Rerun: My Augustine Depression

From this time of year, last year. Still highly relevant ...

A couple of nights ago, I felt myself slide into what I call my Augustine of Hippo depression. Imagine waking up one fine day in 410 AD, only to discover that Alaric the Visigoth has sacked Rome, thereby launching the Dark Ages and making stupidity fashionable. That’s kind of what happened to me one bleak and miserable November evening of 2004 when I returned home thinking I had fired the President, only to discover the very opposite had occurred.

This couldn’t be happening, I could only think. Not in a civilized society.

Augustine’s resulting meditative funk led to “City of God,” mine to “Living Well With Depression and Bipolar Disorder.” Okay, I’m no Augustine - don’t make me any more depressed than I am.

What happened the other night was more of a mini-Augustine depression. I turned on the TV only to discover that the asshole Joe Lieberman had succeeded in forcing both the Senate majority and the Administration to roll over and play dead for him. Real universal healthcare was off the table. In its place was a government hand-out to the insurance industry masquerading as reform.

End of civilization, I decided.

I have a tendency to get carried away. Bear with me ...

This year, the Wilkins Ice Shelf (a whole friggin’ ice shelf!) up and collapsed on us. Earlier, the entire world economic system nearly did the same. What next? A killer comet named after Lieberman?

We know the Roman Empire was in a state of decline long before Alaric and his fellow barbarians dealt the coup de grace. In the third century, the Empire suffered an economic collapse from which it never recovered, resulting in profound changes that set the scene for anarchy, serfdom, and ignorance. Significantly, the middle classes all but disappeared. Thomas Cahill in “How the Irish Saved Civilization” even notes the poetry got bad. More important, as the end drew near, education had virtually vanished. The culture of stupid was fully locked in place.

It’s way too soon to tell whether today’s US equates to the Rome of the third century. Having said that, our culture of stupid is a major worry. Can you name three celebrity airheads with relationship difficulties? Easy. Can you name two Nobel Laureates this year besides Obama? Don’t worry. Neither can I.

A bad economy or a fragile environment is only a crisis if we place no value on the brain power we need to think our way through these situations. But we can't even figure out health care. We've ceded sovereignty to the idiots. Are we really that stupid? Now I’m starting to get worried ... 

Quick Update

I'm working on a complete overhaul of mcmanweb. Being self-employed, my prick of a boss wants it done right now, no excuses, but my genius employee takes three days to figure out what my one-year-old grandson can figure out in three seconds. Oy!

Anyway, this means blog reruns over the next week. Don't worry, reading something twice won't kill you. Okay, some people, maybe. Well, actually, the odds are about the same as driving blindfolded, but don't let that worry you. Yes, reading things twice encourages people to think, and we all know how dangerous thinking is, which is why people choose instead to vote Republican and fall in love and other incredibly stupid things. Oy!

Take a look at the name of this blog, and you will appreciate what we're all up against.

Enough already! Have fun. Talk amongst yourselves. See you soon ...

A Christmas Poem

Twas the night before Christmas, when all through the place
Not a thought was racing, not even a trace;
The meds were all stashed, in the cabinet with care;
A warning to my neurons, behave and beware.

When out on the lawn there arose such a clatter,
Something bad was going down, something was the matter.
Away to the window I flew like a flash,
Oh crap, not again, not another stupid crash.

When what to my wandering brain should appear,
A dude in a sleigh with eight friggin’ reindeer.
Now Dasher! now Dancer! Please tell me I’m dreaming!
On Comet! on Cupid! Time to start screaming!

To the front of the porch! up against the wall!
Get 911 here right now, I’m headed for a fall.
A vision in my head, a harbinger of doom,
Now dash away! dash away! To the emergency room!

He was dressed all in rags, from his head to his foot,
And his clothes were all tarnished in ashes and soot.
He came through the sliding door, in the back entry;
No way to blame his appearance on a dirty chimney.

A bundle of stuff he had flung on his back,
Like a homeless person, with his life in a sack.
I’m the Ghost of Christmas Present, he said in my home.
Dude, I replied, you got the wrong poem.

His eyes - they were hollow, his skin a sickly yellow.
His mouth it trembled, like a defeated fellow;
A stump of a smoke he held tight in his teeth,
Looked like he hadn’t eaten anything in a week.

