Kaethe Weingarten of the Department of Psychiatry at Harvard Medical School recently published a paper describing her experience with four clients who experienced chronic sorrow. The clients, who were all successful, vibrant women, had different pasts and different conditions that caused them to lose their sense of self. Despite these differences, the result was the same for each. They struggled with a sense of deep sadness or chronic sorrow. In one’s case, illness had caused her to lose her independence and ability to live the life she once knew. Another woman became addicted to medication that was prescribed to treat a health problem. The addiction led to psychosis that lasted two years. The third woman was born with a heart defect and has lived a life of longing to be the woman she knows she cannot be. The fourth woman was diagnosed with Chronic Fatigue Syndrome. After over a decade of being doubted by family members, medical professionals, and even therapists, this client eventually committed suicide.

Weingarten, having dealt with her own disability, is all too familiar with the shift from a life of autonomy and ability to one of utter dependence and incapacity. She believes her own experience and those of her clients gives her an insight into chronic sorrow and how to best approach this issue with patients. First, Weingarten believes that chronic sorrow is rooted in a loss of self. The self-narrative of those living with chronic sorrow becomes shattered, dissociative, and disrupted. This can happen as a result of one catastrophic event, such as a debilitating medical diagnosis, or a series or progression of events and symptoms, as was the case for the client with Chronic Fatigue Syndrome. Regardless of how it occurs, this broken narrative is not one that can be fixed. Instead, Weingarten believes that companionship and compassionate witnessing are the keys to living with, and not necessarily overcoming, chronic sorrow.

She believes that witnessing requires developing an empathic understanding of a client’s situation and taking actions to alleviate the psychological pain that ensues. Rather than trying to fully understand, a compassionate witness should accept that they will never fully be able to feel the feelings or loss of their client. Instead of pathologizing and labeling these clients’ reactions to loss of self as bipolar, schizophrenic, or psychotic, a truly compassionate witness will empathize without ever really understanding. “People who live with chronic sorrow need accompaniment,” said Weingarten. By this, she means that clients with chronic sorrow need someone to be with them as they discover how they will interact with the limitations of their minds and bodies. It means showing them the way to peace, teaching them how to tolerate the inconsistency of their lives with support, education, and even humor. It also means requires self-care so that the therapist can be aware of the client’s own boundaries while they take this journey with their client. Weingarten does not believe chronic sorrow can be fixed or healed. But she believes it can be lived with and she suggests compassionate witnessing and companionship as ways to do that.

Reference:
Weingarten, Kaethe. Sorrow: A therapist’s reflection on the inevitable and the unknowable. Family Process 51.4 (2012): 440-55. Print.

Melissa Orlov Jan 25 presenterEditor’s note: Melissa Orlov, LLC, is a marriage consultant who specializes in working with couples impacted by ADHD. She is the author of the award-winning book, The ADHD Effect on Marriage: Understand and Rebuild Your Marriage in Six Steps, and provides seminars for couples and therapists. Her continuing education presentation for GoodTherapy.org, The ADHD Effect on Couples, is scheduled for 9 a.m. PST on January 25. This event is available free with 1.5 CE credits for all GoodTherapy.org members. For details, please click here.

In your couples practice, you may well encounter couples in which one partner is chronically angry while the other keeps making mistakes that are hard to understand, such as regularly forgetting to do something they’ve committed to, constantly irritating their partner by being late, or never cleaning up after themselves. The angry partner tries many things to motivate his or her partner—nagging, scolding, pleading, crying—but nothing seems to work. The forgetful partner is genuinely contrite, yet continues doing the same “stupid” things.

It is possible that this couple’s relationship is being impacted by undiagnosed attention-deficit hyperactivity (ADHD).

Learning how to work with couples affected by ADHD is a relatively new and very much needed skill in couples therapy. It is only recently that we have been thinking much about ADHD in adults, and according to expert ADHD researcher Dr. Russell Barkley, as many as 90% of adults with ADHD remain undiagnosed (1). Clients often don’t know they have ADHD or that it contributes to their marital issues. Many times, neither do their therapists. Unfortunately, unrecognized ADHD can wreak havoc in a relationship—in some research studies, almost doubling rates of marital dysfunction and divorce (2).

