Malignant Self Love - Narcissism Revisited 100 psychological articles and essays available by the same author! http://www.geocities.com/vaksam/faq1.html This letter constitutes a permission to reprint or mirror any and all of the materials mentioned or linked to herein subject to appropriate credit and linkback. The Sample Articles (please scroll down to review them): I. Letter about Trust II. Taming the Beast: Pathological Narcissism and the Quality of Life III. Psychology as Storytelling IV. Eating Disorders and Personality Disorders Author: Sam Vaknin Contact Info: [email protected]; [email protected] AUTHOR BIO: Sam Vaknin has a combined doctorate in Physics and Philosophy. He is an economic and political columnist in many periodicals in a few countries and a published and awarded author of short fiction and reference books in Hebrew, English and Macedonian in Israel, Macedonia and the Czech Republic. He has collaborated with Israeli psychologists and criminologists in the study of personality disorders and is the author of "Malignant Self Love - Narcissism Revisited" (available from Barnes and Noble and, as an e-book, from Booklocker, eBooksonthe.net, SoftLock, MightyWords and from CyberRead). He is the editor of the Mental Health Disorders category in the Open Directory Project and the editor of the Narcissistic Personality Disorder topic in Suite101. He is serving currently as the Economic Advisor to the Government of Macedonia. His new book "After the Rain - How the West Lost the East" is available from Barnes and Noble and, as an e-book, from Booklocker, eBooksonthe.net, MightyWords, SoftLock and from CyberRead. Full CV is available at: http://www.geocities.com/vaksam/cv.html Web addresses: http://narcissism.cjb.net , http://personality.cjb.net , http://musings.cjb.net , http://economics.cjb.net, http://www.ce-review.org/authorarchives/vaknin_archive/vaknin_main.html Email address: [email protected] or [email protected] A Letter about Trust By: Dr. Sam Vaknin The Narcissistic condition emanates from a seismic break of trust, a tectonic shift of what should have been a healthy relationship with his "primary objects" and the transformation of his self into the subject of love. Some of these bad feelings are the result of deeply entrenched misunderstandings regarding the nature of trust and the continuous act of trusting. For millions of years nature embedded in us the notion that the past can teach us a lot about the future. This is very useful for survival. And it is also mostly true with inanimate objects. With humans the story is somewhat different: it is reasonable to learn from someone's past behaviour about his future behaviour (even though this proves erroneous most of the time). But it is mistaken to learn from someone's behaviour about other people's. Actually, most psychotherapy is nothing but the effort to disentangle past from present, to teach the patient that the past is gone and has no reign over him anymore, unless the patient lets it to. Our natural tendency is to trust, because we trust our parents. It feels good to really trust. It is also an essential component of love and an important test. Love without trust is dependence masquerading as love. We must trust, it is almost biological. Most of the time, we do trust. We trust the Universe to behave itself according to the laws of physics, our army not to go mad and shoot us all, our nearest and dearest not to betray us. When trust is broken, the feeling is that a part of us dies, is hollowed out. Not to trust is abnormal and is the natural result of bitter or even traumatic life experiences. Mistrust or distrust are induced not by our own thoughts, nor by some device or machination of ours - but by life's sad circumstances. To continue not to trust is to reward the people who wronged us and made us distrustful in the first place. These people have long abandoned us and still they have a great, malignant, influence on our lives. This is the irony of the lack of trust. So, some of us prefer not to experience this sinking feeling: not to trust and not to be disappointed. This is both a fallacy and a folly. Trusting releases enormous amounts of mental energy, which could be better invested elsewhere. Naturally trust - like knives - can be dangerous to your health if used improperly. You have to know WHO to trust, you have to know HOW to trust and you have to know HOW to CONFIRM the existence of a functioning trust. First let me state clearly: people often disappoint and are not worthy of trust. They are often arbitrary, treacherous and vicious, or, worse, offhanded. You have to select your targets carefully. He who has the most common interests with you, who is investing in you for the long term, who is incapable of breaching trust ("a good person"), who doesn't have much to gain from betraying you - is not likely to mislead you. These people you can trust. You