My old lady was upstairs, zonked out on her meds;
My kids were in the next room, asleep in their beds.
Only one thing to do, very plain to see,
Time to call 911, protect my family.

I put down the phone, in spite of myself,
Something in my brain, maybe an elf.
Set yourself down, I said, You’re in the right poem,
I’ll see what’s in the fridge, make yourself at home.

His eyes how they twinkled! His dimples how merry!
You got that part right, he told me, very very very!
No matter how much we have, how much we own,
We’re all of us homeless, till we find the right poem.

And laying a finger, alongside of his ear,
And, giving a nod, he was no longer here.
Was it a dream? Was it psychosis?
Does my doc need to up my meds, on even higher doses?

But the feeling was real, a peace I had never known;
I was in the right place, in the right poem.
And I heard him exclaim, in a voice that was my own,
“Check what’s inside the fridge. You have found yourself a home.”


***

First posted on HealthCentral two years ago. A happy - and giving - holidays to all. Today marks the second anniversary of my blog. Many thanks to all of you who entered my virtual home strangers and stayed as friends.

The Year That Was - Almost Over, But Not Letting Go: Part II

My second (first here) idiosyncratic installment in looking back on how 2010 unfolded:

Old Movie of the Year: Groundhog Day

Updating the DSM is an exercise that affords us that rare opportunity to think mental illness afresh. The last time this happened was in the late seventies with the publication of the ground-breaking DSM-III of 1980. Think of the DSM-III as the old DOS operating system. Its successor editions (the last one was 1994) were essentially DOS updates. In Feb this year, the American Psychiatric Association unveiled its draft to DOS-5 - um DSM-5 - due for publication in 20013.

In sticking to DOS, as I reported here on numerous occasions, those responsible for the next DSM - which sets the scene for the next 20 years - are keeping us stuck in 1980 Groundhog Day forever.

If nothing else, a soul-searching discussion would have been useful. Hell, I would have settled for an instant message. An instant message where numerals pose as words, even. Is this asking too much? Yes, apparently.

Psychiatrist of the Year: Emil Kraepelin

Okay, he’s sort of dead - well, completely dead - which is a rather large technically. But even dead, this guy leaves the live psychiatrists for dead. (Wait, let me rephrase that.) Kraepelin, who was born the same year as Freud, coined the term, manic-depression, which - contrary to conventional thinking - is not synonymous with bipolar.

Kraepelin saw all forms of depression (even unipolar depression) in an obvious relationship with clear overlap. This translates into a lot of unipolar depressions behaving like bipolar, even if mania is not involved. This may also explain why antidepressants do not work for a good many people, and may indeed be harmful. The DSM-III of 1980 can be forgiven for getting this wrong. The DSM-5, due out in 2013, cannot.

No doubt about it: If we could somehow “undead” Kraepelin, he’d be saying take a match to the DSM and start over. Instant message: "G8 stuff, homey! All 4U! :) :)"

Person of the Year: You

That’s right, you - patients and loved ones. In April this year, I delivered a keynote to DBSA Kansas. As part of my talk, I asked my audience to come up with a one-sentence description of depression. The answers bore some relationship to the DSM, but were much more insightful and in touch with reality:

“Like having two doberman pinschers waiting for you to get out of bed in the morning.”

“You're on a raft, in the middle of a huge ocean, you can't see any land anywhere, on any horizon, and you're totally becalmed.”

“It's like trying to walk through mud up to your neck.”

These were just some of the responses, very much in line from what I have been hearing from fellow patients and loved ones for years. But then again, only we know what we have to live though. Too bad psychiatry isn’t interested in hearing from us. “Is that a better list than the DSM list?” I asked my audience. “Congratulations,” I concluded, “you guys have beat the best psychiatrists in the world. Give yourselves a round of applause.”

More to come ...

The Year That Was - Almost Over, But Not Letting Go

This is the time of the year for looking back, a la Time Magazine and CNN. Following is the first installment in my personal (and highly idiosyncratic) view on how the year unfolded:

Historical Person of the Year: Genghis Khan.

It turned out my first piece of the year just happened to mention this much-maligned conqueror. His name came up in the context of traditional societies, where people have far less mental illness and recover far more quickly than those forced to cope with the demands of modern living. We can debate forever about the hows and whys until the cows come home. We did just that over the course of the year.