One of the side effects of the repetitive missteps of an ADHD partner is that anger builds in the relationship. Chronic distractibility, disorganization, and difficulty remembering things are hallmark traits of adult ADHD that can severely impact one’s life. They also don’t play particularly well in a relationship or at home. A chronically distracted partner is often not particularly good at attending to his or her partner in a way that communicates love. The feelings of love are there, but the partner is simply off doing other things. It is no surprise that non-ADHD partners often report that they feel intensely lonely in their relationship (3).

As distraction, disorganization, and other ADHD symptoms continue unabated, partners of those with ADHD can lose patience and become so angry that it colors every aspect of the relationship. Minor gaffes become major blow-ups because they are symbolic of bigger issues in the relationship. For example, an ADHD partner who leaves the milk out on the counter may be reprimanded by his or her partner for “never paying attention” or being “lazy,” even though in other situations leaving milk out might be considered a “nonevent.”

With enough rebukes, an ADHD partner (who often suffers from self-esteem issues in any event) begins to avoid engaging with the non-ADHD partner. Anger that he or she is being constantly criticized builds, too. Arguments escalate more and more quickly, and the couple find themselves in a strong, negative behavioral spiral. They don’t understand their partner’s seemingly arbitrary behavior, but do understand they don’t like it.

My observation is that by the time ADHD-impacted couples make it to counseling, they are often in very significant trouble. They’ve tried everything they can think of to “fix” things, but because they don’t know about the ADHD, have not found a workable solution to their conflicts. They are suffering from great emotional pain, and are often feeling hopeless about the relationship. Many are trying to decide whether to get divorced, but are confused. They feel they ought to be able to do better and don’t understand why they can’t.

The good news for therapists is that working with these couples can literally turn their lives around. First, couples are typically greatly relieved to realize that there is a reason for their problems. Also, identifying ADHD provides a significant chance for behavioral improvement in the ADHD partner. With effort, about 70% of those with ADHD can find treatment that provides almost complete, or at least very significant, improvement in their symptoms (1).

Naming the problem not only provides renewed hope, it creates an opening for redirecting interactions between partners. Certain types of communication tactics, organizing habits, and ways to “attend” to each other simply work better than others for couples impacted by ADHD. These are often not the same tactics that couples not impacted by ADHD use (3), so therapists need new training to optimize their effectiveness.

Sometimes that training includes learning a new style of interacting with clients. I find that these couples respond well to an “activist” approach to counseling that puts the therapist in multiple roles at different points in the therapy—that of expert educator, listener, ADHD coach, sex advisor, and investigator, to name some of the most common. These couples tend not to learn through self-reflection. Rather, they need active guidance to learn a new skill set that will enable them to live together successfully and bridge their often very considerable differences.

Yes, these couples often have really significant problems. Not all of them stay together. But with the right assistance, many of them are able to turn their relationships back into something they treasure. For therapists, it can be incredibly fulfilling work.

References:

  1. Barkley, R.A. (2010). Taking charge of adult ADHD. New York, NY: The Guilford Press.
  2. Barkley, R. A., Murphy, K. R., Fischer, M. (2008). ADHD in adults: What the science says.New York, NY: The Guilford Press.
  3. Orlov, M.C. (2010). The ADHD effect on marriage: Understand and rebuild your relationship in six steps. Plantation, FL: Specialty Press.

The way in which a person reacts to stress can reveal a lot about their psychological state. Some theories exist that suggest that people with borderline personality (BPD) have an impaired reaction to stress, resulting in hyperactivity to stress and longer time to recover from stressful events. To test this theory, Lori N. Scott of the Department of Psychology at Pennsylvania State University led a study comparing stress reactivity in a group of female participants with BPD, traits similar to BPD (TM), and non-BPD traits (NTM). She measured the cortisol levels and the negative or positive affect of the women before and after they were exposed to stressors.

Scott found that the BPD women reacted less severely to stressors than the TM and NTM women. Although this finding was in contrast to some existing research, Scott believes there is a valid explanation for it. The BPD women had higher levels of stress, based on cortisol levels, and higher negative affect at baseline than the other women. Therefore, because their stress levels were elevated prior to being exposed to a stressor, their reaction to stress is less extreme than those with low baseline stress. Also, negative affect can dampen any reaction and weaken hyperactive stress responses.