should not trust indiscriminately. No one is completely trustworthy in all areas of life. Most often our disappointments stem from our inability to separate one area of life from another. A person could be sexually loyal - but an utter danger when it comes to money (for instance, a gambler). Or a good, reliable father - but a womanizer. You can trust someone to carry out some types of activities - but not others, because they are more complicated, more boring, or do not appeal to his conscience. We should distinguish between people and allocate our trust accordingly. Then, we are not likely to be disappointed. We should not trust with reservations - this is the kind of "trust" that is common in business and among criminals and its source is rational. Game Theory in Mathematics deals with questions of calculated trust. We should trust wholeheartedly but know who to trust in which field. Then we will be rarely disappointed. As opposed to popular opinion, trust must be put to the test, lest it goes stale and staid. We are all somewhat paranoid. The world around us is so complex, so inexplicable, so overwhelming - that we find refuge in the invention of superior forces. Some forces are benign (God) - some arbitrarily conspiratorial in nature. There must be an explanation, we feel, to all these amazing coincidences, to us, to events. This tendency to introduce external powers and ulterior motives permeates human relations, as well. We gradually grow suspicious, inadvertently hunt for clues of infidelity or worse, masochistically relieved, even happy when we find some. The more tested, the stronger our pattern-prone brain will embrace the trust established. Constantly in a precarious balance, our brain needs and devours reinforcements. Such testing should not be explicit - it should be deduced from circumstances. My husband could easily have had a mistress or my partner could easily have stolen our money - and, behold, they haven't. Trust is based on the ability to predict the future. It is not so much the act of betrayal that we react to - as it is the feeling that the very foundations of the world are shaking, that it is no longer safe because it is no longer predictable. These are the throes of death of one theory - and the birth of another, as yet untested. Here is another important lesson: whatever the act of betrayal (with the exception of grave criminal corporeal acts) - it is always limited, confined, negligible. Naturally, we tend to exaggerate the importance of the event. This serves a double purpose: indirectly it aggrandizes us. If we were "worthy" of such an unprecedented, unheard of, major betrayal - we must be worthy, period. The magnitude of the betrayal reflects on us and reestablishes the fragile balance of powers between us and the universe. The second purpose is simply to gain sympathy and empathy - mainly from ourselves, but also from our human environment. Catastrophes are a dozen a dime and in today's world it is difficult to provoke anyone to regard your personal disaster as anything exceptional. Amplifying the event has, therefore, some very utilitarian purposes. But, finally, the emotional lie is absorbed by the very liar and poisons his mental circulation. Re-proportioning, reordering and putting the event in perspective will go a long way towards the commencement of a healing process. No betrayal stamps the world irreversibly or eliminates other possibilities, opportunities, chances and people. Time goes on, people meet and part, lovers quarrel and make love, dear ones live and die. It is the very essence of time that it erodes us all to the finest dust. Our only weapon - however crude and maybe unwise - against this unstoppable process is to trust each other. Taming the Beast: Pathological Narcissism and the Quality of Life By: Dr. Sam Vaknin Part 1 Many textbooks (and many patients ...) claim that the psychodynamic therapies when applied to personality disorders are ineffective. Functional (cognitive, behavioral) treatments should be preferred in certain cases and regarding certain aspects of the disorder. To a Narcissist, I would recommend a beavioral-cognitive-functional and less protracted type of therapy. (1) Know and accept thyself. This is what you are. You are highly intelligent. You are very inquisitive. You are a Narcissist. These are facts. Narcissism is an adaptive mechanism. It is dysfunctional - but it saves you from a LOT MORE dysfunction or even a-function. Make a list: what does it mean to be a Narcissist in your specific case? What are your typical behaviour patterns? Which types of behaviour are counterproductive, irritating, self-defeating or self-destructive? Which are productive, constructive and should be enhanced DESPITE their pathological origin? (2) Decide to suppress the first and to promote the latter. Construct lists of self-punishments, negative feedback and negative reinforcements. Impose