Could Schema Therapy Help Treat Narcissistic Personality?

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Narcissistic personality disorder (NPD), or narcissism, as it’s often called, is one of the cluster B personality disorders, or emotional/impulsive personality disorders.

Narcissism is one of the least studied personality disorders. Different subtypes of narcissism present with varying features, making diagnosis challenging. People with narcissism may also see no need for counseling and consider it pointless or beneath them. If they do begin therapy, they may react angrily when faced with challenges, try to manipulate their therapist, or find it hard to consider things from other perspectives. They often leave therapy early, especially if they don’t see any benefit in it.

Recent research aims to identify new therapy approaches that can help people living with personality disorders achieve lasting change. Schema therapy, one such treatment, is considered helpful for people who don’t respond well to other types of therapy. It’s proven effective in treating borderline personality, another condition long considered difficult to treat.

Research looking at schema therapy for narcissism is still in the early stages, but existing clinical data suggests it has promise.

People living with narcissism have a deep need for admiration and recognition and draw self-esteem from the praise and positive regard of others.

The Roots of Narcissism

Personality disorders are characterized by rigid, long-lasting patterns of behavior that affect life and relationships, causing distress and making it difficult to function. People living with personality disorders may not always recognize that some of their behaviors cause problems or affect others negatively.

Like other personality disorders, narcissism is a serious mental health issue. Many consider it more serious and harmful than most other personality disorders, since people with narcissism generally lack empathy and may not care about the effects of their actions.

The causes of narcissism aren’t fully understood. Some potential factors in development may include:

  • Having a parent who is extremely adoring or overly critical, or a parent who switches between these modes
  • Having a parent with narcissism
  • Inheriting certain traits that increase risk for personality disorders
  • Experiencing trauma, abuse, neglect, or indifferent parenting

People living with narcissism have a deep need for admiration and recognition and draw self-esteem from the praise and positive regard of others. Since connecting with people on an intimate level requires a level of vulnerability, people with narcissism may avoid meaningful relationships in order to protect their illusion of grandiosity and keep an unstable self-identity from being revealed.

Researchers have identified four main subtypes of NPD. It’s possible to have features of multiple subtypes or shift between subtypes at different points in life.

  • Overt narcissism most often involves entitled, attention-seeking behavior. A primary feature is an exaggerated sense of self-importance. People with this subtype tend to be charming and arrogant and often exploit others. They may do fairly well in the workplace but struggle to get along with others or do tasks they consider demeaning or otherwise beneath them.
  • Covert narcissism may include anxiety, significant emotional distress, and extreme sensitivity to criticism or perceived insults. This subtype is often characterized by shyness, even social isolation. People with covert narcissism tend to have an internal sense of superiority and fantasize about their talents being recognized while speaking modestly about themselves, even putting themselves down.
  • High-functioning narcissism involves similar traits to overt narcissism, but people with this subtype can generally function well in society and may not appear to have a personality disorder. They are often able to adapt narcissistic traits such as charm and competitiveness in order to achieve success and may have relationships that are shallow but lasting. Criticism, perceived failure, or age-related challenges such as poor health or perceived loss of attractiveness may cause distress or crisis.
  • Malignant narcissism, considered the most severe subtype, involves overt narcissism traits along with traits of antisocial personality and paranoia. People with this subtype may lie and manipulate others easily, behave in aggressive ways, enjoy intimidating others, and avoid any work or task unless it benefits them in some way. They often have no desire to change, so treatment may be very difficult.

Narcissism often involves symptoms that are less known than grandiosity and lack of empathy, including:

Most people with narcissism struggle to maintain employment and personal relationships, changing partners readily when they don’t receive the admiration they need. It’s also common for people to fantasize about being recognized for their superiority and humiliating people who have “wronged” them.

When therapy can help address these concerns, particularly vulnerability and self-esteem, narcissistic behaviors may improve.

Schema Therapy: An Effective Treatment for Narcissistic Personality?

Even when people with narcissism do seek therapy, whether for distress related to narcissism or other mental health symptoms, treatment can be complicated. Believing a therapist has insulted them, failed to recognize their specialness, or isn’t skilled or reputable enough to treat them leads many people with narcissism to quit therapy early in treatment. Research suggests therapy progresses more slowly for people with narcissism, leading to slower improvement of symptoms.

Schema therapy, however, may have increased potential to treat NPD. Schema therapists offer support and validation while helping people work to understand and address the emotional mindsets causing problems in their life. For narcissism, this is often the persistent, private sense of inferiority and fear of failure.

Schema therapy combines elements of cognitive behavioral therapy, emotion-focused therapy, Gestalt therapy, and psychodynamic therapy, among others. The idea behind this approach is that schemas, or patterns of thought and behavior, develop as a result of unmet emotional needs and other early childhood experiences. These schemas are reinforced throughout life by challenges, abuse, trauma, and other negative or harmful experiences. Unless they’re addressed in positive ways, they contribute to the development of harmful or unhealthy methods of coping. These coping styles can affect behavior throughout life, often in ways that cause distress.

Schema therapists offer support and validation while helping people work to understand and address the emotional mindsets causing problems in their life.

The goal of the approach is to help people identify needs that weren’t met in childhood and learn how to get them met in healthy ways that don’t cause harm, either to themselves or to others. To help clients achieve this goal, schema therapists group schemas and coping responses into modes and use a range of strategies to address them, including roleplay, interpersonal techniques, and cognitive behavioral approaches. Therapists may set limits, as a parent would, within the bounds of the therapeutic relationship to help clients confront schemas.

The schema modes commonly associated with narcissism are:

  • Detached Protector/Self-Soother: This avoidant mode involves behaviors that are soothing, stimulating, or distracting—anything that helps turn off emotions. These behaviors might include substance abuse, risky sex, gambling, fantasizing, or overwork. It’s also common to shut out or reject people as well as emotions. Typical function isn’t always affected, but it may seem almost mechanical and lack any personal investment.
  • Self-Aggrandizer: A mode in the overcompensation category, this involves many behaviors typically associated with narcissism—superiority, entitlement, and manipulative tactics. People in this mode tend to show little interest in anyone but themselves, boast of real or inflated achievements, and openly seek admiration to avoid revealing hidden vulnerabilities and insecurities.

By confronting these modes and working through them with the help of the schema therapist, people in therapy can begin to access the Healthy Adult mode, which helps heal the vulnerabilities of early childhood and fosters healthier modes of coping. After reaching this mode, people may be able to begin functioning at a more typical level and be more able to take responsibility for their actions and see how they affect others.

Schema therapy has been successful in the treatment of other personality disorders, including borderline personality. Clinical trials on its use with narcissism are still forthcoming, but research and clinical observations suggest schema therapy could help people with narcissism have more success in treatment.

Why Do Narcissists Seek Therapy?

People living with NPD often believe themselves superior and struggle to consider the feelings and needs of others. This can make their actions particularly hurtful. Narcissism also often involves intentional manipulation or emotional abuse—behaviors that cause significant pain to partners of people with narcissism. In fact, many therapists specialize in helping the partners of people with narcissism heal.

The typical traits linked to narcissism, along with the tendency of many with NPD to see nothing wrong with their behavior, have contributed to the belief that therapy can’t treat narcissism. But therapy can help people with narcissism improve—if they want to change.

Andrea Schneider, LCSW, a therapist in San Dimas, California, explains what might prompt a person with NPD to seek counseling. “Typically,” she says, “Someone … with narcissistic personality may have some flexibility with some behavioral change when they are confronted with significant stressors (like a relationship ending or other crisis).”

People with NPD may not ever seek therapy for symptoms associated with narcissism. Instead, they might decide to get help for other symptoms or issues. These could be co-occurring conditions or long-term mental health effects associated with narcissism. In many cases, it’s these challenges that contribute to the desire for change.

People with narcissism may seek help for:

Narcissistic personality and associated conditions can significantly impact quality of life and emotional well-being. Addiction and stress can cause health concerns, for example, while the inability to sustain a relationship could lead to complete isolation.

To date, few studies have looked at treatment for narcissism because people with NPD don’t seek therapy often. If they do, they may only do so because someone else has urged them into it. Therapy can still have benefit, but the person with narcissism must recognize the problems with their behavior and make efforts toward change.

Finding a Schema Therapist

People who don’t see a need to address their behavior are unlikely to be able to make lasting change. But research on schema therapy suggests the approach could benefit people living with narcissism when other types of therapy don’t help. Experts do agree that narcissism often poses treatment challenges for therapists and can make progress in therapy difficult.

