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Questions of
the Week
April through June, 1998
April 6, 1998
Q I have never gotten along with my father.
He always reads things into what I am saying, is insulted by minor
things I or anyone else says, seems to distrust others and throughout
my life has had a series of jobs, and I think the changes are the
result of his personality. My psychologist says he is a paranoid
personality. Is this a valid diagnosis?
A If the psychologist examined your father, it
may, indeed, be a valid diagnosis, but perhaps he was telling you that
it sounds like paranoid personality disorder. That disorder is
characterized by a pervasive distrust and suspiciousness of others.
The motives of others are seen as evil. There is not sufficient
justification for their believe that they are being harmed, exploited
or deceived. They are preoccupied with doubts of loyalty and
trustworthiness of others and they are unlikely to confide in others
because they believe data will be used against them. Such individuals,
by adulthood, read critical or threatening meaning into benign events
or remarks. They bear grudges for even minor insults and are quick to
anger and counterattack. Not infrequently, they believe that they are
being betrayed by their sexual partner. Most often such individuals do
not perceive themselves as having a problem and that any suggestion
that they need assistance is proof to then that they are, indeed,
under attack.
April 13, 1998
Q I wondered if there were any research
regarding chat rooms, video conferencing and the type of people who
use them on the internet?"
A There is much clinical speculation as to the
types of individuals and their motivations for accessing the chat
rooms and the video conferences. The anonymous chat and the
semi-protective role of the video conference does allow those with
avoidant personality trends the security that their fear of rejection,
feelings of inadequacy, fears of criticism, and social inhibitions can
be set aside and permit them quasi-social interaction. The concept of
safety appears central in these communications; the passive are
permitted to be aggressive if not hostile, the shy are permitted to be
assertive, and one can hide behind assumed identities which resemble
more of a ego-ideal (fantasy existence) which is stronger and more
socially effective than the existence in which the video conferencing
or chat user finds in his/her daily life. Also there is the issue of
exhibitionism in which the individual encounters recurrent, intense
sexual experience by exposing themselves to unsuspecting strangers or
voyeurism in which the sexual experience is watching the sexual
behavior of others (both are considered paraphilias and are only
pathologic if they create impairment in social, interpersonal or
occupational function). However, there is not, to date, definitive
studies as to the most common drives that attract people to these
distant forms of communication. It could be argued that they are
convenient and time-conserving. It could better be argued that they
offer presumed safety.
April 20, 1998
Q People use this term, I believe it is
called "passive-aggressive" to describe others. The term
makes no sense to me; it almost appears contradictory. One is either
passive or aggressive. Is this one of those psychobabble expressions
that lead us nowhere as far as understanding human behavior?
A The term passive-aggressive, currently is
used somewhat interchangeably with the term "negativistic
personality disorder." The term "passive" was/is
somewhat confusing and is meant to imply that the individuals
resistance to fulfilling social and occupational demands is indirect
and characterized by intentional inefficiency, dawdling and
procrastination. The person will often complain of personal misfortune
and alternates between being hostile and then apologetic. The person
is critical of authority, is sullen and argumentative and sees
himself/herself as being misunderstood and unappreciated. When this
pattern characterizes the majority of the individuals interactions, we
think of it as a pervasive personality pattern (disorder).
April 27, 1998
Q My husband is a gloomy and unhappy man.
He has always seemed that way. These are not periods but seem to be
his "style" of life. He is very self-critical as well as
critical of others. I was told by his internist that he may have major
depressive disorder. Are there other considerations?"