Nevertheless, Genghis Khan reminds us that even people living back in simpler times had cause to be stressed, which kept the discussion honest.

Later in the year, I devoted an entire piece to the man who made Alexander the Great look like a pussy. In his wake, things were never the same, which offered an excellent object lesson on thinking outside the box and paradigm change - my other major theme of 2010. Clearly, the prevailing biological psychiatry paradigm of mental illness is under threat - from its own shortcomings, from new advances in brain science, and from a growing consumer-led recovery movement. New explanations are needed.

Bottom line: In two different thematic approaches to rethinking mental illness, Genghis Khan was there.

Historical Person of the Year, Runner-Up: JFK

“We enjoy the comfort of opinion without the discomfort of thought,” our 35th President said in 1962. He could have been talking about today. Is Republicanism the New Stupid? I questioned in one blog. (Short answer: Yes, but that doesn’t mean Democrats are smart.) In numerous pieces, JFK served as the pin that punctured the fallacy that our choices are based on reason. Whether we are voting for a political candidate or buying a product or choosing a mate, new research is revealing that the thinking parts of the brain cannot make a decision without input from the primitive limbic regions. Our highly-evolved cortical areas, too often, seem to serve no other purpose than to rationalize our emotional reactions.

Kennedy had an undeniable emotional appeal, but of all things the televised 1960 Presidential debates reveal the man’s appeal to our higher reason. “What piece of work is man?” Some surprising answers are revealed by gazing into that distant mirror.

No doubt about it, Kennedy is there.

Fictional Person of the Year: Hamlet

I have of late - but wherefore I know not - lost all my mirth, forgone all custom of exercises; and indeed it goes so heavily with my disposition that this goodly frame, the earth seems to me a sterile promontory …

What is depression, anyway? Feeling sad? Lack of motivation? Psychic numbing? Is it a “normal” reaction to abnormal events or an abnormal reaction to normal events? A loss of energy or a mammalian need to hibernate? A crisis of the soul? Perhaps it’s even a part of our normal personality. Hamlet did a lot of talking, but scholars still debate the true shade of his “nightly colour.”

Obviously, no two depressions are alike, which makes one wonder why psychiatry treats them as if they were. No wonder we don’t get better. All year, on Knowledge is Necessity, we asked the type of questions that psychiatry needs to be asking. Hopefully, one of these years, psychiatry will begin to do some asking of its own.

In the meantime, Ham-o-let is there.

Fictional Work of the Year: The Draft DSM-5

As those of you who read this blog are aware, the DSM-IV bears little semblance to clinical reality. The DSM-5, which is due to come out in 2013, proudly continues in that tradition. In February, the American Psychiatric Association unveiled its draft, which amounted to (with the notable exception of personality disorders) a reissue of the DSM-III of 1980, replete nearly word-for-word with its antiquated and highly misleading symptom checklists.

This definition of depression, vintage 1980: “Depressed mood most of the day.”

Huh?

I could go on and on. For most of the year, I did. But who listens to me?
 
The DSM, the DSM, there's nothing like the DSM
It’s a text in medical shape
An illusion of authority
You may read it in a by-street
You may consult it in the square
But when we need an answer, the DSM’s not there!

Much more to come ...

Personality Disorder: Understanding Dimensionality

The story so far: The DSM-5, due out in 2013, will be the same old book in new covers. The exception is personality disorders, which gets a major overhaul. Not coincidentally, this is the one realm of mental illness where big pharma is conspicuously absent.

My last two blog pieces - Decisions, Decisions, and Bringing Order - looked at the changes on the “categorical” side of personality disorders. Five out of ten of the present disorders will get the boot, while the five left standing (antisocial/psychopathy, avoidant, borderline, obsessive-compulsive, and schizotypy) receive further clarification. The weakness with categories is inevitable overlap, but rather then pretending this doesn’t exist, the DSM-5 openly adopts interchangeable parts, with six “trait domains” (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy) further subdivided into “facets.”

Thus, the new borderline “type” (which replaces the term “disorder”) is loaded with six negative emotionality trait domains and two antagonism domains, while the new antisocial/psychopathy type is heavy on antagonism (six in all) and light on negative emotionality (zero, in fact). The two borderline antagonism facets (hostility and aggression) reappear word-for-word in antipsychocial/psychotic.