Schema therapy involves validation and empathy for a person’s difficulties and distress. When people with narcissism approach therapy with a willingness to change, or at least to make an effort to address harmful behaviors, the mode work involved in schema therapy may help them learn to confront the vulnerabilities they fear in a healthier way.

It can be difficult to find a schema therapist, especially if you live in a smaller city. But many therapists may be trained to incorporate elements of schema therapy into treatment. If you or a loved one has symptoms of narcissistic personality disorder, consider reaching out to a therapist who offers schema therapy or practices mode work. Don’t be discouraged by the myths about narcissism—change is possible for anyone. Begin your search for a trained, compassionate counselor today.

Author’s Note: If you’re involved in a relationship where there is intimate partner abuse of any kind—physical, emotional, or sexual—relationship therapy is usually not recommended. We encourage you to review our crisis page and reach out for support.

References:

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association.
  2. Behary, W. T., & Dieckmann, E. (2011, July 20). Schema therapy for narcissism: The art of empathic confrontation, limit-setting, and leverage. In W. K. Campbell and J. D. Miller (Eds.), The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings, and treatments. Hoboken, NJ: John Wiley & Sons.
  3. Behary, W. T., & Dieckmann, E. (2013). Schema therapy for pathological narcissism: The art of adaptive reparenting. In J. S. Ogrodniczuk (Ed.), Understanding and treating pathological narcissism (pp. 285-300). Washington, DC, US: American Psychological Association.
  4. Caligor, E., Levy, K. N., & Yeomans, F. E. (2015, April 30). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5). Retrieved from https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.14060723?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&
  5. Dieckmann, E., & Behary, W. (2015). Schema therapy: An approach for treating narcissistic personality disorder. Fortschritte der Neurologie-Psychiatrie, 83(8), 463-477. doi: 10.1055/s-0035-1553484
  6. Ekselius, L. (2018). Personality disorder: A disease in disguise. Upsala Journal of Medical Sciences, 123(4), 194-204. doi: 10.1080/03009734.2018.1526235
  7. Mayo Clinic Staff. (2017, November 18). Narcissistic personality disorder. Retrieved from https://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/symptoms-causes/syc-20366662
  8. Ritzl, A., Csukly, G., Balázs, K., & Égerházi, A. (2018, September 13). Facial emotion recognition deficits and alexithymia in borderline, narcissistic, and histrionic personality disorders. Psychiatry Research, 270, 154-159. doi: 10.1016/j.psychres.2018.09.017
  9. Young, J., & First, M. (2003). Schema mode listing. Retrieved from http://www.schematherapy.com/id72.htm
  10. Young, J., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York City, NY: Guildford Press. Retrieved from https://www.guilford.com/excerpts/young.pdf?t

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The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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Why my MA will be my new beginning

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Thursday, 18 April 2019

Why my MA will be my new beginning

In this blog, Alice talks about how even though her undergraduate experience wasn't the best, she's determined to have a more positive time studying for her Master's degree.
University wasn’t the place for me. I’m not saying it was bad. I’m just saying it wasn’t good. I didn’t care about the Mexican Revolution, religious symbolism in the work of J. L. Borges, or the exploration of the self and form in twentieth-century France. Likewise, I did not care about the difference between the pronunciation of “vu” and “vous”, “pero”, and “perro”. I did not care about getting an F in a relatively unimportant presentation. I did not care that my tutor declared my essay on feminism to be “decidedly mediocre”.
Instead, I cared about evenings in pubs, walks in the park and sessions at the gym. I cared about staying up all night watching films and reading books not on the syllabus. I cared about cycling from a bar to my friend’s house at 1am on a Monday morning. I cared about going to gigs, visiting photography exhibitions, and rummaging through Spitalfields market on a Sunday.
When it came to studying, I tried, but only sort of. Half an hour before class was due to start I would open my workbook and frantically scribble something down. In the evenings, I would read novels of my own choosing before embarking on (and then later abandoning) the set texts. As for the presentations, I would usually just miss those classes and carry the fail. Invariably, I would turn up to every class utterly unprepared, having no idea about what was about to be discussed, and caring very little.
At the end of my three-year degree (which took me five years to complete), I received a transcript of my results, telling me that I had received one fail, two thirds, 2:2s, 2:1s, and firsts – all of which averaged out into the most meaningless 2:1 the uni must have ever given.
What the transcript didn’t say was that, during my studies, I had experienced debilitating depression, unrelenting OCD, one terrible coming out, one terrible relationship, one terrible break up, and the onset of Tourette’s syndrome.
OK, maybe university was bad.
This year, though, I have a place on UEA’s Creative Writing MA, and I’m determined to go back to my studies.
But if my undergraduate was so tumultuous, why am I doing this?
The answer is simple: university is, for me, unfinished business. I need to go back: get consistently OK grades, stay on an even keel for the duration of the course, keep my depression and OCD at bay. There’s not much I can do about the Tourette’s, given that it’s both chronic and incurable.
It’s going to be hard. I have the stereotypical swearing kind of Tourette’s. I will be yelling out “fuck” in lectures. I will find it hard to concentrate. I will inevitably be a distraction to myself and others.
But, unlike my BA in French and Spanish, this course has been a dream for a long time. I will spend a whole twelve months doing what I love: reading and writing. Reading helped me through depressive episodes before, and getting my writing published since leaving university has given me a much-needed self-esteem boost.
And if mental illness has taught me anything, it’s to do what you love, and do it a lot.
So that’s what I’m going to do. I’m determined to go back, and I’m going to smash it.
Alice Franklin is a writer who happens to have Tourette's, OCD and autism. She writes at a leisurely pace, runs at a leisurely pace, and hammocks at a leisurely pace. Previously, her work has appeared in two Spanish short story anthologies, the online magazine Liars' League, and the Financial Times. Posted by Student Minds Blogging Editorial Team at 09:00 Email ThisBlogThis!Share to TwitterShare to FacebookShare to Pinterest Labels: Autism, Depression, OCD, Postgraduate study

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A Couple’s Guide to Coping with Infertility

This is an interesting article I found on: www.goodtherapy.org

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If you and your partner have been trying to get pregnant for a year or longer but haven’t yet conceived, it’s possible you are facing fertility issues. You might already have started talking with your doctor about these challenges and your options for getting pregnant.

Most likely, your doctor is monitoring all aspects of your physical health. But it’s important to take care of your emotional well-being too. People who want to have a child but struggle to get pregnant may face a range of emotions, including anger, frustration, grief, and shame. If these emotions aren’t dealt with productively, they can fester and contribute to pain, resentment, or mental health issues such as depression.

Infertility not only affects you and your partner individually, but also your relationship. Here, we’ll discuss problems you may face as a couple if you’re dealing with infertility and ways you can address them. When difficulties are managed in healthy ways, you’re more likely to grow stronger as partners than grow apart.

Social Stigma Around Infertility

Discovering how common infertility is surprises many people. According to the Centers for Disease Control and Prevention, 12% of American women between the ages of 15 and 44 have trouble getting pregnant or struggle to carry pregnancies to term when they do conceive.

Once a couple marries, it’s often assumed they’ll begin trying to have a child. Certainly, this assumption is flawed in more ways than one, but one main issue is the stigma that often results. Your parents and friends might ask prying questions. Social situations may become uncomfortable if your friends don’t seem to understand what you’re going through. People may avoid inviting you to events like birthday parties or baby showers. Even if they do so out of good intentions, you may still end up feeling excluded.

It’s important to experience your feelings as they come, but it’s also important to avoid blaming yourself or your partner. Blame, self-directed or otherwise, can trap you in a painful cycle that leads to more distress.In the past, women took much of the blame for infertility. While it’s known today that infertility can result from male or female factors, women may still struggle with feelings of failure or shame. Men may deal with similar pain but find it harder to talk about. In society as a whole, there can be a general feeling that couples without children are somehow incomplete, a judgment that can make the distress of infertility even more painful.

In recent years, many celebrity couples have shared their experiences with infertility, including Michelle and Barack Obama. Maybe you’ve talked about your infertility with a loved one and felt empowered and supported by their reaction.

Infertility issues often feel like a private struggle. But reducing the stigma could help more people feel comfortable talking about their own difficulties becoming pregnant. People who don’t feel ready to open up may still draw support from knowing they aren’t alone. No matter which factors contributed to infertility, neither you nor your partner should feel shame.

Avoiding Blame and Shame

Letting yourself experience grief is an important part of coping with infertility. Even if you’re pursuing fertility treatments, facing the reality that becoming pregnant may not be possible can have a heavy emotional impact. Grief and sadness may be your first reaction.

