thrilled, but discovered I could lessen the water with the valve if it got to be too much. It went on for a long time, and we whooped and laughed and felt so excited. Finally, the water grew less no matter how wide I opened the valve, and it reached a steady flow.

I noticed the pretty woman from the grill way across the huge area, and she seemed to be looking for someone. I hoped it was me. I opened the door, and went out to go meet her. On the way out, I got grease on my hand, and picked up a rag on the table to wipe it off. The rag had even more grease on it, and so now my hands were completely covered in grease. I picked up another rag on top of a box, and there were wet spark plugs stuck with globs of grease to the underside of the rag, lined up in order as if they used to be in an engine and someone stuck them in this order on purpose, and some of it got on my clothes. The guys with me laughed and I laughed with them, but I left without going to meet the woman, and we went back to the grill.

I found myself in a tiny room with a table in it and a picture window looking out into the area where everyone was sitting and eating. The door was open into a back hallway. I started to go out, but a man was coming into the room. For some reason he frightened me, and I backed up. However, he was robot-like, and walked to the window and looked out to the dining area, making no indication that he even noticed me, and stared blandly at the people having fun. I left and went out into the dining area. I noticed everyone staring at me in an unfriendly way. I started for the exit, but one of the policemen who had arrested the woman from the night before was off-duty in plain clothes and grabbed my arm and twisted me around and shoved me face down on a table. He told me that what I did to the woman was wrong, and that no one liked me because of it. He said that just because I had the law on my side and was in the right didn’t mean anyone would like me. He said if I was smart I would leave town. Others were around me and spit on me.

He let me go, and I left. I was driving in a car alone out of town. I didn’t know what became of the friends I was with. I felt both elated and ashamed at the same time, crying and laughing at the same time, and had no idea where to go and what I was doing.”

The Interpretation

As the dream unfolds, the subject is with two friends. These friends vanish towards the end of the dream and he doesn’t seem to find this worrisome. “I didn’t know what became of the friends I was with.” This is a strange way to treat one’s friends. It seems that we are dealing not with three dimensional, full-blown, flesh and blood friends but with FRIENDLY MENTAL FUNCTIONS. Indeed, they are the ones who encourage the subject to react to the old woman’s antics. “How much more are you going to take before you stand up for yourself?” – they ask him, cunningly. All the other people present at the bar-restaurant do not even bother to tell the woman “to stop, to be civil, to be nice”. This eerie silence contributes to the subject’s reaction of disbelief that mushrooms throughout this nightmare. At first, he tries to emulate their behaviour and to ignore the woman himself. She says negative things about him, goes louder and more derogatory, horribly rude and jabbing and he still tries to ignore her. When his friends push him to react: “I felt sick to my stomach and did not want to confront her.” He finally does confront her because “everyone was noticing” as she was almost screaming at him.

The subject emerges as the plaything of others. A woman screams at him and debases him, friends prod him to react, and motivated by “everyone” he does react. His actions and reactions are determined by input from the outside. He expects others to do for him the things that he finds unpleasant to do by himself (to tell the woman to stop, for instance). His feeling of entitlement (“I deserve this special treatment, others should take care of my affairs”) and his magical thinking (“If I want something to happen, it surely will”) are so strong – that he is stunned when people do not do his (silent) bidding. This dependence on others is multi-faceted. They mirror the subject to himself. He modifies his behaviour, forms expectations, gets disbelievingly disappointed, punishes and rewards himself and takes behavioural cues from them (“The guys with me laughed and I laughed with them”). When confronted with someone who does not notice him, he describes him as robot-like and is frightened by him. The word “look” disproportionately recurs throughout the text. In one of the main scenes, his confrontation with the rude, ugly woman, both parties do not do anything without first “looking” at each other. He looks at her before he raises his voice and tells her to shut up. She looks at him and gets angrier.

The dream opens in a “run down” restaurant/bar with the wrong kind of music and of customers, a smoky atmosphere and greasy food. The subject and his friends were travelling and hungry and the restaurant was the only open place. The subject takes great pains to justify his (lack of) choice. He does not want us to believe that he is the type of person to willingly patronise such a restaurant. What we think about him is very important to him. Our look still tends to define him. Throughout the text, he goes on to explain, justify, excuse, reason and persuade us. Then, he suddenly stops. This is a crucial turning point.

It is reasonable to assume that the subject is relating to his personal Odyssey. At the end of his dream, he continues his travels, continues his life “ashamed and elated at the same time”. We are ashamed when our sense of propriety is offended and we are elated when it is reaffirmed. How can these contradictory feelings coexist? This is what the dream is about: the battle between what the subject has been taught to regard as true and proper, the “shoulds” and the “oughts” of his life, usually the result of overly strict upbringing – and what he feels is good for him. These two do not overlap and they foster in the subject a sense of escalating conflict, enacted before us. The first domain is embedded in his Superego (to borrow Freud’s quasi-literary metaphor). Critical voices constantly resound in his mind, an uproarious opprobrium, sadistic criticism, destructive chastising, uneven and unfair comparisons to unattainable ideals and goals. On the other hand, the powers of life are reawakening in him with the ripening and maturation of his personality. He vaguely realises what he missed and misses, he regrets it, and he wants out of his virtual prison. In response, his disorder feels threatened and flexes its tormenting muscles, a giant awakened, Atlas shrugged. The subject wants to be less rigid, more spontaneous, more vivacious, less sad, less defined by the gaze of others, and more hopeful. His disorder dictates rigidity, emotional absence, automatism, fear and loathing, self-flagellation, dependence on Narcissistic Supply, a False Self. The subject does not like his current locus in life: it is dingy, it is downtrodden, it is shabby, and inhabited by vulgar, ugly people, the music is wrong, it is fogged by smoke, polluted. Yet, even while there, he knows that there are alternatives, that there is hope: a young, attractive lady, mutual signalling. And she is closer to him (10 feet) than the old, ugly woman of his past (30 feet). His dream will not bring them together, but he feels no sorrow. He leaves, laughing with the guys, to revisit his previous haunt. He owes this to himself. Then he continues his life.

He finds himself, in the middle of the road of life, in the ugly place that is his soul. The young woman is only a promise. There is another woman “old, with heavy make-up, poorly dyed hair, loud, obnoxious, drunk”. This is his mental disorder. It can scarcely sustain the deception. Its make-up is heavy, its hair dyed poorly, its mood a result of intoxication. It could well be the False Self or the Superego, but I rather think it is the whole sick personality. She notices him, she berates him with derogatory remarks, she screams at him. The subject realises that his disorder is not friendly, that it seeks to humiliate him, it is out to degrade and destroy him. It gets violent, it hurls food at him, it buries him under a dish of popcorn (a cinema theatre metaphor?). The war is out in the open. The fake coalition, which glued the shaky structures of the fragile personality together, exists no longer. Notice that the subject does not recall what insults and pejorative remarks were directed at him. He deletes all the expletives because they really do not matter. The enemy is vile and ignoble and will make use and excuse of any weakness, mistake and doubt to crack the defence set up by the subject’s budding healthier mental structures (the young woman). The end justifies all means and it is the subject’s end that is sought. There is no self-hate more insidious and pernicious than the narcissist’s.

But, to fight his illness, the subject still resorts to old solutions, to old habits and to old behaviour patterns. He calls the police because they represent the Law and What Is Right. It is through the rigid, unflinching, framework of a legal system that he hopes to suppress what he regards as the unruly behaviour of his disorder. Only at the end of his dream he comes to realise his mistake: “He said that just because I had the law on my side and I was in the right didn’t mean that anyone would like me.” The Police (who appear instantly because they were always present) arrest the woman, but their sympathy is with her. His true aides can be found only among the customers of the restaurant/bar, whom he found not to his liking (“I did not like … the other customers…”). It is someone in the next table who tells him about the dam. The way to health is through enemy territory, information about healing can be gotten only from the sickness itself. The subject must leverage his own disorder to disown it.

The dam is a potent symbol in this dream. It represents all the repressed emotions, the now forgotten traumas, the suppressed drives and wishes, fears and hopes. It is a natural element, primordial and powerful. And it is dammed by the disorder (the vulgar, now-imprisoned, lady). It is up to him to open the dam. No one will do it for him: “Now YOU can open the dam gate.” The powerful woman is no more, she owned the dam and guarded its gates for many years ago. This is a sad passage about the subject’s inability to communicate with himself, to experience his feelings unmediated, to let go. When he does finally encounter the water (his emotions), they are safely contained behind glass, visible but described in a kind of scientific manner (“the level on the glass rose higher the more I turned the wheel”) and absolutely controlled by the subject (using a valve). The language chosen is detached and cold, protective. The subject must have been emotionally overwhelmed but his sentences are borrowed from the texts of laboratory reports and travel guides (“Niagara Falls”). The very existence of the dam comes as a surprise to him. “I said: What?, and he explained.”