Kind of like IKEA. The parts may be the same, but each piece of furniture - one hopes - is very different. So what would happen if we were to dispose of the concept of furniture altogether? Funny you asked.

Enter the “dimensional” model. The same bits and pieces are there - namely the general trait domains of negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy, plus the more specific facets - but instead of looking for labels, we are looking for shadings. Instead of asking “Which one?” (as in borderline or antisocial) we are asking “How many?” and “How much?”

The DSM-5 trait domains are derivative of, and roughly correspond to, the traits in the five-factor model (FFM), already in wide use in clinical practice. The FFM tests for “openness to experience”, “conscientiousness”, “extraversion”, “agreeableness”, and “neuroticism” (OCEAN).

A quick scan, however, reveals that the FFM and DSM-5 investigate essentially the same phenomenon from entirely different viewpoints (“extraversion” vs “introversion”, “agreeableness” vs “antagonism”, “conscientiousness” vs “disinhibition” and “compulsivity”). Whereas the FFM looks at our potential, the DSM looks at what is holding us back.

A good illustration of this is the FFM’s “openness to experience” trait, which has no apparent correspondence in the DSM-5. The opposite to openness to experience is stuck in the mud, which you can hardly associate with any kind of mental disorder. In this context, stuck in the mud is simply less desirable than being creative and intellectually adventurous.

Now let’s examine the one DSM-5 trait with no seeming FFM counterpart. “Schizotypy” broadly describes strange thinking and behavior. Its opposite? May I suggest stuck in the mud? In other words, in a DSM setting, stuck in the mud comes across as a desirable trait. Certainly, no one calls 911 to complain about their boring wife or husband.

The DSM-5 calls for clinicians to rate all 37 facets which make up the six domains on a four-point scale, which invites the instant criticism of clinical unwieldiness. According to Allen Frances, who chaired the DSM-IV, blogging on Psychology Today:

Unfortunately, the reach of DSM-5 far, far exceeds its grasp. Only by going to the website yourself and reviewing the DSM-5 dimensional suggestions can you get a feel for just how remarkably ad hoc, idiosyncratic, and cumbersome they are. I have discussed the suggestions for dimensional personality disorder ratings with a number of experts (and this is also my area) and none of us could decipher the proposal, much less conceive of its ever being workable. One described it as an example of "too many research cooks spoiling a clinical broth".

Dr Frances’ criticism may well be valid, but it also can be interpreted as an egregious case of DSM-worthy “lazy clinician syndrome.” We see this every day in doctors who profess to be far too busy to monitor their patients for weight and blood sugar levels and other red flags when prescribing meds with notoriously high metabolic risks, not to mention other high crimes and misdemeanors.

Personality is fiendishly time-consuming and complex. Clinicians want it quick and simple. But what about our interests?

Much more to come ...

Previous Pieces

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard? 

Personality Disorders: Decisions, Decisions ...

Bringing Order to Personality Disorder

Bringing Order to Personality Disorder

Yesterday, we inspected the house-cleaning performed by the DSM-5 workgroup charged with bringing order to personality disorder. Unlike the rest of the DSM-5, this particular crew actually rolled up its sleeves and went to work. No mere light dusting for them. Five of ten of the personality disorders got tossed. The remaining five (now referred to as “types” rather than disorders) received a major refurbishing and a sense of congruency.

The grand piano, in effect, has been retuned and refinished and moved from the laundry room to the living room, though questions still remain as to what to do with the moose head now in the dumpster (think narcissism). These are the “categorical” reforms. There is a new element of “dimensionality” which we will get into later. Sticking with categories ...

The old (and still current system) was only useful in sorting out the obvious (such as green from blue) but of very little value where the colors blended (green, for instance, contains blue). An impulsive and angry individual with a skewed view of self and others, for instance, may be a candidate for both borderline and antisocial. Throw in a sense of me-me-me/I-I-I, and the narcissism diagnosis comes into play.

The new (and future) system acknowledges the overlap, but puts the reader on notice that we are not exactly dealing with the same phenomenon. The first thing that sticks out in comparing the new borderline to the new antisocial/psychopathy, for instance, is that the former comes loaded with six “negative emotionality” symptoms and only two “antagonism” ones while the latter is heavily laden with six antagonism symptoms and zero negative emotionality ones.

