Saturday, February 18, 2017

Portrait of a Personality Disorder, Part 3: Cognitive Distortions in Cluster B Personalities

We all distort things in our heads.  If you're honest with yourself, you know you do.  We all have distorted memories of relationships and disagreements.  We all have distorted ideas about ourselves.  We all have distorted ideas about other people and other people's motives.

But here's the thing . . .  Some people distort more frequently and to a greater degree than others.  Some people cannot or do not acknowledge their distortions and do not even seem aware they might be distorting.  Like all disorders, Cluster B personality disorders are identified, not by unique traits or behaviors, but the frequency, severity and impact of certain traits and behaviors.  The cognitive distortions seen in Cluster B personalities have a direct impact on how an individual relates to other people.

Human relationships are, by and large, reciprocal phenomena.  There is give and take.  And, there is a feedback loop.  I say something nice to you, you say something nice to me, and we both feel good.  Or, I say something mean to you, you return the favor, and we both feel bad.

With Cluster B personalities, the feedback loop is broken.  The short circuit is a defense mechanism in which the individual unconsciously or semi-consciously edits their awareness of their own behavior in such a way to protect their perception of themselves.  The result is an individual who sees themselves as always the victim (as in Borderline Personality) or always the better person (as in Narcissistic Personality).  Perceptions of other people are not anchored in objective observation but, instead, are wildly changeable based on how the other person makes the personality disordered individual feel at any given time.

Lucy's distorted perception of the same interaction?
Lucy of Peanuts provides us a nice illustration of the principle of distortion and the effect it has on relationships.  Now, how about we look at a real life example, say, a recent example?  Here is an excerpt from Thursday's presidential news conference:
QUESTION: . . . You said that the leaks are real, but the news is fake. I guess I don't understand. It seems that there's a disconnect there. If the information coming from those leaks is real, then how can the stories be fake? 
TRUMP: The reporting is fake. Look, look . . .And I'll tell you what else I see. I see tone. You know the word "tone." The tone is such hatred. I'm really not a bad person, by the way. No, but the tone is such -- I do get good ratings, you have to admit that -- the tone is such hatred. . . .But the tone, Jim. If you look -- the hatred. The, I mean, sometimes -- sometimes somebody gets...Well, you look at your show that goes on at 10 o'clock in the evening. You just take a look at that show. That is a constant hit. The panel is almost always exclusive anti-Trump. The good news is he doesn't have good ratings. But the panel is almost exclusive anti-Trump. And the hatred and venom coming from his mouth; the hatred coming from other people on your network. . . I -- I think you would do much better by being different. But you just take a look. Take a look at some of your shows in the morning and the evening. If a guest comes out and says something positive about me, it's -- it's brutal. . . .Tomorrow, they will say, "Donald Trump rants and raves at the press." I'm not ranting and raving. I'm just telling you. You know, you're dishonest people. But -- but I'm not ranting and raving. I love this. I'm having a good time doing it.But tomorrow, the headlines are going to be, "Donald Trump rants and raves." I'm not ranting and raving.Go ahead. . . . 
QUESTION: Just because of the attack of fake news and attacking our network, I just want to ask you, sir... 
TRUMP: I'm changing it from fake news, though. 
QUESTION: Doesn't that under... 
TRUMP: Very fake news. 
QUESTION: ... I know, but aren't you...(LAUGHTER) 
TRUMP: Go ahead. 
QUESTION: Real news, Mr. President, real news.. . . But aren't you -- aren't you concerned, sir, that you are undermining the people's faith in the First Amendment, freedom of the press, the press in this country, when you call stories you don't like "fake news"? Why not just say it's a story I don't like. 
TRUMP: I do that. 
QUESTION: When you call it "fake news," you're undermining confidence in our news media (inaudible) important. 
TRUMP: No, no. I do that. Here's the thing. OK. I understand what you're -- and you're right about that, except this. See, I know when I should get good and when I should get bad. And sometimes I'll say, "Wow, that's going to be a great story." And I'll get killed.I know what's good and bad. I'd be a pretty good reporter, not as good as you. But I know what's good. I know what's bad. And when they change it and make it really bad, something that should be positive -- sometimes something that should be very positive, they'll make OK. They'll even make it negative.. . . as an example, you're CNN, I mean it's story after story after story is bad. I won. I won.