Sometimes the cause of infertility can’t be determined. But finding out infertility issues stem from you can lead to decreased self-esteem, depression, and anxiety. If your partner is the one who is infertile, you may might feel frustrated. You may struggle to keep from blurting out that it’s their fault, not yours.

It’s important to experience your feelings as they come, but it’s also important to avoid blaming yourself or your partner. Blame, self-directed or otherwise, can trap you in a painful cycle that leads to more distress.

Counselors who work with couples dealing with infertility recommend talking to your partner about how you feel, openly and honestly. This might be difficult when you’re angry, but remember: You and your partner are a team, and communication is essential in a good team. Even if you’re angry, hurt, or ashamed, it’s usually better to talk about your emotions calmly, rather than waiting until they burst out during an argument or stressful moment. You may decide not to share your struggles with family and friends, but commit to being honest with each other.

Choosing Other Fertility Options

Assisted Reproductive Technology (ART) helps many couples treat fertility issues. When considering your options, it’s important for you and your partner to agree on how long you’ll pursue treatment, how much money you can spend, and what treatments you’ll try.

Have an honest discussion with your partner about treatments you’re uncomfortable with before planning on any procedures.Your insurance may not cover all (or any) of the cost of fertility treatments. Beginning treatment with a financial limit can help you avoid putting yourself in financial difficulty by continuing indefinitely.

It’s also helpful to decide on a length of time you’ll try treatment for. ART can give you hope, but treatments don’t always work right away. Sometimes they don’t work at all. The uncertainty and stress associated with treatment can have a negative effect on your relationship. Though you may feel renewed grief if you approach the end of the time period and still haven’t conceived, having a limit in place can help relieve some of the uncertainty and emotional distress.

Depending on your specific fertility issue, a range of treatments may be available. Options include medication, in vitro fertilization, and intrauterine (also called artificial) insemination. You might also choose to use donor eggs or sperm or have a surrogate carry a fertilized egg to term.

Some of these options may not work for you due to religious, ethical, or personal beliefs. For example, some people consider freezing embryos to be unethical. Have an honest discussion with your partner about treatments you’re uncomfortable with before planning on any procedures.

Addressing Infertility in Couples Counseling

Though it’s possible to maintain a strong, committed partnership while navigating infertility issues, taking preventative steps can help keep your relationship healthy. Research suggests infertility is a highly stressful and upsetting experience, and any type of stress can affect a relationship negatively. Couples therapists recommend seeking help early on instead of waiting until the crisis you’re facing starts to significantly affect your relationship.

A 2017 study found evidence to suggest couples with compatible coping methods had better communication and were more likely to develop a stronger relationship despite infertility. In other words, it is often better to deal with the issue as a team, even when your instinct may be to deal with your pain alone. Therapy can help you and your partner develop strong coping strategies and quit maladaptive behaviors such as avoidance.

Therapy also provides a safe space for you to talk about your feelings regarding infertility and mental health symptoms you’re experiencing. (Talking about these in individual therapy may also be recommended). Your therapist can support you and your partner through finding helpful ways to cope, relate, and connect during infertility challenges.

If you aren’t already working with a couples therapist, it can help to begin seeing one, even if fertility issues aren’t affecting your relationship at the moment. Some couples therapists may even have specialized training in infertility counseling. You can begin your search for a couples counselor in GoodTherapy’s directory.

References:

  1. Fertility treatments. (n.d.). Planned Parenthood. Retrieved from https://www.plannedparenthood.org/learn/pregnancy/fertility-treatments
  2. Glenn, L. M. (2002). Loss of frozen embryos. AMA Journal of Ethics. Retrieved from https://journalofethics.ama-assn.org/article/loss-frozen-embryos/2002-12
  3. Infertility FAQs. (2019, January 16). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/reproductivehealth/infertility/index.htm
  4. Infertility. (2018, March 8). Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/infertility/symptoms-causes/syc-20354317
  5. Itkowitz, C. (2018, November 9). Michelle Obama is one of millions who struggled with infertility. Here’s why her broken silence could matter. Washington Post. Retrieved from https://www.washingtonpost.com/politics/2018/11/09/michelle-obama-is-one-millions-who-silently-struggled-with-infertility-heres-why-her-broken-silence-could-matter/?noredirect=on&utm_term=.8d2645a61c30
  6. Pasch, L. A., & Sullivan, K. T. (2017). Stress and coping in couples facing infertility. Current Opinion in Psychology, 13, 131-135. Retrieved from https://www.sciencedirect.com/science/article/pii/S2352250X16300902
  7. The psychological impact of infertility and its treatment. (2009). Harvard Mental Health Letter. Retrieved from https://www.health.harvard.edu/newsletter_article/The-psychological-impact-of-infertility-and-its-treatment
  8. Volmer, L., Rösner, S., Toth, B., Strowitzki, T., & Wischmann, T. (2017). Infertile partners’ coping strategies are interrelated – implications for targeted psychological counseling. Geburtshilfe Frauenheilkd, 77(1), 52-58. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5283173

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The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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Getting Back to Work When You’ve Been Depressed

This is an interesting article I found on: www.psychcentral.com

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“I’m still too depressed to find a job,” says one young man. “I lost my car when I was so depressed so how can I even look?”

From a young woman: “I don’t have the energy for a full-time job and I don’t feel ready to be around people.”

And from a middle-aged guy: “Who wants a 50 year old who’s been in the hospital?”

After months of treatment for acute depression, these people are feeling better. They are taking better care of themselves. Their sleep is good. Their medications are working. Therapy has helped them be more successful at using their coping skills.

Treatment now needs to shift from stabilization to getting back into the world and back to work. Easier said than done. They are finding the move from having good intentions to actually getting back out there so daunting they are stuck.

Yes, these people genuinely want to get back to work, but their self-esteem has taken such a hit, they are convinced they will fail. To avoid failure, they find reasons not to try, all of which have a kernel of truth. But not trying – not doing the personal work to manage their fears and overcome practical obstacles – guarantees not getting anywhere.

If you have ever been there, you can relate.

Sadly, acute distress often sets in motion a habit of discouragement and passivity. Being genuinely unable for a time can convince people that there’s something so fundamentally wrong with them that they are, at their core, deficient. The habit of negative self-talk that is a common symptom of depression hangs on — and on.

How can someone shake the feeling that he or she is fundamentally flawed? How can a person push back at depressive thinking and reclaim the self-confidence required to be a working adult? If you are in recovery and feeling stuck, here are a few thoughts drawn from the field of motivational psychology:

It’s up to you: Step one is to accept that, once out of the acute stage of depression, you need to make a renewed commitment to break the habit of inactivity that came with it. Resist the very understandable pull to go back under the covers with the shades drawn. Your therapist can help you figure out how to set reasonable goals and pace yourself for success.

Use your supports: Feeling better doesn’t mean you don’t need your medication. Talk to your prescriber if you want to reduce or discontinue it. Keep going to therapy. Your therapist can continue to provide encouragement and practical guidance while you figure out how to get back to work. Ask friends and family to lend support. Those who care about you do want to help but they may need guidance about what exactly you would find helpful. Set reasonable expectations together: You aren’t completely well but you are getting there.

Do something: The point is to make a start. You may not be ready for a full-on press for employment but you can certainly start to do more to contribute. Do more around the house. Volunteer for a few hours a week. Take a part-time job. Positive actions do build on each other.

Be willing to start small – even at the bottom: It can be really tough to start over. It can feel like a devaluing of your skills and be a blow to your self-esteem. But after being out of the workforce for a time, it may reduce your anxiety to take a job with less status or salary than you once had. Alternatively, think about going back half time if you can as a way to begin. Starting is exactly that — starting. It can give you a needed chance to prove yourself to yourself. If you are returning to a former job, going part-time or taking a step back may be what’s needed if your employer has doubts about whether you can handle it. Even if you don’t stay or advance in that company, you’ll be honing your skills and rebooting your resume.

Attitude matters: In the 1950s, there was an animated cartoon that featured a salesman at someone’s door saying, “You wouldn’t want to buy this gizmo would you?” It’s funny in a cartoon. It’s not funny in life. Getting out of the habit of assuming inadequacy requires at least pretending that you have the energy and ambition to sell yourself. In a blog on Huffington Post, motivational speaker Mike Robbins wrote about the importance of pretending as a route to accomplishment: “…if we act ‘as if’ something is already occurring in our lives (even if it’s not), or act ‘as if’ we know how to do something (even if we don’t) we create the conditions for it to manifest in our life . . .”

Open yourself to learning. Difficult times, including mental illness, even set-backs and failures, can help us go in a new direction, develop more compassion, or better assess what we want and can do. It’s often useful to take a step back to consider what positive knowledge has come out of a challenging experience.

