Anorexia Nervosa & Borderline Personality Disorder

Gold-Standard Treatments at Odds: 

Complications in Treating Combined Anorexia Nervosa & Borderline Personality Disorder

Any clinician can tell you that treating a life-threatening psychological condition such anorexia nervosa or borderline personality disorder is seriously challenging.  Treating a person with both anorexia nervosa and borderline personality disorder, however, is exponentially more difficult than the treatment of either condition alone.  This is largely because the gold-standard treatments for these disorders are at odds with one another: treating one life-threatening disorder exacerbates the other.  This post discusses how this happens and what to do.

To being to understand this problem, let's start with a discussion of why these disorders are life-threatening.  Eating disorders are life-threatening because the bodily impact of eating disordered behaviors such as severe caloric restriction and purging can respectively result in conditions like severe malnutrition and esophageal tears.  Borderline personality disorder is also life-threatening because people are at risk of engaging in impulsive behaviors, self-injury, and suicidal behavior when because they lack skills to regulate intense emotions.  Clearly, both disorders are life-threatening and must be addressed.  But what do you do if someone has both an eating disorder and borderline personality disorder?  Just treating both conditions at the same time seems like the obvious answer. Quickly after the implementation of this approach, however, one quickly discovers that the gold-standard treatments of the two life-threatening conditions are at odds.  

To further understanding as to why these treatments are at odds, let's first discuss the singular treatment of anorexia nervosa, one type of deadly eating disorder.  In anorexia nervosa, a person becomes underweight following a prolonged period of severe caloric restriction.  This severe caloric restriction is a behavioral strategy used to temporarily decrease the experience of fearing  fatness in a given moment.  In the treatment of this condition, the goal must be weight gain to ensure both physical and psychological recovery.  Further, from a psychological perspective, a person recovering from anorexia nervosa must endure the following exposures: 1) eating a large quantity of food many times per day (upwards of 4,000 calories), 2) eating a variety of high-fear foods every day such as pizza and burgers, 3) enduring a physical feeling of fullness that the eating disordered mind equates with immediate "fatness," 4) actual weight gain slowly occurring all day, every day for what is more often months, rather than weeks, and 5) not engaging in any "safety" behaviors that result in a respite from fear of fatness such as exercising, purging, and taking laxatives.  As such, the treatment of anorexia nervosa involves what can be viewed as a series of multiple, intense, all-day in vivo exposures, that carry on for months.  And because the person is in medical crisis, the intensity of this extended exposure cannot be lessened. There is no luxury of spacing out exposures based on psychological readiness in the treatment of anorexia nervosa.  A person with anorexia nervosa must be thrown into the metaphorical deep end.  As such, I imagine that the series of exposures involved in the treatment of anorexia nervosa are more intense than the treatment of any other disorder.

Now, let's discuss the singular treatment of borderline personality disorder.  In the treatment of borderline personality disorder, we are taught early on in graduate school that it is a bad idea to star therapy by addressing underlying trauma, which of course is normally treated with "prolonged exposure."  The idea is that if someone does not have skills to cope with intense negative emotions that arise when addressing trauma in exposure, they may be at increased risk for impulsive, self-injurious, and suicidal behaviors.  So, rather than implementing exposure in the treatment of borderline personality disorder, we are taught the focus in the treatment must be on skill building.*  Returning to a deep-end metaphor, learning coping skills is the equivalent of learning how to swim.  The skills, of course, are very helpful to know before being thrown into the deep end.  

As such, in the treatment of BPD, teaching skills decreases impulsive behaviors, the life-threatening component of the disorder.  A person with anorexia nervosa, however, is not immediately saved in the same way with skills.  Because the treatment of anorexia nervosa first requires medical & nutritional interventions that are psychologically experienced as exposures, there isn't enough time to teach skills before the interventions begin.  Further, even intelligent people with malnourished brains are much more likely to think inflexibly, and therefore, skills such as flexible & dialectical thinking may not be absorbed even if taught well to smart folks.

Now with a greater understanding of the individual disorders, let's return to the problem: focusing on treatment of an eating disorder in which intense exposure is needed can exacerbate the emotion dysregualtion inherent in borderline personality disorder, increasing the odds for impulsive behavior, self-injurious behavior, and suicide; alternatively, focusing primarily on skill building to treat the borderline personality disorder would does not allow for the rapid weight gain needed to ensure medical stability in the treatment of anorexia nervosa. 

To increase understanding of this problem even further, let's combine the above concepts with understanding a bit about how the brain is impacted by both disorders. A patient with anorexia nervosa has a malnourished brain that will result in inflexible thinking, further obsessionally, increased irritability, and other cognitive deficits.  If this person also has borderline personality disorder, not only is the brain malnourished, but the system in the brain in charge of emotion regulation is malfunctioning.  As such, the brain is malnourished - and needs nourishment to function properly - but the process by which re-nourishment occurs involves intense, all-day, multiple exposures that predictably result in rather severe emotion dysregulation, which is efficiently calmed by the immediate escape of negative emotion through the sabotage of the re-nourishment process (e.g. purging).  Big problem.

The problem is so big, in fact, that I do not think that simply treating someone with both outpatient gold standards of treatment - Family Based Therapy for anorexia nervosa and Dialectical Behavior Therapy for borderline personality disorder - will be helpful.  I do, however, have some strategies for fighting the two-headed monster that is comorbid anorexia nervosa and borderline personality disorder.

When clinicians finally see a patient with anorexia nervosa and borderline personality disorder in treatment, the complex interplay of psychological and physical pathology has already seriously compromised the patient's overall health.  Without any time for fostering full understanding of our rationale, the only thing to do in the moment is push the person into the deep end of the pool.  As clinicians we must also, however, dive in after them.  In the pool, we can hold them up until they learn how to swim.

I don't believe there is much hope of recovering from comorbid anorexia nervosa and borderline personality disorder without massive amounts of support.  Inherent in the disorder of anorexia nervosa, the person with this diagnosis cannot reach the conclusion that consuming large volumes of food and gaining weight will result in recovery.  We have to show them this.  As such, an outpatient level of care is very rarely enough.  It makes sense to me that most people who are severely underweight with anorexia nervosa and borderline personality disorder must be hospitalized on a psychiatric unit with staff and structure that can limit dangerous behaviors.  Because re-nourishment will inevitably be an awfully triggering experience, we must be as emotionally supportive as possible  We must also must be practically supportive and help the person learn as many coping skills as possible.  When someone is very underweight, we don't have the medical luxury of spending time focusing on skills, nor is it likely that most people can effectively learn the skills with a malnourished brain and body.  I think we must focus on re-nourishment while mitigating as many destructive behaviors as possible and teaching skills.  Once the person is stabilized, going to a structured program, likely makes the most sense.  

Unfortunately, in 2017 America, people with anorexia nervosa do not stay on inpatient units until they are 100% weight restored, even without the added complications that borderline personality disorder brings.  On a larger scale, I intend to advocate for a return to a time when patients stay until they have truly weight restored, especially if there is co-morbid borderline personality disorder.  In short, a presentation of both anorexia nervosa and borderline personality disorder really seems to call for the highest levels of care that you can get for the longest amount of time that you can get.  Whether you are a provider, patient, or loved one: I urge you to convey the information in this post to foster an understanding of the serious problem the comorbidity that anorexia nervosa & borderline personality disorder presents to advocate for more time in higher levels of care.

*Please note: there is evidence that PTSD & BPD can be treated simultaneously (Harned and colleagues; for more info: http://bit.ly/2cCrbiy).   But let's think about the treatment of borderline personality disorder and co-morbid PTSD v.s. anorexia nervosa a bit more. In the treatment of PTSD, "prolonged exposure" typically refers to about an hour of exposure once per week, the intensity of which is selected based on the psychological readiness of the patient.  From the perspective of someone who has undergone treatment for anorexia nervosa, the term "prolonged" is likely to seem sarcastically adorable.  I can imagine my patients saying "Wait, that is considered prolonged?  Ha!"  Although PTSD might be able to be treated in the context of BPD with careful consideration, the challenge of treatment anorexia nervosa is much greater.