them upon yourself when you exhibit one of the behaviours in the first list. Make a list of prizes, little indulgences, positive feedbacks and positive reinforcements. Use them to reward yourself when you display a behaviour of the second kind. (3) Keep doing this with the express intent of conditioning yourself. Be objective, predictable and just in the administration of both punishments and awards, positive reinforcements and feedback and negative ones. Learn to trust your "inner court". Constrain the sadistic, immature and ideal parts of your personality (known as "superego" in psychoanalytic parlance) by the application of a uniform codex, a set of immutable and invariably applied rules. (4) Once sufficiently conditioned, monitor yourself incessantly. Narcissism is sneaky and it possesses all your resources because it is you. It is intelligent because you are. Beware and never lose control. With time this onerous regime will become a second habit and supplant the Narcissistic (pathological) superstructure. All the above can be amply summed by suggesting to you to become your own parent. This is what parents do and the process is called "education" or "socialization". If your particular path to the adoption of this course is a particular therapy - go ahead. As a metaphor, a narrative, no therapeutic approach is better or worse than any other Part 2 In the previous part we discussed the healing prospects of a Narcissist. yet, how can a False Self be anything but false? How can anyone on a permanent diet of reflections ever see true objects? How can the Narcissist - whose essence is the devouring of meaningful others and their transformation into meaningless and other - ever love? The answer is: discipline, decisiveness, clear targets, conditioning, justice. The Narcissist is the product of unjust, capricious and cruel treatment. He is the finished product of a production line of self recrimination, guilt and fear. He needs to take the antidote to counter the Narcissistic poison. Unfortunately, there is no drug I know of which can ameliorate pathological Narcissism. Confronting one s parents and childhood is a good idea if the Narcissist feels that he is ready for it. Can he take it? Can he cope with new truths, however painful? The Narcissist must be careful. This is playing with fire. But if he feels confident that there is nothing that can be revealed to him in such a confrontation that he cannot withstand - it is a good and wise move in the right direction. My advice to the Narcissist would then be: just dedicate a lot of time to rehearsing it and define well what is it exactly that you want to ask. Do not turn this into a monodrama, group dynamics or trial. Ask so that you shall be answered. Don't try to prove anything, to vindicate, to avenge, to take revenge, to win, to exculpate. Talk as you would with yourself. Do not try to sound professional, mature, intelligent, knowledgeable and distanced. There is no "problem to solve" - just a condition to adjust yourself to. Think about it as diabetes. At the risk of sounding heartless, I will make three concluding comments: (a) The Narcissist should take life in general and yourself, in particular, much less seriously. Being immersed in one's self and in one's condition is never the right recipe to functionality, let alone happiness. The world is a comic, absurd place. It is indeed a theater to be enjoyed. It is full of colors and smells and sounds to be treasured and cherished. It is varied and it accommodates and tolerates everyone and everything, even Narcissists. (b) The Narcissist should regard your condition as an advantage. I am NPD. So I write about it. My advice to the Narcissist would be: ask yourself what can you do with it? In Chinese the ideogram for "crisis" and "opportunity" is one and the same. Why don't you transform the curse in your life - into a blessing in other people's lives? Why don't you tell them your story, warn them, teach them how to avoid the same pitfalls, how to cope with the damage? Why don't you do all this in a more institutionalized manner? For instance, you can start a discussion group on the internet. You can establish " Narcissists Anonymous" in some community shelter (despite your temporary incapacity). You can open a correspondence network, a help center for women in your condition ... the possibilities are endless. And it will instill in you a regained sense of self worth, a purpose, self-confidence and reassurance. It is only by helping others that we can help ourselves. This is, of course, a suggestion - not a prescription. But it demonstrates the ways in which you can derive power from adversity. (c) It is easy for the Narcissist to think about Pathological Narcissism as the source of all that is evil and wrong in his life. Narcissism is a catchall phrase, a conceptual scapegoat, an evil seed. It conveniently encapsulates the