Tag Archives: narcissism

Why are personality disorders so difficult to treat?

Why are personality disorders so difficult to treat?

Well, there’s a complicated question! This post attempts to present an overview response.

A personality disorder, like just about all mental disorder diagnoses, is made based on a checklist of complaints, symptoms, and observations. However, personality disorders are very different from what we normally think of as emotional problems.

Consider, for example, depression. “Depression” is diagnosed when 2 weeks have passed and certain criteria have been met (and there’s no “pass” given for grief or other traumatic events in the new diagnostic manual, although we’re supposed to note it in the records). Most people know when they’re sad, irritable, unhappy, and hopeless. It feels awful and they want to get that bad feeling off of them. Some people might not think of it as “depression.” They might identify it as a “low time,” or it might be grief, or a normal adjustment to a new phase of life such as marriage, an empty nest, or graduating from college. It might be a normal but very painful response to some new curveball life has thrown at them: an illness, a layoff, retirement, etc.

A personality disorder is different because it is pervasive; like the personality of any person, it is part of everything. Your personality impacts how you interpret everything that happens, the way you react to people and events, the emotions you experience. This goes for healthy people as well as those whose patterns are far enough from the big, wide range of normal to merit a “disorder” status. So, when someone seems to have a personality disorder (say, narcissism), they are not experiencing their diagnosis as a messy, icky experience to be stopped. They are rolling along (over other people) and having their life. Everything comes through a lens that assures them that they are special, entitled to preferential treatment and to have their way, and, well, let’s face it, just better than us. Problems are experienced as due to the outside world and their own role in those problems is not apparent.

From a therapist’s perspective, when someone comes in with depression, even if that’s not what they, or we, might call it, they know they are unhappy and they want very much to feel like themselves again. They are hopeful that a counselor can help them push through this difficult time.

When someone who meets criteria for a personality disorder comes to treatment, it’s usually because of some other issue, such as work or relationship problems. Remember that each of us is walking around, seeing the world through our own eyes and interpreting everything we experience, including our own thoughts and feelings, through our unique mental structure. You build that mental structure from the earliest moments of life. Is the world safe? Are my needs met? Are the grownups who tend to me patient, gentle and kind? Babies are already sorting out information and creating a set of basic assumptions about the world that will become essential aspects of their personality. It’s so deep, it’s hard to not take for granted that our way of making sense of things isn’t necessarily the only, or best, way. So when patterns of problems arise with colleagues, bosses or family, it’s hard to believe that the problem is fundamental to our mental structure; it defies logic and could be very insulting. The person may be suffering terribly, every day. This is definitely the case with some of the personality disorders, such as Borderline Personality Disorder, Avoidant Personality Disorder and Dependent Personality Disorder. Whether these or any of the personality disorder diagnoses, the person did not choose this burden and it isn’t their fault. However, presenting it as an internal problem – to them – can feel like blaming and attacking – which is definitely not the therapist’s intention.

Imagine if something terrible happened to you: a tsunami. Your workplace is destroyed. You lose your house. You lose your stuff. You catch a mosquito-borne illness and suffer long-term ramifications. It’s a series of terrible events and you find yourself traumatized and perpetually anxious. Is that anxiety your fault? Certainly not. Just so, the early life experiences that set people up for the challenges we call personality disorders are not their fault. However, it’s a problem that they can learn to heal, but that can sound like blaming the victim. Thus, if someone meets criteria for a personality disorder, trying to sell them on dealing with the personality disorder is pretty much like saying, “Look, an awful lot about the way you think and respond to things is kind of messed up. But, never fear! Together we can bulldoze your personality and how you think, feel and behave, pour a new slab, and then we’ll rebuilding you from the ground up. You’ll learn new ways of thinking, feeling and behaving.”

Even when it’s dressed up in tactful, compassionate psychological language, that, my friend, is a very hard sell indeed.

Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Oh, the drama!

It’s about 2/3 of the way through the spring term, so it’s time again for my intro psychology students to learn about the various personality disorders, as defined by the American Psychiatric Association. One interesting one – and not necessarily in a good way – is Histrionic Personality Disorder (HPD).

Traditionally, HPD was estimated to occur in perhaps 2-3% of the population. You know these folks; you’ve known them all your life. They’re exciting, intense, and fun; the life of the party, the center of attention…and they can’t turn it “off” when appropriate. It’s the “friend” who wears a very well-fitted white dress to your wedding; the family member who always has to make it “about them,” when it’s very, very much about someone else; the middle-aged parent who is trying to compete with a teenaged child to the point of embarrassment (for the child, that is). They lack empathy for anyone but themselves, but can emote with the best of them. Recent studies indicate that incidence of HPD is exploding – with some estimates as high as 27% of the young adult (under 35) population now meeting criteria for the psychiatric diagnosis. It’s thought that the two-generation long emphasis on having high self-esteem absent any achievement of good character or performance might be involved, as well as the current culture that elevates attention (any attention) as better than just chugging along, living your life happily with the people you love.

Which of our grandparents would ever, in million years, have imagined everyday people talking about how many “followers” they have, as if they were Jesus?

Like almost all psychiatric diagnoses, HPD is defined by a checklist; meet enough criteria according to the clinician holding the checklist, and you’ve earned the label. Of course, someone with HPD isn’t coming for therapy for help with HPD. Others may come for help with them, or it may become apparent within the context of counseling for some other issue: relationships, work conflicts, etc.   It’s sad, really, that it can be so difficult to realize one needs help, because at the root of this is a small child, still jumping up and down crying out, “Mommy! Watch this! Mommy – look at me!” and that small child in the unconscious just doesn’t realize that all the jumping up and down cannot make them feel “seen,” and they need to find other ways – more adult, meaningful ways – to feel connected and recognized. After all, everyone wants to be seen by eyes that love them; didn’t the film Avatar touch on that well, where the most intimate thing people could say to another living being was, “I see you”?