Still, this is nothing short of a revolution. It is the first time that the subject acknowledges that there is something hidden behind a dam in his brain (“cavernous room”) and that it is entirely up to him to release it (“I was told that I could turn it whenever I wanted”). Instead of turning around and running in panic, the subject turns the wheel (it is a control valve, he hurries to explain to us, the dream must be seen to obey the rules of logic and of nature). He describes the result of his first encounter with his long repressed emotions as “thrilling”, “incredible” “roar(ing)”, “torrent(ial)”. It did frighten him but he wisely learned to make use of the valve and to regulate the flow of his emotions to accord with his emotional capacity. And what were his reactions? “Whooped”, “laughed”, “excited”. Finally, the flow became steady and independent of the valve. There was no need to regulate the water anymore. There was no threat. The subject learned to live with his emotions. He even diverted his attention to the attractive, young woman, who reappeared and seemed to be looking for someone (he hoped it was for him).

But, the woman belonged to another time, to another place and there was no turning back. The subject had yet to learn this final lesson. His past was dead, the old defence mechanisms unable to provide him with the comfort and illusory protection that he hitherto enjoyed. He had to move on, to another plane of existence. But it is hard to bid farewell to part of you, to metamorphesise, to disappear in one sense and reappear in another. A break in one’s consciousness and existence is traumatic no matter how well controlled, well intentioned and beneficial.

So, our hero goes back to visit his former self. He is warned: it is not with clean hands that he proceeds. They get greasier the more he tries to clean them. Even his clothes are affected. Rags, wet (useless) spark plugs, the ephemeral images of a former engine all star in this episode. Those are passages worth quoting (in parentheses my comments):

“I noticed the pretty woman from the grill (=from my past) way across the huge area (=my brain), and she seemed to be looking for someone. I hoped it was me. I opened the door, and went out to go meet her (=back to my past). On the way out, I got grease on my hand (=dirt, warning), and picked up a rag on the table to wipe it off. The rag had even more grease on it (=no way to disguise the wrong move, the potentially disastrous decision), and so now my hands were completely covered in grease (=dire warning). I picked up another rag on top of a box, and there were wet (=dead) spark plugs stuck with globs of grease to the underside of the rag, lined up in order as if they used to be in an engine (=an image of something long gone) and someone stuck them in this order on purpose, and some of it got on my clothes. The guys with me laughed and I laughed with them (=he laughed because of peer pressure, not because he really felt like it), but I left without going to meet the woman, and we went back to the grill (=to the scene of his battle with his mental disorder).”

But, he goes on to the grill, where it all started, this undefined and untitled chain of events that changed his life. This time, he is not allowed to enter, only to observe from a tiny room. Actually, he does not exist there anymore. The man that enters his observation post, does not even see him or notice him. There are grounds to believe that the man who thus entered was the previous, sick version of the subject himself. The subject was frightened and backed up. The robot-like person (?) looked through the window, stared blandly at people having fun. The subject then proceeded to commit the error of revisiting his past, the restaurant. Inevitably, the very people that he debunked and deserted (the elements of his mental disorder, the diseased occupants of his mind) were hostile. The policeman, this time off duty (=not representing the Law) assaults him and advises him to leave. Others spit on him. This is reminiscent of a religious ritual of ex-communication. Spinoza was spat on in a synagogue, judged to have committed in heresy. This reveals the religious (or ideological) dimension of mental disorders. Not unlike religion, they have their own catechism, compulsive rituals, set of rigid beliefs and “adherents” (mental constructs) motivated by fear and prejudice. Mental disorders are churches. They employ institutions of inquisition and punish heretical views with a severity befitting the darkest ages.

But these people, this setting, exert no more power over him. He is free to go. There is no turning back now, all bridges burnt, all doors shut firmly, he is a persona non grata in his former disordered psyche. The traveller resumes his travels, not knowing where to go and what he is doing. But he is laughing and crying and ashamed and elated. In other words, he, finally, after many years, experiences emotions. On his way to the horizon, the dream leaves the subject with a promise, veiled as a threat “If you were smart you would leave town.” If you know what is good for you, you will get healthy. And the subject seems to be doing just that.

 Metaphors of the Mind

The Dialogue of Dreams

Treatment Modalities and Psychotherapies

Three preparatory studies for promoting implementation of outpatient schema therapy for borderline personality disorder in general mental health care,  Behaviour Research and Therapy, Volume 47, Issue 11, November 2009, Pages 938-945 – Dissemination and Implementation of Cognitive Behavioural Therapy

Marjon Nadort et al..

Abstract:

Objective

Three studies were conducted to prepare for the implementation of Schema Therapy (ST) for Borderline Personality Disorder (BPD) in general mental healthcare settings. Two were surveys to detect promoting and hindering factors, one was a preliminary test of a training program in ST.

Methods

In 2004, a diagnostic analysis of factors promoting and hindering implementation of a new treatment for BPD was conducted among both managers (n = 23) and therapists (n = 49) of 29 Dutch mental healthcare institutes through a written survey (Study 1). Next, a training program, including a set of DVDs displaying the major therapeutic techniques, was developed and tested among eight therapists. The training program was evaluated by the participants. After the training, three independent raters evaluated therapists’ adherence and competence, viewing videos of the therapists completing structured role-plays (Study 2). In 2008, a second written survey was conducted in 22 mental health institutes to study factors for future nationwide implementation of ST (Study 3).

Results

Both surveys indicated that the situation in most institutes was favorable for implementing a new effective treatment, as participants were not satisfied with the existing treatments, had suitable professional backgrounds, worked in settings with (B)PD-oriented care programs, and expressed a need for change. The surveys yielded clear results for promoting or hindering successful implementation of ST. Promoting factors included scientific evidence for the effectiveness of the treatment, structural changes in the patient’s personality, rapidly noticeable effects for the patient, low drop-out rates and a favorable cost-effectiveness. Possible barriers included implementation mandated unilaterally by management, choosing ST based on financial or organizational needs, extending implementation over a lengthy period of time and providing telephone support by therapists beyond office hours. The eight-day training program received very positive ratings. After the training, therapists were rated as sufficiently adherent and competent applying ST to treat BPD patients, with peer supervision and supervision recommended as a supplement to the training.

Conclusion

This study showed that the situation in 2005 was advantageous to start implementation of ST. Evaluation of the training and the achieved competence scores of trainees concluded that the training program was a good basis for training therapists in ST. Outcome of the survey in 2008 demonstrated that there was a clear interest for implementation of ST for BPD patients in the future.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Family guidelines taken from “family groups” literature,  written by John G Gunderson MD and Cynthia Berkowitz MD

pdf version of this can be found in the “files” page of our yahoo groups website carers4pd.  If you are not a member please go to our support page for details.

These guidelines are invaluable

GOALS: GO SLOWLY

1. Remember that change is difficult to achieve and fraught with fears. Be cautious about suggesting that “great” progress has been made or giving “You can do it” reassurances. Progress evokes fears of abandonment.

The families of people with Borderline Personality Disorder can tell countless stories of instances in which their son or daughter went into crisis just as that person was beginning to function better or to take on more responsibility. The coupling of improvement with a relapse is confusing and frustrating but has a logic to it. When people make progress – by working, leaving day treatment, helping in the home, diminishing self-destructive behaviors, or living alone- they are becoming more independent. They run the risk that those around them who have been supportive, concerned, and protective will pull away, concluding that their work is done. The supplies of emotional and financial assistance may soon dry up, leaving the person to fend for herself in the world. Thus, they fear abandonment. Their response to the fear is a relapse. They may not make a conscious decision to relapse, but fear and anxiety can drive them to use old coping methods. Missed days at work, self-mutilation, a suicide attempt, or a bout of overeating, purging or drinking may be a sign that lets everyone around know that the individual remains in distress and needs their help. Such relapses may compel those around her to take responsibility for her through protective measures such as hospitalization. Once hospitalized, she has returned to her most regressed state in which she has no responsibilities while others take care of her.

When signs of progress appear, family members can reduce the risk of relapse by not showing too much excitement about the progress and by cautioning the individual to move slowly. This is why experienced members of a hospital staff tell borderline patients during discharge not that they feel confident about their prospects, but that they know the patient will confront many hard problems ahead. While it is important to acknowledge progress with a pat on the back, it is meanwhile necessary to convey understanding that progress is very difficult to achieve. It does not mean that the person has overcome her emotional struggles. You can do this by avoiding statements such as, “You’ve made great progress,” or, “I’m so impressed with the change in you.” Such messages imply that you think they are well or over their prior problems. Even statements of reassurance such as, “That wasn’t so hard,” or, “I knew you could do it,” suggest that you minimize their struggle. A message such as, “Your progress shows real effort. You’ve worked hard. I’m pleased that you were able to do it, but I’m worried that this is all too stressful for you,” can be more empathic and less risky.

