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Questions of the
Week
August
Through October, 1997
August 4, 1997
Q I hate the shape and
size of my nose, truly loathe it. I do not date much and assume that
if I were socially active that my appearance would be something that
would keep me from meeting the type of people I really want to date. I
have taken a job as a computer programmer since it allows me less
social interaction. My parents think I "should get some
help." What are my options?
A Likely you already
know your options and even the nature of your problem although perhaps
not the terminology. Obviously, there are two options: (not
necessarily in order)
- Consultation with a plastic surgeon
to determine the viability of a rhinoplasty to potentially have
the shape and size of your nose changed, and/or
- Consult a psychologist to be certain
that this preoccupying concern with your appearance is not an
excuse for other problems that you are not addressing.
The preoccupation with an imagined
defect or excessive concern for a valid defect which causes social and
occupational problems is called a body dysmorphic disorder. The one
concern I would have is (and you do not state your age) that if you
have carried this self-perception for an extended period that you may
need psychological care even if you elect to pursue the rhinoplasty
due to the history of unpleasant experiences and self-derogating
thoughts you have had to this point in your life.
August 11, 1997
Q I am dating a boy
who initially said that he wanted to wait until after we were married
before we had sex, but recently he admitted that the reason he was
postponing things was because he had pain in his groin when he even
thought about sex or when we have any physical contact. Is this
possible?
A You do not mention
whether your boyfriend has been in prior sexual relationships and what
his response had been in those situations. However, there is a
condition called sexual pain disorder or dyspareunia. Most often we
think of this as occurring in females, but, in reality, some males
report genital pain during intercourse. I had a patient who experience
diffuse pelvic pain when he would either have a sexual fantasy or even
hear others discuss sexual topics. Two things need to be explored
concurrently: a. the existence of a psychological causation for the
problem and/or b. the existence of a physical cause including
substance or medication abuse which could give rise to the symptom(s).
August 18, 1997
Q My sister has had a
number of problems with drugs. We have tried to help her, but she
either clings to my parents or rages against them and refuses contact.
She will work with a doctor for awhile and then suddenly says that he
does not understand her. This problem has destroyed her life, but it
has also impacted the rest of the family. Any thoughts as to what
might be going on?
A You might want to check the September,
1997, issue of The Psychosomatic Letter. You sister could be
suffering from what is called borderline personality disorder.
Borderline personality disorder is characterized by unstable and
intense relationships, fluctuating self-image, impulsive self-damage
(such as substance abuse or sexual excesses), emotional instability,
intense anger, suicidal gestures and often paranoid ideation.
Borderline patients do not know the true cause of their mood swings,
dysphoric periods or self-destructive tendencies. They will falsely
attribute causation to others, to outside events or to circumstances
other than their own fragile personality development.These behaviors
are addressed in a recently developed clinical treatment procedure
referred to as dialectical behavioral therapy (DBT) designed for the
chronically suicidal borderline patient. This, when successfully
implemented, has resulted in a decrease in suicide attempts,
hospitalizations and need for medication, as well as reduction in drug
abuse and extremes of anger.
August 25, 1997
Q I have been married
for a few months. Even before we married, however, she would become
incredibly angry of what seemed to be small events and either
destroyed things in our apartment or, several times, threw things at
me and once at my car. She was apologetic afterwards, but the behavior
continued. Most recently, when she becomes this upset she has tried to
attack me and twice struck me with objects within her reach. Will she
out-grow this? I cannot determine what is causing it.
A The best predictor of probable future behavior is
past behavior. Since you do not know the cause, you cannot determine a
solution. You do not mention whether she has had, or would accept,
professional assistance. There is an impulse disorder called
intermittent explosive disorder in which the individual cannot resist
the aggressive impulse which is out of proportion to the events
occurring at that time. Assuming she does not have a medical condition
causing this problem and that it is not related to a prescribed and/or
abused substance, there are several clinical disorders and personality
disorders which can also give rise to such outbursts. There is no
reason to believe that this pattern, which you suggest may be of
longstanding duration, will simply cease without professional care.
September 2, 1997
Q I am sixteen and my best friend loves
to go shopping with me and steal clothes, make-up and jewelry. She
says that the "stores deserve it for charging so much," and
she will actually steal more if any of her friends tell her that what
she is doing is wrong. I do not know why she has become a kleptomaniac
or where to turn for help.