Here, like Lucy, we have an individual who sees himself as a victim and simultaneously better than, a clear sign of a narcissist (more on that later). And, like Lucy, he is seemingly oblivious to his part in any contentiousness. You can see the distortions all serve to bolster, not just the image of the man, but more specifically, his self-image.

This is a clear and beautiful example of a neurotic process expressed publicly and recorded by worldwide news outlets.  It is less an argument than the man's internal process expressed outwardly, for he is not attempting to convince his audience of his greatness and their badness so much as his argumentation serves to reinforce his internal beliefs.  By stating his distortions externally, they become more real for him internally.

And, this is exactly what is so challenging about relating to and attempting to have a reason-based conversation with someone with a Cluster B personality type.  There is no real give and take.  The disordered individual is simply having an argument with himself or herself, and, while you may be the target, you cannot meaningfully take part in the manner you are used to if you are expecting a reciprocal give-and-take relationship.

Portrait of a Personality Disorder, Part 2: What Are Cluster B Personalities?

So, we have ten standard personality disorders and they are grouped into three clusters, A, B, and C.  Here, we are going to focus on cluster B, arguably the most difficult and controversial of the three clusters, but before we dive in, lets take a quick glance at A and C, and get that out of the way.

Cluster A is the "odd duck" cluster of personality types.  These are clustered together because they share certain attributes and characteristics.  To a layperson, seeing someone with a Cluster A personality on the street, you might assume that person is seriously mentally ill.  They might keep to themselves, they might be dirty and unbathed with an unkempt look, they might be wearing a heavy coat in the middle of a warm summer, they might act paranoid.  Basically, they look mentally ill.  The only thing is, they aren't.  There are no delusions, no auditory hallucinations, no manic episodes.  This is a person who has separated themselves from society and from normative social standards.  They have made themselves social isolates, and there they stay (unless there is a dramatic change to their personality at some point).  The specific Cluster A disorders are Paranoid Personality, Schizoid Personality, and Schizotypal Personality Disorders.

Cluster C is the anxious and fearful cluster of personalities.  These are people whose personalities and habits have been shaped by lifelong anxiety and fear, resulting in avoidance, dependence on others, obsessiveness and compulsive behaviors.  These are personalities that could be associated with the popularized version of neurosis--bundles of worries with irrational behaviors.  The specific disorders are Avoidant Personality, Dependent Personality, and Obsessive-Compulsive Personality Disorders.  Please note that Obsessive-Compulsive Personality Disorder is distinct from Obsessive-Compulsive Disorder per se, which was categorized as an anxiety disorder in DSM IV but in the 5th edition was placed in the new category of Obsessive Compulsive and Related Disorders.  The very brief explanation of the difference is that OCD per se is more severe and has a higher subjective experience of distress, whereas the personality disorder is characterized by a person who finds comfort in the OCD type behaviors and therefore is not usually motivated to change.

And, now, what we are really here for, Cluster B personalities.  These are your worst nightmares, as a therapist.  These are people for whom everyone else is wrong.  Everyone else is at fault.  They are blind to their own role in the making of their misery.  Their behaviors are motivated to manipulate and use others while seemingly unaware of what they are doing.  They have deep seated defense mechanism and are rarely motivated to change.  After all, why should they change when they're never at fault?  It's your fault.  You made me this way.  You change.

Cluster B personalities are familiar to everyone, but they are notoriously difficult to define and understand.  The characteristics that make up these personalities are somewhat disparate, and yet they appear together as a pattern again and again.  You will rarely find Cluster B defined or described as a whole, because it is so difficult for people to get a conceptual grip on it.  The APA's diagnostic manual, keeping it simple, describes Cluster B thus, "Individuals with these disorders often appear dramatic, emotional, or erratic."  That's it.  That's what the DSM has to say on the subject.  The UK's NHA describes Cluster B thus, "Someone with a cluster B personality disorder struggles to relate to others. As a result, they show patterns of behaviour (sic) most would regard as dramatic, erratic and threatening or disturbing."