2. Lower your expectations. Set realistic goals that are attainable. Solve big problems in small steps. Work on one thing at a time. “Big”, long-term goals lead to discouragement and failure.

Although the person with BPD may have many obvious strengths such as intelligence, ambition, good looks, and artistic talent, she nonetheless is handicapped by severe emotional vulnerabilities as she sets about making use of those talents. Usually the person with BPD and her family members have aspirations based upon these strengths. The patient or her family may push for return to college, graduate school, or a training program that will prepare her for financial independence. Family members may wish to have the patient move into her own apartment and care for herself more independently. Fueled by such high ambitions, a person with BPD will take a large step forward at a time. She may insist upon returning to college full time despite undergoing recent hospitalizations, for example. Of course, such grand plans do not consider the individual’s handicaps of affect dyscontrol, black and white thinking, and intolerance of aloneness. The first handicap may mean that, in the example given, the B received on the first exam could lead to an inappropriate display of anger if it was thought to be unfair, to a self-destructive act if it was felt to be a total failure, or severe anxiety if it was believed that success in school would lead to decreased parental concern. The overriding issue about success in the vocational arena is the threat of independence —much desired but fraught with fear of abandonment. The result of too large a step forward all at once is often a crashing swing in the opposite direction, like the swing of a pendulum. The person often relapses to a regressed state and may even require hospitalization.

A major task for families is to slow down the pace at which they or the patient seeks to achieve goals. By slowing down, they prevent the sharp swings of the pendulum as described and prevent experiences of failure that are blows to the individual’s self-confidence. By lowering expectations and setting small goals to be achieved step by step, patients and families have greater chances of success without relapse. Goals must be realistic. For example, the person who left college mid-semester after becoming depressed and suicidal under the pressure most likely could not return to college full time a few months later and expect success. A more realistic goal is for that person to try one course at a time while she is stabilizing. Goals must be achieved in small steps. The person with BPD who has always lived with her parents might not be able to move straight from her parents’ home. The plan can be broken down into smaller steps in which she first moves to a halfway house, and then into a supervised apartment. Only after she has achieved some stability in those settings should she take the major step of living alone.

Goals should not only be broken down into steps but they should be taken on one step at a time. For example, if the patient and the family have goals for both the completion of school and independent living, it may be wisest to work on only one of the two goals at a time.

FAMILY ENVIRONMENT

3. Keep things cool and calm. Appreciation is normal. Tone it down. Disagreement is normal. Tone it down, too.

This guideline is a reminder of the central message of our educational program: The person with BPD is handicapped in his ability to tolerate stress in relationships (i.e., rejection, criticism, disagreements) and can, therefore, benefit from a cool, calm home environment. It is vital to keep in mind the extent to which people with BPD struggle emotionally each day. While their internal experience can be difficult to convey, we explain it by summarizing into three handicaps: affect dyscontrol, intolerance of aloneness, and black and white thinking. To review:

Affect Dyscontrol:

A person with BPD has feelings that dramatically fluctuate in the course of each day and that are particularly intense. These emotions, or affects, often hit hard. We have all experienced such intense feelings at times. Take for example the sensation of pounding heart and dread that you may feel when you suddenly realize that you have made a mistake at work that might be very costly or embarrassing to your business. The person with BPD feels such intense emotion on a regular basis. Most people can soothe themselves through such emotional experiences by telling themselves that they will find a way to compensate for the mistake or reminding themselves that it is only human to make mistakes. The person with BPD lacks that ability to soothe herself. An example can also be drawn from family conflict. We have all had moments in which we feel rage towards the people we love. We typically calm ourselves in such situations by devising a plan for having a heart-to-heart talk with the family member or by deciding to let things blow over. The person with BPD again feels such rage in its full intensity and without being able to soothe himself through the use of coping strategies. It results in an inappropriate expression of hostility or by acting out of feelings (drinking or cutting).

Intolerance of Aloneness:

A person with BPD typically feels desperate at the prospect of any separation – a family member’s or therapist’s vacation, break up of a romance, or departure of a friend. While most of us would probably miss the absent family member, therapist or friend, the person with BPD typically feels intense panic. She is unable to conjure up images of the absent person to soothe herself. She cannot tell herself, “That person really cares about me and will be back again to help me.” Her memory fails her. She only feels soothed and cared for by the other person when that person is present. Thus, the other person’s absence is experienced as abandonment. She may even keep these painful thoughts and feelings out of mind by using a defense mechanism called dissociation. This consists of a bizarre and disturbing feeling of being unreal or separate from one’s body.

Black & White Thinking (Dichotomous Thinking):

Along with extremes of emotion come extremes in thinking. The person with BPD tends to have extreme opinions. Others are often experienced as being either all good or all bad. When the other person is caring and supportive, the person with BPD views him or her as a savior, someone endowed with special qualities. When the other person fails, disagrees, or disapproves in some way, the person with BPD views him or her as being evil and uncaring. The handicap is in the inability to view other people more realistically, as mixtures of good and bad qualities.

This review of the handicaps of people with BPD is a reminder that they have a significantly impaired ability to tolerate stress. Therefore, the family members can help them achieve stability by creating a cool, calm home environment. This means slowing down and taking a deep breath when crises arise rather than reacting with great emotion. It means setting smaller goals for the person with BPD so as to diminish the pressure she is experiencing. It means communicating when you are calm and in a manner that is calm. It does not mean sweeping disappointments and disagreements under the rug by avoiding discussion of them. It does mean that conflict needs to be addressed in a cool but direct manner without use of put-downs. Subsequent guidelines will provide methods for communicating in this fashion.

4. Maintain family routines as much as possible. Stay in touch with family and friends. There’s more to life than problems, so don’t give up the good times.

Often, when a member of the family has a severe mental illness, everyone in the family can become isolated as a result. The handling of the problems can absorb much time and energy. People often stay away from friends to hide a problem they feel as stigmatizing and shameful. The result of this isolation can be only anger and tension. Everyone needs friends, parties, and vacations to relax and unwind. By making a point of having good times, everyone can cool down and approach life’s problems with improved perspective. The home environment will naturally be cooler. So you should have good times not only for your own sake, but for the sake of the whole family.

5. Find time to talk. Chats about light or neutral matters are helpful. Schedule times for this if you need to.

Too often, when family members are in conflict with one another or are burdened by the management of severe emotional problems, they forget to take time out to talk about matters other than illness. Such discussions are valuable for many reasons. The person with BPD often devotes all her time and energy to her illness by going to multiple therapies each week, by attending day treatment, etc. The result is that she misses opportunities to explore and utilize the variety of talents and interests she has. Her sense of self is typically weak and may be weakened further by this total focus on problems and the attention devoted to her being ill. When the family members take time to talk about matters unrelated to illness, they encourage and acknowledge the healthier aspects of her identity and the development of new interests. Such discussions also lighten the tension between family members by introducing some humor and distraction. Thus, they help you to follow guideline #3.

Some families never talk in this way, and to do so may seem unnatural and uncomfortable at first. There may be a hundred reasons why there is no opportunity for such communication. Families need to make the time. The time can be scheduled in advance and posted on the refrigerator door. For example, everyone may agree to eat dinner together a few times a week with an agreement that there will be no discussions of problems and conflict at these times. Eventually, the discussions can become habit and scheduling will no longer be necessary.

MANAGING CRISES

PAY ATTENTION BUT STAY CALM

6. Don’t get defensive in the face of accusations and criticisms. However unfair, say little and don’t fight. Allow yourself to be hurt. Admit to whatever is true in the criticisms.

When people who love each other get angry at each other, they may hurl heavy insults in a fit of rage. This is especially true for people with BPD because they tend to feel a great deal of anger. The natural response to criticism that feels unfair is to defend oneself. But, as anyone who has ever tried to defend oneself in such a situation knows, defending yourself doesn’t work. A person who is enraged is not able to think through an alternative perspective in a cool, rational fashion. Attempts to defend oneself only fuel the fire. Essentially, defensiveness suggests that you believe the other person’s anger is unwarranted, a message that leads to greater rage. Given that a person who is expressing rage with words is not posing threat of physical danger to herself or others, it is wisest to simply listen without arguing.

What that individual wants most is to be heard. Of course, listening without arguing means getting hurt because it is very painful to recognize that someone you love could feel so wronged by you. Sometimes the accusations hurt because they seem to be so frankly false and unfair. Other times, they may hurt because they contain some kernel of truth. If you feel that there is some truth in what you’re hearing, admit it with a statement such as, “I think you’re on to something. I can see that I’ve hurt you and I’m sorry.”

Remember that such anger is part of the problem for people with BPD. It may be that she was born with a very aggressive nature. The anger may represent one side of her feelings which can rapidly reverse. (See discussion of black and white thinking.) Keeping these points in mind can help you to avoid taking the anger personally.

7. Self-destructive acts or threats require attention. Don’t ignore. Don’t panic. It’s good to know. Do not keep secrets about this. Talk about it openly with your family member and make sure professionals know.