A First, this is not likely kleptomania
at all. Kleptomania is an inability to control the impulse to steal
items that are not needed for personal use or stolen due to their
monetary value. Kleptomania is also not associated with seeking
vengeance on the store or anger because someone else has the item that
is stolen. In true, kleptomania, the individual feels an irresistible
urge to steal items that are actually not needed, and the individual
feels appreciable tension just before stealing and a sense of relief
or pleasure after the theft. It is an impulse that the person cannot
control (not all that different from what is seen in compulsive or
pathological gambling). It may well be that your friend may be
exhibiting anti-social personality trends in which the standards or
society are less meaningful for her than for you. Ultimately, she
faces appreciable social and legal risks and until someone intrudes
into these thefts, they are unlikely to cease.
September 8, 1997
Q Since my divorce, I have felt removed
from things, almost like being in a fog. It is as though I watch
myself going through my daily activities, but it is almost like seeing
it in a movie. This has been going on for over a year, and I am
forgetting my work responsibilities, and although I do not receive
that many social invitations, those which I receive, I often forget.
If I follow through and show for the social events, it is like
watching someone else at the party or the gathering. Later, if I think
about it at all, it is as though it was all a dream or just a fantasy
of having gone. I do not really recall the conversations or much about
the events. Likely, I am not following through on what people tell me,
and more than one person has told me that I have asked them the same
questions repeatedly. I do not know what this is, what is causing it,
or what to do about it.
A You begin by mentioning your divorce, and perhaps the divorce,
or your response to it, plays a central role. Most individuals have
experiences of detachment and feelings as though things are somehow
unreal. This can happen with fatigue, with illness and during times of
extreme anxiety. When such feelings persist, there are two concerns
which should be considered:
The possibility that this is an anxiety created condition called
depersonalization disorder, a psychological attempt to deal with the
trauma of the divorce or some other critical event in your life,
and/or
The potential for a physical problem that would give rise to these
sensations and responses.
This sense of detachment is not likely to be an isolated symptom of a
physical problem, but such considerations should always be made, and
your primary physician can help you determine this. However, since the
probability is that this is arising from anxiety over crises in your
own life, you may wish to consider seeking psychological consultation
to determine the source of the anxiety and solution to this anxiety.
September 15, 1997
Q My wife is in her late 40s. For the
past several years, not months, she has been unbelievably irritable,
but that is not the strange part. There are periods of time, sometimes
long periods of time, when she seems to have boundless energy,
unbelievable enthusiasm, extreme sexual interest and very little need
for sleep. There periods are preferable to her other pattern which is
periods of times of being irritable, wanting to sleep most of the time
with a whining, complaining and pessimistic way of responding to me or
friends. Does this problem sound familiar? Are there some things I
should be considering or investigating?
A You do not mention
whether your wife has gone through or is going through menopause,
whether you have children, whether she has a career or widely varying
pressures in her life to which she must continually respond. But let
us assume that everything is stable besides your wife's moods and
behaviors. I shall also assume that she is physically healthy and
there are no edocrinologic (hormonal, etc) reasons for her behavioral
fluctuations. You describe these periods as being over extended
periods and not simply a matter of days. I feel you would have
mentioned if these were truly bizarre behavioral patterns. You see to
be saying that they are essentially normal responses but they appear
to occur without outside provocation, simply marked mood/behavioral
changes that last for extended periods. There is a disorder called
cyclothymic disorder, and as is true with any psychological disorder,
you have to be certain that this is not a response to prescribed or
other drugs, even adverse reaction to nonprescribed, over-the-counter,
medications. But if we can assume that this is cyclothymic disorder,
there are several concurrent approaches that can be considered:
- Psychological evaluation for the
presence of recurrent stressors either causing the problem or
arising from the problem
- Psychological consultation to
determine if she needs to be considered for medication
consultation to determine if there is a mood regulating
medication that would assist her.
- A conservative approach would be
to secure literature from the Internet on cyclothymic and
related mood disorders and to see if this additional information
suggests that this is a possible concern.
September 22, 1997
Q My husband was
injured in an automobile accident two years ago. He has a disc
herniation and apparently longstanding degenerative disc disease in
his spine. He is in a lot of pain. He was taking a medication called
Percocet, but this was changed to Vicodin. He is supposed to take it
when he needs it for pain. He takes four or more per day, usually in
the evening. I think his problem is depression since he does not sleep
well, is irritable and seems forgetful. He does not try to do anything
with his available time. My belief is that he needs to be treated for
depression. Any thoughts?