predicament of the Narcissist. It introduces logic and causal relations into his baffled, tumultuous world. But this is a trap. The human psyche is too complex to be captured by a single, all-encompassing explanation, however convincing. The road to self-help and self-betterment passes through numerous junctions and stations. Narcissism is the first and the foremost. But there are many other participants in the complex dynamics that is the soul of the Narcissist. The Narcissist should take responsibility for his life and not relegate it to some hitherto rather obscure psychodynamic concept. This is the first and most important step to healing. REFRRENCES: (1) Freud S. - Three Essays on the Theory of Sexuality (1905) - Standard Edition of the Complete Psychological Works of Sigmund Freud - Vol. 7 - Hogarth Press, 1964 (2) Horowitz M.J. - Sliding Meanings: A defense against threat in narcissistic personalities - International Journal of Psychoanalytic Psychotherapy - 1975;4:167 (3) Kernberg O. - Borderline Conditions and Pathological Narcissism - Jason Aronson, 1975 (4) Kohut M. - The Analysis of the Self - International Universities Press, 1971 Psychology as Storytelling By: Dr. Sam Vaknin Storytelling has been with us since the days of campfire and besieging wild animals. It served a number of important functions: amelioration of fears, communication of vital information (regarding survival tactics and the characteristics of animals, for instance), the satisfaction of a sense of order (justice), the development of the ability to hypothesize, predict and introduce theories and so on. We are all endowed with a sense of wonder. The world around us in inexplicable, baffling in its diversity and myriad forms. We experience an urge to organize it, to "explain the wonder away", to order it in order to know what to expect next (predict). These are the essentials of survival. But while we have been successful at imposing our mind's structures on the outside world - we have been much less successful when we tried to cope with our internal universe. The relationship between the structure and functioning of our (ephemeral) mind, the structure and modes of operation of our (physical) brain and the structure and conduct of the outside world have been the matter of heated debate for millennia. Broadly speaking, there were (and still are) two ways of treating it: There were those who, for all practical purposes, identified the origin (brain) with its product (mind). Some of them postulated the existence of a lattice of preconceived, born categorical knowledge about the universe - the vessels into which we pour our experience and which mold it. Others have regarded the mind as a black box. While it was possible in principle to know its input and output, it was impossible, again in principle, to understand its internal functioning and management of information. Pavlov coined the word "conditioning", Watson adopted it and invented "behaviorism", Skinner came up with "reinforcement". But all ignored the psychophysical question: what IS the mind and HOW is it linked to the brain? The other camp was more "scientific" and "positivist". It speculated that the mind (whether a physical entity, an epiphenomenon, a non-physical principle of organization, or the result of introspection) - had a structure and a limited set of functions. They argued that a "user's manual" could be composed, replete with engineering and maintenance instructions. The most prominent of these "psychodynamists" was, of course, Freud. Though his disciples (Adler, Horney, the object-relations lot) diverged wildly from his initial theories - they all shared his belief in the need to "scientify" and objectify psychology. Freud - a medical doctor by profession (Neurologist) and Bleuler before him - came with a theory regarding the structure of the mind and its mechanics: (suppressed) energies and (reactive) forces. Flow charts were provided together with a method of analysis, a mathematical physics of the mind. But this was a mirage. An essential part was missing: the ability to test the hypotheses, which derived from these "theories". They were all very convincing, though, and, surprisingly, had great explanatory power. But - non-verifiable and non-falsifiable as they were - they could not be deemed to possess the redeeming features of a scientific theory. Psychological theories of the mind are metaphors of the mind. They are fables and myths, narratives, stories, hypotheses, conjunctures. They play (exceedingly) important roles in the psychotherapeutic setting - but not in the laboratory. Their form is artistic, not rigorous, not testable, less structured than theories in the natural sciences. The language used is polyvalent, rich, effusive, and fuzzy - in short, metaphorical. They are suffused with value judgements, preferences, fears, post facto and ad hoc constructions. None of this has