Get ready for luck: Business consultant Idowu Koyenikan has been quoted as saying, “Opportunity does not waste time with those who are unprepared.” Being prepared means working at your talents and skills every day, regardless of whether you feel like it. Practicing what we want to do for work may not seem like it is paying off. It may seem like no one is paying attention. But when opportunity knocks, and it usually does at some point, you’ll be ready to respond.

Don’t wait until you feel better to look for work: Psychologists and motivational speakers will tell you that waiting to feel better before getting back to work isn’t helpful. It works the other way. Getting back into life is what will help you feel good again.

Getting Back to Work When You’ve Been Depressed

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How Trauma and Dissociation Disrupt Your Ability to Form Memories

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“Memories warm you up from the inside. But they also tear you apart.” Haruki Murakami

We all know from popular drama (TV shows, movies, etc.) that traumatic events are often forgotten by the sufferer. People who experience a devastating event such as a car accident, natural disaster, or terror attack often cannot remember the incident. It’s also common not to remember what took place right before or right after the incident. In a similar way, many adults who suffered child abuse have difficulty recalling large chunks of time from childhood. In these cases, problems with memory can continue into adulthood as well, particularly when faced with emotional distress.

Our brain and nervous system have evolved to do spectacular things: we can read, write, make music, and contemplate the meaning of life. But the brain’s first and foremost duty is to keep us alive. When it comes to traumatic events, the part of our brain that protects our physical and emotional well-being takes control. In this process, the parts of the brain that are responsible for higher thought processes, such as forming and retrieving memories, are suppressed.

How the Brain Forms Memories

On a regular stress-free day, memories for facts are made and stored in three steps: acquisition, consolidation, and retrieval.

  • Acquisition occurs through the combination of sensory experience and emotion. The amygdala processes and interprets the experience so it can become a memory.
  • The hippocampus consolidates the experience and sends the information off to the appropriate place for storage (memories are stored all over the brain).
  • It is thought that retrieval of factual memories occurs as a function of the prefrontal cortex. When we want to think of a fact, such as the definition of a word, the prefrontal cortex retrieves it and we remember.

When we are confronted with life-threatening danger, the brain behaves differently. The amygdala sends an emergency signal to the hypothalamus, which in turn activates the fight or flight response. Corticosteroids are then released into the bloodstream in order to prepare the body for action. Blood pressure, heart rate, and respiratory function all increase to provide the body and brain with extra energy and oxygen. Our alertness increases, and our body is ready to move.

When this is happening, the amygdala inhibits the activity of the prefrontal cortex. When faced with danger, this is useful, as the prefrontal cortex operates substantially slower. While it is trying to work out what is happening, our body may be harmed. The quicker, action-oriented part of the brain enables us to respond rapidly and try to avoid danger. We act fast. Later, once we are safe, we have time to think. In respect to memory, the parts of the brain involved in memory formation are shut down when faced with a traumatic experience.

The activation of the fight or flight response prevents the parts of the brain responsible for creating and retrieving memory from functioning effectively. This is why we can forget what occurred around a traumatic event. In the case of ongoing trauma, such as with childhood abuse, ongoing problems with memory and the related process can occur, leading to what is understood as dissociation.

Dissociation and Memories

At the heart of dissociation is memory disruption.At the heart of dissociation is memory disruption. During dissociation, the normally integrated functions of perception, experience, identity, and consciousness are disrupted and do not thread together to form a cohesive sense of self. People with dissociation often experience a sense that things are not real; they can feel disconnected from themselves and the world around them. Their sense of identity can shift, their memories can turn off, and the connection between past and present events can be disrupted.

In understanding the human response to trauma, it is understood that dissociation is a central defense mechanism because it provides a kind of mental escape when physical escape is not possible. This type of defense is often the only kind available for children living in abusive situations. Posttraumatic stress (PTSD) and complex posttraumatic stress (C-PTSD) often go hand in hand with dissociation. In studies investigating the impact of PTSD and memory, researchers have found that people with dissociative symptoms have a greater impairment with both working memory and long-term memory.

Long-Term Impact of Memory Impairment

To understand the long-term impact of memory impairment due to dissociation, we need to look at the context from which it arises. Dissociation occurs as a result of ongoing trauma which is associated with chronic stress. A chronically stressed brain and nervous system have difficulty learning. The hippocampus, critical for memory formation and consolidation, can become damaged from ongoing exposure to stress hormones. Researchers have found that the hippocampus actually shrinks in people who suffer from major depression. In addition to the emotional impact of chronic stress and abuse, difficulties with learning and memory can occur as well.

Implications range from difficulties with academics to reduced on-the-job learning and performance. In terms of survival, the implications are serious, as we all need the ability to prepare for, find, and keep employment. Unfortunately, once a person frees him or herself from an abusive childhood, the effects can follow into adulthood in unexpected ways. A damaged hippocampus and overactive nervous system can make life more difficult than it has to be. Over time, self-esteem and confidence can be negatively impacted as well.

Fortunately, the prognosis of dissociation can be optimistic. Researchers have found treatment with antidepressants can increase hippocampal volume. Talk therapy and other therapeutic approaches that are designed to reduce stress and increase emotional resilience may also help.

If you are experiencing trauma or dissociation, you can find a mental health professional here.

References

  1. Bedard-Gilligan, M., & Zoellner, L. A. (2012). Dissociation and memory fragmentation in post-traumatic stress disorder: An evaluation of the dissociative encoding hypothesis. Memory, 20(3), 277-299. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22348400
  2. Lanius, R. A. (2015). Trauma-related dissociation and altered states of consciousness: A call for clinical, treatment, and neuroscience research. European Journal of Psychotraumatology, 6(1), 27905. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4439425
  3. Nuwer, R. (2013, August 1) Why can’t accident victims remember what happened to them? Smithsonian. Retrieved from https://www.smithsonianmag.com/smart-news/why-cant-accident-victims-remember-what-happened-to-them-21942918
  4. Özdemir, O., Özdemir, P. G., Boysan, M., & Yilmaz, E. (2015). The relationships between dissociation, attention, and memory dysfunction. Nöro Psikiyatri Arşivi, 52(1), 36-41. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5352997
  5. Phelps, E. A. (2004). Human emotion and memory: Interactions of the amygdala and hippocampal complex. Current Opinion in Neurobiology, 14(2), 198-202. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/15082325
  6. Rosack, J. (2003, September 5) Antidepressants may prevent hippocampus from shrinking. Psychiatric News. Retrieved from https://psychnews.psychiatryonline.org/doi/full/10.1176/pn.38.17.0024
  7. Sapolsky, R. M. (2001). Depression, antidepressants, and the shrinking hippocampus. Proceedings of the National Academy of Sciences, 98(22), 12320-12322. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC60045

© Copyright 2019 GoodTherapy.org. All rights reserved. Permission to publish granted by Fabiana Franco, PhD, therapist in New York City, New York

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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How to Deal with Unrequited Love for a Friend

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Unrequited love is part of the human experience. At some point in life, most people will develop romantic feelings for someone who doesn’t feel the same way about them. A study of college students and high school students found unrequited love was 4 times as common as reciprocated, equal love. This type of one-sided love is typically more intense than a passing crush, and it often lasts longer.

Experiencing rejection after you’ve risked telling someone how you feel can cause a great deal of pain. In fact, some research has suggested pain associated with rejection causes brain activity resembles that caused by physical pain. Yet knowing unrequited love happens to most of us may not make that pain any easier to bear.

If you’ve ever loved someone who doesn’t return your feelings, you may have tried to cope by turning to your friends for support. But what happens when the object of unrequited love is a friend? Dealing with the pain of unrequited love may be even harder if you’re already close to the person you’ve fallen for. You might not understand how they can reject you when you’ve shared so much.

Over time, though, you may come to believe it’s more important to treasure the friendship you do have instead of wondering about other possibilities. If you want to sustain the friendship through the challenge of unrequited love, know that it’s often possible to do so.

Keep in mind, though, that it’s important to consider your intentions honestly. If you continue the friendship because you’re secretly hoping they’ll change their mind, you’re not honoring yourself, your friend, or your friendship. In the end, this deception can lead to more pain for you and your friend.

Why Do We Fall for Our Friends?

Developing romantic feelings for friends isn’t uncommon. Love grows over time, and strong friendships that last for years often provide numerous opportunities for intimacy to flourish.