As for narcissism (may it rest in peace), a number of the old narcissist traits have been  folded into the new antisocial/psychopathy diagnosis. Not one appears in the new borderline diagnosis. Yes, it would be nice to have the narcissism diagnosis back in the picture (and I will be making that case in a future piece), but in this context its absence brings into sharper relief the inflated/lack of sense of self that separates borderline from antisocial.

The DSM-IV bunched the ten personality disorders into three clusters (A, B, and C), but with only five types left to choose from in the DSM-5, there is no sense in retaining these walls of separation. Again, we are dealing with overlap and loading. The new “avoidant,” for instance, contains nearly as many negative emotions as borderline (five in all, two of them the same as borderline) plus five “introverted” ones (such as “intimacy avoidance”) with nothing in the “antagonism” department.

Meanwhile, we know obsessive-compulsive (the personality disorder, not the Axis I diagnosis) and schizotypy are horses of a different color, but nevertheless they do share some of the primary colors across the personality spectrum.

So what are we looking at? According to the DSM-5:

Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual’s cultural norms and expectations.

This harkens back to the Freudian-influenced DSM-I of 1952 and the DSM-II of 1968 when even the likes of schizophrenia were seen as maladaptations to one’s environment. The DSM-5 revives the idea of maladaptation, but dials it back to personality disorders. In other words, personality type is a tip-off to our default protection mechanisms.

Do we, for instance, try to dominate those around us? (Antisocial.) Or do we freak out and lose it? (Borderline.) Or do we withdraw into a comforting cocoon? (Avoidant.) Maybe we look for order where none exists. (Obsessive-compulsive.) Perhaps we harbor unusual perceptions of reality. (Schizotypal.)

We may argue over what else should be there (such as Narcissism), and what more could have been done to clarify the different types, but when all is said and done, we are looking at a greatly improved navigational system.

Meanwhile, we all have personality in abundance and come preloaded with all manner of quirks and flaws. We may be successful adapters, but - trust me - we will all see a bit of ourselves in the DSM looking glass. In this sense, we are likely to get more out the DSM-5 than our clinicians. 

Much more to come ...   

Recent Personality Posts

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard? 

Personality Disorders: Decisions, Decisions ...

Personality Disorder: Decisions, Decisions ...

The story so far:

In the one thing those charged with the DSM-5 did right, personality disorders will receive a major overhaul. Five of the ten current personality disorders will be axed and the current “categorical” system will be supplemented by a “dimensional” model.

Let’s look at the categorical reforms. The wisdom of the DSM-5 is readily apparent in relieving clinicians of the agony of having to decide between the likes of “schizotypal” and “schizoid” (schizotypal makes the cut, schizoid gets the axe). Similarly, only those prone to histrionic displays are shedding crocodile tears over the demise of “histrionic,” which is way too easy to confuse with “narcissism,” which will - Wait! What the f...? - you mean narcissism goes too?

Okay, we’ll get to the issue of narcissism later. In the meantime, sayonara, as well, to “paranoid” and “dependent.” And in a Nobel-worthy gesture (medicine or peace, take your pick), the foul and malignant NOS (“personality disorder not otherwise specified”) gets the deep-six. Clinicians will actually have to decide between the disorders left standing ("antisocial/psychopathy", "avoidant", "borderline", "obsessive-compulsive", "schizotypal"). But will they be happy making their choices? Let’s use the new borderline and antisocial/psychopathy as our examples:

The first thing readers will notice in the new borderline diagnosis is a lengthy narrative description of the illness. Thus:

Individuals who match this personality disorder type have an extremely fragile self-concept that is easily disrupted and fragmented under stress and results in the experience of a lack of identity or chronic feelings of emptiness.  As a result, they have an impoverished and/or unstable self structure and difficulty maintaining enduring intimate relationships. ...

And so on and so on. The checklist that follows roughly corresponds to the one in the DSM-IV, but looks a lot different. The following, for instance, is symptom #6 from the old checklist:

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Here’s how that same symptom (#1) in its new form will appear:

Negative Emotionality: Emotional Lability
Having unstable emotional experiences and mood changes; having emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

“Negative emotionality” is what the DSM-5 calls a “trait domain,” one of six for the five personality "types". (“Introversion”, “antagonism”, “disinhibition”, “compulsivity”, and “schizotypy” are the others.) Every symptom includes a trait domain, further modified by “trait facets,” such as “emotional lability.”