A Vicodin, like
Percocet, is a synthetic opioid. It is a narcotic analgesia (pain
killer) and patients can develop both an increased tolerance for the
medication and an increased demand for the medication. Importantly,
for some individuals, these medications can interfere with sleep, and
while the patient feels drowsy, they may actually sleep quite poorly.
In turn, as the medication can be associated with mood lability
(swings of emotions) from euphoria to intense irritability. My first
concern, therefore, is actually how much of the medication is he truly
taking, and what impact is the medication having upon his mood and
behavior? It is not uncommon for patients in chronic pain to be
depressed. It may be advisable to have him evaluated for depression,
but you need to be certain that whoever examines him is also aware of
his pattern of medication intake and whether the current medication is
a contributing factor.
September 29, 1997
Q I am a psychologist
practicing in Nevada. I had a married couple I am seeing in
psychotherapy. Although it is not part of their treatment, they
revealed that they have had intercourse only once in their eight years
of marriage. They are in their late 20s. Both behave as though they
are comfortable with this pattern. When either has a sexual urge, the
other encourages his/her partner to masturbate, and should they
concurrently have sexual needs (which apparently rarely happens), they
then engage in oral sex. There is, however, no contact between
genitals which both find abhorrent. Any thoughts about this case?
A You indicated that this was not their chief
complaint or presenting concern which brought them into treatment.
Although Sexual Aversion Disorder is one of the first diagnoses that
come to mind, that diagnosis assumes that it is:
- a clinical disorder
- that the disorder causes distress or
interpersonal problems
- and not often involves both members
However, we may have a couple who have
found each other due to their shared aversion of genital contact.
While it is possible that both have developed the aversion due to
similar trauma, religious belief, or self-doubt, it is equally likely
that they have disparate reasons for their avoidant behaviors, and the
marriage has permitted them a relationship that is a sanctuary from
the demands that others would make.
Ultimately, as clinicians, we must
separate from treatment those overt problems with which the patient
exists, appears comfortable and creates no burden for themselves or
others. While we may label the behavior as pathologic, there are other
human behavioral trends (such as obsessive-compulsive behaviors) which
are actually quite adaptive in certain contexts and for certain
individuals. Globally, we are there to treat what the patient accepts
as a problem regardless of our doubts as to their wisdom in that
decision making.
October 6, 1997
Q I was in business with my
brother-in-law. He ran the business into the ground, siphoning money
from the business to buy himself expensive clothing and automobiles.
He then drives the cars recklessly endangering the life of others. He
has been accused in the past of embezzling funds from companies for
which he has worked. He states that these are false accusations since
they occurred in other states with people using his name. When
challenged, he has become physically threatening. He always has an
excuse, always blames others, and never appears the least apologetic
for his actions. I told my sister, his wife, that I think he is a
psychopath, but she insists that psychopaths are rare and that the
term refers to killers. I am confused as to what describes this man's
behavior and what we, the family, can do.
A The term, psychopath, is more likely
to be used by the media than by clinical sciences. There was also the
term sociopath that was used to describe perhaps less dangerous
individuals but who consistently defied the rules of society.
Currently, we use the term anti-social personality disorder which
refers to a developmental defect in an individual over 18 years of age
in which the individual
- fails to conform to the lawful
restrictions of society
- is deceitful for purposes of
pleasure and/or profit
- acts upon impulse
- is irritable if not aggressive
- shows a disregard for others
- is irresponsible in work and
honoring financial promises
- lacks remorse for what he/she has
done; does not benefit from past punishment
- There is evidence of a conduct
disorder prior to age 15, and the problem is not due to some mood
or thought disorder.
Society will incarcerate such
individuals and attempt to rehabilitate them, but the prognosis for
change with such individuals is not positive. They often have
secondary problems with narcissism (sense of self importance and
deserved invulnerability). Perhaps the best option available in such
cases is to recognize the pattern and protect oneself from emotional
and financial vulnerability to individuals with anti-social
personality disorder.