  • Friendship as a gateway to love: Many people believe a strong friendship is an essential foundation of a romantic partnership and prefer to build a friendship with potential partners first. This belief could help create a tendency to see friends as potential love interests.
  • Proximity: People generally spend a lot of time with close friends. Eventually it may become difficult to imagine not seeing a particular friend often.
  • Shared hobbies: Friendships often grow out of shared interests. Having multiple hobbies, interests, or other things in common with one person can make them seem even more like an ideal romantic partner.
  • Mixed signals in a friendship: Some friendships are characterized by flirtatious jokes, physical affection, or other behaviors typical of romantic relationships. Mixed signals won’t “make” you fall in love with someone if attraction isn’t already there. But frequent touching or affectionate nicknames can fan the flames, so to speak, by giving the impression of a mutual interest.
  • Attachment style: A 1998 study found people with an anxious/ambivalent attachment style were more likely to experience unrequited love. Attachment styles have their basis in childhood. If your primary caregiver was unpredictable with affection or met your needs inconsistently, you may grow up unconsciously reenacting that dynamic in adulthood. In other words, you may be more likely to develop romantic attraction for people who are unlikely to return your feelings.

Can Friendship Survive Rejection?

You told your friend how you feel. They apologized and said they just didn’t feel the same way, though they valued your friendship. You agreed the friendship was important and assured them you wanted to stay friends. You feel sad and hurt, but you’ve experienced rejection before and know the feelings will pass in time. In the meantime, how do you deal with frustration and pain while continuing to spend time with your friend as if nothing had happened?

First, it’s important to understand your feelings are normal. It’s normal to grieve, to feel hurt, sad, confused, or angry. But it’s also important not to direct those feelings at your friend. As long as they didn’t lie to you or lead you on, they’re simply being honest about their feelings, just as you were with yours. Your friend can’t help having platonic affection for you, just as you can’t help having romantic affection for your friend.

When your friend doesn’t return your romantic feelings, you both might struggle to deal with the situation. Yet friendships can recover from unrequited love if the situation is addressed with care and maturity. What happens next depends on both you and your friend.

Dealing with Awkwardness

Some friendships may continue but feel slightly different. You might experience some awkward interactions or occasionally feel embarrassed around each other. This isn’t necessarily anyone’s fault—this can happen even if you both truly want to remain friends. It may simply indicate you both need time to recover.

According to research published in Michael Motley’s Studies in Interpersonal Communications, friendships often end after a confession of unrequited love when awkwardness or embarrassment develops. To avoid awkwardness, it may help to avoid bringing up the situation once you’ve agreed you want to stay friends. Instead, move forward from it.

Jealousy is a common emotion, and it’s not inherently harmful. However, it’s important to manage jealousy in safe and healthy ways. Acknowledging what you feel is often a helpful way to start.It may feel more natural to completely avoid your friend, but Motley’s research suggests friends who continue to talk and see each other are more likely to remain friends than those who stay away from each other. This isn’t to say you shouldn’t give yourself some space. Even if you don’t feel you need it, it can help to take time for healing.

Your friend might also need space. If they seem distant after you’ve told them how you feel, consider that they too may need to work through what happened. They may feel sadness or guilt and wonder how to act to prevent hurting you further. Give them some time. If you communicated daily in the past, after a few days you might send a casual message letting them know you’re there when they’re ready. Then wait for them to reach out.

On the other hand, your friendship could also bounce back right away. But this scenario can present other challenges. If your friend has a partner already or begins dating someone before you’ve fully healed from the rejection, you may feel hurt and jealous. You may end up comparing yourself to their partner, and anger or resentment can develop.

Jealousy is a common emotion, and it’s not inherently harmful. However, it’s important to manage jealousy in safe and healthy ways. Acknowledging what you feel is often a helpful way to start. Open communication can also help. If this isn’t possible in your situation, try talking to another close friend or a counselor.

Tips for Moving On

If you’re struggling to get over the rejection after an extended period of time, it may be best to draw back from the friendship while you heal. It may help to interact with your friend in group settings rather than one-on-one. If you find yourself texting or calling them frequently, it may be best to take a break from contacting them.

If your friendship was characterized by affectionate gestures or flirtatiousness in the past, it’s probably better for you both to avoid this behavior, at least until your friendship has healed. Otherwise you might give your friend the impression you aren’t actually okay with remaining friends.

It is common to feel a decreased sense of self-worth or low self-esteem after rejection. Rejection can have an even more significant effect if your friend has been supportive through other instances of heartbreak. Reaching out to other loved ones can help when you’re having trouble separating the pain of rejection from your worth as a person.

Meeting new people can also help. Trying to date when you’re still recovering from rejection may not seem appealing at first. If you’re still feeling heartbroken, you may not feel ready to consider any other potential romantic partners. But dating casually—meeting someone for a short coffee date, for example—can actually help you begin to heal. Even if you plan to keep things casual, a few fun dates can distract you from what you’re feeling. It can also help you realize that you have plenty of romantic options.

Getting Help for Heartbreak

Grief and jealousy often accompany rejection and heartbreak, and it’s not always easy to cope on your own. Therapy is highly recommended when painful emotions interfere with daily life or make it hard to think about anything else. If you’re struggling, we encourage you to reach out to a mental health professional.

It may seem hard to believe, but you will heal in time. A therapist or counselor can support healing by helping you work through what you’re feeling in a productive way. Our therapist directory can help you find a compassionate mental health provider in your area.

References:

  1. Aron, A., Aron, E. N., Allen, J. (1998, August 1). Motivations for unreciprocated love. Personality and Social Psychology Bulletin, 24(8), 787-796. Retrieved from https://journals.sagepub.com/doi/10.1177/0146167298248001
  2. Bringle, R. G., Winnick, T., & Rydell, R. J. (2013). The prevalence and nature of unrequited love. SAGE Open. Retrieved from https://scholarworks.iupui.edu/bitstream/handle/1805/15150/2158244013492160.pdf?sequence=1&isAllowed=y
  3. Davis, S. (2018, October 22). Anxious/ambivalent attachment style: An examination of its causes and how it affects adult relationships. Retrieved from https://cptsdfoundation.org/2018/10/22/anxious-ambivalent-attachment-style-an-examination-of-its-causes-and-how-it-affects-adult-relationships
  4. Morain, C. (2009, January 21). Unrequited love: How to stay friends. Retrieved from https://www.ucdavis.edu/news/unrequited-love-how-stay-friends
  5. Weir, K. (2012). The pain of social rejection. Monitor on Psychology, 43(4). Retrieved from https://www.apa.org/monitor/2012/04/rejection

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Is Your Mood Episode Hypomania or Mania?

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Mania and hypomania are states of elevated mood that occur with bipolar. Mania is the more severe of the two states. Mania only occurs in the context of bipolar type I. Hypomania can occur in both bipolar type I and type II, though people with type II are more likely to experience it.

If you experience symptoms of a mood episode, you may not be sure if you’re having a manic episode or a hypomanic episode. They present with similar symptoms, so it’s not always easy to tell them apart.

But it’s important to seek help, especially if mood episodes make daily life difficult, affect typical function, or put you at risk of harming yourself or others. Untreated bipolar can be serious. Suicide risk for people who have bipolar is about 15 times greater than suicide risk for the general population, according to The Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

If you have symptoms of bipolar, including signs of a manic or hypomanic episode, and aren’t currently working with a counselor, we urge you to reach out. You can begin your search for a qualified therapist using our directory.

Hypomania vs. Mania

The DSM-5 lists the same criteria for manic episodes and hypomanic episodes. Three symptoms (four if your mood is only irritable) are required for diagnosis:

  1. Increased sense of self-esteem, feelings of grandiosity
  2. Feeling energetic despite getting less sleep
  3. Feeling unable to stop talking or be still
  4. Racing thoughts and ideas, jumpiness
  5. Easily distracted
  6. Risky or impulsive behavior
  7. Increased productivity or workflow, including creative work

One key difference between hypomania and mania is how severe or intense symptoms are. By definition, hypomania does not cause significant impairment in daily life and isn’t severe enough that you’ll want to consider going to the hospital.

During a hypomanic episode, your mood is more elevated than usual but not as elevated as a manic mood. You might feel euphoric, charged, and well-rested, even after very little sleep. Some people may experience an irritable mood. A period of hypomania lasts four days or longer, and you’ll experience symptoms most of the time during the episode.

Learning more about your condition can help you manage it more effectively. Mania describes an extremely elevated or irritable mood where symptoms persist most of each day for at least a week. Because mania symptoms can be severe, people around you will likely notice symptoms of mania more readily than symptoms of hypomania.