When Scott looked at recovery time, she found that all the groups had similar rates of recovery from stress. Even though the BPD women experienced stress increases that were smaller in scale compared to the reactions of the other women, the time it took them to return to their elevated baseline stress levels was equal to that of the other women, whose stress increases were much steeper. “Our results provide some support for the high emotional intensity aspect, but not hyperreactivity and impaired recovery aspects, of current clinical theories of affective dysregulation in BPD,” said Scott. However, this study did not account for medication or comorbid conditions such as PTSD and substance use, all of which could influence stress reactivity in women with and without BPD. Future work may consider these issues when exploring the full range of reactions in women with BPD.

Reference:
Scott, L. N., Levy, K. N., and Granger, D. A. (2012). Biobehavioral reactivity to social evaluative stress in women with borderline personality disorder. Personality Disorders: Theory, Research, and Treatment. Advance online publication. doi: 10.1037/a0030117

GoodTherapyorg-Grief-and-Loss-BlogsGrief has many causes and can manifest in many ways. Whether it’s triggered by divorce or separation, illness, trauma, or death, grief is a normal part of human experience. However, coping with grief can be extremely challenging; if grief is intractable, the support of a mental health professional may be needed. In fact, the upcoming fifth release of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), used by mental health practitioners to diagnose and treat a wide range of issues, does more to acknowledge the link between bereavement and depression than any DSM before it.

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Acknowledgment of the profound effects of grief and loss isn’t enough, of course. More must be done to point grieving people toward resources that can help them cope and heal. According to the National Institute for Mental Health, only 10% of grieving people will ever seek professional help.

While GoodTherapy.org is at its core a directory of therapists committed to treating issues such as grief and loss, it is also a comprehensive resource for people seeking mental health treatment and information. It is with that in mind that we selected the 10 best resources on the Internet in 2012—GoodTherapy.org excluded—for people experiencing grief and loss. Among the criteria we used to select our top 10 websites are quality and depth of content, presentation, and functionality.

We welcome your submissions for consideration in our Top 10 lists. Click here to nominate a site.

Woman sits thinking while man is in bedThe new movie This is 40 has a lot of people talking. It is not only crass and funny, but also controversial. The two main characters in the movie reveal that they have secretly fantasized about killing each other. The wife admits to her husband that she has thought about poisoning him with a cupcake. The husband, on the other hand, tells his wife that he had contemplated putting her through a wood chipper. And as they share their morbid fantasies, the married lovers lie in bed looking relaxed and playful. Their fantasies, detailed in the warm light of their bedroom and the safety of a loving relationship, are as far from threatening as they could be. But what does it say about their relationship that they actually do have fantasies like this?

According to Benjamin Karney, a psychology professor at the University of California in Los Angeles, people who fantasize about killing their spouse, or about being a widow or widower, may do so because it allows them to escape taking blame for the failure of the marriage. They may think of it as an escape from a difficult marriage, but an escape without blame. It is not clear how many married couples have these types of fantasies. Rarely do you hear a spouse ask their husband or wife, “Do you ever think of killing me?”  But it doesn’t mean it never happens. Violence of any kind, including intimate partner violence, is not something to joke about. Rates of partner homicide are startlingly high. But the movie does show that communication styles can say a lot about a relationship, even when that communication is murderous.

Howard Markman, a psychology professor and co-director of the Center for Marital and Family Studies at the University of Denver, said that when the stars of the movie had their gruesome conversation, they were playful and intimate with each other. In fact, the whole topic of murder began with the wife wanting to discuss their conflicts. The husband, who was anxious and worried that another conflict would erupt, chose to use humor as a way to broach the subject. According to Markman, this type of strategy, even without the wood chipper or poison cupcake, can indicate a successful relationship.  “They still need to talk about her initial question, but this is a great model for couples,” said Markman. “It starts out negative, but then turns positive.” The movie is raising a few eyebrows; that’s for sure. But it also shows us that there is no one model for a successful marriage.

Reference:
Coe, Alexis. The truth of ‘This Is 40’: It’s actually not weird to want your spouse to die. (n.d.): n. pag. The Atlantic. 20 Dec. 2012. Web. 20 Dec. 2012. http://www.theatlantic.com/sexes/archive/2012/12/the-truth-of-this-is-40-its-actually-not-weird-to-want-your-spouse-to-die/266479/

Man praying over his ill friendAs I sat to write my end-of-the-year complementary and alternative medicine blog post, I questioned the wisdom of discussing prayer for healing, as prayer remains one of the most hotly debated CAM therapies. For many people, prayer is a meaningful part of their daily lives; for others, it may be engaged in more out of duty than beliefs. And for some, prayer is simply a practice in which other people engage.