October 13, 1997
Q I was told recently
by a doctor friend that I have an "obsessive compulsive
disorder." Personally, I just feel that I am perhaps a little
overly organized, and it is hard for me to complete a task because of
wanted to make sure it is done right. I don't have time for a lot of
friends; I feel my work is more important. The only other thing that I
have noted is that I am more financially responsible than other people
and realize that money needs to be saved for the future. Also, I do
tend to save a lot of items around my apartment that I believe I may
need in the future. I have heard that there are antidepressants that
deal with compulsiveness (sic). Should I be on one of these?
A There is a
difference between obsessive-compulsive personality disorder and
obsessive-compulsive disorder. The former is a developmental pattern
that may interfere with work completion and/or relationship formation.
There is some question as to whether medications are helpful with this
problem. It should, however, be differentiated from
obsessive-compulsive disorder in which the person may have intrusive
and unwanted thoughts that cause distress, and the person spends
considerable time trying to block or exclude these thoughts or images
from their thinking. The person knows that the thinking is faulting
but the problem persists. It may or may not be accompanied by
repetitive acts or thoughts in which the individual feels driven to
count, arrange, clean or repeat things. The individual repeats these
things in an attempt to ward off distress but the repeated behavior
itself becomes distressful. In obsessive-compulsive disorder, these
rituals interfere with normal routine and are time consuming. You may
wish to discuss your thinking and behavioral patterns with a
psychologist to determine whether and how you should deal with them.
There are many terms that have fallen into common usage and may be
inappropriately applied to an individual. As in many disorders, there
is a range of behaviors from the expected to the destructive. You need
to determine where on that continuum your own behaviors rank and what,
if anything, needs to be done about them.
October 20, 1997
Q I have a sixteen year old son who has
us both concerned. He refers to most social activities as embarrassing
which is difficult to understand because he engages in almost no
social contact. When asked about that, he refers to himself as looking
foolish to others and fearing that others will make fun of him. In the
past few years, this has become worse. He initially would ask us to
reassure him that people would like him and not make tease him, but
now even when forced to interact, he is very withdrawn. I feel that he
is lonely and admits that he is when asked, but he also sees himself
as unattractive and having less to offer than his classmates. This is
not improving. Any thoughts would be appreciated.
A There is a series of emotional and
social characteristics called avoidant personality disorder which
arises during the course of the developmental period. It is
characterized by fears of criticism and disapproval. The person
mobilizes all resources to insure that they are not rejected and are
preoccupied with the fears/thoughts of rejection. Likely for some
individuals this spontaneously subsides when success experiences
occur. However, your son is in his mid-teens and many valuable social
experiences are being avoided due to fear of rejection. It sounds as
though you are concerned that this will not merely subside but is, in
fact, increasing over time. It may be important to obtain the input of
his school to determine if there have been events of which you are
unaware that would have contributed to this pattern of behavior.
Likely, there was not a specific event but rather social anxiety which
his avoidance has permitted to grow.
Ask your son if he would be willing to discuss these concerns and
internal experiences with a child and adolescent psychologist
- Determine if you son identifies this
as a problem upon which he is willing to work
- Explore with your church or school
the community options (E.g. small group participation) in which he
is assured a degree of social success
- It may be possible to interface with
another family with similar aged child/children to which your son
can feel he may be safely exposed
- Help your son explore his skills and
abilities, those for which social rewards can arise
- Remember that his greatest concern
is that of failure, but his greatest need is that of acclaim and
accomplishment.
The assistance he needs is in
determining those interests and abilities that make him blend with
others to offset his focus upon his fears of being different and
unacceptable.
October 27, 1997
Q My sister has pulled
the eyelashes from both eyes and the eyebrows from her right eye. She
does this repeatedly and tells me that she feels better after doing
this. She indicates that there is no itching or rash, merely a feeling
that she wants to pull the hairs. I wonder if this is caused by
problems with her metabolism or hormones or something. Have you heard
of such a thing?
A From your
description, it appears that you sister suffers from trichotillomania
which is a compulsive need to pull one's hair resulting in hair loss.
This is not an uncommon disorder. You did not indicate whether this is
creating problems for her in social and occupational functioning, but
it is difficult to imagine that it is not having such impact. There
are behavioral therapies, cognitive behavioral therapies, and
medications with anti-obsessional effects that will be of assistance
to her. Contact your State's psychological association and ask for
recommendation of those who work with obsessive-compulsive disorders.
Technically, this qualifies as a Impulse Control Disorder, but both
groups of disorders are treated similarly.r
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