There are many ways in which the person with BPD and her family members may see trouble approaching. Threats and hints of self-destructiveness may include a variety of provocative behaviors. The person may speak of wanting to kill herself. She may become isolative. She may superficially scratch herself. Some parents have noticed that their daughters shave their head and color their hair neon at times when they are in distress. More commonly, what will be evident is not eating or reckless behavior. Sometimes the evidence is blunt – a suicide gesture made in the parent’s presence. Trouble may be anticipated when separations or vacations occur.

When families see the signs of trouble they may be reluctant to address them. Sometimes the person with BPD will insist that her family “butt out.” She may appeal to her right to privacy. Other times, family members dread speaking directly about a problem because the discussion may be difficult. They may fear that they would cause a problem where there might not be one by “putting ideas into someone’s head”. In fact, families fear for their daughter’s safety in these situations because they know their daughters well and know the warning signs of trouble from experience. Problems are not created by asking questions. By addressing provocative behaviors and triggers in advance, family members can help to avert further trouble. People with BPD often have difficulty talking about their feelings and instead tend to act on them in destructive ways. Therefore, addressing a problem openly by inquiring with one’s daughter or speaking to her therapist helps her to deal with her feelings using words rather than actions.

Privacy is, of course, a great concern when one is dealing with an adult. However, the competing value in these situations of impending danger is safety. When making difficult decisions about whether to call your loved one’s therapist about a concern or call an ambulance, one must weight concern for safety against concern for privacy. Most people would agree that safety comes first. There may be a temptation to under-react in order to protect the individual’s privacy. At the same time, there may be a temptation to overreact in ways that give the person reinforcement for her behavior. One young woman with BPD told her mother excitedly during an ambulance ride to a psychiatric hospital, “I’ve never been in an ambulance before!” Families must apply judgment to their individual situation. Therapists can be helpful in anticipating crises and establishing plans that fit the individual family’s needs.

8. Listen. People need to have their negative feelings heard. Don’t say, “It isn’t so.” Don’t try to make the feelings go away. Using words to express fear, loneliness, inadequacy, anger, or needs is good. It’s better to use words than to act out on feelings.

When feelings are expressed openly, they can be painful to hear. A daughter may tell her parents that she feels abandoned or unloved by them. A parent may tell his child that he’s at the end of his rope with frustration. Listening is the best way to help an emotional person to cool off. People appreciate being heard and having their feelings acknowledged. This does not mean that you have to agree. Let’s look at the methods for listening. One method is to remain silent while looking interested and concerned. You may ask some questions to convey your interest. For example, one may ask, “How long have you felt this way?” or “What happened that triggered your feelings?” Notice that these gestures and questions imply interest but not agreement. Another method of listening is to make statements expressing what you believe you’ve heard. With these statements, you prove that you are actually hearing what the other person is saying. For example, if your daughter tells you she feels like you don’t love her, you can say, even as you are contemplating how ridiculous that belief is, “You feel like I don’t love you?!?” When a child is telling her parents that she feels as if she has been treated unfairly by them, parents may respond, “You feel cheated, huh?” Notice once again, these empathic statements do not imply agreement.

Do not rush to argue with your family member about her feelings or talk her out of her feelings. As we said above, such arguing can be fruitless and frustrating to the person who wants to be heard. Remember, even when it may feel difficult to acknowledge feelings that you believe have no basis in reality, it pays to reward such expression. It is good for people, especially individuals with BPD, to put their feelings into words, no matter how much those feelings are based on distortions. If people find the verbal expression of their feelings to be rewarding, they are less likely to act out on feelings in destructive ways.

Feelings of being lonely, different, and inadequate need to be heard. By hearing them and demonstrating that you have heard them using the methods described above, you help the individual to feel a little less lonely and isolated. Such feelings are a common, everyday experience for people with BPD. Parents usually do not know and often do not want to believe that their daughter feels these ways. The feelings become a bit less painful once they are shared.

Family members may be quick to try to talk someone out of such feelings by arguing and denying the feelings. Such arguments are quite frustrating and disappointing to the person expressing the feelings. If the feelings are denied when they are expressed verbally, the individual may need to act on them in order to get her message across.

ADDRESSING PROBLEMS

COLLABORATE AND BE CONSISTENT

9. When solving a family member’s problems, ALWAYS:

a) involve the family member in identifying what needs to be done

b) ask whether the person can “do” what’s needed in the solution

c) ask whether they want you to help them “do” what’s needed

Problems are best tackled through open discussion in the family. Everyone needs to be part of the discussion. People are most likely to do their part when they are asked for their participation and their views about the solution are respected. It is important to ask each family member whether he or she feels able to do the steps called for in the planned solution.

By asking, you show recognition of how difficult the task may be for the other person. This goes hand in hand with acknowledging the difficulty of changing.

You may feel a powerful urge to step in and help another family member. Your help may be appreciated or may be an unwanted intrusion. By asking if your help is wanted before you step in, your assistance is much less likely to be resented.

10. Family members need to act in concert with one another. Parental inconsistencies fuel severe family conflicts. Develop strategies that everyone can stick to.

Family members may have sharply contrasting views about how to handle any given problem behavior in their relative with BPD. When they each act on their different views, they undo the effect of each other’s efforts. The typical result is increasing tension and resentment between family members as well as lack of progress in overcoming the problem.

An example will illustrate the point. A daughter frequently calls home asking for financial bail outs. She has developed a large credit card debt. She wants new clothing. She has been unable to save enough money to pay her rent. Despite her constant desire for funds, she is unable to take financial responsibility by holding down a job or living by a budget. Her father expresses a stem attitude, refusing to provide the funds, and with each request and insisting that she take responsibility for working out the problem herself. The mother meanwhile softens easily with each request and gives her the funds she wants. She feels that providing the extra financial help is a way of easing the daughter’s emotional stress. The father then resents the mother’s undoing of his efforts at limit setting while the mother finds the father to be excessively harsh and blames him for the daughter’s worsening course. The daughter’s behavior persists, of course, because there is no cohesive plan for dealing with the financial issue that both parents can stick to. With some communication, they can develop a plan that provides an appropriate amount of financial support, one that would not be viewed as too harsh by the mother, but would not be considered excessively generous in the father’s eyes. The daughter will adhere to the plan only after both parents adhere to it.

Brothers and sisters can also become involved in these family conflicts and interfere with each other’s efforts in handling problems. In these situations, family members need to communicate more openly about their contrasting views on a problem, hear each other’s perspectives, and then develop a plan that everyone can stick to.

11. If you have concerns about medications or therapist interventions, make sure that both your family member and his or her therapist/doctor/treatment team know. If you have financial responsibility, you have the right to address your concerns to the therapist or doctor.

Families may have a variety of concerns about their loved one’s medication usage. They may wonder whether the psychiatrist is aware of the side effects the patient is experiencing. Can the psychiatrist see how sedated or obese the individual has become? Is he or she subjecting the patient to danger by prescribing too many medications? Families and friends may wonder if the doctor or therapist knows the extent of the patient’s non-compliance or history of substance abuse.

When family members have such concerns, they often feel that they should not interfere, or are told by the patient not to interfere. We feel that if family members play a major supportive role in the patient’s life, such as providing financial support, emotional support, or by sharing their home, they should make efforts to participate in treatment planning for that individual. They can play that role by contacting the doctor or therapist directly themselves to express their concerns. Therapists cannot release information about patients who are over the age of 18 without consent, but they can hear and learn from the reports of the patient’s close family and friends. Sometimes they will work with family members or fiends but obviously with their patient’s consent.

LIMIT SETTING

BE DIRECT BUT CAREFUL

12. Set limits by stating the limits of your tolerance. Let your expectations be known in clear, simple language. Everyone needs to know what is expected of them.

Expectations need to be set forth in a clear manner. Too often, people assume that the members of their family should know their expectations automatically. It is often useful to give up such assumptions.

The best way to express an expectation is to avoid attaching any threats. For example, one might say, “I want you to take a shower at least every other day.” When expressed in that fashion, the statement puts responsibility on the other person to fulfill the expectation. Often, in these situations, family members are tempted to enforce an expectation by attaching threats. When feeling so tempted, one might say, “If you don’t take a shower at least every other day, I will ask you to move out.” The first problem with that statement is that the person making the statement is taking on the responsibility. He is saying “I” will take action if “you” do not fulfill your responsibility as opposed to giving the message, “You need to take responsibility!” The second problem with that statement is that the person making it may not really intend to carry out the threat if pushed. The threat becomes an empty expression of hostility. Of course, there may come a point at which family members feel compelled to give an ultimatum with the true intention to act on it. We will discuss this situation later.

13. Do not protect family members from the natural consequences of their actions. Allow them to learn about reality. Bumping into a few walls is usually necessary.