Mania has more serious implications than hypomania. A manic episode makes it difficult to go about your daily life as you normally would. You could also experience psychotic symptoms such as hallucinations or delusions. Hospitalization is usually recommended if you experience these symptoms or believe you might harm yourself or others.

Dysphoric Mania

Dysphoric mania, also called mixed mania, is now more commonly known as bipolar with mixed features. You can experience mania and hypomania with mixed features. It’s also possible to experience a depressive episode with manic or hypomanic features.

Listed in the DSM-5 as a specifier for bipolar, bipolar with mixed features is diagnosed when you meet diagnostic criteria for a manic episode and also experience symptoms of depression at the same time. These symptoms include:

  1. Dysphoria and depression
  2. Not enjoying or being interested in most (or all) activities
  3. Lack of energy or feeling fatigued
  4. Moving slowly and feeling like your thoughts have slowed, to the point where others can notice
  5. Feelings of guilt and worthlessness
  6. Thoughts of death, suicidal ideation

Experiencing mania and depression simultaneously can cause significant distress. You could feel fatigued and weighed down while experiencing racing thoughts or jumping from one idea to another. Or you could be energized and unable to sleep while feeling disinterested in life events or having thoughts of suicide. Your symptoms might also shift rapidly. For example, you could suddenly make an impulsive or risky decision after a period of feeling empty or hopeless.

This specific type of bipolar has an even higher risk of suicide than bipolar without mixed features. Thus, it’s important to get help right away if you or a loved one has mixed symptoms of mania and depression. Even if mood symptoms are hypomanic, it’s still important to seek professional support since symptoms can rapidly get worse. Tell your health care provider about all of your symptoms, even if some don’t make sense or seem less important.

Treating bipolar with mixed features can be challenging, especially when symptoms are severe, because treating only depression or mania could make the other issue worse. It’s important to get an accurate diagnosis and treat all features at the same time. Treatment may involve a combination of an atypical antipsychotic drug, a mood stabilizer, and therapy.

Hypomania Can Occur Outside of Bipolar

Some people who don’t have bipolar also experience hypomania. Symptoms of hypomania (or mania) may develop after a period of insomnia or sleep deprivation. They might also be an effect of substance abuse.

Some research has shown other potential causes of hypomania. For example, a 2017 study found that traits of borderline personality and attention-deficit hyperactivity (ADHD) in childhood could indicate greater risk for hypomania in young adulthood. Results of a 2018 study suggest teenage use of cannabis (pot) could increase risk for hypomania in young adulthood. It’s important to understand that these risk factors won’t necessarily cause hypomania, but they can contribute to its development if you are at risk.

Getting Help for Hypomania or Mania

If you experience hypomania or mania, you might not always realize your mood has shifted. If you do realize, you may find the state favorable. Mania often leads to euphoric feelings. Many people experiencing hypomania feel more productive, creative, and confident.

However, these positive feelings often have a cost. During hypomania or mania, you could act impulsively or make decisions you later regret. A period of depression is likely to follow a manic or hypomanic state. Even when mood symptoms don’t seem serious, it’s still essential to seek support. Untreated hypomania can increase in severity and may develop into mania.

It’s not possible to prevent hypomania or mania. But lifestyle changes can help lower your chances of having a mood episode. These may include:

  • Getting enough sleep on a regular basis
  • Eating nutritious foods
  • Avoiding caffeine and alcohol
  • Making time for daily physical activity

Learning more about your condition can help you manage it more effectively. For example, keeping track of your moods can help you recognize patterns and avoid triggers. Eventually you may be able to notice warning signs of mania or hypomania. Catching an episode early can help you take steps to reduce its severity.

If you’ve been diagnosed with bipolar or another condition where you experience hypomania or mania, it’s important to carefully follow your treatment plan. Hypomania can often be managed with lifestyle changes and therapy, but mania may be so severe that medication is recommended. If you’re taking medication, it’s important to keep taking it. If you experience side effects that cause distress, work with your care provider to make changes instead of skipping doses.

If you’re experiencing symptoms of mania or hypomania, reach out today. You can begin your search for a trained, compassionate counselor at GoodTherapy.

References:

  1. Akiskal, H. S., & Benazzi, F. (2005). Toward a clinical delineation of dysphoric hypomania – operational and conceptual dilemmas. Bipolar Disorders, 7(5). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16176439
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association.
  3. Bipolar disorder. (2016). National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
  4. Do, E. K., & Mezuk, B. (2013, June 2). Comorbidity between hypomania and substance use disorders. Journal of Affective Disorders, 150(3), 974-980. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4080889
  5. Hu, J., Mansur, R., & McIntyre, R. S. (2014, April 17). Mixed specifier for bipolar mania and depression: Highlights of DSM-5 changes and implications for diagnosis and treatment in primary care. The Primary Care Companion for CNS Disorders, 16(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116292
  6. Hypomania and mania. (2016). Mind. Retrieved from https://www.mind.org.uk/information-support/types-of-mental-health-problems/hypomania-and-mania/#.XHTLoOJKjOQ
  7. Lazzari, C., Shoka, A., Papanna, B., & Rabottini, M. (2018, March 7). Insomnia induced brief manic-psychotic episodes. Sleep Medicine & Disorders: International Journal, 2(2). Retrieved from https://medcraveonline.com/SMDIJ/SMDIJ-02-00038.pdf
  8. Marwaha, S., Winsper, C., Bebbington, P., & Smith, D. (2018, October 17). Cannabis use and hypomania in young people: A prospective analysis. Schizophrenia Bulletin, 44(6), 1267-1274. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29207008
  9. McIntosh, M., Sussmann, J., & Goodwin, G. M. (2010). Mood disorder. In Companion to Psychiatric Studies, 8th ed. London, England: Churchill Livingstone.
  10. Miller, M. C. (2010). Ask the doctor: What is hypomania? Harvard Mental Health Letter. Retrieved from https://www.health.harvard.edu/newsletter_article/what-is-hypomania
  11. Mistry, S., Zammit, S., Price, V. E., Jones, H. J., & Smith, D. J. (2017, October 15). Borderline personality and attention-deficit hyperactivity traits in childhood are associated with hypomanic features in early adulthood. Journal of Affective Disorders, 221, 246-253. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28662455
  12. Richards, P. (n.d.). What is dysphoric mania? Retrieved from https://www.dualdiagnosis.org/mental-health-and-addiction/what-is-dysphoric-mania
  13. Tohen, M. (2018). Expert Q & A: Bipolar disorder. American Psychiatric Association. Retrieved from https://www.psychiatry.org/patients-families/bipolar-disorders/expert-q-and-a

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Can Nonbinary People Experience Gender Dysphoria?

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Gender nonbinary people—who often call themselves enby—do not identify with the male-female gender binary. There are a wide range of gender expressions and identities under the enby umbrella, including agender, gender outlaw, genderqueer, and genderfluid. Gender nonbinary people are not a monolith. Some see gender as a problematic concept to be rejected and fought. Others do not object to gender yet feel they personally do not fit into a specific gender identity. Many enbies identify as trans.

Trans people often report a feeling of gender dysphoria. This is stress, anxiety, and frustration associated with being labeled as a gender with which one does not identify. For example, a trans boy whose parents force him to wear dresses may feel intense gender dysphoria that affects his self-esteem and mental health. Gender dysphoria is highly prevalent among people who are not allowed to express their gender identity.

A person does not have to identify with either the male or female gender to experience dysphoria. Enbies can feel dysphoria, too.

What Gender Dysphoria Looks Like in Nonbinary People

Some of the DSM-5’s diagnostic criteria for gender dysphoria are inclusive of enbies. Common symptoms include:

  • Inconsistencies between one’s lived gender identity and assigned gender identity
  • Wanting to be treated as a member of a different or alternative gender
  • Dislike of or frustration with gender signifiers

However, the DSM-5 also focuses heavily on gender dysphoria as the desire to be the “opposite” gender. Because gender nonbinary people do not wish to be the “opposite” gender, they may not feel included in traditional diagnostic criteria.

Gender dysphoria in nonbinary people may manifest in slightly different ways, including:

  • A shifting attitude toward gender signifiers. For example, a person might dislike their breasts one day but feel fine with them on another day.
  • Feeling troubled by some gender signifiers but not others. For instance, a person might want to be rid of their chest hair but like their penis.
  • Feeling pressured to defend their gender identity. Some enbies report being told that they are adopting a trend, not expressing their identity and lived experience.
  • Facing pressure to conform to multiple gender roles. Some enbies present in androgynous ways or embrace signifiers of two or more gender identities. They may face pressure to conform to conflicting gender identities.