Further Musings on Potential Predictors of Suicidal Behaivor

In the last post I discussed thoughts on why certain groupings of physiological measurements may turn out to be a better predictor of suicidal behavior than genes (check out that post here).  On top of that, I have some general ideas as to how this may play out.

I would imagine that each psychological disorder may end up having its own constellation of physiological factors with predictive power.  For instance, people with major depression without psychotic features would have a different constellation of physiological factors associated with suicidal behavior than people with schizophrenia.   The people in the major depression group may have lots of indicators of very low mood but a certain amount of anxiety / excitement too.  Currently, it is a commonly held belief among clinicians, researchers, and even the general public that a certain amount of energy is required to make a suicide attempt.  Rather than a 1 to 1 correlation between low mood and suicide - i.e. the people w/ the lowest mood are at the highest risk of making an attempt - low mood plus a certain amount of motivation/excitation to attempt is believed to be in the mix.  It's worth noting that the excitation wouldn't necessarily improve one's mood.  Low mood and excitation are not only likely to be separate and valid psychological constructs, but they would represent themselves differently physiological tests.   Speaking in terms of totally made up units of measurement to illustrate a point, a person with major depression may need lower than -100 endorphins (representing low mood) and somewhere between +15 and +30 cortisol (representing excitation) in order to qualify as being at imminent risk for suicide.  On the other hand, a person with schizophrenia may need lower than only -25 endorphins (representing low mood) and higher than +200 cortisol (representing excitation) to be at imminent risk for suicide attempt.  Continuing down the path of this totally fabricated example, high levels of excitation may be more indicative of imminent suicide risk in schizophrenia than in major depression for a couple of reasons.  If someone with schizophrenia attempts suicide, it has a decent likelihood of being because they heard a voice in their head commanding them to do so.  As such, the experience of hearing a scary voice telling them to kill themselves would hypothetically induce a physiologically state of excitation. On the other hand, a relatively low but existent amount of excitation would hypothetically be required for a person with major depressive disorder to attempt suicide.  Concurrently, their mood would presently need to be extremely low to be at risk for such destructive behavior.

Pulling back out of the examples and towards the larger picture, in short, I would imagine that each disorder would have it's own set of physiological risk factors.  Major depression, schizophrenia, bipolar, borderline personality disorder, etc. would all have different high-risk constellations.  Some more thoughts on the specifics to come.

Musings on Potential Predictors of Suicidal Behavior

I was recently asked for my thoughts about blood tests as a genetic predictor of suicide on Twitter.  I tweeted them out, but I thought I'd quickly organize them here as well.  It admittedly may be very flawed, but here's my logic:

1. Completing suicide is one isolated behavior that results from a complex myriad of genetic, biological, environmental, and situational factors.   As such, simply looking to genetics - the building blocks of life - to predict one isolated behavior seems far fetched.

2.  There's also a lot of noise introduced when your outcome is the one isolated behavior of a suicide attempt resulting in death.  Someone who may be prone to suicide, for instance, may die in an accident before they ever have the change to attempt suicide.   Further, people who may be prone to suicide otherwise may lead a charmed life & the thought may never cross their minds.  Alternatively, someone not genetically prone to suicide may have a terrible life, develop a substance abuse habit, and impulsively kill themselves one night while under the influence.  Because the environment and circumstance play such a large role in whether or not someone actually dies by suicide, looking to genetics intuitively doesn't feel right to me.  Studying epigenetic factors, however, may yield something very interesting, but my money isn't on it.  I don't think it will be the silver bullet we want it - or hype it - to be.  Think back to the human genome project. (P.S.  Psychologists will recognize this argument as part of the "low base rate behavior" issue.)

3.  It is true that suicidal behavior is linked with psychological disorders, but is perhaps more important to focus on this: the behavior of completing suicide is intimately tied to the circumstances in the immediate environment.  These immediate circumstances will have an immediate effect not a a person's genetics per se, but on their physiology.

For instance, on any given day, a woman with moderate depression may be at a certain point in her menstrual cycle, on substances, vulnerable from a myriad of factors (e.g. relationship stress, lack of sleep, health condition, etc.), and feeling particularly impulsive.  Lets just say that we add a life tragedy to this vulnerable mix of factors and she gets admitted to an inpatient unit for suicidal thoughts.  Eventually she reports her suicidal thoughts have remitted, she is discharged, and then our hypothetical woman unfortunately makes a suicide attempt.  Some of the aforementioned factors (e.g. menstrual cycle, etc.) have a specific physiological impact.  If we had measurements taken from the inpatient unit of this woman's estrogen/progesterone levels, oxytocin, waking levels of cortisol, toxicity, etc. it would result in a specific constellation of physiological factors.  Over time, scientists can examine which constellation(s) of physiological indicators most often co-occur with recent (serious) suicide attempts / completions.  Determining & using immediate constellations of physiological factors to predict suicidal behavior in the near future seems to me like it will be much more accurate (i.e. have "incremental predictive validity") than our current tools (e.g. self-report questionnaires).  The general idea is that in the future we may be able to divine what people are actually feeling based on physiological measures rather than self-report.

4.  One last thought about the utility (and sensitivity) of genetic testing for suicide:
Not only do I think that blood tests for genetic factors will not yield reliable predictors of suicide completion, they will likely not be of much practical utility.  Consider this: what course of action must a clinician take with the information that a person is at genetic risk for suicide?  If someone is admitted to a psychiatric inpatient unit because of depression and suicidal thoughts, at some point they report they are not imminently at risk.  At that point, we must then discharge them from the hospital.  We would not be able to detain them longer based on a genetic test.  Correct?  How much longer would we keep someone on an inpatient unit based on a genetic test?  Genetic markers are not what we call sensitive measures - they are not sensitive to change.  They are static.  We would, however, have a more firm basis for detaining someone in the hospital if we had evidence that certain physiological constellations were present in a person & evidence that this type of constellation is associated with imminent risk of suicide.  Over time, we would have an idea about how generally someone would be feeling based on the output of physiological tests. Of course, how accurate or difficult to manipulate these hypothetical physiological constellations may be is unknown.  But if I were a betting woman, I would put my money on the scientists examining circumstantial physiological compositions winning the race of determining the most accurate, useful, & sensitive predictor of suicidal behavior.

In short, a suicide attempt is a behavior, not a disorder.  I'm not so sure that treating suicide attempts like a disorder by examining genetic contributions will produce the best predictors of this behavior.  Exploring physiological factors that represent immediate shifts in a person's internal experience however, intuitively feels more promising to me.

P.S.  This post was in response to this CNN article: link.

Life Isn't a Story: The Narrative Fallacy

I noticed something familiar at the very top of an important list.  Author and designer, Frank Chimero, published a post on New Years Day entitled Some Lessons I Learned in 2013.  The number one lesson here is "life isn't a story."  But seeing as this blog isn't life, here's a true story.

The True Story:
One late December evening in 2013, I was shuttling Frank around Brooklyn in my brand new but beat up car.  The winter was pretty rough in NYC and my car was literally weathered.  Unfortunately, it wasn't only a trying winter, but a trying year.  As such, we were discussing how not to handle hardship.  Frank said something along the lines of "I know that creating a story out of life messes people up.  But I don't know why.  Tara, you're a psychologist and you've probably thought much more about this.  Why is it that making life into a narrative isn't helpful?"  Frank was in for an earful, a blog post, and a birthday present.

I immediately conjured up a label for the phenomenon Frank was describing, "the narrative bias."  My next thought was "hm, maybe I'm the first person to think up this term... wouldn't that be cool?"  Five months later, I finally got around to looking into it.  So today, which is Frank's birthday, I did a Google search for "narrative bias."  Then it happened: I learned that someone I've actually met beat me to the punch!  He's not even a psychologist.  His name is Nassim Taleb.  He wrote a book called The Black Swan.  And no, not the one about the ballet dancer, but the one about improbable events (how relevant).  Anyhow, I was introduced to Taleb while dining at Naya, a swanky Lebanese restaurant in midtown, with a friend of mine who is a professor of aerospace engineering (or as we laypeople call it, "rocket science").  But the events of that night are a whole other story!