People with BPD can engage in dangerous, harmful, and costly behaviors. The emotional and financial toll to the individual and the family can be tremendous. Nonetheless, family members may sometimes go to great lengths to give in to the individual’s wishes, undo the damage, or protect everyone from embarrassment. The results of these protective ways are complex. First and foremost, the troublesome behavior is likely to persist because it has cost no price or has brought the individual some kind of reward. Second, the family members are likely to become enraged because they resent having sacrificed integrity, money, and good will in their efforts to be protective. In this case, tensions in the home mount even though the hope of the protective measures was to prevent tension. Meanwhile, the anger may be rewarding on some level to the individual because it makes her the focus of attention, even if that attention is negative. Third, the individual may begin to show these behaviors outside of the family and face greater harm and loss in the real world than she would have faced in the family setting. Thus, the attempt to protect leaves the individual unprepared for the real world. Some examples will illustrate the point.

* A daughter stuffs a handful of pills in her mouth in her mother’s presence. The mother puts her hand into the daughter’s mouth to sweep out the pills. It is reasonable to prevent medical harm in this way. The mother then considers calling an ambulance because she can see that the daughter is suicidal and at risk of harming herself. However, this option would have some very negative consequences. The daughter and the family would face the embarrassment of having an ambulance in front of the house. The daughter does not wish to go to the hospital and would become enraged and out of control if the mother called the ambulance. A mother in this situation would be strongly tempted not to call the ambulance in order to avoid the daughter’s wrath and to preserve the family’s image in the neighborhood. She might rationalize the decision by convincing herself that the daughter is not in fact in immediate danger. The primary problem with that choice is that it keeps the daughter from attaining much needed help at a point when she has been and could still be suicidal. The mother would be aiding the daughter in denial of the problem. Medical expertise is needed to determine whether the daughter is at risk of harming herself. If the daughter’s dramatic gesture has not been given sufficient attention, she would be likely to escalate. As she escalates, she may make an even more dramatic gesture and face greater physical harm. Furthermore, if an ambulance were not called for fear of incurring her wrath, she would receive the message that she can control others by threatening to become enraged

* A 25-year old woman steals money from her family members while she is living with them. The family members express great anger at her and sometimes threaten to ask her to move out, but they never take any real action. When she asks to borrow money, they give the loan despite the fact that she never pays back such loans. They fear that if they do not lend the money, she may steal it from someone outside the family, thus leading to legal trouble for her and humiliation for everyone else involved. In this case, the family has taught the daughter that she can get away with stealing. She has essentially blackmailed them. They give her what she wants because they are living with fear. The daughter’s behavior is very likely to persist as long as no limits are set on it. The family could cease to protect her by insisting that she move out or by stopping the loans. If she does steal from someone outside the family and faces legal consequences, this may prove to be a valuable lesson about reality. Legal consequences may influence her to change and subsequently function better outside the family.

* A 20-year old woman who has had multiple psychiatric hospitalizations recently and has been unable to hold down any employment decides that she wants to return to college full time. She asks her parents to help pay tuition. The parents who watch their daughter spend most of her day in bed are skeptical that she will be able to remain in school for an entire semester and pass her courses. The tuition payments represent great financial hardship for them. Nonetheless, they agree to support the plan because they do not want to believe she is as dysfunctional as she behaves and they know their daughter will become enraged if they do not. They have given a dangerous “You can do it” message. Furthermore, they have demonstrated to her that displays of anger can control her parents’ choices. A more realistic plan would be for the daughter to take one course at a time to prove that she can do it, and then return to school full time only after she has demonstrated the ability to maintain such a commitment despite her emotional troubles. In this plan, she faces a natural consequence for her recent low functioning. The plan calls upon her to take responsibility in order to obtain a privilege she desires.

Each of the cases illustrates the hazards of being protective when a loved one is making unwise choices or engaging in frankly dangerous behavior. By setting limits on these choices and behaviors, family members can motivate individuals to take on greater responsibility and have appropriate limits within themselves. The decision to set limits is often the hardest decision for family members to make. It involves watching a loved one struggle with frustration and anger. It is important for parents to remember that their job is not to spare their children these feelings but to teach them to live with those feelings as all people need to do.

14. Do not tolerate abusive treatment such as tantrums, threats, hitting and spitting. Walk away and return to discuss the issue later.

Frank tantrums are not tolerable. There is a range of ways to set limits on them. A mild gesture would be to walk out of the room to avoid rewarding the tantrum with attention. A more aggressive gesture would be to call an ambulance. Many families fear taking the latter step because they do not want an ambulance in front of their home, or they do not want to incur the wrath of the person having the tantrum. When torn by such feelings, one must consider the opposing issues. Safety may be a concern when someone is violent and out of control. Most people would agree that safety takes priority over privacy. Furthermore, by neglecting to get proper medical attention for out-of-control behavior, one may turn a silent ear to it. This only leads to further escalation. The acting out is a cry for help. If a cry for help is not heard, it only becomes louder.

15. Be cautious about using threats and ultimatums. They are a last resort. Do not use threats and ultimatums as a means of convincing others to change. Give them only when you can and will carry through. Let others – including professionals – help you decide when to give them.

When one family member can no longer tolerate another member’s behavior, he or she may reach the point of giving an ultimatum. This means threatening to take action if the other person does not cooperate. For example, when a daughter will not take a shower or get out of bed much of the day, an exasperated parent may want to tell her that she will have to move out if she does not change her ways. The parent may hope that fear will push her to change. At the same time, the parent may not be serious about the threat. When the daughter continues to refuse to cooperate, the parent may back down, proving that the threat was an empty one. When ultimatums are used in this way, they become useless, except to produce some hostility. Thus, people should only give ultimatums when they seriously intend to act on them. In order to be serious about the ultimatum, the person giving it probably has to be at the point where he feels unable to live with the other person’s behavior.

Dedicated personality disorder services: A qualitative analysis of service structure and treatment process, Journal of Mental Health, 2009

Katy Price et al..

Department of Psychological Medicine, Faculty of Medicine, Imperial College London

Mental Health Foundation

Abstract:

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Dear Baldy,

Usually there’s an imaginative  search parameter or two daily among your fans two-stepping into here from Google but lately it’s been repeats involving tattoos, jews, and L Anne Carrington searching for herself. Yawn.

Two of the most repeated searches from yesterday make me laugh for totally different reasons. Both involve obsessional women.

“smartie “l’anne carrington” ebook” – L Anne, L Anne, L Anne. She’s quaking in her boots trying to find out if Idletard’s Smartie actually is compiling an Ebook of her adventures.  I feel the rumblings up over the Alleghenies and the Blue Ridge right now and smell her arid sweat. Never fear, Smartie is doing just that and David I’d recommend you get a copy as soon as it comes out. You’ve stated you like to read and it’s going to be a fascinating study into mental illness, plagiarism and crime.  I promise you’ll laugh, cry, throw up and gasp before coming back for another plate of crazy.

Personally I think they should build L Anne her own special wing at the Trans Allegheny Lunatic Asylum. She can keep company with the spooks and haints and leave the rest of us alone. It’s just south of her home in the burbs of Pittsburgh.

“David Cook Uncensored” – I’ve never visited this site run by Mary Ann/Holly containing various sockpuppets of Holly pretending to be other people yet only cheering Holly on and I don’t plan on it. I don’t even have the addy but I do understand that there’s one heck of a battle going on right now over that mysterious tattoo of yours. Apparently you getting a tattoo is turning off Mary Ann/Holly to the point where she’s almost ready to toss you on the Idol scrapheap of former lust objects along with Clay Aiken and Constantine.  Fickle fans. Mary Ann – Holly needs to join L Anne at the TALA.

The question that most springs to mind on these two is why Pennsylvania? Why the high percentage of completely wacko obsessed fans in the Keystone state? Is it something in the water?  I know my most insane clients at work come out of the Philly area and seem like they could be characters on “It’s Always Sunny In Philadelphia”. Something must be seriously wrong with that part of the world

Personality disorders.  How does a personality get disordered?  How does a disorder get a personality?  In terms of mental illness, Schizophrenia, Bipolar Disorder, and Depression are the big three, none are personality disorders.  Social anxiety, panic attacks, obsessive-compulsive disorder, borderline personality disorder, autism as a spectrum are all becoming more legitimized in mainstream thinking, with two of them (obsessive-compulsive and borderline) being personality disorders. 

But how about histrionic personality disorder, schizotypal personality disorder, avoidant personality disorder, dependent personality disorder, narcissistic personality disorder, schizoid personality disorder?  These DSM-IV diagnoses, however, have simply lacked the elucidation that advocacy movements provide or seem to be perceived as behavioral patterns that are simply the result of a lack of pragmatic self-improvement… 

As of late, I’ve been trying to get a better understanding of personality disorders.  I can recognize myself in more than one and therefore would fall under the label–Mixed Personality Disorder.  But how much stock do I put into all this?  Before I started reading up on personality disorders, I admit to having judged them as abstractions constructed by “trigger-happy” clinicians looking for targets to flex their diagnostic prowess.  After all, I have a Bachelors in Psychology, so obviously I knew all I needed to know about mental illness, right? 