Gender Dysphoria in Nonbinary Youth

Binary trans people—those who identify as male or female—and enbies generally report developing gender dysphoria around the same time. For most people dysphoria sets in around puberty, getting progressively more intense as puberty changes the body.

John Sovec, LMFT, a California therapist who works with LGBT clients, says, “Gender dysphoria is often discussed in the treatment of adult nonbinary clients, but it is important to also note its influence on the development of nonbinary adolescents. When you reflect on the pressures to fit in that already exist in a teen’s world, imagine the distress and anxiety that can manifest when gender dysphoria is present.

Adolescents are already experiencing the myriad changes that are occurring during the onset of puberty, and these changes in the body can magnify the feelings of dysphoria. “Adolescents are already experiencing the myriad changes that are occurring during the onset of puberty, and these changes in the body can magnify the feelings of dysphoria. What was once a generalized feeling of being uncomfortable with their physical sex and/or gender role can be heightened with the onset of puberty and manifest in feelings of depression, anxiety, shame, and self-hatred.

“It is important to assist adolescents in establishing their identity by actively exploring identity-related choices and encouraging identity development in their affirmed identity in a safe and supportive environment.”

Research suggests enbies face significant difficulty accessing gender-affirming health care. This may be because traditional notions of gender dysphoria take the gender binary for granted. A 2018 study of more than 800 trans youth found that just 13% of nonbinary youth sought hormone therapy, compared to 52% of binary trans youth. They were also more likely report encountering barriers to accessing hormone therapy.

The study also found that older enbies (aged 19-25) were significantly more likely than older binary youth to avoid necessary health care. However, younger enbies and binary trans people (aged 14-18) saw no differences in foregoing primary health care. Cultural shifts in attitudes regarding gender may play a role in this. As awareness of enbies increases, so too may the willingness of younger enbies to identify as nonbinary and demand gender-affirming health care.

When Nonbinary People Seek Treatment for Gender Dysphoria

Gender nonbinary people are sometimes reluctant to seek health care for gender dysphoria, as well as for unrelated issues. This may be because doctors commonly believe inaccurate stereotypes about enbies or are unaware of their existence.

A 2017 study of enbies seeking health care found that they often feel misunderstood, stigmatized, disrespected, or pigeonholed into the incorrect gender. Even when enbies seek care at gender-affirming clinics, they may encounter clinicians who are accustomed to relying on a strict gender binary. According to the study, nonbinary people may feel pressure to conform to the gender binary in health care settings.

In some cases, a health care provider may trigger feelings of dysphoria. For example, a doctor might call a chest binder a bra. This can deter enbies from seeking appropriate medical care and make it more difficult to access hormonal therapies and other treatments for dysphoria.

Research consistently shows significant health care disparities between trans and cis individuals. There may be similar disparities between binary and nonbinary trans people. This could affect access to all forms of health care, including potentially life-saving treatments that are unrelated to gender.

How Therapy Can Help Nonbinary People with Gender Dysphoria

The right therapist can provide a supportive, affirming environment for enbies with gender dysphoria. In therapy, a nonbinary person can discuss their feelings about gender in general, as well as their own gender identity. Therapy that supports these feelings instead of stigmatizing them can be a powerful antidote to the pressure many nonbinary people face to conform to a gender binary.

A therapist may also:

  • Support a nonbinary person in accessing dysphoria treatment options, finding a supportive health care provider, and choosing the treatment most consistent with their identity.
  • Help a nonbinary person discuss their identity with friends or family. Not all nonbinary people present as obviously nonbinary. They may need help coming out, discussing their identity, and educating loved ones about what it means to be nonbinary.
  • Discuss issues such as self-esteem, body image, depression, and anxiety.
  • Help a nonbinary person understand that being nonbinary is not a mental health condition or a personal failing.

In therapy, a nonbinary person can better understand their own identity, become a stronger advocate for their needs, and tackle internalized dysphoria and transphobia.

References:

  1. Clark, B. A., Veale, J. F., Townsend, M., Frohard-Dourlent, H., & Saewyc, E. (2018). Non-binary youth: Access to gender-affirming primary health care. International Journal of Transgenderism, 19(2), 158-169. Retrieved from https://www.tandfonline.com/doi/abs/10.1080/15532739.2017.1394954
  2. LGBTQ 101: terminology and tips. (n.d.) Retrieved from https://www.kenyon.edu/about-kenyon/diversity-at-kenyon/lgbtq-plus/terminology
  3. Lykens, J. E., Leblanc, A. J., & Bockting, W. O. (2018). Healthcare experiences among young adults who identify as genderqueer or nonbinary. LGBT Health, 5(3), 191-196. Retrieved from https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC6016091&blobtype=pdf
  4. Mamone, T. (2017, October 19). Yes, non-binary people experience gender dysphoria. Retrieved from https://theestablishment.co/yes-non-binary-people-experience-gender-dysphoria-c056eb3df3c9
  5. Providing affirmative care for patients with non-binary gender identities. (n.d.). Retrieved from https://www.lgbthealtheducation.org/publication/providing-affirmative-care-patients-non-binary-gender-identities

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Counselling in Hebden Bridge

This Is When You Think You’re Crazy…

This is an interesting article I found on: www.goodtherapy.org

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(The following is an excerpt from Sarah Swenson’s upcoming book, COACHING SUPPORT FOR NEURODIVERSE COUPLES.)

You have learned how to phrase things in such a way that you are least likely to get blamed or criticized. You have learned to distinguish with fine skills the difference between when it’s okay to speak and when it’s better to wait until another time.

You also know when the only thing you can do is keep your mouth closed. Sometimes, when you do that, tears burn down your cheek.

That’s when you hear, “What’s the matter now?”

And what do you actually hear? You hear the word now. That’s all.

Because, once again, your partner has read your facial expression, come to a conclusion, and judged you incorrectly. Judged you and condemned you with that critical tone and that final word now, as if your emotional life were a continuous saga of assaults against them.

This is when you feel crazy.

You feel crazy, because you know there is no satisfactory answer to this question. If you venture forth into describing your hesitation to bring up a topic, you risk being told you’re being ridiculous. If you actually make an effort to explain the thoughts or feelings you initially resisted sharing and which brought on the tears in the first place, your partner’s critical reaction tells you immediately that you were being smarter when you decided, in the beginning, to keep them to yourself. By giving them voice, you have created precisely the situation you feared: your partner not only doesn’t understand what you are talking about, but also dismisses your feelings, and on top of that, is angered or dismayed by the fact that you had to cry in order to get their attention—which was a pretty pathetic cry for attention at that.

Yes, this is when you feel crazy.

You are caught in a double bind.

You can speak your mind, and you will be judged or criticized.

You can remain quiet, and you will be judged or criticized.

You cannot win.

You’re probably not even sure what normal looks like anymore. You think it may have something to do with getting what you want.

I’d like to suggest that there’s more to it than that.

It has more to do with getting what you need.

Please believe that you are not asking for the moon or the stars when you are asking your partner to listen to you. Please believe that you have the right to ask for this. Please believe that you are hurting yourself by thinking you should expect anything less.Within an intimate relationship, by virtue of the agreement into which you both freely entered, you have a right to expect that your partner will respect you enough to listen to you, to hear you, and to care enough to have your back. To respond to your emotions. To listen to your concerns. To discuss things that are on your mind.

These are not just things you want.

These are essential components of your mental health.

When they are missing in a relationship, and especially when they are replaced with blaming, judgment, or criticism—when you get the message that you don’t even have a right to have such an opinion or that you are out of your mind to think such a thing—those are the times of the deepest pain. Those are the moments of the greatest loneliness. Those are the times when your self-esteem is at its greatest risk for erosion.

Please believe that you are not asking for the moon or the stars when you are asking your partner to listen to you. Please believe that you have the right to ask for this. Please believe that you are hurting yourself by thinking you should expect anything less.

You are not crazy to expect your partner to respect and love you. That’s what you were promised when you entered into this relationship.

It is still valid to believe.

If your partner is not holding up their side of the agreement, that is not a reflection of your self-worth. It is a reflection of their inability or unwillingness to give the person who loves them what they need.

Changes are possible to the extent that your partner is willing and able to enter into conversation that cuts to the root of your not being heard. This may require the help of a counselor. If you are fortunate, your partner will agree to take the steps toward healing.

I leave you with one more thought: you are not crazy. In fact, you’d be crazy to believe you deserved anything less than respect and love from your partner. Unfortunately, emotionally unavailable individuals often convince their partners that they deserve exactly what they get: nothing.

© Copyright 2019 GoodTherapy.org. All rights reserved.

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Avoidant Personality and Social Anxiety: What’s the Difference?