methodological, systematic, analytic and predictive merits. Still, the theories in psychology are powerful instruments, admirable constructs of the mind. As such, they are bound to satisfy some needs. Their very existence proves it. The attainment of peace of mind is a need, which was neglected by Maslow in his famous rendition. People will sacrifice material wealth and welfare, will forgo temptations, will ignore opportunities, and will put their lives in danger - just to reach this bliss of wholeness and completeness. There is, in other words, a preference of inner equilibrium over homeostasis. It is the fulfillment of this overriding need that psychological theories set out to cater to. In this, they are no different than other collective narratives (myths, for instance). In some respects, though, there are striking differences: Psychology is desperately trying to link up to reality and to scientific discipline by employing observation and measurement and by organizing the results and presenting them using the language of mathematics. This does not atone for its primordial sin: that its subject matter is ethereal and inaccessible. Still, it lends an air of credibility and rigorousness to it. The second difference is that while historical narratives are "blanket" narratives - psychology is "tailored", "customized". A unique narrative is invented for every listener (patient, client) and he is incorporated in it as the main hero (or anti-hero). This flexible "production line" seems to be the result of an age of increasing individualism. True, the "language units" (large chunks of denotates and connotates) are one and the same for every "user". In psychoanalysis, the therapist is likely to always employ the tripartite structure (Id, Ego, Superego). But these are language elements and need not be confused with the plots. Each client, each person, and his own, unique, irreplicable, plot. To qualify as a "psychological" plot, it must be: a. All-inclusive (anamnetic) - It must encompass, integrate and incorporate all the facts known about the protagonist. b. Coherent - It must be chronological, structured and causal. c. Consistent - Self-consistent (its subplots cannot contradict one another or go against the grain of the main plot) and consistent with the observed phenomena (both those related to the protagonist and those pertaining to the rest of the universe). d. Logically compatible - It must not violate the laws of logic both internally (the plot must abide by some internally imposed logic) and externally (the Aristotelian logic which is applicable to the observable world). e. Insightful (diagnostic) - It must inspire in the client a sense of awe and astonishment which is the result of seeing something familiar in a new light or the result of seeing a pattern emerging out of a big body of data. The insights must be the logical conclusion of the logic, the language and of the development of the plot. f. Aesthetic - The plot must be both plausible and "right", beautiful, not cumbersome, not awkward, not discontinuous, smooth and so on. g. Parsimonious - The plot must employ the minimum numbers of assumptions and entities in order to satisfy all the above conditions. h. Explanatory - The plot must explain the behaviour of other characters in the plot, the hero's decisions and behaviour, why events developed the way that they did. i. Predictive (prognostic) - The plot must possess the ability to predict future events, the future behaviour of the hero and of other meaningful figures and the inner emotional and cognitive dynamics. j. Therapeutic - With the power to induce change (whether it is for the better, is a matter of contemporary value judgements and fashions). k. Imposing - The plot must be regarded by the client as the preferable organizing principle of his life's events and the torch to guide him in the darkness to come. l. Elastic - The plot must possess the intrinsic abilities to self organize, reorganize, give room to emerging order, accommodate new data comfortably, avoid rigidity in its modes of reaction to attacks from within and from without. In all these respects, a psychological plot is a theory in disguise. Scientific theories should satisfy most of the same conditions. But the equation is flawed. The important elements of testability, verifiability, refutability, falsifiability, and repeatability - are all missing. No experiment could be designed to test the statements within the plot, to establish their truth-value and, thus, to convert them to theorems. There are three reasons to account for this shortcoming: a. Ethical - Experiments would have to be conducted, involving the hero and other humans. To achieve the necessary result, the subjects will have to be ignorant of the reasons for the experiments and their aims. Sometimes even the very performance of an experiment will have to remain a secret (double blind