Regardless, according to a large-scale survey by the National Institutes of Health, approximately 43% of Americans say they pray to improve their health, and about 24% indicated asking others to pray on their behalf. In the scientific community, however, the topic of prayer can be as polarizing as many of the other issues and events that marked 2012.

What’s the Evidence?

The research evidence for whether intercessory prayer (prayer on behalf of another for the purpose of healing) can improve mood, heal wounds, or enhance other health-related outcomes has been subject to much scrutiny and harsh debate. The quality of the research has been variable, as have the results. There are also many who believe it is inappropriate to test whether prayer can affect change. Yet prayer for healing, specifically, remains one of the most commonly used CAM “techniques.”

Several prayer studies have found positive effects, whereas others have found prayer to make no difference with regard to health (or even be associated with slightly poorer outcomes). Many have pointed out, not incorrectly, the tendency for the prayer research to create more questions than it answers. Researchers in both the “pro” and “against” camps regarding prayer agree that one challenge in evaluating this type of intervention is that it is not possible to completely rule out whether those in the control or “no prayer” group have in fact also received prayers from loved ones or clergy during the study period. If those in the “no-intervention” group are prayed for, and prayer does have an effect, theoretically this would make it difficult or impossible to tell the difference between one group and another. Thus, even if prayer for others could help them heal, we would be unlikely to detect this effect in a research situation described above.

Of course, no study can answer whether there is, in fact, a God or other divine organizing principle; if He or She answers study-related or other prayers; or whether religious affiliation of the one praying has any impact on the outcome.

Why Pray, Then?

The question of whether prayer should be studied, or if it has any efficacy as a tool for healing, will not be answered here. Regardless of the scientific evidence available, people who pray will likely continue to do so for themselves and others. Prayer brings millions of people comfort, and helps them feel connected to others as well as to something greater than themselves. Thus, given the time of year, and especially in light of the events of recent months, it seems relevant and important to mention it here.

As someone who has engaged in research, I know that my questions may never be adequately answered by the data, and yet, as a human being, I admit that when I or someone I care about has been ill or experienced significant difficulty, I have very much appreciated and at times solicited prayers, healing intentions, and “good vibes.” Over the years, I have also worked with many medically ill children and adults, and I can say that prayer is very common in the hospital setting and elsewhere, even when it is not obvious.

Perhaps there is a difference between private prayer for oneself, a loved one, or for one’s community, as compared to prayer for a stranger identified only by a study ID number, at least with regard to the meaning it has for us. Although I am not a religious person, on occasion I have prayed for my clients, although I have never prayed with any of them. At these times, when I have prayed for or hoped on someone’s behalf, or tried to visualize a positive outcome, I have often felt a sense of connection with something greater than myself—whether this is evidence of the divine or simply a sense of knowing I am part of a caring community, or a benefit I receive simply from striving to do good in some way, I cannot say for certain. And at those times, I am not really sure that finding “proof” matters all that much anyway.

Whatever your beliefs, my wish for us all in the coming year is to treat each other with respect, kindness, and compassion. If you do pray, among other things, pray for peace.

Goodwill to all!

References:

  1. Davis, J. L. (2006). Can prayer heal? http://www.webmd.com/balance/features/can-prayer-heal
  2. Mind and body: Do music, imagery, touch, or prayer improve cardiac care? (2006). Harvard Men’s Health Watch; 11, 6-7. http://www.health.harvard.edu/newsletters/Harvard_Mens_Health_Watch/2006/December/Mind_and_body_Do_music_imagery_touch_or_prayer_improve_cardiac_care
  3. More than one-third of U.S. adults use complementary and alternative medicine, according to new government survey(2004). http://nccam.nih.gov/news/2004/052704.htm

Housing options for low-income families are limited. Research has shown that disadvantaged communities can contribute to emotional and behavioral challenges for children. But few studies have looked at the quality and kind of housing affects the developmental trajectory of children. Rebekah Levine Coley of the Applied Developmental and Educational Psychology Department at Boston College decided to explore this issue in a recent study. Coley looked at housing contexts including stability, housing quality, renting versus owning, and subsidized housing. She examined how these factors affected well-being in both the children and the parents.