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The silhouette of a person standing in a field of yellow mustard flowers.Social anxiety and avoidant personality disorder share some common features, but they are separate mental health conditions. Because the two conditions appear similar in many ways, it’s not uncommon for people to mistake one for the other.

Sometimes simply getting help is more important than having a specific diagnosis. But some people also find it beneficial to know what’s affecting them. In some cases, the best approach to treatment differs for separate mental health issues, so misdiagnosis can affect treatment and make it harder for a person to improve.

Social anxiety, or social phobia, is a specific type of anxiety characterized by a fear of social situations. People with social anxiety worry about embarrassing themselves in public or doing something that will cause others to judge them negatively. It’s fairly common for people to feel nervous about doing something embarrassing in public, but the feelings of fear and anxiety that occur with social phobia can become so distressing they cause difficulty at work, school, or other parts of daily life. About 75% of people with social anxiety are between the ages of 8 and 15 when diagnosed.

Avoidant personality disorder is a cluster C personality disorder. Personality disorders are a specific kind of mental health issue where patterns of thought and behavior affect daily life, and those with personality disorders often experience difficulty in professional and personal life because they have a hard time understanding other people and common situations.

Levana Slabodnick, LISW-S, a therapist in Columbus, Ohio, notices one difference between social anxiety and avoidant personality may lie in how a person views their own experience. She explains, “A fundamental difference between social anxiety disorder and avoidant personality disorder relates to how the sufferer perceives their own pain. Those with anxiety understand on a basic level that their anxiety is irrational and that the world doesn’t judge them as harshly as they judge themselves. Those with APD, on the other hand, lack this insight. They hold deep rooted feelings of insecurity and worthlessness that they believe to be factual.”

People with avoidant personality often feel socially awkward and inferior to others. They tend to be very sensitive to criticism and rejection and often avoid making friends or participating in social events unless they are sure of their welcome. Feelings of shame or self-loathing are more strongly associated with avoidant personality than social anxiety. This condition is not often diagnosed in children, though it often develops in childhood.

Avoidant Personality Disorder vs. Social Anxiety

Social anxiety and avoidant personality share an intense fear of being embarrassed or judged in social situations. People might describe a person with either condition as shy, timid, awkward, or fearful.

Fear associated with these conditions can present in many ways, such as:

  • Avoiding social situations
  • Avoiding interactions with strangers
  • Low self-esteem
  • Shyness or timidity around other people
  • Isolation from others or complete social withdrawal

Debate over whether avoidant personality is a more severe type of social anxiety exists among mental health experts. According to the fifth edition of the DSM, these issues are often diagnosed together and can overlap to the point where they might seem like different presentations of the same concern. But while avoidant personality typically involves patterns of avoidance in most or all areas of life, social anxiety may only involve avoidance in a few specific situations. The DSM continues to categorize them separately.

Debate over whether avoidant personality is a more severe type of social anxiety exists among mental health experts.

The two issues continue to share similarities when it comes to risk factors. Genetic and environmental factors can contribute to the development of either condition. Avoidance can be a learned response. People might begin to avoid social situations after a negative experience, for example. Being shy as a child can also increase the likelihood a person will go on to develop social anxiety or avoidant personality, though being shy does not necessarily mean a person will develop either issue for certain.

Experiencing abuse, trauma, bullying, or other negative events in childhood can increase risk for both social anxiety and avoidant personality. But neglect, particularly physical neglect, is a significant risk factor for avoidant personality. A 2015 study comparing the two conditions found that having disinterested caregivers, feeling rejected by caregivers, or not having enough affection in childhood was more common in people with avoidant personality.

Certain risk factors do differ between the two conditions:

  • Some research has suggested avoidant personality may be more likely when someone’s physical appearance changes after illness.
  • Research suggests brain structure may contribute to anxiety. If your amygdala, which is believed to help regulate your response to fear, is very active, you may experience greater anxiety in certain situations than other people do.
  • Having a parent or sibling with social anxiety makes it 2-6 times more likely a person will develop the condition, according to the DSM-5.

Should I Get Treatment for Social Anxiety or APD?

Therapy is generally recommended for both avoidant personality and social anxiety. Only a mental health professional can diagnose mental health issues. If you think you might have symptoms of either avoidant personality or social anxiety, making an appointment with a qualified therapist or counselor can be a good place to start.

Letting any potential counselors know your particular symptoms and describing your specific experience can help them decide whether they’re qualified to help you. Not every therapist has experience treating every mental health condition, but an ethical therapist will always let you know if they think another therapist might be more helpful.

Social anxiety is often treated with cognitive behavioral therapy (CBT). This therapy helps you identify thoughts that cause distress and affect you negatively. Once you identify them, you learn how to change them. You can do CBT alone, but some people find group therapy helpful.

Exposure-based CBT is a specific approach to CBT where you slowly expose yourself to feared situations. This approach often involves skills practice or role-playing techniques, both of which can help people get more comfortable interacting with others in the safe space of therapy.

According to a 2015 study, performing random acts of kindness for others led to a decrease in symptoms of social anxiety in study participants after 4 weeks.

While therapy can have great benefit, sometimes social anxiety doesn’t improve right away. If you are working with a counselor and still experience significant difficulty in your daily life, a psychiatrist may recommend medication, such as:

Anxiety medication can help relieve some symptoms of social anxiety, but it’s a good idea to continue with therapy at the same time, as therapy helps you learn how to cope with what you’re experiencing. This can have a more lasting effect on your symptoms.

Many people believe personality disorders are not treatable, but this isn’t the case. They can be difficult to treat, especially if you’ve had symptoms for a long time. But therapy can still be very helpful. People with avoidant personality often seek treatment when they experience loneliness and distress as a result of being unable to participate in social events.

Research has shown people with avoidant personality may do better in therapy if they have the support of family members.

Any kind of talking therapy can be helpful for avoidant personality. CBT is commonly used to treat this condition, but other helpful approaches include family and group therapy. Research has shown people with avoidant personality may do better in therapy if they have the support of family members. Group therapy can help people learn how to develop relationship and communication skills in a safe space, and it’s often recommended for treating personality disorders.

There’s no specific medication used to treat avoidant personality. However, antidepressants and anti-anxiety medications may help relieve some severe symptoms.

Conclusion

Social anxiety and avoidant personality have some similarities, and some approaches to treatment may be similar. Regardless of which condition you have, therapy can help. It’s important to reach out for help if you’re struggling with social situations. When social anxiety or avoidant personality go untreated, complications like depression, isolation, and substance abuse can develop. Some people may experience significant loneliness and distress.

Talking to a therapist can help you get a diagnosis. But you’ll also begin to learn ways to cope with the feelings you experience and explore methods of overcoming these feelings. Therapy can help you become more used to the company of others. In time, you may find it easier to participate in social situations.

If you need help finding a counselor in your area, our therapist directory is a good place to start. Remember, you aren’t alone!

References:

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association. 103-110.
  2. Anxiety disorders. (2017, December 15). Cleveland Clinic. Retrieved from https://my.clevelandclinic.org/health/diseases/9536-anxiety-disorders
  3. Avoidant personality disorder. (2017, November 20). Cleveland Clinic. Retrieved from https://my.clevelandclinic.org/health/diseases/9761-avoidant-personality-disorder
  4. Eikenaes, I., Egeland, J., Hummelen, B., & Wilberg, T. (2015, March 27). Avoidant personality disorder versus social phobia: The significance of childhood neglect. PLoS One, 10(5). doi: 10.1371/journal.pone.0122846
  5. Kvarnstorm, E. (2016, April 6). Avoidant personality disorder goes beyond social anxiety. Bridges to Recovery. Retrieved from https://www.bridgestorecovery.com/blog/avoidant-personality-disorder-goes-beyond-social-anxiety
  6. Lampe, L. (2016). Avoidant personality disorder as a social anxiety phenotype: Risk factors, associations and treatment. Current Opinion in Psychiatry, 29(1), 64-69. doi: 10.1097/YCO.0000000000000211
  7. Personality disorders. (2016, September 23). Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/personality-disorders/symptoms-causes/syc-20354463
  8. Smith, K. (2018, November 19). Avoidant personality disorder. Retrieved from https://www.psycom.net/avoidant-personality-disorder
  9. Social anxiety disorder (social phobia). (2017, August 29). Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/social-anxiety-disorder/symptoms-causes/syc-20353561
  10. Trew, J. L., & Alden, L. E. (2015, June 5). Kindness reduces avoidance goals in socially anxious people. Motivation and Emotion, 39(6), 892–907. Retrieved from https://link.springer.com/article/10.1007/s11031-015-9499-5

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