The Narrative Fallacy:
Much to my dismay, Taleb more astutely coined this concept as "the narrative fallacy."

The narrative fallacy addresses our limited ability to look at sequences of facts without weaving an explanation into them, or, equivalently, forcing a logical link, an arrow of relationship upon them. Explanations bind facts together. They make them all the more easily remembered; they help them make more sense. Where this propensity can go wrong is when it increases our impression of understanding.

—Nassim Nicholas Taleb, The Black Swan

The Story I Told You:
Clearly, humans are verbal animals who are naturally inclined to connect series of events into a narrative.  I've already done it here.  First, I introduced you to Frank.  In case you missed it, I very intentionally called him an "author," not a "writer."  Anyone can be a writer, not everyone can be an author.  Next, I included a link to Frank's Twitter page so that you might happen across the fact that he has quite a following.  All of a sudden, this story is a bit more interesting.  You were already being sold a story before it was told.  Next, I'm officially telling you a story about how Frank and I are palling around BK.  For some artistic flare, I made an uncharacteristic attempt at a harsh-winter-and-personal-hardship metaphor.  We were talking about serious stuff.  But wouldn't ya know it, today is Frank's birthday!  There's levity promised.  But wait, what's his birthday present?  Perhaps you, the reader, will have a voyeuristic opportunity to peek in on a slice of this friendship.  Then, depending on your opinion, another entertaining stunt or cheap trick was pulled.  I told you how a real-life rocket scientist introduced me to Nassim Taleb, the guy who created a better term than the one I was trying to coin with this blog post [It's a letdown.  Maybe you wanted me to be the first because you're reading a story about it.]  Name drop, plop.  But hey... were you interested?  Did it work?  Maybe, maybe not.

The Story I Told Myself:
It doesn't matter if it worked.  Because now you see, the problem is this: in the process of attempting to entertain you with a story, I was telling myself a story.  Reflecting on the company I keep, I'm now starting to liken my life to Midnight in Paris even though it's 8pm in Brooklyn.  Nevertheless, I'm sitting here in the same neighborhood that my friend's mom said "it wasn't worth the risk" to come visit me in, and I'm really starting to consider myself a New York City intellectual.  Spilling coffee on my socks this morning seems like a distant memory.  The fact that I befriended the professor while working a 12 hour shift at a cigar bar cleaning ashtrays is totally lost.  Instead, I start to bet that the reader thinks the professor and I became friends at something like a highly secretive Freemason meeting... that allows women.  Perfect.  The professor and I are practically Freemasons anyhow, right?

Wrap-up:
In short, writing a two paragraph story has made me a delusional egomaniac.  It appears that stringing completely factual events together into a story has a side effect: myopic viewpoint.  A story - whether it be funny or sad -is interesting.  A story is easy to remember.  But when we remember a story, we lose the real richness of our actual experience.  Our balance is lost.  The altered photograph becomes the memory.

Frank, I hope that my attempt at storytelling and delusions have helped illustrate why creating a narrative out of life messes people up.  Anyhow, I need to jet.  Phone call with the Pope!
P.S. Happy birthday.

-Tara

New Autism Theory: "The boy whose brain could unlock autism"

The article "The boy whose brain could unlock autism" from https://medium.com/ is beautiful. It is beautifully written. It is hosted on a beautifully designed site. And most importantly, the non-judgmental theory of autism presented is beautiful.  This theory is also pretty brilliant.

The article presents a theory that reconceptualizes autism as an "intense world syndrome."  This theory suggests that autism is not best thought of as a disorder characterized by a lack of empathy or intelligence, but by the existence of an overload of emotion plus a great capacity to learn.  Further, intense world syndrome suggests that people with autism experience sensations differently.  What an awe-inspiring idea.

There are so many different issues to discuss now!

Let's start with empathy.  Just because it may appear that people with autism lack empathy, doesn't mean this interpretation is correct.  It could be that a person's mind with autism is so overloaded that focusing on someone else is next to impossible.  Over time, this could result in lacking empathy for others.  Further, if people with autism are constantly bombarded with not only intense emotions (e.g. anxiety), but aversive sensory experiences as well (e.g. the act of brushing your teeth produces the internal sensations that nails on a chalkboard would typically evoke), certain consequences can be expected.  We know that spikes in anxiety result in increased calcium release and the encoding of memories.  This process could result in really rigid thinking.  Not to mention, one's focus is really narrowed in those moments.  So if there is constant anxiety, the brain is in a state of rapid-fire learning...on one hand.  On the other hand, it may be difficult to focus on anything but a particular target.  This combination of increased anxiety and rapid fire learning may carve out some pretty "strange" observable behavior patterns over time.  For instance, perhaps a hyper focus on learning calendar dates could result.  Also, the manner of brain processing could leave very little left over for attention on others, hence our current/previous perception of lack of empathy in people on the spectrum.

Speaking of the "spectrum," as a field we are very comfortable examining autism on this spectrum.  But it seems to me that there is still the perception of a dichotomous cutoff whereby some people have autism and others don't.  Right now, once a diagnosis of autism is made, then you are examined on the spectrum as compared to others with this diagnosis.  But what if we viewed every single person as representing a different degree of autism on a full spectrum?  What if the spectrum was thought to encompass all humans?  Well, I think that'd do us a huge service when conceptualizing cases.

Eating disorders, OCD, and self-injury are all jumping into my mind as relevant to this new theory of autism.

Let's take eating disorders for starters.  I'm too invested in writing this blog post right now to look it up, but I remember learning at this year's International Conference on Eating Disorders in Montreal that autism and eating disorders are related.  This was an internal hypothesis of mine for ages.  When I saw the data, I literally scribbled "I knew it!!!" in my notes.  [P.S. Even though I'm not going to look up the exact presentation I saw, here's a Medical News Today article on the relationship between eating disorders and autism from August 2013.]

Similar to what this new theory of autism posits, people with eating disorders are also in a state of anxiety, which results in rigid thoughts (e.g. "fat is bad"), compulsive behaviors (e.g. calorie counting), and a self-centered focus.  There's also usually an increased level of intelligence in people with eating disorders... or perhaps it's better conceptualized as "fast learners."   Sounds a bit like high-functioning autism, huh?  

Unlike autism though, many times people with eating disorders report desperately wanting the approval of others.  So, even if the behavior is seemingly self-centered (e.g. wanting to look good), I maintain that the function of the behavior is not completely egocentric.  But reconciling this seemingly self-centered focus and a desire to please others is usually not easy for family members of people with eating disorders.  The idea is difficult to grasp that intense anxiety about other's approval ironically results in a "self-centered" disorder. In short, I think it could be really useful to use intense world syndrome concepts in fostering understanding about eating disorders. 

Here are a few last notes before I move on with my Sunday: I think eating disorders relate to autism in the same way OCD is related to autism.  In fact, I conceptualize eating disorders as a specific subtype of OCD.  It appears to me that the process is the same in both disorders, but the content of the worry differs.  And as such, slightly different treatments are needed... but not too different.  I'll publish more on what I've written about this in the future.

And lastly, there is the example of how self-injury may relate to autism.  I've blogged here before about my hypothesis on self-injury's relation to sensory integration issues.  To read, click this link.  The idea that intense emotions can create perceptual disturbances (auditory hallucinations such as hearing voices) is not new in psychology.  But the idea that intense emotions can also lead to sensory disturbances remains an area where we need work.  Taking that a step further, exploring exactly how emotions are moderated with sensory acts like self-injury (or even doing things like soothing oneself with lavender hand lotion) is worth researching.

We need to know the following: is there a dose response relationship between intense anxiety/emotion and 1) sensory disturbances, 2) learning, 3) rigid thinking, 4) compulsive/repetitive behaviors, and 5) a self-centered focus?  If not, is there some relationship?  What mediates/moderates that relationship?

This new idea of conceptualizing autism as "intense world syndrome" clicked a few pieces into place of an enormous puzzle that I have been kicking around in my brain for years.  I very much look forward to learning from research on this theory in the coming years. 