A There has been research on a diagnostic
classification currently referred to as depressive personality
disorder. This disorder differs from major depressive disorder and is
not episodic in nature, and the symptoms are not as severe. It is
characterized by a pervasive sense of dejection, cheerlessness, and
unhappiness. These gloomy and joyless individuals feel inadequate and
worthless. Their low self-esteem is displayed as being critical,
self-blaming and derogatory. They brood, worry, are judgmental of
others and are prone to periods of guilt and remorse. Since this is a
developmental defect, the impact of antidepressant medications is
currently unknown, but certainly if his internist wishes a trial on
such a medication, ideally he will be compliant. You do not mention
whether he has ever been in psychological care or whether he perceives
himself as having a problem warranting professional attention. Perhaps
with his internist, you could encourage him to at a minimum attempt
several sessions of psychological care, then consider a joint session
with the psychologist to determine his impressions as to the cause and
direction of the problem. Ideally, this care will begin with a
psychodiagnostic examination in which test instruments may reveal to
both of you more about his problems and concerns and give an
indication of what care would be effective for him.
Q I think we have all met people with
characteristics of the personality disorders you have been discussing,
but, at least in my experience, there are people that have most of the
characteristics of one of these disorders and some of the
characteristics of other disorders. For example, I worked with a man
who had symptoms obsessive-compulsive, narcissistic and paranoid
personality disorder. He met the criteria for all of one disorder,
most of one disorder, and some of a third. Is this possible?"
A Although there are individuals who
meet only the criteria for a specific personality disorders. There are
individuals who do not meet the criteria for a specific personality
disorder and have mixed symptoms of more than one disorder and the
combination of those symptoms causes impairment in social and
occupational functioning. These mixed disorders are sometimes
described as Personality Disorder Not Otherwise Specified with (for
example) paranoid features and obsessive-compulsive and narcissistic
traits. There are individuals who meet the full diagnostic criteria
for more than one personality disorder and are diagnosed as having
(for example) both Dependent Personality Disorder and Histrionic
Personality Disorder. The others that fall into this "not
otherwise specified" classification are those that we have
previously discussed such as individuals with passive-aggressive or
depressive personality characteristics.
May 11, 1998
Q Could you help me understand what
comprises a mood disorder?"
A These disorders are still sometimes referred
to as affective disorders or disorders in the appropriate experience
and expression of emotion. The mood episodes are components of the
mood disorders, more or less their building blocks, and the episodes
include:
Major Depressive Episode - at least two weeks depressed mood or loss
of interest, most of the day, every day, decreased pleasure from
activities, change of weight (>5% in a month), insomnia or
hypersomnia, psychomotor agitation or retardation, fatigue, feelings
of worthlessness, diminished ability to thinking, concentrate or
decide and/or recurrent thoughts of death.
Manic Episode - at least one week of persistently elevated, expansive
or irritable mood, accompanied by inflated self-esteem, decreased need
for sleep, pressure of speech, racing thoughts, distractibility,
agitation, and/or excessive involvement in risky behaviors.
Hypomanic Episode - at least four days of manic symptoms (as described
above).
Mixed Episode - meets the criteria for both manic and major depressive
episodes with symptoms sufficient to cause marked impairment in social
and/or occupational functioning and is not the result of substance use
or a general medical condition.
May 25, 1998
Q My father has manic-depressive
disease. He really doesn't seem to ever get hyper as such, but he is,
at times, awfully irritable and seems to take on tasks that really are
too much for him to accomplish. Can you help me understand if his is
manic-depressive?"
A What was once called
manic-depressive disorder is now referred to as BIPOLAR DISORDER of
which there are two subcategories (please see Mood Disorders section
of CyberPsych® for discussion of mood episodes). If you review this
brief overview of these two disorders, you will note that your father
could, indeed, suffer from BIPOLAR DISORDER without the behavioral
excesses that you expect:
BIPOLAR I DISORDER involves a clinical course characterized by one or
more manic episodes or mixed episodes. Often these patients may have
also had one or more major depressive episodes. This can be a first or
recurrent episode. Recurrence involves a shift in polarity of the
episode from manic to depressive or an interval of at least two months
without the manic symptoms. Like Major Depressive Disorder, Bipolar I
Disorder can be mild, moderate or severe (with or without psychotic
symptoms), with catatonic features, or with postpartum (following
childbirth) onset. It can be a chronic disorder, have melancholic or
atypical features. And the pattern can be with or without full
interepisode recovery, with seasonal pattern and/or with rapid
cycling.