experiments). Some experiments may involve unpleasant experiences. This is ethically unacceptable. b. The Psychological Uncertainty Principle - The current position of a human subject can be fully known. But both treatment and experimentation influence the subject and void this knowledge. The very processes of measurement and observation influence the subject and change him. c. Uniqueness - Psychological experiments are, therefore, bound to be unique, unrepeatable, cannot be replicated elsewhere and at other times even if they deal with the SAME subjects. The subjects are never the same due to the psychological uncertainty principle. Repeating the experiments with other subjects adversely affects the scientific value of the results. d. The undergeneration of testable hypotheses - Psychology does not generate a sufficient number of hypotheses, which can be subjected to scientific testing. This has to do with the fabulous (=storytelling) nature of psychology. In a way, psychology has affinity with some private languages. It is a form of art and, as such, is self-sufficient. If structural, internal constraints and requirements are met - a statement is deemed true even if it does not satisfy external scientific requirements. So, what are plots good for? They are the instruments used in the procedures, which induce peace of mind (even happiness) in the client. This is done with the help of a few embedded mechanisms: a. The Organizing Principle - Psychological plots offer the client an organizing principle, a sense of order and ensuing justice, of an inexorable drive toward well defined (though, perhaps, hidden) goals, the ubiquity of meaning, being part of a whole. It strives to answer the "why's" and "how' s". It is dialogic. The client asks: "why am I (here follows a syndrome)". Then, the plot is spun: "you are like this not because the world is whimsically cruel but because your parents mistreated you when you were very young, or because a person important to you died, or was taken away from you when you were still impressionable, or because you were sexually abused and so on". The client is calmed by the very fact that there is an explanation to that which until now monstrously taunted and haunted him, that he is not the plaything of vicious Gods, that there is who to blame (focussing diffused anger is a very important result) and, that, therefore, his belief in order, justice and their administration by some supreme, transcendental principle is restored. This sense of "law and order" is further enhanced when the plot yields predictions which come true (either because they are self-fulfilling or because some real "law" has been discovered). b. The Integrative Principle - The client is offered, through the plot, access to the innermost, hitherto inaccessible, recesses of his mind. He feels that he is being reintegrated, that "things fall into place". In psychodynamic terms, the energy is released to do productive and positive work, rather than to induce distorted and destructive forces. c. The Purgatory Principle - In most cases, the client feels sinful, debased, inhuman, decrepit, corrupting, guilty, punishable, hateful, alienated, strange, mocked and so on. The plot offers him absolution. Like the highly symbolic figure of the Saviour before him - the client's sufferings expurgate, cleanse, absolve, and atone for his sins and handicaps. A feeling of hard won achievement accompanies a successful plot. The client sheds layers of functional, adaptive clothing. This is inordinately painful. The client feels dangerously naked, precariously exposed. He then assimilates the plot offered to him, thus enjoying the benefits emanating from the previous two principles and only then does he develop new mechanisms of coping. Therapy is a mental crucifixion and resurrection and atonement for the sins. It is highly religious with the plot in the role of the scriptures from which solace and consolation can be always gleaned. Eating Disorders and Personality Disorders By: Dr. Sam Vaknin Patients suffering from eating disorders binge on food and sometimes are both Anorectic and Bulimic. This is an impulsive behaviour as defined by the DSM (particularly in the case of BPD and to a lesser extent of Cluster B disorders in general). Some patients adopt these disorders as their way of self mutilating. We may be witnessing a convergence of two criteria: self-mutilation and an impulsive (rather, compulsive or ritualistic) behaviour. The key to improving the mental state of patients with dual diagnosis (a personality disorder plus an eating disorder) lies in concentrating upon their eating and sleeping disorders. In my view, these disorders are a blessing in disguise. It is very rarely, even in the lives of normal human beings, that they are faced with a veritable, identifiable enemy. By controlling their eating disorders, patients can assert control over their