Is Multiple Personality Disorder Real? - The Response

In April 2011, I wrote a post called "Is Multiple Personality Disorder Real?"   It is the third most popular post I've written here and certainly generates the most polarized comments / emails.   While I encourage you to read the original if you're interested in the following response, the gist is that Dissociative Identity Disorder (DID) - which was once called Multiple Personality Disorder (MPD) -  could potentially be Borderline Personality Disorder peppered with some delusional qualities. 

One very interesting & thought-provoking comment from 9/25/2012 inspired me to write this (belated) response.

Comment:
This blog post reads like it was written by someone who's never read a book or an article on DID, who's never worked with people with DID, who's just making wild assumptions. There are people dx'ed with both DID and BPD. There are also people dx'ed with BPD who don't have BPD at all, but have DID. You also make no mention of PTSD which all DID patients have, but not all BPD patients have. Look at somewhere that actually treats DID and PTSD specifically like the trauma Ward at Sheppard Pratt. But your theories seem a little half cocked.

This is my response:
Fair enough - I've admittedly not had much experience with DID - however; allow me a belated response (apologies for the delay).

First, I was generally very impressed when visiting Sheppard Pratt in May 2012.  My impression was that they offer top-of-the-line treatment.

As for DID though, I have read a bit about it.  For a summary, I would see Prof. Rich McNally's book "What is Mental Illness?" from 2011, copyright, President and Fellows at Harvard College.

In short, the book explains right after the book Sybil was published, "from near-nonexistence, MPD spread throughout North America, with the number of diagnosed cases soaring to 50,0000."  And then the "epidemic of MPD ended abruptly" because a study showing that asking leading questions is more likely to "create false memories than to recover them" (Ceci & Loftus, 1994).

The book also reads "MPD therapists inadvertently undermined the credibility of their own field when they began helping patients recall alleged memories of satanic ritual abuse" (McNally, Remembering Trauma). And that the FBI failed to uncover any physical evidence of these types of abuses (Lanning, 1992).

Interestingly enough, stories about abuse and trauma Sybil herself endured were also unfounded.  What seems to be the (even more disturbing) truth is that Sybil sought treatment with Dr. Cornelia Wilbur, who appears to have implanted false memories with the (unwitting) use of leading questions and social positive reinforcement.  When treatment tapes of the sessions between Wilbur and Sybil were researched, convincing evidence of this was revealed.  The book also states "indeed, Sybil admitted in writing to Wilbur that she had manufactured her MPD symptoms."

As such, while the symptoms of DID are in the DSM-IV, this does not mean that the disorder is not socially constructed, at least for the vast majority of cases.

[By the way, I'm not saying that there was never an organic (non-socially constructed) case of DID out there.  Saying that 100% of DID cases are socially constructed is a bit like meeting 50,000 Elvis impersonators in the year 2013 and then concluding Elvis Presley never existed. It stands though, that the ratio of hypothetical Elvis impersonators to Elvis Presley himself is still 50,000:1.] 

If someone presents with a case of DID, undoubtedly the situation is severe; however, I would argue that give the citations provided above, the idea  that the etiology (or cause) of the disorder is organic seems dubious at best.  Of course, understanding etiology is extremely important for treatment - especially if the treatment itself is indicated as a possible cause of the disorder, as was in the case of Dr. Cornelia Wilbur and Sybil.

For the cases that are not organic, but socially-constructed - which the evidence seems to suggest is most of them - perhaps a BPD identity disturbance / delusional quality may be present.  That's all.

Dysregulation of the Anxiety System & Bipolar

As per usual, I'm trying to focus on work now, but get completely derailed with a thought I feel the need (compulsively) to blog about.

I saw that someone somewhere on a remote part of the globe was reading a post I wrote a while ago postulating that fear was the first emotion to appear on the evolutionary scene. I decided to revisit it. Here's the link: http://taradeliberto.blogspot.com/2011/03/first-emotion-fear.html

While rereading the post, I had the thought that bipolar disorder may result from a dysregulation of the anxiety system. Long story short, in depression, we see that prolonged anxiety can lead to chronic sadness (via chronic exposure to cortisol and what I conceptualize as over-use of the hypothalamus-pituitary-adrenal axis). We can also see that exhilaration and anxiety are quite similar emotions. Combining these two thoughts, perhaps bipolar disorder could arise out of the dysregulation of a primary anxiety system - sometimes leading to chronic sadness and other times leading to chronic exhilaration.

Interestingly, bipolar is pretty hereditary, but like most psychiatric disorders, it is thought to be prompted by none other than stress, perhaps indicating that it stems directly from some a dysregulation of the anxiety system.

I realize that this is being done already, but the fact that stress / anxiety can trigger the onset of disorders might be a signal to look at how anxiety relates to the course of the illness (with the consideration that anxiety could be the ultimate primary emotion). In this case, while stress may trigger bipolar disorder, lack of ability to regulate anxiety may maintain the behavior. While research in which I am involved examines reward sensitivity in bipolar, I'm wondering if a layer beneath reward sensitivity is anxiety sensitivity, being that we're conceptualizing anxiety as the ultimate primary emotion in this post.

I also realize that to say anxiety dysregulation may prompt bipolar disorder because stress prompts the onset utilizes circular reasoning. But circular reasoning notwithstanding (lol), I still think this is interesting to consider anxiety sensitivity as it relates to two separate constructs of bipolar - both onset and course of the illness.

Ok, back to work.

Triggers - Avoid or Expose?

I was just thinking about the practice of identifying and avoiding triggers in therapy. Sure, inherently harmful triggers are best avoided... but what about triggers that are what we call "conditioned stimuli?"

[For the non-psychologists out there: some of us are triggered by certain things that are actually harmless, but during the course of our lives, we somehow came to associate them with feeling like crap. For instance, walking by a restaurant you used to frequent with an ex could trigger negative emotions. The restaurant itself is harmless, but you've been conditioned to feel sad when walking by it. As such, the restaurant is now a trigger.]

Some therapists may urge their patients to simply avoid all triggers. Sure, this sounds like a good idea, but is it truly helpful? If the patient is in acute / reactive pain, then throwing some more negative experiences their way probably isn't a good idea. But typically, I think that systematically exposing people to triggers, just like you would to anxiety provoking stimuli, would lead to habituation.

While this may be common practice for treating some disorders, it doesn't seem to be the case for all of them (i.e. eating disorders). For instance, when a particular food may trigger a binge, the general advice simply seems to be to avoid that food. Well, I'm just not so sure.

Sensory Integration and Self-Injury

I spent the last semester working with children who have autism.  During this time, I heard the term "sensory issue" a bunch of times, but had no clue what it really meant.  Even after asking questions about it, I never felt like I really understood it.

I ended up learning the most about sensory integration issues at an unsuspecting event - at a writer's conference in NYC.  There, I so happen to have met Nancy Peske, the co-author of the book, Raising a Sensory Smart Child, and a mother of a child with the conceptually elusive sensory integration issue.  I figured she'd be the perfect person to ask about this stuff.

I ended up learning that some people are prone to either seek out intense stimulation or find even the most mild sensations aversive.  For instance, some children have an extremely high tolerance for what would cause most of us pain.  Conversely, the same child may find light tickling painful or aversive.  Although many people with autism have these types of sensory integration issues, we also see this in people who don't happen to have autism.

Relevant to my past research, we find that children who engage in self-injury are more likely to have a high pain tolerance and engage in repetitive behaviors.  While we previously thought that having a high pain tolerance was caused by repeated episodes of self-injury, I'm wondering if actually there is an underlying sensory integration issue here.  [In fact, we're finding that the traditional tolerance theory is not supported.]

On top of that, we have been conceptualizing repetitive behaviors as a precursor to self-injury; however, now I'm thinking that perhaps they both emerge out of the same sensory integration issue that may have been present from before / soon after birth.

And speaking of birth, in Deliberto & Nock, 2008, we report that in utero complications are seen more in children who engage in self-injury than in controls.  Like repetitive behaviors and in utero complications, these findings are also seen in people who have autism.  Although these data are correlational, the relationship among in utero complications and repetitive behaviors, self-injury, and autism is worth considering in my opinion.