Borderline comes heavily loaded with negative emotionality, six symptoms of 10 in all involving, besides emotional lability, “self harm”, “separation insecurity”, “anxiousness”, “low self-esteem”, and “depressivity”. There are two “antagonism” domains (with “hostility” and aggression” as facets) to borderline, plus a “disinhibition” domain (“impulsivity” as a facet), and one “schizotypy” domain (with “dissociation proneness” as a facet).

A quick comparison to the new version of antisocial/psychopathic shows a very different loading, with six antagonism traits and zero negative emotionality traits. Right off the bat, clinicians are put on notice that they are dealing with two entirely different species of personality. The narrative highlights the contrast:

Individuals who match this personality disorder type are arrogant and self-centered, and feel privileged and entitled.  They have a grandiose, exaggerated sense of self-importance and they are primarily motivated by self-serving goals.  They seek power over others and will manipulate, exploit, deceive, con, or otherwise take advantage of others, in order to inflict harm or to achieve their goals. ...

In addition to hostility and aggression, the antisocial/psychopathic symptom list includes the antagonism traits of “callousness”, “manipulativeness”, “deceitfulness”, and “narcissism”. Intriguingly, hostility and aggression are word-for-word replicas of what appears in the borderline list. But the symptom overlap comes across as deliberate and in context rather than random and coincidental. In other words, in constructing the various categorical diagnoses, we appear to be looking at an ordered modular system with interchangeable parts.

(We see another interchangeable part in antisocial/psychopathy with “disinhibition-impulsivity”, but with the further emphasis of “irresponsibility” and  “recklessness”.)

Here’s where the DSM-5 personality symptom lists radically differ from those in the DSM-IV. Instead of just checking off the relevant symptoms and counting them to arrive at an arbitrary diagnostic threshold (such as five out of nine symptoms), the clinician rates each symptom on a five-point scale, from “very good match” to “no match”. Thus, from a severity perspective, a pair of fives may trump several threes. The current draft offers no magic threshold numbers, which suggests that in making the final call the clinician will be accorded a lot more discretion. Presumably, this works when when the clinician has clear guidelines.

Sounds good in theory.

Much more to come ...

Recent Personality Disorder Blog Pieces

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard?

Why is Spotting the Personality Disorder So Damned Hard?

In my last piece, Let's Play Spot the Personality Disorder, I posted a quiz asking readers to match the four DSM-IV Cluster B personality disorders (antisocial, borderline, histrionic, narcissistic) to 15 DSM symptoms. Now try matching these DSM descriptions to the same list of disorders:

1 “A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts ...”

2 “A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts ...”

3 “There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years ...”

4 “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 ...”

Easy, right? Here's the answers:

1 Histrionic, 2 Borderline, 3 Antisocial, 4 Narcissism.

But if this quiz was so easy, why was the last one so difficult? Here’s the explanation. The DSM descriptions are basically assigning colors to various illnesses, much like different houses: Green, blue, yellow, orange. The symptoms are the paint, and here we run into problems. Green is a combination of blue and yellow, yellow is present in three of the paints, and all use white as a base (I won’t even get into the issue of the various tints).

Thus, for example, these two interchangeable symptoms (antisocial and borderline, respectively):

• "Irritability and aggressiveness, as indicated by repeated physical fights or assaults."
• "Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)."

It gets worse. The DSM-IV symptom checklist for narcissism mentions nothing about anger or aggression, but a review of the literature brings up the phenomenon of “narcissistic rage” (against those who poke holes in their ego).

Obviously, the narcissist is living in a world of self-delusion (“believes that he or she is ‘special’ and unique”), but so is someone living with borderline (“identity disturbance”, “alternating between extremes of idealization and devaluation”), and histrionic (“considers relationships to be more intimate than they actually are”). Likewise, further reading reveals that those with antisocial have difficulty separating out fantasy from reality.

Here, we’re looking at the white paint of a fundamental failure in perception, of people living in universes of their own imaginations, with highly distorted views of themselves and the people around them. Something is obviously not processing right in the cortical areas of the brain.

Then there is all the blue and yellow paint from the emotional areas:

“Impulsivity in at least two areas” (borderline), “impulsivity or failure to plan ahead” (antisocial), “uncomfortable in situations ...” (histrionic), “often envious of others” (narcissistic).