Eventually, I succumbed to my thirst for knowledge and found myself reading Malignant Self-Love by Sam Vaknin regarding Narcissistic Personality Disorder a couple of years ago.  NPD was a way to define a lot of behaviors that I had recognized in myself that were not severe enough to cause high alarm but were severe enough to adversely effect me and others, psychologically and emotionally.  Several months go by and I also end up considering that there may be some congruency between the autism spectrum and me but that’s for another post in the near future.  A couple of years go by and I realize that NPD and autism spectrum are not complete enough models to describe the pervasiveness of my issues.  I knew I wasn’t Schizophrenic or Bipolar.  Dysthmia (fewer or less serious symptoms than major depression but lasts longer) better describes me than Major Depressive Disorder.    So I decided to return to personality disorders for more personal research on what’s going on with me.  I come to find that, presently, I fit rather neatly within three distinct personality disorders according to DSM-IV criteria: Avoidant, Schizotypal, and Borderline. 

Looking back into my past, I see that Schizotypal has been present since my high school years.  With Avoidant, the transition from the relatively familiar routines and expectations of the world of high school  to the strange, new ”universe” that was college and “adulthood” was so jarring that I see myself having turned Avoidant at that transition.  Borderline, like Schizotypal, was probably always in the background since high school, but it didn’t come into “bloom” until my high school and neighborhood friends were no longer a part of my life and the perception of persistent abandonment from friends and family had begun to set in by my late-twenties.  Traits reminiscent of narcissistic, histrionic, dependent, passive-aggressive, depressive, and obsessive-compulsive disorders seem to come and go for me, but Avoidant, Schizotypal, and Borderline have probably been the most consistent and persistent.  The criteria for masochistic personality disorder would also define a large part of who I am quite precisely, but it has since been excluded from the DSM-IV. 

So how is it that I am the accumulation of so many personality disorder traits?  How could I have lived up to the age of 32 without fully realizing how messed up I apparently am?  Here’s my theory: the thing about being an Avoidant “veteran” is that one becomes adept at avoiding situations that would make one’s pathologies painfully obvious.  I’ve mostly avoided relationships, friendships, and many adult responsibilities, these of which, could have ”broken” me into the self-awareness of something pathological.  Also, the magical thinking and ideas of reference that are characteristic of the Schizotypal have a way of transforming what should be painfully obvious into material for imaginative “narratives”.    Avoidant and Schizotypal traits worked hand-in-hand to keep me secluded from acknowledging reality checks.  Borderline, however, is more difficult to avoid or imagine away as the consequences of borderline behavior have a more concise impact on one’s life.  So when my Borderline traits started to erupt during my late-twenties, I could no longer be in denial about my strange behavior, and this is when I started to wonder what the hell is actually wrong with me. 

Do I really have personality disorders?  I guess I’d have to rely on one of those “trigger-happy clinicians” for a valid and reliable  diagnosis.   My attempts at self-diagnosis are hypotheses born from deductive, inductive, and associative investigations of a private nature.  Nothing professional or academic, just a personal search for answers.  To further my awareness, I hope to find a decent therapist with a sliding-scale system; full cost is just too high.  Previous therapists couldn’t really pin me down diagnostically; now that I’m armed with new knowledge, me and the therapist will hopefully not have to start from scratch.

Personality disorders improve in patients treated for major depression, Acta Psychiatrica Scandinavica, 2009

R. T. Mulder, P. R. Joyce, C. M. A. Frampton Abstract:

Objective: To examine the stability of personality disorders and their change in response to the treatment of major depression.

Method: 149 depressed out-patients taking part in a treatment study were systematically assessed for personality disorders at baseline and after 18 months of treatment using the SCID-II.

Results: Personality disorder diagnoses and symptoms demonstrated low-to-moderate stability (overall κ = 0.41). In general, personality disorder diagnoses and symptoms significantly reduced over the 18 months of treatment. There was a trend for the patients who had a better response to treatment to lose more personality disorder symptoms, but even those who never recovered from their depression over the 18 months of treatment lost, on average, nearly three personality disorder symptoms.

Conclusion: Personality disorders are neither particularly stable nor treatment resistant. In depressed out-patients, personality disorder symptoms in general improve significantly even in patients whose response to their treatment for depressive symptoms is modest or poor.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Forensic nurses perceptions of labels of mental illness and personality disorder: clinical versus management issues, Journal of Psychiatric and Mental Health Nursing, 2009

T. MASON, R. HALL, M. CAULFIED, K. MELLING

Professor of Mental Health and Learning Disabilities,   ² Lecturer/Practitioner, Faculty of Health and Social Care/Cheshire and Wirral Partnership NHS Foundation Trust, and   ³ Research Officer, Faculty of Health and Social Care, University of Chester, Chester, UK Correspondence to  T. Mason
Faculty of Health and Social Care
University of Chester
Parkgate Road
Chester
CH1 4BJ
UK

Abstract:

Anecdotally, forensic psychiatric nurses generally have a more negative perception of people diagnosed with a personality disorder and this negativity is focused more towards managing the behaviours rather than on treatment efficacy and clinical outcomes. This study reports on research carried out across the High, Medium and Low secure psychiatric services in the UK. One thousand two hundred questionnaires were distributed with a response rate of 34.6%. The results indicated a statistically significant difference across High (z= 9.69; P≤ 0.01), Medium (z= 11.06; P≤ 0.01) and Low (z= 9.57; P= 0.01) security with a focus on the management of people with a personality disorder using the Wilcoxon paired samples test. There was also a statistically significant difference in relation to a more clinical/treatment focus for those with a diagnosis of mental illness in Medium (z= 9.69; P≤ 0.01) and Low (z= 9.57; P≤ 0.01) security but not in the High security services. Finally, the results showed significant differences between High, Medium and Low security on each of the four scales of Personality Disorder Clinical–Personality Disorder Management and Mental Illness Clinical–Mental Illness Management. This raises issues of stigma, prejudice and discrimination and suggests a refocus on skills development, acquisition and application for those with a label of personality disorder.

Accessible summary

•  Labelling people may lead to staff pre-judging patients and expect that they will behave in certain ways.

•  Patients with those labels may act on the expectations that the labels carry.

•  This may affect how patient care is delivered and the treatment outcome for the patient.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Psychotherapy of borderline personality disorder,  Acta Psychiatrica Scandinavica, 2009, Volume 120 Issue 5, Pages 373 - 377

M. C. Zanarini

Objective: Psychotherapy is considered the primary treatment for borderline personality disorder (BPD). Currently, there are four comprehensive psychosocial treatments for BPD. Two of these treatments are considered psychodynamic in nature: mentalization-based treatment and transference-focused psychotherapy. The other two are considered to be cognitive-behavioral in nature: dialectical behavioral therapy and schema-focused therapy.

Method: A review of the relevant literature was conducted.

Results: Each of these lengthy and complex psychotherapies significantly reduces the severity of borderline psychopathology or at least some aspects of it, particularly physically self-destructive acts.

Conclusion: Comprehensive, long-term psychotherapy can be a useful form of treatment for those with BPD. However, less intensive and less costly forms of treatment need to be developed.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Assessing high risk offenders with personality disorder, British Journal of Forensic Practice, 2009 Sep; 11 (3): 14-8

Greenall PV

Forensic Personality Disorder Assessment and Liaison Team, Greater Manchester West Mental Health NHS Foundation Trust, UK

Abstract:

Personality disorder was once a ‘diagnosis of exclusion’ and consequently many people, including offenders, were unable to access appropriate care. Some offenders therefore slipped through the net, with devastating consequences. However, recent developments in the health and criminal justice fields have sought to address this problem. One such initiative was the establishment in the Northwest of England of three specialist multi-disciplinary Forensic Personality Disorder Assessment and Liaison Teams. Their task is to assess high-risk offenders with personality disorder and provide a gate keeping and monitoring function to agencies involved in their care and management. This practice-based paper outlines the work of the Greater Manchester team. It describes the team’s approach to the assessment of these individuals and outlines some of the professional and ethical challenges encountered so far.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

A treatment guideline for people with antisocial personality disorder: Overcoming attitudinal barriers and evidential limitations, Criminal Behaviour and Mental Health, 2009,Vol. 19 ( 4), Pages 219 - 223

Abstract:

Mental health professionals have always been ambivalent in their response to treating and managing those with personality disorder, and this especially applies to those with antisocial personality disorder (ASPD). Even forensic practitioners, who might be expected to be more sympathetic, are often antagonistic, viewing therapeutic interventions for this group as no more than sanctioning exploitative and rule-breaking behaviour. Thus, the decision by the National Collaborating Centre for Mental Health to develop a guideline to cover the prevention, treatment  and management of the disorder is a courageous step. The guideline also has a preventative aspect, as it examines interventions for conduct disorder in childhood.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

I got rather long winded in Rekindling the Flame With A Passive Aggressive Pt. 1 yesterday, but here is part 2 as promised.