Like some of the other personality disorders, particularly Antisocial Personality Disorder, Borderline Personality Disorder, and Narcissistic Personality Disorder, the person with Histrionic Personality Disorder will seem fine…in fact, better than fine. All four can be very charming, interesting, and fun. They can seem special and their attention can make the next victim caught in their vortex feel special until all heck breaks loose.

Be compassionate but beware. No matter how wonderful, loving and patient you are, healing the wounded heart under HPD is not a one-man or one-woman task.

Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Review: The Collapse of Parenting: How We Hurt Our Kids When We Treat Them Like Grownups, by Leonard Sax, M.D., Ph.D.

A friend recommended this book and this past weekend I read a large portion of it. It’s aimed at parents and others who are directly involved in raising children, and cites some pretty striking research about the negative outcomes of giving children more freedom and flexibility than they can handle. Children being given the control over their lives that ought to be reserved for responsible adults are far more likely to develop anxiety, depression and obesity; they have less attachment to their families and adults in general, and are more likely to turn to peers for advice. Their peers, of course, are not apt to know any more than them about making wise choices about life.

It’s a conundrum for some: after all, kids have to learn how to make choices, but they can’t handle the full variety of options that many parents want to give them. Learning how to present a narrow, fair range of choices is, apparently, a challenge for parents who are desperate to be liked. This craving for their children’s approval underlies a lot of dysfunctional, but seemingly well-intended, parenting. I described a parent’s style as a “democracy” (the children are school age) and the parent took it as a compliment…as if being democratic with children, where no one is really in charge and knows best, was a good plan.

Do kids need choices? Absolutely. Do they need – or can they even handle – the full range of options that an adult might handle? Absolutely not.

For parents, teachers, grandparents and others who work with children, this book is a friendly, accessible but thoroughly footnoted guide.

Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Way 30, Day 30: Make it a great year: Let go of having to have an opinion on everything

A lot of us grew up hearing well-intentioned grownups say things like, “Stand up for yourself! Your opinion is as good as anyone else’s!” This was supposed to build up self-esteem but it can end up creating narcissism or, if not to that level of pathology, a very disagreeable arrogance.

An opinion, after all, is supposed to be based on knowledge. It’s different than a preference, which is more a matter of liking something. So I might have an opinion that one kind of food is healthier (based on facts) but have a tremendous preference for another (based on its taste).

In Toxic Mythology (© 2015), I addressed this for a full chapter. You have no doubt encountered people who have opinions on everything, even if they have no real knowledge on which to base that opinion. An opinion, after all, is supposed to be based on knowledge and expertise. Its value (to others) comes from that knowledge and expertise.   I suspect that a lot of people feel anxious about not having an opinion, as if it means they are foolish, uninformed, or wishy-washy. If it’s something critical to your life, then you probably ought to be doing the homework to develop an informed opinion. If it is something about which you have no interest and no need for interest, why do you care? Is your insecurity about being judged leading you to pass judgment on things and situations about which you have insufficient information?

Punt on having an opinion when you’re lacking information. It’s easier than you might think:

“I don’t know enough about that topic to have an opinion. What are your thoughts?”

“I haven’t looked it into sufficiently to really have a full picture. What sources would you recommend?”

See, that was easy.

Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

I didn’t intend to eavesdrop…

August 5, 2015

Timeline: breakfast in Savannah, July 30.

I certainly didn’t intend to eavesdrop – listening in feels too much like the part of family psychotherapy called the enactment, when we observe a few moments of an argument that randomly unfolds before us, just to get an understanding of how problems are addressed – but the “free” breakfast in a small, historic inn doesn’t give a lot of space for privacy. So there we were, my hubby and I, in a beautiful old inn, forced to listen to two intelligent, good-hearted parents making fools of themselves in an attempt to talk a school-aged child into eating breakfast. Their efforts included cajoling, bribing, self-deprecating jokes about the father’s supposed fatness and thus how it would be OK for him to go hungry (but not the child), and more increasingly shrill gambols in gambling with their little angel.

How wearisome for them, and how sad for the child, who apparently holds all the cards in this little trio. All day, every step is manipulated by the whims of a child who really doesn’t need or want this much control. The professional part of my brain darkly predicted that this is how they live. The little narcissist-in-training laughs (now adorably but not so for long) at dad’s loving goofiness as he describes himself as “fat” to make her smile and perhaps pick at a bagel and some fruit. Mom tries a bit less hard than dad. I suspect she wishes he would be less willfully weak and is fast losing respect for him, and herself, and feels guilty at her burgeoning resentment towards the dictator-daughter. The teenage years ahead loom miserably, unless the parents decide to nudge their little darling out of the driver’s seat.

They did not ask, and I did not offer…but all that suffering (on the part of all of them – a child running a household suffers, too) is unnecessary. The parents can change how they behave, and the child will catch on quickly enough. No need to drag the girl in for counseling: she is merely taking the scepter handed to her. No, this is an adult problem. If the parents will it, we can fix it. If they choose not to, I predict that the parents’ marriage will suffer and the child, too, will grow up to be  impatient, bossy, and self-absorbed: an impossible-to-please adult who feels entitled to happiness.

As I remarked, at this point, the parents can change that future.

But I was on vacation, not in the office, and it was not dire enough to necessitate violating their privacy by speaking to them.

Still, I wish I could tell them, hey, you can fix this.

 

Dr. Lori Puterbaugh

© 2015

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.