Coley used data from over 2,400 participants ranging in age from 2 to 21 years old. The data was collected over a 6 year period and was used to determine how cognitive, behavioral and emotional well-being was affected by housing. The study revealed that several aspects of housing affected childhood development. Coley said, “Within the four characteristics of housing considered in this research, poor quality housing was the most consistently and strongly predictive of children’s well-being across the span of childhood.” Poor housing quality affected the emotional and behavioral development of the younger participants the most and had a strong negative impact on adolescents’ reading and math skills. Stress from living in poor conditions also contributed to negative outcomes. Coley believes that parental stress from inadequate living resources, as well as stress from neighborhood factors, including crime, violence, and drugs, could culminate to decrease parental emotional availability. Combined with the stress of the child, the result could be decreased coping skills and higher levels of internalizing and externalizing behaviors.

Housing stability was examined and revealed mixed results. For instance, multiple moves led to more externalizing and internalizing. But a move within the prior year led to lower maladaptive coping and better reading skills. This could be the result of moving to a better home or better community. Although Coley didn’t fully examine the details of the stability, these contradictory findings should be explored in future research. Finally, the developmental differences of children who rented versus owned, or who lived in subsidized versus non-subsidized housing, were minimal. The cost to own a home may put a financial burden on families that outweighs the benefits of owning. And aside from the environment in which subsidized housing is located, private versus subsidized renting did not directly affect developmental outcomes. Coley hopes that future research will further examine the impact of the home, in all its contexts, on overall development and well-being in children from all socioeconomic classes.

Reference:
Coley, R. L., Leventhal, T., Lynch, A. D., and Kull, M. (2012). Relations between housing characteristics and the well-being of low-income children and adolescents. Developmental Psychology. Advance online publication. doi: 10.1037/a0031033

According to a recent study led by Tara M. Chaplin of the Department of Psychiatry at Yale University School of Medicine, boys and girls have very different emotional tendencies, but these fluctuate depending on age and context. In her study, Chaplin reviewed data from over 21,000 participants from over 160 separate studies focusing on emotional expression from birth to adolescence. Chaplin looked at internalizing and externalizing emotions as well as positive and negative expressions. The study revealed some interesting and novel results. Chaplin said, “Our findings suggest that there are small but significant gender differences in emotion expressions, with larger gender differences emerging at certain ages and in certain contexts.” She found that in infancy, the boys and girls exhibited similar emotional displays. However, as the children aged, significant differences emerged.

Specifically, Chaplin found that the girls internalized their emotions more than the boys, but they also displayed more positive emotions. For instance, the girls had higher rates of anxiety and sadness than the boys, but outwardly expressed more cheerfulness and joy. The boys, on the other hand, were more likely to exhibit anger and aggression than the girls. But these variances were only evident when the children were in the presence of strangers. When they were with their parents, the children expressed a wide range of emotions, making the gender differences virtually non-existent. Chaplin believes that children may feel more comfortable with parents and may feel free to express all of their emotions. In social settings, children may feel the need to conform and therefore may not freely express their true emotions, leading to internalizing behaviors.

Although these emotional differences were very noticeable during the toddler and elementary school ages, they were less apparent as the children matured. For instance, externalizing behaviors diminished in the boys and increased in the girls, almost to the point of being equal. Two other findings revealed concerning patterns. The adolescent girls had higher levels of shame than the boys. Because shame and guilt have been shown to be a factor in several psychological problems, including depression, self-harm, and disordered eating, this should be a key point of focus for educators and clinicians working with teen girls. Also, boys felt more joy than girls when they were provided the opportunity to taunt or tease another individual. This is disturbing too because this could increase the risk for these boys to engage in bullying and aggressive behavior. Because the trajectory of emotional expression changes as children mature, and because it is heavily influenced by family environment, social factors, and other external conditions, children will display a wide range of emotions as they develop. However, Chaplin believes it is also important to be able to identify which expressions are normal and which are signs of concern.