I'm sure I can't expect to do better than the APA or the NHA, but here's my best shot . . . (1) thinking is characterized by cognitive distortions in the form of strongly developed defense mechanisms in which the individual fails to recognize the negative impact to them from their own actions and behaviors (more on this next time), (2) excessive use of out and out dishonesty and subterfuge, (3) actions and interactions frequently tied to secondary gains (i.e., attention seeking behavior), (4) excessive emotional reactions, and (5) apparent lack of substantive empathy (but superficial empathy may be expressed).  These personality disorders, besides having some common characteristics, are conceptually tied because there is a fair degree of co-morbidity.  In other words, it is not uncommon to find someone, for example, who has a combination of narcissistic and anti-social traits.  And this holds true for all four Cluster B disorders.

In this cluster, we have Anti-Social Personality Disorder.  This is very broadly defined disorder that accurately describes just about anyone who has found themselves up against the criminal justice system more than once.  It is more widely known by the older term of psychopathic personality.  It's characteristics include lack of empathy, lack of stress reaction to violence, dishonesty, disregard for the safety of self and others (but, especially others), lack of remorse, impulsivity, consistent irresponsibility, etc.  One point I would like to emphasize is that anti-social types often fail to plan or think ahead.  This, of course, is tied to impulsive behaviors, lack of ability to get one's needs met through normative behaviors (e.g., holding a job and budgeting your money to pay rent), and lack of concern about consequences (because cognitively the individual is trapped in the moment, they seem blithely unaware that tomorrow is going to happen).

Then there is Borderline Personality Disorder.  This is the most difficult to understand and relate to, but we see this pattern of behavior quite frequently in the mental health system.  With this personality profile, you often see intense emotional reactions, misunderstandings, the individual frequently attributes negative motivations to others, self harm behaviors (e.g., cutting), suicidal gestures, suicide attempts, intense anger (but often masked), and highly unstable relationships.  Being in any kind of relationship with such an individual can be very difficult due to the constant manipulation and polar emotional swings between clinging and anger.

Histrionic Personality Disorder is the least often diagnosed of this cluster.  Many clinicians and researchers have questioned the validity of this diagnosis, but I think it is more accurate to say it is an anachronism in the sense that it is an idiom of emotional distress that was common in the cultural context of the past but is much less common now.  To give you a sense of the flavor, criteria include (1) Is uncomfortable in situations in which he or she is not the center of attention, (2) . . . inappropriate sexually seductive or provocative behavior, (4) . . . uses physical appearance to draw attention to self, (6) shows self-dramatization, theatricality, and exaggerated expression of emotion.  Et cetera.

And, lastly, we have Narcissistic Personality Disorder.  It's been splashed all over the news, of late.  Most people already have a sense of what narcissism is, but that concept is not necessarily the same as the personality disorder.  Anyway, I'll save this one for a later, dedicated, blog post.

In our next installment we'll try to get a grip on those pesky Cluster B cognitive distortions that are so damn crazy making.

Portrait of a Personality Disorder, Part 1: What Is a Personality Disorder?

Can a personality be an illness?

Well, not exactly.  Everyone has a unique personality.  And, some are more likable than others, I suppose, but when and how is it appropriate to slap the "disorder" label on someone's personality?

In answering this question, it is important to understand that all mental disorders, including severe disorders such as schizophrenia, are defined by behaviors and/or inner states that cause distress or dysfunction for the individual or for people around them.  This concept is true of the larger medical field, as well.  Take for instance the individual with six digits on each hand.  It is an unusual condition, yes, but do we consider it an illness?  No, nor should we (unless of course, having six fingers is excessively distressing and dysfunctional or you simply want to say it is so the insurance will pay for surgical "correction," but that's a wholly different blog post, for another day).  On the other hand, being born with the inability to produce blood clotting components is considered a disease for the simple fact that it will lead to a quick demise unless treated.

Biologically, every individual is unique, and the human population presents a vast range of phenotypes.  Disease cannot be defined by deviation from the norm, alone, but must be defined by impact, dysfunction, pain and death.  This is even more true with mental disorders.  We cannot pathologize based on what looks different or anormative, alone.  We have to limit our determination of disorder to the impact of behaviors and inner states, i.e., distress and dysfunction.  And, this is even more important when discussing the pathology of personalities.  Why?  Because, it is far too tempting for us to label people we don't like or don't understand as disordered.