So, failure in perception meets runaway emotion. Or, it could be a deficit of emotion:

“Shallow expression of emotion” (histrionic), “chronic feelings of emptiness” (borderline),  “lack of remorse, as indicated by being indifferent ...” (antisocial), “lacks empathy” (narcissistic).

Either way you look at it, we’re talking about an emotional thermostat set way too high or too low, or one that’s simply on the fritz. Thus, faulty perception meets unregulated emotion. Worlds collide, strange behavior happens. In a reasonably operational brain, the thinking areas pick up that something is amiss, and we work at changing our behavior. But here we’re dealing with “a pervasive pattern” rather than a mere episode, which puts us back in the realm of faulty perception. Again and again, the individual fails to come to terms with his or her thoughts and actions. Thus:

“Preoccupied with fantasies ...” (narcissistic), “rationalizing having hurt ...” (antisocial), “Is suggestible” (histrionic), “paranoid ideation” (borderline).

Avoid these people like the plague, you think. Not so fast. If you happen to believe that the narcissist in your presence walks on water, then the two of you will get along just fine - until, perhaps, you start noticing that your new boon companion is wearing wet clothes.

Conversely, someone with borderline may think it is you who walks on water (and who are you to question their good judgment?) - that is, until he or she decides you are really the Antichrist, after all. Meanwhile, who isn’t drawn to a histrionic enchanter or enchantress? - at least until we start thinking with our brains again. And, of course, chances are you will be profusely thanking that very charming (but antisocial!) individual you have just handed over your entire life savings to.

And there you are - the “normal” one in this relationship - left to pick up the pieces, humiliated, mystified, abused, jilted, duped, conned, and perhaps much worse. These people definitely need therapy, but - thanks to them - you may need it more. But where does the therapist start? We may know a “classic” narcissist or borderline when we see one, but personality - much less life - is never that simple.

Diagnostic psychiatry can no more explain the reality of personality than theology can explain God. At best, psychiatry (and theology) can come up with an approximation of reality, based on what we know at the time. Clearly, a better approximation is needed. The people working on the DSM-5 recognized that, too.

Much more to come ...

Let's Play Spot the Personality Disorder

In a recent blog post, I discussed narcissism in the context of its proposed downsizing from the DSM-5 as a stand-alone “categorical” diagnosis to one of many “core impairments” in a dimensional schema of “personality functioning.” Personality is complex, and clinicians have a hell of a time trying to sort out what is going on. To give you an idea, I have prepared a little quiz:

Following are symptoms taken from the four DSM-IV “Cluster B” personality disorders: Antisocial, Borderline, Histrionic, Narcissistic.  See if you can match the symptom to the disorder. Answers and commentary further down:

1 "Is uncomfortable in situations in which he or she is not the center of attention."

2 "Requires excessive admiration."

3 "Impulsivity or failure to plan ahead."

4 "Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)."

5 "A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation."

6 "Considers relationships to be more intimate than they actually are."

7 "Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another."

8 "Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others."

9 "Displays rapidly shifting and shallow expression of emotions."

10 "Identity disturbance: markedly and persistently unstable self image or sense of self."

11 "Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations."

12 "Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations."

13 "Shows arrogant, haughty behaviors or attitudes."

14 "Irritability and aggressiveness, as indicated by repeated physical fights or assaults."

15 "Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)."

Answers

1 Histrionic

2 Narcissistic

3 Antisocial

4 Borderline

5 Borderline

6 Histrionic

7 Antisocial

8 Narcissistic

9 Histrionic

10 Borderline

11 Narcissistic

12 Antisocial

13 Narcissistic

14 Antisocial

15 Borderline

Commentary

I think you get the point. Namely, we have a preponderance of overlapping symptoms that defy easy categorization. Yes, we all sort of know what a narcissist is, for instance, but some of the features are strikingly close to histrionic and borderline, which in turn appears to be the female twin of the more male antisocial, which yet in turn can be difficult to distinguish in certain respects from narcissism. Enough, already!

I’d be interested in how well or how badly you fared, and other sundry opinions. Please give me feedback in the comments below. Confession: In the course of assembling this quiz, I couldn’t keep track of the correct answers, myself. I was obliged to keep rechecking and rechecking again ... and again.

Obviously, we need a lot more clarity in the next DSM. But will the new dimensional system only result in far more confusion?

Much more to come ...