SINGLE MANIC EPISODE: no past major depressive episodes
MOST RECENT EPISODE HYPOMANIC: currently or most recently in a
hypomanic episode
MOST RECENT EPISODE MANIC: currently or most recently in a manic
episode
MOST RECENT EPISODE DEPRESSED: currently or most recently in a major
depressive episode
BIPOLAR II DISORDER (RECURRENT MAJOR DEPRESSIVE EPISODES WITH AT LEAST
ONE HYPOMANIC EPISODES): As with Bipolar I Disorder, the individual
may have mild, moderate or severe (with or without psychotic)
symptoms, with catatonic features, or with postpartum (following
childbirth) onset, but Bipolar II Disorder is categorized as:
HYPOMANIC or DEPRESSED
The chief way of conceptualizing the difference difference between
Bipolar I and Bipolar II Disorders is that one involves manic episodes
(Bipolar I) and the other has hypomanic episodes.
The history that your father and your family is able to provide the
psychologist will help differentiate from which, if any, of the
Bipolar Disorders your father suffers, but you may also wish to see
next weeks CyberPsych® discussion on Cyclothymic Disorder.
June 1, 1998
Q I have been following the discussion of
mood disorders and especially the bipolar disorders. I was wondering
if it is possible to have a bipolar disorder in which the person is
not quite as depressed but their mood seems extremely variable and has
been like this for years."
A A person can have a history of at least two
years of hypomanic episodes with periods of depressive symptoms that
are not severe enough to be considered a major depressive episode.
This disorder is called Cyclothymic Disorder. To be diagnosed with
Cyclothymic Disorder, the individual must have a history of at least
two years of recurrent hypomanic episodes interspersed with numerous
periods of depressive symptoms. The person is not without the symptoms
for more than three months. And, as in all mood disorders, it must be
determined if the symptoms are not better accounted for by drug abuse,
adverse prescribed drug reaction or another mental disorder that has
not been previously diagnosed. In the case of Cyclothymic Disorder, it
is possible for the individual to later develop true manic episodes in
which case, Bipolar I disorder is diagnosed, or to develop major
depressive episodes in which case Bipolar II disorder may be
diagnosed. Thus, it is possible for someone with cyclothymic disorder
to develop symptoms Bipolar disorder.
June 8, 1998
Q My problem is rather
simpler than what you have been describing. I have been depressed
since I lost my job, and my wife left. I am dating, do not enjoy it,
feel depressed most of the time, but there are some periods where I
feel better, but they do not last long. This has been going on for
about three years now. I keep waiting for it to go away but wondered
if it represented a definable problem."
A There is a condition called Dysthymic
Disorder in which the patient has depressed mood most of the day and
for most days of any given week. The individual has had this problem
for at least two years (although for children and teens, it may be
diagnosed after one year and can be expressed as irritability rather
than depressed mood). The person suffering from dysthymic disorder may
show appetite changes, sleep changes, lack of energy, low
self-concept, poor concentration and/or decision making and often
feeling of hopelessness. It must be determined that there has been no
major depressive episode during that period or manic episode, that it
is not due to a health condition or use of medication or drug abuse,
and the patient has not been within symptoms for greater than two
weeks during the period of the disorder. In the past, this was
sometimes referred to as neurotic depression or depressive neurosis
since it was associated with unresolved loss or other external
obstacles the individual confronted. You do not mention whether you
have considered psychological care, and/or what to date you have done
about your concerns, but they do warrant your taking time for a
clinical opinion from someone in your geographical area. The best of
luck, and please let me know what you decide to do.
June 15, 1998
Q I have been following the discussion of
mood disorders, but my problem seems to be somewhat different. My wife
left me about four months ago. Initially, I was tense, nervous and
tearful much of the time, and I did not sleep well at first and was
not all that hungry. But after about two months, I began to feel that
my life could go on and tried to begin thinking about the future.