According to the American Psychiatric Association (APA) in the latest diagnostic manual (DSM 5), "A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations 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" (emphasis mine).

This definition attempts to limit the idea of personality disorder within strict parameters, but let's face it, it's still wide open.  The DSM 5, like its predecessor, the DSM IV TR, then goes on to list 10 specific personality disorders grouped into three clusters, A, B, and C, and an eleventh, "unspecified" personality disorder for personalities that meet the general definition but do not meet criteria for any one of the 10 specific disorders.  Lastly, there is a disorder for personality change due to a medical condition.

Personality disorders carry some controversy in the field and some clinicians simply refuse to acknowledge them or diagnose them, but this is the minority of clinicians, I think.  I too was very skeptical as a new clinician, but over two decades of working with a wide variety of clients, I have come to recognize there really are some distinct patterns of personality dysfunction and pathology, and it does us no good to pretend it does not exist.

Personality disorders are categorically distinguished from major mental illness.  This idea goes back a ways, well before Freud, even.  The personality disorder idea is the intellectual descendant of the concept of moral insanity.  This was a diagnostic category proposed in 1835 by a certain Dr. Prichard.  He defined it as "madness consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses, without any remarkable disorder or defect of the interest or knowing and reasoning faculties, and particularly without any insane illusion [delusions] or hallucinations."  It remains an important distinction that personality disorders are defined by cognitive distortions and aberrant behaviors and emotions as opposed to cognitive impairment or delusions or hallucinations as these are indicative of major mental illness.

Well, there's a nice little overview.  Not too boring I hope.  In the next installment, we will take a big bite into Cluster B types and figure out why they leave such a bad taste in your mouth.  Then, we'll examine what we mean by cognitive distortions and why it leaves you wondering if you're the crazy one.  Finally, we will narrow our focus on narcissists and what you can do when your family member, or your boss, or your president has this personality disorder.

Wednesday, November 6, 2013

Making Our Children Conform Using Mental Trickery

Here is an absolutely excellent article by Elizabeth Weil in the New Republic in which she analyzes the increasing use of various therapeutic techniques to get kids to conform to expected classroom behavior. It is a more subtle but insidious form of pathologizing children who are being normal children.  Much of it is predicated on the now well known delayed gratification studies of young children.  You've heard it before--the test child is told not to eat the marshmallow in order to get two marshmallows in a few minutes.

Everyone who has a child with childhood impulses is immediately struck by inner fear.  Is my child the one who can't wait?  What does this mean for her/his future career?

Now this is the basis for all kinds of behavior modification schemes used in schools.  The problems Weil outlines include that (1) we are telling our children they are mentally sick or wrong, and (2) the empirical evidence does does not support the actual interventions being used.

It is yet another case of wanting to believe this is the right way to do things because it sounds good.

Please take a look, it is worth the read.

Wednesday, October 9, 2013

Seeking Safety from Trauma

Over the last decade we have seen a deluge of spilled ink and sermons delivered on the topic of Trauma (capital letter intended).   Therapists and other clinicians are wont to see Trauma as the cause of all mental/emotional distress and disorder.  Payers and regulators want to see Trauma informed care as the standard for all services.

Please don't misunderstand and think I am about to argue against trauma as a factor of etiology.  I am not.  Please do not think I am going argue against trauma sensitive care.  I am not.

I do, however, have to take issue with a number of things.  One of which, I will briefly introduce here, is an intuitive response to emotional trauma (or the vision of Trauma in the mind's eye of the therapist).  I have noticed a tendency among my colleagues to fix Trauma through the exclusive use of invoking Safety (capital letter intended).

What is Safety?  It is a mythical destination we point people to who we believe are wounded by emotional trauma.  In its simplest and cliched manifestation, it is the "safe place" we tell people to go to inside themselves when they are distressed by Traumas past or current.  In its most Utopian manifestation, it is the construction (socially and physically) of a space (or whole communities) designed to remove all sources of trauma and reminders of trauma.  A Safe place is a place where people speak to each other exclusively in soft and supportive tones.  A Safe place has no rules to remind us we are not in control.  In a Safe place no one tells me I am wrong.  A Safe place is a place without "no".

