The Fallacies of Psychological Diagnosis

Joseph Burgoin
Shame/Narcissism
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Society and Culture
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The Medicalization of Mental Health
14

As you may have heard, the American Psychiatric Association is in the midst of a revision to its Diagnostic and Statistical Manual of Mental Disorders, used to identify different mental illnesses and assign diagnostic labels to patients.  This newest edition, the DSM-V, will be published some time in 2013.   Among the more controversial changes is the elimination of five of the 10 personality disorders currently listed, the best known of which is Narcissistic Personality Disorder (NPD).

This revision seeks to move diagnosis toward a greater emphasis on descriptive traits, based on the undeniable fact that individuals diagnosed with one personality disorder often demonstrate traits associated with another.  As many clinicians have pointed out, the personality disorders exist along a spectrum.  I suppose this refinement in the DSM is a step in the right direction as it appears to treat people a bit more like individuals than categories, but I have a more fundamental problem with the idea of assigning diagnostic labels in the first place.

The fundamental assumption behind the DSM is that its categories of mental illness, with their official code numbers, actually correspond to a discrete syndrome exhibited by real people; in this sense, it is meant to be the psychological counterpart of the International Classification of Diseases 9 (ICD-9) used by physicians to diagnose and label physical illness.  In theory, applying the DSM-IV label Narcissistic Personality Disorder should carry the same weight and have as much scientific validity as an ICD-9 code for, say, diabetes.  The impending elimination of NPD from the DSM-V proves that such an analogy is fallacious.   Can you imagine if the American Medical Association suddenly announced it intended to eliminate diabetes from the ICD-9?
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Celebrity and Romantic Love: “Meaning” in the Modern World

Joseph Burgoin
Love and Hatred
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Shame/Narcissism
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Society and Culture
12

In our modern culture, a huge number of people seem to derive a sense of meaning in their lives through the worship of celebrity (combined with a longing to achieve personal notoriety) and/or the pursuit of idealized romantic love.  I've discussed these issues in my earlier posts on celebrities and love junkies; my good friend Marla Estes has also done extensive work on the subject of romantic love in the seminars she teaches.  I'd like to enlarge those ideas into a discussion of personal values and how we derive a sense of purpose in our lives.

You might have heard about Jake Halpern's book Fame Junkies.  In a survey of several hundred middle-school students in upstate New York, Halpern found that just under 50 percent would prefer to work as a personal assistant to a celebrity over being a university president, corporate CEO, Navy Seal or U.S. Senator.  These students valued mere proximity to a celebrity over other kinds of prestigious work.  Another poll conducted by the Pew Research Center found that the vast majority of 18-25 year-olds surveyed in 2007 listed fortune and fame as the top two goals for their generation.

I find these results discouraging but they come as no surprise.  Grocery store news racks, the ones at the check-out lines, mostly hold magazines with movie and TV stars on their covers.  The shopping public seems to have an inexhaustible interest in famous people and their love lives, even though such stories concern the same mundane events that vast numbers of Americans personally experience:  dating, starry-eyed romance that leads to an idealized wedding, followed by disillusionment, infidelity and broken families.  I'll bet another survey would show that most people would prefer to be a wealthy celebrity going through a painful divorce than a schoolteacher basically satisfied with his or her marriage.  Most people feel that to be famous gives their lives meaning and rescues it from the uninspired realm of ordinary life.

TV reality shows give the average man or woman a chance to participate in that world of celebrity, if only for a brief time.  I believe this is why so many people are willing to expose the most personal and painful details of their lives on nationally-televised shows like Dr. Phil or Jerry Springer.  Quaint notions of privacy or appropriate shame have no force when overpowered by the lure of notoriety.  Maybe my empty life is a total mess, my marriage a shambles and my family alienated from me, but as long as I can be on television, it will nonetheless mean something!
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Different Types of Depression

Joseph Burgoin
Anxiety
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Depression and Bipolar Disorder
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Points of Departure
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Shame/Narcissism
28

As I discussed in an earlier post, most people use the word "depression" to describe many separate and distinct experiences -- grief, disappointment, mild forms of unhappiness, etc.  When I use the word here, I mean clinical depression, the sort of mental and emotional suffering that sends people into therapy or to their physician for prescription-based relief.  I've seen many depressed men and women over the years; from my experience, the roots of their suffering usually lie in three common areas.  I'd like to offer some thoughts about these types of depression and their origins.  I don't view them as necessarily distinct; they often overlap and mingle in various ways.