lives. This is bound to reduce their depression (even eliminate it altogether as a constant feature of their mental life). This is bound to ameliorate other facets of their personality disorders. Here is the chain: controlling eating disorders=controlling my life=I am worthy, I have self-confidence, self esteem and self-worth=I have a challenge, an interest, an enemy to subjugate=I am strong=I can socialize=I feel better (I am a success) etc. When a patient has a personality disorder and an eating disorder, I see no point in concentrating at first on anything but his eating disorder. Personality Disorders are intricate and intractable. They are rarely cured (though certain aspects, like OCD, can be dealt with using medication). It calls for the enormous, persistent and continuous investment of resources of every kind by every one involved. This is not realistic. Also this is not a realistic threat. If a personality disorder is cured but the eating disorders are aggravated, the patient might die (though mentally healthy) ... An eating disorder is both a signal of distress (I wish to die, I feel so bad, somebody help me) and a message: "I think I lost control. I am very afraid of losing control. I will control my food intake and out-take. This way I control at least ONE aspect of my life". This is where we can and should begin to help the patient. Help him to regain control. The family or other supporting figures must think what they can do to make the patient feel that he is in control, that he manages things his own way, that he is contributing, has his own schedules, his own agenda, possesses both authority and responsibility. BY FAR the most important element in such a patient's mental abnormalcy is his eating disorders. He is usually right in emphasizing them over his personality disorders. They indicate the strong combined activity of an underlying sense of lack of personal autonomy and an underlying sense of lack of self control. The patient feels inordinately, paralyzingly helpless and ineffective. His eating disorders are an effort to exert and reassert mastery over his own life. At this stage, he is unable to differentiate his own feelings and needs from those of others. His cognitive and perceptual distortions (for instance, regarding body image) only increase his feeling of personal ineffectiveness and his need to exercise even more self control (of his diet, the only thing left). The patient does not trust himself AT ALL, not in the slightest. He is his worst enemy, a mortal enemy and he knows it. Therefore, any efforts to collaborate with HIM against his disorder - will be perceived by him as collaboration with his worst enemy against his only mode of controlling his life to some extent. The patient views the world in terms of black and white, of absolutes. So, he cannot let go even to a very small degree. He is HORRIFIED - constantly. This is why he finds it impossible to form relationships: he mistrusts (himself and by extension others), he does not want to become an adult, he does not enjoy sex or love (which both entail a modicum of a loss of control). All this leads to a chronic absence of self esteem. These patients like only their disorder. Their eating disorder is their only successful feat in life. Otherwise they are ashamed of themselves and disgusted by their shortcomings (expressed through shame and disgust directed at their bodies). There is a chance to cure the patient of his eating disorders (though the duality of eating disorder plus the existence of a PD is not favourable prognosticator of recovery). This - and ONLY this - must be done at the first stage. The patient's family or closest should consider therapy AND support groups (the equivalent of Alcoholics Anonymous or a 12 step program for eating disorders). Recovery prognosis is good after 2 years of treatment and support. The family must be heavily involved in the therapeutic process. Family dynamics usually contribute to the development of such disorders. Medication+ cognitive or behavioral therapy+psychodynamic therapy+family therapy ought to do it. The change in the patient IF the treatment of his eating disorders is successful is VERY MARKED. His major depression disappears together with his sleeping disorders. He becomes socially active again and goes on with the business of living. His personality disorder might make it difficult for him - but, in isolation, without the exacerbating circumstances of his other disorders - he finds it much easier to cope with. Patients with eating disorders may be in mortal danger. Their behaviour is ruining their bodies relentlessly and inexorably. They might attempt suicide. They might do drugs. It is only a question of time. Our goal is to buy them time. The older they get, the more experience they accumulate, the more their body chemistry changes with age - the better their prognosis.
Copyright © 1999 Sam Vaknin |