Reference:
Chaplin, T. M., and Aldao, A. (2012). Gender differences in emotion expression in children: A meta-analytic review. Psychological Bulletin. Advance online publication. doi: 10.1037/a0030737

MH900202063The Family Man, starring Nicholas Cage, is a great Christmas movie, and I watched it last night. Nick’s character makes a choice at the beginning of the movie and, more than a decade later, is a very wealthy man. There’s a message from his old girlfriend, Kate, but he does not call her at that point. After a brush with fate, the next morning there’s a change in his life: He’s with Kate, two kids, little money, and he’s got to figure out what is important to him.

When he finally realizes what is important, he wakes up having never been married, and meets up with Kate—who is going to be flying to Paris and wants to give him back his old stuff. Back in his penthouse, he sifts through a box of memories. He goes to the airport to try to stop her and convince her about the life they would have had if only he’d made a different choice. If you have not seen the movie, I do not believe I totally spoiled it for you, but if I did, I am sorry. I wanted to capture the basics of the movie, but you will have to watch it to get the essence of the movie.

It’s Christmas time, and every year at this time, we are scrounging around to get the best gifts for our families or friends. The stores are packed, the after-Christmas sales will be going on very soon, people will be returning gifts to get what they really want, and the attitudes of people are not always joyous. If you do not need to be out shopping, then don’t. Each year, the shopping comes earlier and earlier, more sales, etc. I also think that each year, the meaning of Christmas—the birth of Jesus, being around family, friends, sharing love, kindness, helping others, and spreading cheer—diminishes. This is my opinion.

We each have a choice to make. Yes, I have fallen into making sure that my family and friends get the “best gift,” and feel so ragged that it can be hard to be joyous. Having a kid changes your perceptions on what is important and what is not.

With my almost 2-year-old son, I am reminded that it is not about the quantity of gifts that I give or receive but rather the quality of the time I spend with my family and friends. Whether it’s baking homemade peppermint patties (York need not worry about going out of business), decorating cookies, reading about the birth of Jesus, or watching holiday movies, it’s what I am doing with family and friends that counts. It’s watching my son’s face light up when we play with Legos together, or crash his trains and get the toy ambulance to come and help the trains get all bandaged up. The quality time I have with my husband is very important as well—how I do my part to strengthen the relationship (not talking about sex), the unity that we have, and help each other stay focused and not get lost in the emptiness that can come with giving a gift because it’s on sale.

Almost all Christmas movies are about being with the ones you love, spreading joy and cheer, laughing, playing, creating memories, etc. Many are also about people who are trying to get ahead and how empty they may feel because they are not connected to their friends or family. It’s like a wake-up call, and it happened to Nick in The Family Man.

This is your wake-up call. Remember: Each day, not just at Christmas time, tell your friends and family how much you love them, and play with your children and friends’ kids when you visit them. Allow the children to help you relive your childhood memories, and after Christmas, keep spreading that joy all year long.

Watch The Family Man. It might remind you of what is really important and help you find balance in your life.

Happy older coupleBeing married to the same person for a long time can be quite an achievement. But for many older couples, the celebration of a long life together is overshadowed by health issues, caregiver stress, and lack of independence. Tensions can run high when one spouse is no longer able to care for themselves or tend to their partner’s needs the way they used to. But experts say there are a number of things that couples in their golden years, and their children can do to keep the marriage happy, healthy, and firing on all pistons. One of the first tips that experts give is for children, especially those who have assumed the role of caregiver, to butt out! “Couples who have been together for 60 years tend to have worked out ways to manage conflict – or they wouldn’t still be together,” said psychologist Dr. Gordon Herz from Wisconsin.

In fact, most experts agree that couples who could benefit from some third party direction would be better off consulting a relationship therapist rather than their own children. Some studies suggest marital therapy is most beneficial for older couples because that is when change is most difficult. Lifestyle changes, social changes and physical changes make the older years some of the most stressful. Marriage therapy can help individuals work through their challenges and continue to have a happy and healthy relationship.

Even if couples are struggling with physical and cognitive problems, intimacy is still one of the core elements of a strong relationship. Holding hands, cuddling, or engaging in an activity together can help couples bolster intimacy. But experts also warn not to spend too much time together. As couples age, they tend to be less active and spend more time with each other and not socializing with other people. This is particularly true if one spouse is disabled in some way. It is important for each spouse to take time to care for themselves and rejuvenate their bodies and minds so that they can be fully plugged in when they interact with each other. One recommendation is for spouses, especially those who feel dependent on others, to take time to volunteer in a way that allows them to feel productive and useful. This will improve their well-being and will spill over into their relationship with their spouse.