Upfront I would like to apologize to Dr. Harville Hendrix for being rather disrespectful yesterday when I referred to him as “this guy Hendrix”. I’ve since done a little more research and he’s quite the Ph.D and a best-selling author on relationships (which by the way I have updated the Recommended Reading List over the last few days, so you may want to take a look). A couple of his books look very interesting for the kind of  relationships we’re in. I confess I haven’t read them yet as I just learned about them, but they look like they have strong possibilities and have received very good reviews.

Now, onto the “rest of the story”. LOL.

One thing Dr. Hendrix says besides that conflict in a relationship is natural is that “Divorce does not solve the problems of a relationship. We may get rid of our partners, but we keep our problems, carting them off to the next relationship.”  Personally I’m not sure how much I agree with that statement. I’m facing problems now with my passive aggressive BF that I have never faced before in my life, like no “intimacy” for example. Oh sure I’ve had times in my life where you go to bed angry (a no-no) and nobody touches anybody, but I’ve never experienced it as a way of life. Yes we take our problems with us as far as any problems we personally have, but we don’t take their problems with us which is usually what divorce solves.

Researcher John Gottman, head of the Gottman Institute says he can spot couples with 90% accuracy that are doomed to fail. He says what happens is couples in midlife are exhausted from conflict. I can see where that would be the case. After awhile you get tired of beating your head against a wall. I know I myself just resigned myself to living this way.

He describes these couples as “These couples are alienated and avoidant. They are people you see in a restaurant who are not talking to each other. They raised kids together, but there is not much going on with each other and they realize their marriage is empty,” he says. “These couples stifle things and do not raise issues with their partner. Their marriages are a suppression of negative emotion and a lack of positive emotion. It is a very passive and distant relationship with no laughing, love or interest in each other. This style of suppression can cause intense loneliness that’s almost like dying.”

I think that last line describes it very well. How many of us involved with passive aggressive partners or spouses have felt so terribly isolated and alone? I think from the comments I get here and the research I’ve done, it is definitely a common symptom.

People ask themselves, or other people ask them “If you’re so unhappy, why don’t you leave?” or “Why didn’t you leave?” when it’s someone who has lived miserably for several years. I think we all know the answer to that.

Even though we know it’s futile, we can’t help holding on to the hope that things will change, that the man/woman we fell in love with will return, and we’ll live happily ever after. Another big reason people don’t leave after awhile is because, while it may be a state of unhappiness, it’s known. It’s a “comfort zone”. They just get tired of starting over.

One of the short videos on Dr. Hendrix’s website answers the question “What if my partner won’t work with me?” He says to do the work yourself then, which is what I’ve always said about therapy or counseling. If he/she won’t go to couples counseling than at least get help and support for yourself.

If you’ve decided you’re interested in “Rekindling the flame with your passive aggressive” I wish you all the success in the world. If it works please share with us what worked for you in the “comments” section. We’d all like to know. LOL.

Personality disorder and offending behaviour: findings from the national survey of male prisoners in England and Wales, Journal of Forensic Psychiatry & Psychology, 2009

Amanda D. L. Roberts ^a; Jeremy W. Coid ^b

^a School of Psychology, University of East London, Stratford, London, UK

^b Unit of Forensic Psychiatry, Forensic Psychiatry Research Unit, St Bartholomew’s Hospital, London, UK

Abstract:

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Personality Disorders

Narcissistic Personality Disorder

Dealing With A Narcissist: Emotional Freedom in Action

Narcissistic Personality Disorder pt 1

Narcissistic Personality Disorder pt 2

Narcissistic Personality Disorder pt 3

Borderline – Narcissistic Personality Disorder (BPD-NPD)

http://www.youtube.com/watch?v=frCIcYJuWwg

Gestures of Aggression & Narcissism: narcissistic arms poses

Background Articles and Videos

Personality Disorders

“…Personality disorders, formerly referred to as character disorders, are a class of personality types which deviate from the contemporary expectations of a society.^[1]

A personality disorder is a severe disturbance in the characterological constitution and behavioral tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption. Personality disorder tends to appear in late childhood or adolescence and continues to be manifest into adulthood.

It is therefore unlikely that the diagnosis of personality disorder will be appropriate before the age of 16 or 17 years. General diagnostic guidelines applying to all personality disorders are presented below; supplementary descriptions are provided with each of the subtypes.

Diagnosis of personality disorders is very subjective; however, inflexible and pervasive behavioral patterns often cause serious personal and social difficulties, as well as a general functional impairment. Rigid and ongoing patterns of feeling, thinking and behavior are said to be caused by underlying belief systems and these systems are referred to as fixed fantasies or “dysfunctional schemata” (Cognitive modules).

Personality disorders are defined by the American Psychiatric Association (APA) as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it“. ^[2] These patterns, as noted, are inflexible and pervasive across many situations, due in large part to the fact that such behavior is ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and, therefore, perceived to be appropriate by that individual. The onset of these patterns of behavior can typically be traced back to late adolescence and the beginning of adulthood and, in rarer instances, childhood.^[2]

Personality disorders are also defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10), which is published by the World Health Organization. Personality disorders are categorized in ICD-10 Chapter V: Mental and behavioural disorders, specifically under Mental and behavioral disorders: 28F60-F69.29 Disorders of adult personality and behavior. It is seeking to develop an international diagnostic system. The ICD-10 has been structured in part to mesh the DSM’s multiaxial system and diagnostic formats.^[3]

Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV-TR (fourth edition, text revision) of the American Psychiatric Association.

General diagnostic criteria

According to DSM-IV-TR (see page 689)^[7], the diagnosis of a personality disorder must satisfy the following general criteria, in addition to the specific criteria listed under the specific personality disorder under consideration.

A. Experience and behavior deviating markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

1. cognition (perception and interpretation of self, others and events)
2. affect (the range, intensity, lability and appropriateness of emotional response)
3. interpersonal functioning
4. impulse control

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning.

D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not due to the direct physiological effects of a substance or a general medical condition such as head injury.

People under 18 years old who fit the criteria of a personality disorder are usually not diagnosed with such a disorder, although they may be diagnosed with a related disorder. In order to diagnose an individual under the age of 18 with a personality disorder, symptoms must be present for at least one year. Antisocial personality disorder, by definition, cannot be diagnosed at all in persons under 18. …”

List of personality disorders defined in the DSM

The DSM-IV lists ten personality disorders, grouped into three clusters. The DSM also contains a category for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder. This category is labeled Personality Disorder NOS (Not Otherwise Specified).

Cluster A (odd or eccentric disorders)

• Paranoid personality disorder: characterized by irrational suspicions and mistrust of others.
• Schizoid personality disorder: lack of interest in social relationships, seeing no point in sharing time with others.
• Schizotypal personality disorder: characterized by odd behavior or thinking.

Cluster B (dramatic, emotional or erratic disorders)

• Antisocial personality disorder: “pervasive disregard for the law and the rights of others”.
• Borderline personality disorder: extreme “black and white” thinking, instability in relationships, self-image, identity and behavior.
• Histrionic personality disorder: “pervasive attention-seeking behavior including inappropriate sexual seductiveness and shallow or exaggerated emotions”.
• Narcissistic personality disorder: “a pervasive pattern of grandiosity, need for admiration, and a lack of empathy”.

Cluster C (anxious or fearful disorders)

• Avoidant personality disorder: social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction.
• Dependent personality disorder: pervasive psychological dependence on other people.
• Obsessive-compulsive personality disorder (not the same as obsessive-compulsive disorder): characterized by rigid conformity to rules, moral codes and excessive orderliness.

Appendix B: Criteria Sets and Axes Provided for Further Study

Appendix B contains the following disorders^[8]. They are still widely considered amongst psychiatrists as being valid disorders, for example by Theodore Millon.^[9]

• Passive-aggressive personality disorder (negativististic personality disorder) – is a pattern of negative attitudes and passive resistance in interpersonal situations.
• Depressive personality disorder – is a pervasive pattern of depressive cognitions and behaviors beginning by early adulthood.

Deleted from DSM-IV

The following disorders are still widely considered amongst psychiatrists as being valid disorders. They were in DSM-III-R but were deleted from DSM-IV for political reasons.

• Sadistic personality disorder – is a pervasive pattern of cruel, demeaning and aggressive behavior.
• Self-defeating personality disorder (masochistic personality disorder) – is characterised by behaviour consequently undermining the person’s pleasure and goals. …”

http://en.wikipedia.org/wiki/Personality_disorder

Narcissism

“…The term narcissism’ refers to the personality trait of self-esteem, which includes the set of character traits concerned with self-image or ego. The terms narcissism, narcissistic, and narcissist are often used as pejoratives, denoting vanity, conceit, egotism or simple selfishness. Applied to a social group, it is sometimes used to denote elitism or an indifference to the plight of others.