There are some things about her leaving that I don't understand, and I
still feel somewhat sad at times (places we went together; friends in
common). Does this constitute a mood disorder, and should I get, or
have gotten, psychological care?"
A From what you describe, this is not likely
to have been a mood disorder. There is a group of disorders called
adjustment disorders. These arise in response to one or more stressors
that occur within three months of the onset of the patient's symptoms.
The symptoms can be emotional and/or behavioral. If the symptoms last
longer than six months due to an enduring stressor (one that continues
to occur or whose consequences continue to occur), they are referred
to as chronic. If the symptoms last less than six months, the disorder
is referred to as acute. There are adjustment disorders with anxiety,
with depressed mood and adjustment disorders with a mixture of anxiety
and depressed mood. With some adjustment disorders, there is a
disturbance of conduct in which the patient becomes rebellious or
reckless, and, obviously, some adjustment disorders are characterized
by changes in both emotions and conduct.
By definition, an adjustment disorder is characterized by distress in
excess of what would be expected and causes a significant impairment
in social and/or occupational functioning.
The event in your life, and your adjustment to it, may not represent
an adjustment disorder at all, merely the stages of adjustment to
transient stress. If, however, you feel that social and/or
occupational problems are arising as a result of her leaving, then
seeking a psychological opinion my be appropriate. The best of luck
and let me know what you decide.
June 22, 1998
Q I have a question about this Viagra
thing...My wife wants me to try it, but I really do not see a problem.
I could have sex if it interested me, but it simply does not. We have
been married for about 18 months, and this has been a problem between
us because she states that something is wrong. I tell her that it is
not because she is unappealing or anything; I just never have had any
interest in that stuff at all. She said I should ask you about
it."
A Sexual Dysfunctions are characterized by
disturbance in sexual desire and the physical changes that
characterize the response cycle of sexual excitation and sexual
activity. They are dysfunctions when they case personal distress
and/or interpersonal (social) difficulties. They can arise in the area
of desire, excitement, orgasm, and/or resolution. They can be of
lifelong or acquired duration and can be generalized to many
situations or situational and occur only in specific situations. They
can be due to psychological factors or due to a combined physical and
psychological problem.
Hypoactive Sexual Desire Disorder is described as a deficiency or
absence of sexual fantasies and desire for sexual activity. This is
considered a disorder if it causes distress for the patient or
problems in the patient's relationships. It must be determined that
this is not the result of another psychological disorder which is the
primary problem. If the sexual partner of a patient with suspected
hypoactive sexual desire disorder feels that this is a problem within
the relationship, that concern should be sufficient for the individual
to seek psychological consultation.
June 29, 1998
Q I am somewhat confused by the question
and answer of last week in which you discussed sexual disorders. You
referred to "hypoactive sexual desire disorder" in which
there is a decrease in sexual desire, but my wife seems repulsed by
sex. I thought this was just a problem with premarital sex, but if
left to her, we simply would have no sexual relationship. She finds
scenes on television and movies or even discussion among friends to be
distasteful. This does not appear related to our relationship and
seems to have always been true. Is this the same thing? It does not
seem to be."
A There is a disorder called Sexual
Aversion Disorder. It can be acquired or be of lifelong duration and
it can be generalized to most relationship or be situational and occur
only in some contexts. Some patients with this disorder will have
extreme feelings of anxiety and the associated physical complaints of
anxiety (panic, terror, nausea, shortness of breath, palpitations,
etc) in anticipation that they will be exposed to a sexual situation.
Occasional aversion is not considered a disorder but when it
interferes with interpersonal relationships or creates marked
emotional distress, it warrants professional attention. It results in
either aversion or avoidance of almost all sexual contact and must be
differentiated from other psychological conditions which may be the
primary cause and have gone undiagnosed. Some have an aversion toward
all sexual stimuli, even kissing and touching."
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