In short, I'd bet that both self-injury and some of the underlying commonalities between this behavior and autism are sensory integration issues relating to touch.


---




---

Why Do People Talk about Cutting Themselves?

I just received the following inquiry: I know some one thats very public about cutting themselves. Is this normal? And why do you think this is?

Here's my answer:

Good question. Although I cannot assume I understand this specific person, I can speak generally about the topic of openly discussing one's own self-injurious behavior.

My first inclination is that the person may be seeking what we call "social reinforcement." There are two types of social reinforcement - positive and negative.

What we call "positive social reinforcement" is what people not in the biz call "getting attention." This would come in the form of sympathy, interest, concern, or even people expressing shock. Particularly if a person feels disconnected / a lack of social support (and want these things), they may be prone to be seeking interaction with other people in this way.

So what we call "negative social reinforcement" does actually not mean punishment. In my experience, people in the public misuse the term "negative reinforcement" quite frequently. Negative reinforcement simply means to remove something aversive or to get out of a responsibility. For instance, an adolescent working on a boring group project might tell her peers that she's a "cutter" so they put less of a workload on her. In this example, if the teen gets out of doing something boring, she is negatively reinforced for telling people she cuts.

This brings us to an interesting point. It is my opinion - which is not shared among people with whom I've worked - that when people are socially reinforced (either negatively or positively) for telling people they self-injure, it isn't necessarily the cutting itself that is affected. What I think is more influenced is the actual disclosure of the behavior. This would mean that if someone is socially reinforced for telling people they cut, the actual act of cutting wouldn't necessarily increase, but the number of times self-injury is discussed would increase. To be crystal clear, I think that social reinforcement may shape the largely impulsive behavior of cutting itself, but not as strongly as the seemingly more deliberate act of discussing the behavior.

It is my opinion that people primarily engage in self-injury for emotion regulation purposes. In other words, to decrease their anxiety or to pull them out of a disoriented state (to learn more, I posted a link about this at the bottom of the page). It doesn't make sense to me that people engage in self-injury just so that they can receive attention for it later. My intuition tells me that the reinforcer of social approval is too far removed from that actual act of cutting to be incredibly potent. To my knowledge though, no research has been conducted to support this. In fact, self-report studies show that people report thinking they engage in self-injury to gain approval, therefore, it is advisable to take this into consideration when considering the thoughts previously expressed.

Perhaps self-injury can start out so that one may gain approval (positive social reinforcement) or even get out of something (negative social reinforcement). It could also be the case that someone starts cutting just for the emotional effects, but then starts telling people about it. I just can't buy into the idea that the only reason someone would cut is for social reinforcement.

Anyhow! I digress. Back to your question. It could be the case that this person is trying to connect with people, shock them, or remove his/herself from responsibility. On the other hand, perhaps he/she is just trying to work through previous shame about the behavior and finds it liberating to talk about it. I really don't know. But these are my best guesses!

Speaking to your question regarding whether or not it is normal: based on no data but my experience, about half of people who cut themselves report telling other people, while the other half don't tell anyone but maybe a mental health professional. While I'm not sure how normative it is for people to talk at length about their self-injury, I have some thoughts about this.

We can't make assumptions that talking about engaging in self-injury is necessarily a maladaptive / bad thing. For instance, perhaps the person will end up getting into the right treatment and get support for stopping the behavior. And as previously mentioned, perhaps the person used to feel much shame about the behavior and is working through it by speaking about cutting. Who knows?

On the other hand, one could make the case that if the person is socially reinforced for disclosing that he/she self-injures, the behavior could be maintained. I'm just not sure exactly why this person may be openly discussing engaging in self-injury.

As you can imagine, it is quite complicated!

Great question though. I've never been asked this.

To read more check this out: http://taradeliberto.blogspot.com/2011/02/why-do-people-cut-themselves.html

The Evolutionary Reason We Obsessively Check Facebook

Today's topic is how we're evolutionarily programmed to obsessively check Facebook.

Let's just say that you log on to Facebook and get a good laugh out of a friend's status. You log on a few more times that day, but nothing is interesting. But of course, before going to bed, you log back on one more time just in case. And lucky you - you get another late night chuckle.

First, in this little story, the funny statuses play the role of the reinforcer. Second, the fact that you never know when someone is going to write something clever makes the reinforcer intermittent - or, in other words, random. Put them together and what do you get? A little term us psychologists call intermittent reinforcement.

So the interesting thing is this: when we are intermittently reinforced, we tend to display obsessive behavior (e.g. gambling). Following the rule that intermittent reinforcement leads to obsessive behavior, in this example, never knowing when you're going to read something funny partially explains why we tend to check Facebook all the time as a species. [We also find humor, human interaction, and gossip particularly rewarding.]

So what may the evolutionary advantages to intermittent reinforcement be? Well, I'm not sure if there are too many evolutionary advantages to obsessively checking Facebook, but there certainly are for the underlying mechanism.

Specifically, I was thinking that animals may have evolved to become sensitive to intermittent reinforcement because if we become more persistent in the face of scarce reinforcement / resources, we may increase our chances of success.

Let's consider the definition of perseverance: steady persistence in a course of action, a purpose, a state, etc., especially in spite of difficulties, obstacles, or discouragement.

In that definition, if "difficulties, obstacles, and discouragement" is conceptualized as a lack of reinforcement, then "persistence in a course of action" can be viewed as the somewhat obsessive behavior seen when intermittent reinforcement is given.

While perseverance (with a positive connotation) is readily associated with success, before today, I never considered perseverance as the behavioral result of an environment that is intermittently reinforcing. I'm guessing that will power comes into play too... but honestly, who really knows?

Now, while being sensitive to intermittent reinforcement may be helpful for us to persevere when times are tough, this tendency likely shaped by evolution won't serve us well in every scenario.

There is definitely a darker side to all of this. For instance, if you're more sensitive to intermittent reinforcement, you might be more inclined to stay in a roller coaster relationship, become a compulsive gambler or get engrossed with more trivial matters to increase your mood (e.g. check Facebook more times than you'd like to admit).

We typically think about engaging in these types of activities as a means to avoid feeling negative emotions like boredom, sadness, etc. It may certainly be the case that we engage in behaviors like obsessively checking Facebook to both avoid life and gain pleasure. At the same time, the obsessive nature of Facebook checking may be attributed to the underlying process may be one of intermittent reinforcement.

On a related note, rather than viewing psychopathology in terms of reward sensitivity, I wonder if sensitivity to specific types of reinforcement (or "schedules" as we call them) matters. Namely, sensitivity to intermittent reinforcement may be at the root. Food for thought.

----

[And some food for later thought: perhaps this whole idea of valuing one's own naturally persevering nature somehow relates to asceticism. Together they combine to a pretty intense personality that is sensitive to reward.]

Teaching a Little Guy to Recognize Emotion

Here on this rainy lazy Sunday in NYC, I was drinking my usual morning green tea and thinking about the cases I've seen of alexithymia - or the inability to recognize emotions - in children.  What do we do about alexithymia?  Well, definitely the usual stuff like playing games like emotion charades where we have to guess what emotions / feelings we're acting out, practice problems solving / acting out solutions to various conflicts, etc.  But what else?

Here's a made up case to illustrate my thoughts:

Let's say that I'd been treating a 8 year old boy with alexithymia with the usual techniques until one day his mother asked to talk to me womano-a-womano.  She says that he doesn't understand important feelings she has about a specific family situation and takes the opportunity to tell me about her emotions.  So I go into session and directly discuss what mom might be feeling in these tough family scenarios.  The boy is surprised to learn how she might be feeling and feels a bit badly about his behavior.  Then we discuss what he can do differently in the future that takes his mothers emotions into consideration.  During the next week's session, mother reports that the boy was appropriately attentive to her from the moment they left therapy and throughout the entire week.

Now, even though our hypothetical session - that is a hybrid of multiple sessions with various patients - apparently produced the most effective behavior change outside of session, it was probably the most (mildly) aversive session we ever had.  Compared to past sessions where I have been teaching through games, this was no walk in the park.