Reference:
Seliger, Susan. In the middle: Helping unhappy couples. (n.d.): n. pag. The New York Times. 18 Dec. 2012. Web. 19 Dec. 2012. http://newoldage.blogs.nytimes.com/2012/12/18/in-the-middle-helping-unhappy-couples/

Woman popping zitThe Diagnostic and Statistical Manual of Mental Disorders serves as the “bible” of mental health practitioners, who rely on it to match diagnostic criteria with behaviors. The American Psychiatric Association periodically examines trends in mental health conditions and recent scientific evidence to revamp the criteria. The latest edition, the DSM-5, is slated for release in May 2013, and the APA recently approved several changes.

Among the new diagnoses is excoriation, which is associated with chronic skin-picking. The issue is most common among women between the ages of 30 and 45. It’s classified as an impulse control disorder and is related to obsessive compulsion.

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What Is Excoriation?
Although excoriation disorder is the name of the new “official” diagnosis, the issue has been studied for years—sometimes called neurotic excoriation, compulsive skin-picking, dermatillomania, and psychogenic skin-picking. The issue was not included in previous editions of the DSM because it is believed to sometimes be a symptom of another issue.

Skin-picking is common among people with autism spectrum as well as obsessive compulsion. When it does not co-occur with another issue, however, it qualifies for its own diagnosis. Symptoms of the issue include compulsive skin-picking that leads to injuries or wounds as well as stress. Skin-picking is relatively common. Some people pick their skin to the point of bleeding or pain by popping pimples, picking at hangnails, or peeling scabs.

Controversy Surrounding Diagnosis
Whenever the APA adopts new diagnoses or symptoms, there is always some controversy, and excoriation is no exception. Although the diagnosis has received considerably less attention than some other changes, some mental health experts have expressed concern. Because excoriation often is a symptom of an underlying issue, a separate diagnosis might stigmatize people by giving them multiple diagnoses when only one is necessary.

Some clinicians have argued that excoriation does not meet the criteria for a mental health diagnosis and is more akin to a habit. By creating diagnostic criteria for a habit, the DSM might eventually have to include other habits. However, excoriation does sometimes occur on its own, and people with the condition can experience considerable distress, so the APA opted to include it.

How Excoriation Is Treated
When compulsive skin-picking occurs, it’s important to rule out a potential medical cause such as allergies or infection. Occasionally, skin conditions can superficially resemble symptoms of excoriation. Further, excoriation can cause dermatological problems, so patients frequently need dermatological treatment along with mental health treatment.

Antidepressants are the first line of treatment for excoriation. Opioid antagonist medications, which interfere with the body’s ability to respond to endorphins and opioids, also are sometimes effective. Because compulsive skin-picking often co-occurs with anxiety, anti-anxiety medications can be helpful.

Psychotherapy that helps people develop better approaches for dealing with anxiety, enables them to develop better impulse control, and helps patients cope with changes to appearance as a result of excoriation is also a typical part of treatment.

References:

  1. American Psychological Association. APA concise dictionary of psychology. Washington, DC: American Psychological Association, 2009. Print.
  2. Brauser, D. (2012, December 3). Experts react to DSM-5 Approval. Medscape Reference. Retrieved from http://www.medscape.com/viewarticle/775526
  3. Colman, A. M. (2006). Oxford dictionary of psychology. New York, NY: Oxford University Press.
  4. Neurotic excoriations. (2012, June 27). Medscape Reference. Retrieved from http://emedicine.medscape.com/article/1122042-overview
  5. Neurotic excoriation. (n.d.). SkinPick. Retrieved from http://www.skinpick.com/neurotic-excoriation

Unisex door symbolAfter decades of intense and relentless criticism by advocacy groups, gender identity disorder will finally disappear from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Many transgender and gender nonconforming individuals have been diagnosed with gender identity disorder, but this diagnosis can contribute to the pathologization of gender nonconformity–which is not a mental health condition. Gender dysphoria, the diagnosis replacing GID, attempts to reduce stigma and prevent pathologization by focusing on the incongruence between an individual’s actual gender and the gender assigned at birth.