Freud believed that some narcissism is an essential part of all of us from birth.^[1] Andrew P. Morrison claims that, in adults, a reasonable amount of healthy narcissism allows the individual’s perception of his needs to be balanced in relation to others.^[2]

While most people possess some degree of narcissistic traits, higher levels of narcissism can be dysfunctional, and may be classified as pathologies such as narcissistic personality disorder and malignant narcissism. …”

“…Healthy narcissism has to do with a strong feeling of “own love” protecting the human being against illness. Eventually, however, the individual must love the other, “the object love to not become ill”. The person becomes ill, as a result of a frustration, when he is unable to love the object.^[6] In pathological narcissism such as the narcissistic personality disorder and schizophrenia, the person’s libido has been withdrawn from objects in the world and produces megalomania. The clinical theorists Kernberg, Kohut and Millon all see pathological narcissism as a possible outcome in response to unempathetic and inconsistent early childhood interactions. They suggested that narcissists try to compensate in adult relationships.^{[7] …”}

http://en.wikipedia.org/wiki/Narcissism

“…Narcissistic personality disorder (NPD) is a personality disorder defined by the Diagnostic and Statistical Manual of Mental Disorders, the diagnostic classification system used in the United States, as “a pervasive pattern of grandiosity, need for admiration, and a lack of empathy.”^{[1] …”}

DSM IV-TR criteria

“…A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:^[1]

1. has a grandiose sense of self-importance
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love (megalomania)
3. believes they are “special” and can only be understood by, or should associate with, people (or institutions) who are also “special” or of high status
4. requires excessive admiration
5. has a sense of entitlement
6. is interpersonally exploitative
7. lacks empathy
8. is often envious of others or believes others are envious of him or her
9. shows arrogant, haughty behaviors or attitudes ..”

http://en.wikipedia.org/wiki/Narcissistic_personality_disorder

“Theodore Millon identified six types of narcissist:^[4]

• normal narcissistic type – by nature a competitive and self-assured person who believes in himself or herself. Charming, clever, confident and ambitious, such a person often becomes an effective and successful leader.

• unprincipled type – the charlatan – is a fraudulent, exploitative, deceptive and unscrupulous individual. Although people displaying this type of narcissism are usually succesful in society and manage to keep their activities within the accepted norms, they can also be found in drug rehabilitation programs, jails and prisons.

• amorous type – the Don Juan or Casanova of our times – is erotic, exhibitionist and seductive, aloof, charming and exploitative, and reluctant to get involved in deep, mutually intimate relationships.

• compensatory type – has illusions of superiority and an image of high self-worth, but with an underlying emptiness, insecurity and weakness. This type is sensitive to others’ reactions and prone to feeling ashamed, anxious and humiliated.

• elitist type – the achiever – corresponds to Wilhelm Reich’s “phallic narcissistic” personality type, with excessively inflated self-image. The individual is elitist, a “social climber”, superior, admiration seeking, self-promoting, bragging and empowered by social success.

• fanatic type – is a severely narcissistically wounded individual, usually with major paranoid tendencies who holds onto an illusion of omnipotence. These people are fighting the reality of their insignificance and lost value and are trying to re-establish their self-esteem through grandiose fantasies and self-reinforcement. When unable to gain recognition of support from others, they take on the role of a heroic or worshipped person with a grandiose mission. These people can be found amongst sect leaders, in mental hospitals if their delusions become sustained and extensive, or in prison, if their missions counteract those of society. …”

http://en.wikipedia.org/wiki/Narcissistic_personality_disorder

Mayo Clinic

 Narcissistic personality disorder

“…Narcissistic personality disorder symptoms may include:

• Believing that you’re better than others
• Fantasizing about power, success and attractiveness
• Exaggerating your achievements or talents
• Expecting constant praise and admiration
• Believing that you’re special
• Failing to recognize other people’s emotions and feelings
• Expecting others to go along with your ideas and plans
• Taking advantage of others
• Expressing disdain for those you feel are inferior
• Being jealous of others
• Believing that others are jealous of you
• Trouble keeping healthy relationships
• Setting unrealistic goals
• Being easily hurt and rejected
• Having a fragile self-esteem
• Appearing as tough-minded or unemotional

Although some features of narcissistic personality disorder may seem like having confidence or strong self-esteem, it’s not the same. Narcissistic personality disorder crosses the border of healthy confidence and self-esteem into thinking so highly of yourself that you put yourself on a pedestal. In contrast, people who have healthy confidence and self-esteem don’t value themselves more than they value others.

When you have narcissistic personality disorder, you may come across as conceited, boastful or pretentious. You often monopolize conversations. You may belittle or look down on people you perceive as inferior. You may have a sense of entitlement. And when you don’t receive the special treatment to which you feel entitled, you may become very impatient or angry. You may also seek out others you think have the same special talents, power and qualities — people you see as equals. You may insist on having “the best” of everything — the best car, athletic club, medical care or social circles, for instance.

But underneath all this grandiosity often lies a very fragile self-esteem. You have trouble handling anything that may be perceived as criticism. You may have a sense of secret shame and humiliation. And in order to make yourself feel better, you may react with rage or contempt and efforts to belittle the other person to make yourself appear better. …”

http://www.mayoclinic.com/health/narcissistic-personality-disorder/DS00652/DSECTION=symptoms

Distinguishing Between Personality Disorders, Stereotypes, and Eccentricities in Older Adults  Journal of Psychosocial Nursing & Mental Health Services,  Jul 2009. Vol. 47, Iss. 7; p. 19 (6 pages)

Magoteaux AL; Bonnivier JF

Assistant Professor of Nursing, Gerontology and Psychiatry, Columbus State Community College, Columbus, Ohio

Abstract:

 Personality disorders, especially in older adults, are among the most difficult psychiatric disorders for nurses to assess. When aging further complicates these disorders, nurses’ therapeutic skills are challenged. It has long been thought that personality disorders “age out,” but new research indicates that personality disorders may in fact continue throughout the life span. In addition, the primary and secondary changes of aging further complicate assessment. Assessment of personality disorders in older adults may also be distorted by ageist stereotypes and a lack of understanding of cultural context. Likewise, nurses must be careful about misinterpreting “eccentric” older adult behavior as a personality disorder. In this article, we focus on assessment challenges in older adults to help nurses distinguish between characteristics of personality disorders, stereotypes, and eccentricities in this population.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

My husband told me yesterday that while October’s rent has been paid, November’s rent is going to be tough. We’ve been liquidating all of our bank accounts and apparently we might go negative trying to pay for November. This of course doesn’t even begin to take into account household expenses like utilities, food, and pet care. (The dog went to the vet today for an eye infection, thankfully, the vet gave us a reduced price).

How’d it get to this point? A lot longer unemployment than I ever thought possible. The economy hitting the shitter far harder than the TV news people ever predicted (so much for paying attention to the news).

My husband is supposed to be the breadwinner. He’s been out of work since March and is no closer to a job now than he was then. We don’t even get call-backs for interviews.

Both of our applications for disability are still pending. My husband is having a semi-invasive outpatient surgical procedure tomorrow that he should’ve gotten several years ago. He’ll be checking again when he arrives for the appointment to make sure Medicaid is covering it.

We’re not finding aid programs to help us with our finances. Turning to family isn’t much of an option. His grandfather has cancer, his mother has already declared bankruptcy and is working two jobs, and my mother, with her OCPD-inspired miserliness, isn’t about to give me much of anything.

Talking to my mom on the phone yesterday, I told her that I was applying for disability and told her for the first time that I’m mentally ill. As per usual, she showed no interest in hearing about it, learning about it, knowing any of the details, etc. Instead, she wanted to talk about how she disagrees with my sister, an adult, buying concert tickets and speculating about the supposed tawdriness of her personal life. This is very, very, very typical of my mom and why I didn’t bother telling her years ago that I was having problems. The difference now is my economic situation and preparing to beg for money / a loan.

It’s hard to think of myself as poor since my husband and I both grew up in lower to middle class families. While we’ve been living an extremely frugal lifestyle ever since we became a couple, it’s hard to think of ourselves as needing government assistance. We have college degrees. We were supposed to get jobs to cover our household expenses. The embarrassment of asking for help is long gone. On the bus yesterday, with my clunky “granny shopping cart,” a woman, unprompted, told me about a local food pantry. I thanked her and told her of one I knew. I guess I’m even starting to look poor.

The problem with government assistance is that it may never come, and even if it does, it’s probably far too late. The Chicago Housing Authority isn’t accepting applications, nevermind waitlisting.

Does anyone have any ideas on who we can call for help or what programs we can apply to?

Thanks for reading.