During a game like emotional charades, the emotions remain impressionistic by nature. So where do we go from there? Sure this may be a good starting point and we also spend some time discussing issues that are upsetting outside of the session, but what about evoking real emotion in session?

By discussing the feelings that his mom might have, a little light bulb went off in his head.  He first reported feeling sad, but after some pressing, he also reported feeling a little bit guilty about his lack of attentiveness to his mother. After all, we are talking about a very kind child, here.

Notably, those emotions of sadness and guilt were freshly created as a direct result of newly learned content in the session. These emotions were not re-conjured from past events outside of session, nor impressionistic. Something to think about.

Because this session was mildly aversive though, my concern for next week was that he would not want to come back. After all, in his mind, we typically just play games. (Sure, these techniques can produce some change, but it is my opinion that they remain surface.)

Flying in the face of my nagging worry, this little guy was actually quite eager to return to session the following week. I suppose that I'll never be sure as to why. We can only speculate that perhaps it was because of a long standing therapeutic rapport and a learning history that coming to therapy is fun. A second option is that he did not experience the sadness and guilt intensely enough for it to deter him longer term.

But what about the results of Walter Mischel's studies?  We know some children can appreciate something more aversive & meaningful in the long-term, but not a barrel of laughs in the short term. 

Maybe this little guy appreciated learning something new and subsequently having his environment change.  After all, mom did say things were much better at home following that session.

Who knows?

To summarize, there are three ways of dealing with emotion in session:
1) evoking then processing new emotion in session as a result of new information / insight
2) rehashing previously felt emotion
3) creating impressionistic expressions of emotions

Maybe #1 is preferable.  Something to think about.

Therapy and Eastern Religion

As I mentioned in the post, Near Death Euphoria and the Link to Suicide, I love www.Reddit.com. On this site, a member asked me about the connection between CBT and Eastern Religions. This was my response:

So, there have been three "waves" of CBT. The first was behavior therapy, the second was cognitive behavior therapy, and the third is mindfulness/meditation related.

The Third Wave CBT approaches are very tied into Eastern religion. The names of the most well known Third Wave approaches are Acceptance and Commitment Therapy (ACT; pronounced "act"), Compassion Focused Therapy, and DBT (which I mention elsewhere on this blog). I am a huge fan of Third Wave approaches.

The cognitive Second Wave approaches work on correcting "irrational" beliefs (e.g. I am a worthless person). For instance, we might examine the evidence for and against the argument that you're worthless. As it turns out, once you think about it, maybe you're not really all that worthless.

But the Eastern-influenced Third Wave CBT treatments emphatically do not aim to correct irrational beliefs!

Third Wave approaches mainly focus on noticing thoughts like "I'm worthless" and trying to change one's relationship to the thought, but not the content of the thought itself.
For instance, a Third Wave approach might simply focus on the fact that "I'm worthless" is coming into the mind and that it isn't a particularly useful thought to attend to. The treatment would aim to pull the person out of their head and into contact with the present. So instead of attending to the thought "I am worthless," a person may be encouraged to shift the attention to the breath, for example.

Third Wave approaches offer a lot more than just this, and are very rich approaches, but I think this represents the general idea.

If you're interested in learning more, I highly suggest reading The Compassionate Mind and The Compassionate Mind Approach to Overcoming Anxiety.

For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.

"Suicide is Selfish"

I often hear people say things like "suicide is the most selfish thing you can do" and "suicidal people must not care about their families at all."

Well, I just don't think that is the case.

First of all, many do not have families who are particularly supportive, which may be part of the problem in the first place. In fact, many times people who attempt suicide are surrounded by people who are extremely abusive. Especially if the person is a teenager or has limited resources, they may see no way out.

And even if people who have attempted suicide do have people in their lives that are supportive, the person may be truly in so much psychological pain - e.g. they may be bombarded with flashbacks of a very traumatic event or paralyzed by depression - that it might be nearly impossible to take into consideration the perspective of a loved one.

On top of this, some people may feel so worthless that they think ending their lives will actually be doing their loved ones a favor. What's even more upsetting is that in some situations, the person's perception may be accurate - it isn't always, but it could be.  Stigma against people with mental health is strong and I'm sure some family members might consider a person with mental health issues to be a burden.  Of course, this isn't always the case, but it's certainly a possibility.

Please note that whether or not a person's family actually does believe them to be a burden has no bearing on whether or not a person should kill themselves.  Clearly this question is out of the depth of this blog post.  In this post I am merely illustrating reasons why it is myopic to negatively judge people who have suicidal thoughts.  I've heard stories so horrific, it seems incredible that a person could have any will to live at all.  It is not a therapist's job to judge whether or not a person should kill themselves.  It is our job, however, to do everything possible to teach skills that can make life more bearable.

My advice is simply this: don't be so quick to judge.

Near Death Euphoria and the Link to Suicide

I was asked by a friend if I ever came across someone who attempted suicide not to escape suffering, but because they knew it would feel good.  Although not suicidal, the person asking the question was curious because he had experienced a near-death situation in which he was injured and felt euphoria.

I thought this was a really thought-provoking question. The link between near-death euphoria and suicide never crossed my mind before.

This was my response:

I have heard of people recounting similar types of experiences, but I had never considered the link between near-death euphoria and the intention to commit suicide.

A brief discussion of Thomas Joiner's theory of suicide is in order. The basic gist is that people may build a tolerance for the negative feelings associated with hurting / killing themselves by engaging in self-injurious or thrill seeking activities. While it is not necessarily intentional, the negative feelings about death may lessen over time.

Let's just say a person regularly sky dives. Then, for whatever reason, they become suicidal. If you're already used to jumping out of planes, the idea is maybe you won't be that scared to jump off of a bridge.

There is another relevant example to this discussion as well. Namely, if a person regularly cuts themselves (without intent to die) when they're upset, they may not be scared to make life-threatening incisions when suicidal urges come up.

While I formerly thought of this concept as similar to "building up the courage" to attempt suicide via repeated episodes of cutting / dare-devil behavior, this question has me thinking differently. Perhaps there is an additional component here that is consistent with Joiner's theory.

When people cut their skin with no intent to die, it is thought that endorphins are released. This would create reduction in the negative feelings that may prompt self-injury, like shame, anxiety, sadness, etc. Perhaps people also feel mild euphoria, or positive feelings, from the endorphins. This might suggest that for some, self-injury has at least two psychological functions - reducing negative feelings and increasing positive feelings - perhaps produced by the same biological mechanism (i.e. endorphin release).

In any event, a link between injuring oneself and feeling good is formed. Maybe this association generalizes to suicide in the sense that injuring yourself is linked with feeling good.

Now, getting more to the point of suicide, endorphins are not only relesaed during self-injury, but during a traumatic / near-death event as well. This is very interesting to me because a link can be formed between feeling good and death, specifically. In the sky diving example used above, an association is formed between feeling good and jumping from a height, but not necessarily death. In the case of a traumatic event, the link is formed between feeling good and specifically being near-death.

While people may not report chasing the feeling of euphoria that comes with being close to death, if they've experienced it, the drive for this positive feeling could theoretically propel future suicidal behavior. Whether or not the person is aware that they are driven to suicide because of past feelings of euphoria when close to death, it could be a biological function maintaining the behavior.

In short, while I had formerly thought of suicide as a behavior maintained by the function of wanting to escape pain, this point raises the question of whether or not people want to commit suicide to actually feel better. Again, while I don't think people would necessarily report wanting to die to feel that euphoria, it could influence their suicidal drive and behavior.

[For people familiar with psychology lingo on this blog, the function may not necessarily just be automatic negative reinforcement, but automatic positive reinforcement as well.]

Truly, a fascinating point. Thank you so much for asking.

For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.

Is There Anything to be Learned from Freud's Oedipal Complex?

Ever wonder if what happened between Oedpius and his mother could happen in real life? Well, apparently it can. And there is a name for it: genetic sexual attraction.

Genetic sexual attraction occurs when genetic relatives meet for the first time in adulthood and an attraction develops. Although it is a rare occurrence, there has been an increase in the number of reported cases in recent years, typically as a consequence of adoption (according to Wikipedia).

I'm no fan of Freud, but it kind of makes me think.