1.  Post-Apocalyptic Rage:

Beginning with Freud, psychotherapists have noted the frequent connection between anger and depression; you may heard depression described as "anger turned inward."  I'd take this a step further and say that explosive and violent rage often lies at the heart of certain severe forms of depression.  I use the phrase "post-apocalyptic" because, with many severely depressed clients, I have felt almost as if a nuclear bomb has gone off inside them, devastating their minds and laying them waste.  Such clients might make it to session but lie inert and mute on the couch; they might say they feel nothing, or describe their body as feeling numb, weighted down by a pressure that flattens all emotion.  In the room with these clients, I often feels as if meaning has been completely destroyed and the emotional realm is void.  Such clients might describe themselves as feeling no interest or motivation to do anything.  They often mention intense pressure around their eyes or face.

Re-creating the emotional events that led to this state of devastation takes time and patience.  The task is complicated by the fact that the rage is almost always unconscious:  the client has no idea that he or she has been raging.  Sometimes you might hear hints of it in the client's material when he or she begins to speak; more often, you see it in dreams or simply feel it by intuition.  The landscape of the apocalypse often appears in the dreams of depressed people: bleak ghettoes, vast lifeless deserts or scorched terrain borrowed from movies such as The Terminator.  If you have a strong empathic link with your client, you may find feelings of rage rising inside you during the silence, for no reason you can understand.

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Defenses Against Shame

Joseph Burgoin
Defense Mechanisms
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Detours
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Shame/Narcissism
56

Over the years of my practice, I've found that most clients who come into treatment struggle on some level with issues of neediness and shame.  In other posts, I've discussed difficulties in bearing need; now I'd like to address in detail three core defenses against the experience of unbearable shame:  narcissistic flight, blaming and contempt.  Denial of internal damage lies at the heart of all three defenses.  Feelings of basic shame also form the core of what is commonly referred to as "low self-esteem".

Narcissism is the primary defense against shame and often goes hand-in-hand with the other two defenses.  When people suffer from an unbearable sense of shame, they often seek to elicit admiration from the outside, as if to deny the internal damage.  Beautiful outside versus ugly inside.  We've all known such narcissistic types.  As friends or acquaintances, they tax our patience and drain us emotionally because of their constant need to draw attention to themselves; their narcissistic behavior makes social interactions dull and one-sided.  Recognizing that these people suffer from unbearable shame may help
us to feel some compassion but it doesn't make the relationships any more satisfying.

The shame-driven client poses a major therapeutic challenge.  If the therapist tries to discuss narcissistic behavior as a defense, to go beneath the "beautiful" outside and get closer to the "ugly" inside, it can easily feel to the client like a narcissistic injury, unbearably painful; rather than feeling that the therapist wants to help them get closer to  something true but unrecognized, such clients often feel humiliated.  I discussed such a client in my post on 'Avatar' and toxic shame avoidance.  As we got closer to the core of shame in our work together, whenever I tried to put him in touch with the damaged David hiding behind his narcissistic Internet encounters, he'd often begin to scream, accusing me of misunderstanding or purposefully humiliating him.  It felt to me as if the shame were so excrutiating that he had to "scream it out," to rid himself of that searing pain and project it into me.  As his therapist, I found the experience deeply painful but at the same time, it helped me understand the degree of his suffering, the intense pain he was constantly warding off.

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Narcissism vs. Authentic Self-Esteem

Joseph Burgoin
Destinations
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Self-Esteem and Self-Sabotage
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Shame/Narcissism
34

You may have seen or heard about these two new studies on self-esteem in college students.  A recent New York Times article reports that, when given the choice, most college students prefer to receive a boost to their self-esteem in the form of a compliment or good grade over eating a favorite food such as pizza or having sex.  The article begins with the following question:  "Are young people addicted to feeling good about themselves?"

At first, I found this question idiotic.  I am sick and tired of how our culture has adapted the language of addiction to describe everything.  The more I thought about it, however, it did make a (limited) kind of sense to me, especially if you consider addiction to actual drugs as a means to avoid some other experience or to seek an inappropriate remedy for a very real problem.  As I've written elsewhere, narcissistic people crave attention and admiration in order to ward off feelings of inferiority and to  bolster a fragile sense of self.  In other words, they have no authentic self-esteem and look to others to provide a substitute for it.  The problem with external sources of self-esteem, as with all drugs, is that they wear off and you have to secure more of it to feed your habit.  As a result, those individuals without genuine self-esteem have an insatiable need for their their egos to be bolstered by the people around them.  In this sense, I suppose it makes sense to talk about them as addicts, even if "addicted to self-esteem" sounds ridiculous.  Besides, receiving a compliment has nothing to do with authentic self-esteem.

In my experience, you can't obtain real self-esteem from the outside.  Yes, it's important that our parents praise and encourage us as we grow up.  We internalize that praise, along with their values and standards and those of our teachers, peers and social environment; then, once they've become a part of us, we must live up to those standards if we're to feel good about ourselves.  I'm not referring to perfectionistic and overly harsh standards, impossible to meet.  I mean our own ideas and expectations, evolved from the disparate influences of family, peer group and culture, about what it means to be and behave like a person we would respect.

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