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Thursday, June 23, 2011

Random Thoughts

I know I said I'd polish off the last two personality disorders this week, but I'm in Sacramento, which is not necessarily an impediment in and of itself, but I've been thinking a lot about the ephemeral nature of life and that's far more front and center than psychiatric diagnoses right now.

My own life will be changing soon since I plan to retire from my lengthy career in mental health; and my mother is terminally ill. She's had an incredible life. At 95, she has every right to fade out of life. Nonetheless, there's something about having a parent standing between you and the void. The inescapable message, once one's parents are gone, is that you'll be next. Or, more pertinently, I will be since it's not your mother who's dying.

In addition to life, I've been thinking about "stuff". Mom had lots of it. I know because I just got through clearing fifty years worth of accumulation out of her home. When I was done, it was just four walls and a roof and I was struck by how little it takes to dismantle someone's life. Oh, don't get me wrong. I worked like a mad thing for a couple of weeks. But, that's not very long, really, to dispose of a long life's worth of things. They won't do her any good in the nursing home. And, they assuredly wouldn't have been able to follow her to whatever comes next. So, in the final analysis, it's just "stuff". Once the dust settles, I think I'd like to clear out some of my own.

When we moved to Mammoth Lakes ten years ago, I did a pretty thorough job sorting since we paid the movers by the pound. But, it's amazing how much new "stuff" a couple of active adults can gather in a ten year span. We have a three thousand square foot house that's full. Oh, I suppose it could hold a tad more. But, why? As it is, I brought things back from Mom's house that probably should have gone to the Goodwill. And so it goes. I listened to Mom for years as she talked about how she should really clean out her closets. Well, she was right. She should have. At least then she'd have had some say about the disposition of everything. As things stand, she's way too demented to weigh in on much of anything.

Which brings me to another topic: modern medicine. We have increcible interventions. When I used to work for a Family Medicine residency training program, the standing black-humor joke was that we live in America where death has become optional. Well, that's not so far from the truth. Mom develops infections that could easily sweep her away, but the MDs keep bringing her back, despite the fact that she has advanced directives telling them not to. All I can do, since I'm so far away, is sit back and grind my teeth. I got into an incredible argument with one of the hospital intensivists a couple of months ago. After the perky little doctor insisted she could save Mom, I asked "What for?", following that up with, "She has no quality of life." Well, the MD didn't have an answer for me. But, she pulled Mom through anyway. In spite of me? Because of me? Hard to say . . .

Truth be told, I'd far prefer it if my mother was still hale and hearty. But, she's not. In fact, she's so miserable, it breaks my heart. We euthanize animals. Yet, we let people suffer. It makes little to no sense. Anyway, I'll get off my soapbox.

Today's blog was far more personal than usual. Promise I'll get back to business as usual next week.

Friday, June 17, 2011

The Psychology of Character Development, Part VIII

I finally have time to get back to this weekly blog. I’ve actually missed doing it as it gave me an opportunity to think about how psychiatric diagnoses have helped me build story characters.

Starting off with Borderline Personality Disorder, I think it’s safe to say that this is one of the most challenging diagnoses for any clinician. Borderlines are characterized by a severe and pervasive fear of abandonment; they’ll stop at nothing to ensure that the people in their lives stay connected.  About 75% of persons with this disorder are female. Self mutilation and multiple suicide attempts, that are more attention-getting gestures than true suicide attempts, are common. Despite the fact that the Borderline doesn’t really want to die, they often miscalculate; thus, this group suicides at a rate roughly ten times greater than the general population.  Medications are fairly ineffective treating this disorder. There are some newer, highly structured, psychotherapeutic interventions that have shown some promise, though.

The most distinctive characteristic of persons with BPD is their hypersensitivity to rejection and their preoccupation with abandonment. Unfortunately, their perception of whether or not another cares for them involves unrealistic levels of availability and validation. So, the individual with BPD alternatively idealizes, then devalues, others. In storybook land, this could be a supporting character who is uber–demanding, constantly upping the emotional ante to get their needs met.

As a personal aside, the very few suicides I’ve had in my practice over the years have all carried this diagnosis. They are difficult to treat because they do not trust easily, so the development and maintenance of a therapeutic alliance is a perpetual challenge.

Narcissistic Personality Disorders aren’t any easier to treat than Borderlines, but at least they lack the lethal element.  Narcissists actually make great antagonists. They’re the ones with an elevated sense of their own importance, a sense of entitlement, and fantasies of unlimited success/power/brilliance. They can be haughty and arrogant. They also tend to be interpersonally exploitive, lack empathy and are envious of others. I can think of lots of storybook antagonists who fit that bill: Joffrey in the Fire and Ice Series, Saruman in LOTR, Ambrose in Rothfuss’s Name of the Wind, to name but a few.

Narcissists hardly ever come into psychotherapy. The idea that they would even need to consider fixing anything about themselves is anathema to them. Underneath the bravado, though, is brittleness. In depth work, they train practitioners to be wary of too much confrontation with this disorder (assuming you’d ever see one in your practice!) because the theory is once you’ve pulled their covers, there’s no ego strength beneath to shore them up.

Another thing to keep in mind is that the personality disorders rarely occur singly. Generally individuals have traits from more than one of these disorders. So, Joffrey was also an antisocial personality disorder, as was Saruman. The Diagnostic and Statistical Manual of Mental Disorders (we’re on the fourth edition at the moment) defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”.

In plain speak, what this means is that personality disorders see the world in a way that diverges from most of the rest of us. The more severe disorders have their roots in very early childhood (age 0-3). And, clinicians (who often do not agree on much) agree that all of these disorders begin prior to age 5.
Today’s blog is getting too long to finish the last two disorders. However, I’d be more than glad to entertain any questions about this series so far.

Wednesday, June 15, 2011

Contest Winner!!

Ken Schneyer is the winner of a signed print copy of Psyche's Prophecy. Thanks for signing up for my blog. It's much appreciated.
I'll be running another contest as soon as Psyche's Search becomes available.

Thursday, June 2, 2011

On the Road . . .

Traveling this week, so my usual Friday blog post will be a few days late. Stay tuned though, I plan to polish off the personality disorders next time. So, that will include schizotypal, borderline, narcissistic and avoidant.

I've always loved the myth about Narcissus. Remember him? He was a hunter who was so taken by his reflection in a still pond that he simply sat there admiring himself till he died. The earlier part of that story includes Echo, a nymph who was in love with Narcissus. Spurned by him, she, too, wasted away till there was nothing left of her but her voice. It always seemed fitting to me that Narcissus met his end the same way Echo did, by self induced starvation.

Maybe when I'm done with the personality disorders, I'll segue into mythology. There are lots of amazing stories that haven't lost a thing despite the fact their roots are thousands of years old.