The idea of creating Safety seems to come to some practitioners by intuition and without need for training.  For other practitioners (e.g., Sandra Bloom) it is a treatment model that is bottled, trademarked and sold, but more than that it is a morally driven world view.  It is true by faith and has to be defended against the unbelieving (read: medical model).

Why do we need to create Safety?  Because Trauma doesn't just hurt in the moment, it continues to harm day after day, year after year.  Life's little annoyances and disappointments are more than they are.  They are reminders of the Trauma.  Triggers and re-triggers.  It harms even when the individual has no idea it continues to harm.  Why?  Because the clinician believes.  Sometimes the individual doesn't even know they were Traumatized.  In those cases, the true believing therapist has to help the individual remember . . . (we know where that leads).

That's the reasoning for it.  I can't fault the premise (that psychological trauma hurts), but I doubt the conclusions.

So then, does creating a Safe place help?  I feel the need to ask, if only because so many around me seem to take it on faith.

I haven't come across so much empirical evidence apart from the some apocryphal study about mice and cat hairs.  But maybe this Trauma-Safety dilemma has a corollary in Happiness?  Seeking Happiness for the Sad seems like a very similar impulse to me.  And in that realm I think we do have some evidence that tells us it is a fool's quest.  Turning Sadness into Happiness through the power of affirmations, replacing negative self talk with positive self talk, while intuitively sensible, turns out to be the psychological equivalent of trying to catch a rainbow.  Every time I tell myself I'm beautiful and smart and wonderful, the opposites of those things echo in the mind and I have to increase my affirmations louder and louder to myself, but in the end, affirmations in a vacuum do not lead to Happiness.

Could the quest for Safety be a similar fairy tale?  A nagging doubt tells me so.   The fact that no one questions it, makes me worry all the more.
  • Focusing so exclusively on Safety paradoxically highlights an individual's vulnerability.
  • Focusing so exclusively on past Trauma reifies victimhood and takes the person out of the here and now.
  • By focusing on victimhood we take away a person's agency.
  • By focusing on the past we can't change, we forget the here and now where a person actually does have the power to change things.
  • By externalizing cause and effect we have taken all control away from the person.
Considering these things, is it any wonder that we see so many people taking part in this therapeutic approach sink deeper and deeper into dysfunction?

Monday, September 9, 2013

Autism's Tipping Point

Besides being an expert at neuroscience, to the benefit of the greater good neuroskeptic also dabbles in cultural criticism of science and healthcare with an eye toward empirical observation of the ethnocultural processes of those areas.  A bit of armchair social science, but well done.

His latest piece on the phenomenal growth of autism:

Many have observed the unnatural increase in autism over recent years.  In the midst of this apparent epidemic, news stories push "autism awareness" and "promising findings" about the cause(s) of autism.

Among practitioners, among psychiatric naysayers, among the small community of social scientists who make medicine, psychiatry and science their field of study, there has been much conjecture about the sociocultural factors behind the growth.  The usual conclusion based on observation and/or conjecture, is that the incidence of the underlying condition has probably not changed dramatically, but instead we are seeing an expanding practical definition of autism as interpreted by clinicians in the field.  You can add to this the fact of heightened awareness of the diagnosis resulting in people (clinicians, parents, teachers, etc.) seeing it where they didn't see it before (rightly or wrongly).  This, in the context of a loosely defined spectrum disorder that (like all mental health diagnoses) is determined by a check list of behavioral signs and indicators allowing for broad differences of interpretation and understanding.

Sadly the places and people with money to pay for research don't seem particularly interested in putting resources into resolving this question.

Lucky for us we have a guerrilla social science researcher in neuroskeptic who counted the number of research papers (via PubMed) on the subject of autism, relative to several other disorders.  He found that autism research has increased eight fold in 12 years, about twice the rate of ADHD (the next highest growth disorder) and maybe 4x (about) the growth of schizophrenia research.  It is hugely out of proportion to the 4% growth in science (as a whole) per year.

I might take it a step further and just state what has been clear over the last 150 years or so of psychology and psychiatry--the field, popular and professional, is driven by fads.