Gender Identity Disorder vs. Gender Dysphoria

The American Psychological Association has incorporated a number of significant changes into the latest revision of the DSM to differentiate gender dysphoria from the previous diagnosis of GID. Some of the diagnostic criteria remain the same, but while the diagnostic criteria for GID placed more emphasis on an individual’s behavior and outward manifestations of gender, gender dysphoria primarily takes into account the sense of incongruence between the gender assigned at birth and actual gender identity, and any associated feelings of distress, whether these feelings occur as a result of body dysphoria or social dysphoria.

Under diagnostic criteria for GID, a person assigned female at birth who engaged in stereotypically masculine behavior or dressed in stereotypically masculine clothes met some of the criteria for GID. However, the person in this scenario would not be diagnosed with gender dysphoria without also experiencing a sense of incongruence between the gender assigned at birth and the gender actually identified with. [fat_widget_right]

Reasons for the Changes

As people become increasingly aware of gender-related issues, there has been a strong push to avoid pathologizing those who are transgender or gender nonconforming. Many mental health professionals and transgender rights advocates have pushed to remove any form of gender nonconformity as a mental health diagnosis, but others argue there are benefits to leaving some form of diagnosis in the DSM. 

Individuals who have a gender identity that differs from the gender assigned at birth may choose to pursue hormone treatment or gender confirmation surgery to align their physical characteristics with their gender. Doctors who prescribe hormones or perform gender confirmation surgery may not do so without an associated diagnosis from a mental health professional, and many insurance companies will not cover any part of the surgery if the individual seeking surgery or hormones has not been diagnosed. Thus, removing the diagnosis from the DSM entirely may effectively bar a number of people who wish to physically transition from doing so.

Gender Dysphoria as a Diagnosis

Many transgender rights activists have pointed out the potential harm in diagnosing people with a mental health condition based on gender identity.  The inclusion of gender dysphoria as a diagnosis aims to reduce stigma and harm by removing some of the emphasis on gender nonconformity and providing a diagnostic term that instead places more focus on the ways gender incongruence can impact an individual. Transgender and gender nonconforming individuals diagnosed with gender dysphoria may experience feelings of distress or discomfort with certain of their physical characteristics, feel as if they are in the wrong body, or experience distress when others misgender them or call them by the wrong name.

The DSM-5 will give gender dysphoria its own chapter, in recognition of the fact that it is not a sexual dysfunction, a paraphilic disorder, or a mental disorder of any kind.

Some critics, however, believe the new diagnosis does not go far enough to reduce stigma or the view of gender nonconformity as a mental health condition. Diagnostic criteria still use phrasing such as “desire to be of the other gender/some alternative gender” and largely emphasizes “thinking” or “feeling” like “the other gender,” which may not accurately reflect the knowledge transgender individuals have of their true gender and may also reinforce the false concept of a gender binary. However, the DSM-5 does include some language supporting the broader, now widely upheld idea of a gender spectrum.

Though the new diagnosis of gender dysphoria may not completely eliminate stigma toward transgender individuals, this change is largely considered to be a significant improvement over the diagnosis of GID and a positive step forward in health care for those who are of a different gender than the one assigned at birth and who may experience distress as a result.

References:

  1. Beredjick, C. (n.d.). DSM-V to rename gender identity disorder gender dysphoria. Advocate. Retrieved from http://www.advocate.com/politics/transgender/2012/07/23/dsm-replaces-gender-identity-disorder-gender-dysphoria
  2. Decuypere, C., Knudson, G., & Bockting, W. (n.d.). Response of the World Professional Association for Transgender Health to the proposed DSM-5 criteria for gender incongruence [.PDF]. World Professional Association for Transgender Health.
  3. Lowder, J. B. (n.d.). Being transgender is no longer a disorder. Slate Magazine. Retrieved from http://www.slate.com/articles/health_and_science/medical_examiner/2012/12/dsm_revision_and_sexual_identity_gender_identity_disorder_replaced_by_gender.html
  4. Winters, K. (n.d.). The proposed gender dysphoria diagnosis in the DSM-5. GID Reform Weblog by Kelley Winters. Retrieved from http://gidreform.wordpress.com/2011/06/07/the-proposed-gender-dysphoria-diagnosis-in-the-dsm-5
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