It should definitely be noted though, that for the vast majority of people, it is thought that living in close domestic proximity as children become desensitized to later attraction. This hypothesized phenomenon is known as the Westermark effect. It only pertains to children being raised together, and does not take into consideration whether or not they are genetically related.

I'm not so much wondering about whether or not there is unconscious attraction between members of domestically-cohesive family units in the way Freud talked about it, but how the concepts of both genetic sexual attraction and the Westermarck effect can relate to normative relationships.

Sure, there have been documented accounts of attraction in types of incestuous relationships, but this certainly isn't the norm. Nor do I think this is due to under-reporting! And no, I'm not so sure that a lack of awareness of unconscious motivations is the reason either.

I think it might go something like this:

The Westermarck effect occurs for most people, but there might be a genetic reason why it doesn't kick in for some. I'm guessing this might be the case for the people in a documentary I watched - two genetic siblings who were raised together, eventually developed a relationship and started a family. [What was your physiological reaction to that little story? That's your Westermarck effect in action.]

So while there are probably genetic components coming into play when we see a lack of Westermarck effect, I'm guessing there might be some environmental components at work as well. I'll spare you the details of my thoughts about this, though! Suffices to say that there is usually a mix of genetics and environment resulting in any behavior - normative or not. [Basically, I'm guessing certain conditions can prompt this behavior. I also think that a lack of development of the Westermarck effect could be observed in people who are attracted to people in roles similar to that of a parent (e.g. the classic example of women without a father figure dating a much older man).]

Ok, so while the Westermarck effect (and any generalization about attraction to people in parental roles) may be the norm, what about the genetic sexual attraction sometimes seen in some people who are adopted?

Well, despite the popular cliche` that opposites attract, I'm not so sure. I've certainly come across research saying that people tend to pair off who are similar across many different areas. As you've probably experienced, bonding can occur when you have similar thoughts to someone else. Sure it would be boring if you were exactly the same, but I'm guessing you're probably more similar to the people you're close with than different.

Basically, if you're genetically similar to someone that you meet in adulthood, you could actually be very similar to them, being that genetics play such an important role in personality formation. An account from an adopted woman about her eventual relationship with her genetic father, described a close bond forming because she was more similar to him than anyone she had ever met.

In short, I don't think that we all have suppressed genetic sexual attraction - probably due to the Westermarck effect developing (and most of the time generalizing to people in similar roles). I'd imagine that people are simply attracted to people who directly or indirectly validate them because of similar attitudes.

For more posts from The Psychology Easel, visit the homepage.

---------------------------------------------------------------------------------------------

As a side note: the problem of marriages or relationships going stale because more of a sibling relationship can develop, may be an interesting generalization of the Westermarck effect. I wonder if some have a stronger inclination for this effect (perhaps couples with a lack of sex drive). It may also have something to do with early development. Different types of effects could theoretically occur (e.g. quick forming attraction and then the Westermarck effect kicking in). Who knows? Something to think about.

Is Multiple Personality Disorder Real?

Although it is very rare, early in my career I met two (different) people with Dissociative Identity Disorder (DID; formerly known as Multiple Personality Disorder). The first person I met with DID was a patient at a clinic in Harvard Square, where I was conducting research. Over the course of my two years there, I watched her slowly unravel from displaying one personality to many. By the time I left, she had the voice and demeanor of a seven year old child. Frankly, witnessing this was quite unsettling.

The second person I met with DID was in the psychiatric emergency room at Massachusetts General Hospital, where I was working on another study. I remember the conversations amongst the staff about her case well - some thought she was faking it, while some thought a diagnosis of DID was legitimate.

In short, this is what I think:

People with Borderline Personality Disorder, which is characterized by self-injury, suicide attempts, extreme mood swings, and stormy relationships also has another very important feature that is often less discussed - identity disturbance. Basically, very different personae are displayed depending on the situation. As Kiera Van Gelder describes in The Buddha and The Borderline, a memoir about recovery from this disorder, she would be a hippie one day and a goth the next if it would get her the sexual attention she wanted. In other words, she would drastically change her personality from day to day (in this case, it was for social approval).

The problem is this: A therapist looking at someone who is a goth one day and a hippie the next might conclude that these are just various forms of the self that need to be expressed. (Yikes!)

While chameleoning can be viewed as adaptive in a sense, the person with BPD / identity disturbance seems to be paying little attention to whether or not they actually enjoy a given activity they are engaging in for social approval. Often, people use these different personae as a tool - and a tool only. The who acts as a hippie today has no real affinity for hippie culture in itself. Expression of one's "hippie side" is resoundingly not to be encouraged.

Introducing certain types of therapy that emphasize different parts of the self to people who already have identity disturbance, may cause further polarization. The patient may be reinforced for behaving in certain ways and expressing themselves from various personalities. Hence, the development of DID. Without a question in my mind, this is what happened with the first patient with DID I watched unravel - she initially had a diagnosis of Borderline Personality Disorder (w/ the identity disturbance feature) - and in two years time (after "parts therapy") she had multiple personalities.

People with identity disturbances crave belonging and unity of their behaviors by definition. Slapping a label of DID on someone who is desperately trying to figure out who they are is dangerous. The person knows that a lot effort needs to be put in to establish a sense of self. These uncharted territories of not living for social approval are scary. This unifying label is an excuse to avoid all the anxiety that will come with establishing a sense of self. It is easier to exaggerate the different forms of self that already exist and diverge further.

In the effort to display many personalities, a unifying role of being an interesting patient is maintained.

While the presentation of someone having several personality disorders is certainly real, I highly doubt this is organic. It seems to me that this disorder is related to the same underlying identity disturbance seen in Borderline Personality Disorder. In fact, I'd be willing to bet that a very large number of DID cases are really Borderline cases gone horribly astray due to treatment with talk therapies that have not been supported by research.

I'd also like to add that after having worked with people who have schizophrenia, there is a definite psychotic flavor to DID as well. My gut feeling is that the core underlying feature is the identity disturbance seen in BPD on top of a psychotic tendency to believe what the mind is constructing. It is these two underlying features that combine to the expression of different personalities. In no way do I think there are actually two different personalities encased in one person. In short, I'd reason that DID is simply a specific form psychosis with the core BPD component of identity disturbance.

In treatment, instead of focusing on expression of various external presentations, focus should be on developing a sense of self. Figuring out what the person likes independent from the approval or opinions of others seems vital.

Lastly, unlike depression or anxiety, there is an ego-syntonic feel to multiple personality disorder. In other words, people like having the disorder to some degree and want to continue any associated dysfunctional behavior. Another example of ego-syntonic disorders would be anorexia, where people typically want to continue restricting food intake. In the case of DID, people want to keep their multiple personalities, as they are potentially useful in different circumstances. As such, the expression of different personalities should be particularly discouraged by all staff members at a facility once rapport has been developed and treatment is underway.

Thoughts on Secret Fears of the Super Rich

by Tara Deliberto

I came across this article "Secret Fears of the Super Rich," and thought it was pretty interesting. I posted a link to it in an online forum, and one of the readers responded with this Ayn Rand quote: "Only the man who does not need it, is fit to inherit wealth, the man who would make his fortune no matter where he started."

Here are my brief thoughts on this marvelous quote from a psychological perspective:

Being in my line of work, I'm acutely aware of the fact that people need to build their own sense of mastery. Without mastery, feelings of helpless set in and a general lack of motivation is fostered. Translated into clinical terms, people become depressed and anxious. So perhaps if an individual is given everything, their sense of mastery can be diminished because they have not had to take opportunities to succeed on their own.

There are several possible reasons why these opportunities are not taken. For one, when the bar is set so high by a family member who built a fortune, it may be too frightening to even approach success. It is seems safer not to attempt anything at all and live a comfortable life. But is it better for one's own well being to never have tried?

While fear of failure might drive this behavior, the possibility also exists that it is that once wealth is attained or inherited, there may simply be no perceived need to achieve. Perhaps if the same person who inherits wealth and chooses not to engage in tasks to build mastery is put under real pressure, he or she might very successfully build resources. But without ever needing to, attempts are not made to earn one's own living.

In short, I'm conceptualizing two paths, the first would be an anxiety-avoidance path while the second is a contentment/maintenance path.

Whether or not they want to, people who inherit money may benefit from continually engaging in mercenary tasks where failure is possible along with adopting an accepting attitude that they may never achieve at the level of their family members. The idea is that when any amount of success is achieved, their own sense of mastery may increases, motivation can ignite, and life many feel more purposeful.

I think this idea fits nicely w/ Ayn Rand's - one needs to be motivated to achieve for their own sense of self-worth. Sometimes having an inheritance can take away one's own sense of importance while increasing entitlement. While importance and entitlement are often linked, perhaps they are very different constructs. While a person may not view themselves as being meaningfully able to contribute to the world (importance), they may think they deserve everything (entitlement).

The Relationship between Negative Thoughts & Serotonin

I'm happy to be a member of an online community where some intellectual forum discussions are generated. In this setting, a question was posed to me pertaining to the relationship between negative thinking and serotonin from Scott in Auckland. Since other people may be curious about the same topic, I thought I'd post my response here.

Reply:
I absolutely love this question! The interplay between what we do as psychologists and biology is one of my favorite topics. How we are trained through all of our collective learning experiences to think - and more specifically, appraise, evaluate, and interpret - has a direct effect on our physiology and biology.

For those of you not familiar with Cognitive Behavioral Therapy (CBT) it involves very active Socratic questioning on the therapists part about thoughts the patient currently has. This type of therapy is in stark contrast to old-fashioned Freudian type therapies that mainly just involve combing over events of your past. If a patient comes into my office and says "I'm a loser," my response would be "Oh, yeah? It must stink to think that. But what is the evidence that you're a loser?... Have you ever won anything?... Even if you are a loser now - whatever that means - will you always be a loser?" etc.

After all this questioning, we usually end up laughing together about what I ridiculous statement "I'm a loser" really is and how true it can feel. Through this process, the rift between what our mind thinks and what is actually true is created. After the initial separation between thought and belief is fostered, we go come up with rational responses to these types of negative automatic thoughts like "I'm a loser" and practicing mentally rehearsing the rational responses as homework.

So, that is a brief description of the cognitive piece of cognitive-behavioral therapy. Interestingly, the behavioral piece has been shown to be more effective than the cognitive piece at changing the interpretation of thoughts. Let's take, for example, someone who has social phobia. You can tell them that their phobia of talking to other people is silly all you want, but they still may not believe you. The best thing to do is act.

We start small. I might grab the secretary into the therapy room and ask her to have a 5 minute conversation about something like traveling with the patient. After five minutes, the secretary says it was lovely chatting and leaves. Now, that wasn't so bad was it?

Then as homework assignments, the patient is to engage in social activities, starting with a small anxiety producing task, and working their way up to doing something very scary like public speaking, over the course of weeks. In this way, their own thoughts are directly challenged by the outcome of their behavior. They always think it will be worse than it ends up being. In this way, they engage in little "behavioral experiments" that directly test their maladaptive beliefs.

It is worth noting here that while the behavioral piece has been shown to be more effective, people may not be willing to engage in the behavioral piece without both a strong rationale for it. It is my opinion that going through the cognitive part of the therapy and disputing thoughts that automatically pop up is an extremely useful first step that must be taken with a vast majority of people before jumping into the behavioral piece. In fact, a client of mine expressed this sentiment completely of her own accord to me today.

While we have discussed both the cognitive and the behavioral piece at this point, there is a third very important piece that changes our relationship to our thoughts - Eastern mindfulness practice. Learning to be aware of our thoughts and release the less useful ones is extraordinarily helpful as well. As a side note, I practice letting go of thoughts every day during yoga, which I use as a moving meditation more than exercise. '

I'll talk more later about integrating these components of treatment, but for now, back to your question! There have been many studies showing that CBT is as useful as treating depression as antidepressants; however, CBT has the added effect of continuing to work even after treatment ends. In terms of whether or not it increases serotonin in the synapse, there are huge ongoing clinical trials in the U.S. examining this right now. So far the evidence points that learning to regulate your emotions through these types of treatments does effect serotonin.

Here's a link to clinical trial information.

Do We Have The Ability to Change?

Similar to the last entry, here I repost my responses to questions posed to me in a forum thread from Eline, whose blog you can find at (http://businessbabyandblog.blogspot.com/).

Eline's Question:
My knowledge of phychology is at best very basic, but I do find it a fascinating subject, and I'm also interested in coaching, and I'd love to know what you think about a question that I have asked myself lately... On the one hand, the hypothesis is that there is high hereditability for almost everything (including personality), and that anything non genetic comes from non shared environment, and thus that personality traits are stable over time. On the other hand, I believe in free will, and that it's possible to change your values, beliefs, thoughts and actions. Taking it further, if you believe in free will, to what extent could we use the plasticity of the brain to shape and transform our personality ourselves? I'm thinking, with so many self-help books on the market, what proportion of identity is really up to us?


My Reply:
You ask a very interesting question! Speaking very broadly - from a combination of fancy statistics and studying identical twins who were adopted into different families, we have estimates that genetics and environment contribute about equally to various personality traits, behaviors, and disorders. Let's first discuss these factors before getting into free will.

From an evolutionary perspective, this makes sense. It is favorable to survival to have some traits passed on from one generation to the next. On the other hand, there needs to be some room for adaptability.

In some people personality traits are really stable across time; however, stability cannot be confused with heritability. In other words, just because something is stable, doesn't mean that it is inherited or genetic. For example, someone could have experienced something extremely traumatic early on in their childhood and would remain fearful and avoidant their entire lives. In this case, the environment would be the main contributor to a fearful and avoidant personality. While this is true, a complex interplay of genetic and environmental factors after the trauma may also maintain a fearful personality.

As someone who studies the treatment of "personality disorders," which are considered to be such stable disorders that they are part of one's personality, I can tell you that personality disorders are not stable over time. A very difficult disorder to treat called Borderline Personality Disorder - which involves suicidal tendencies, behaviors like cutting, chronic feelings of emptiness etc - has been shown to be effectively treated with a talk-therapy called Dialectical Behavior Therapy (DBT). This suggests, that even very difficult and stable traits can be changed with a psychological treatment. Because it is obviously not gene therapy, therapeutic change can be viewed as the environment (along with the individual) shaping behavior.

As I mentioned on this thread where this blog post originated, the mind and body are shaped by the environment. Talk-therapies and experiences can actually re-wire the brain. So even if we're born with a genetic predisposition to something, we can mold it, within certain limitations that are hard to estimate, with experience. There is, however, very likely an element of choice in whether to proceed with and effective treatment.

Although this is likely the case, free will is a really difficult topic to discuss with confidence. We are often very influenced by factors completely outside of our awareness. We also make up reasons for why we do things, when we really have no idea why on earth we do. Many cleverly designed studies have shown this.

With that being said, my own ideas on free will are this: when we become aware of our thoughts and actions, perhaps through the practice of meditation, we have an increased ability to choose. As we hone this ability, over time, we become less like a pinball careening towards different springs that just send us hurling in random directions. We can shape the way in which are brains are rewired by choosing to practice a craft, studying a topic, or participating in an effective treatment like CBT or DBT where psychological management skills are learned.

Eline's Repsonse:
How interesting! Thanks for such a complete answer! I just completed an introductory course in psychology and am having a hard time putting the pices together. What you say really makes sense..

Now I'm thinking about meditating again, I did it for a while, but never really made it a routine or a priority.. :)

My Response:
Eline, my pleasure! If you have any more questions, this thread is here :)

I absolutely love meditation - I research, practice, and teach it. I just wrote an article about meditation here:
http://www.tidytemple.com.au/AnnouncementRetrieve.aspx?ID=45454

If you have the time to check it out, let me know what you think!

Eline's Response:
Great article! I used to share the same misconceptions you address, and I'm sure there are many like me.. I also like the idea of starting with 2 minutes, I started directly at 15 and found it really long, maybe that's why I stopped

My Response:
Thanks for the positive feedback, Eline! It is much appreciated.