Taming the Negative Introject: Empowering Patients to Take Control of Their Mental Health [1 ed.] 1138584584, 9781138584587

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Taming the Negative Introject

In this book, Dr. Carol W. Berman describes how to help patients control the self-sabotaging element of their unconscious minds, often called the punitive superego, the negative introject, or the hurt child. The negative introject can provoke horrendous acts against the self, ranging from suicide and addiction to making hurtful comments to loved ones. The role of the psychotherapist is to make the unconscious conscious, allowing the sufferers to take back control of their actions. Dr. Berman uses case studies to personalize the theory and demonstrate how the negative introject can take hold and impact the lives of those suffering from a variety of illnesses and disorders, including depression, anxiety, eating disorders, obsessive-compulsive disorder, and bipolar disorder. Each chapter concludes with a guide demonstrating how the negative introject was tamed in each case, showing the reader that the negative introject can be identified and then brought into some control. This book is essential reading for all kinds of psychotherapists, from psychiatrists to social workers and psychologists, as well as all those who wish to identify the negative introject, and help “tame” it. Carol W. Berman, M.D., is a clinical assistant professor of psychiatry at N.Y.U. Langone Medical Center. This is Dr. Berman’s fourth book. She is also the author of 100 Questions and Answers About Panic Disorder, Personality Disorders, and Surviving Dementia: A Clinical and Personal Perspective.

“The creator, writer, and psychiatrist, Carol Berman has done it yet again. Written in such a creative yet practical way, this book is a must for any practitioner who is looking to help patients or themselves understand and move past negativity. The clinical case examples are so varied in terms of the pathologies presented, yet spot on. Her easily broken-down tables and charts make this the best guide for those who are looking to build clinical strategies on a tight schedule. Can’t wait to use these strategies with my patients!” Asha D. Martin, M.D., N.Y.U. Langone Medical Center “Dr. Carol Berman breathes new life into the old psychoanalytic term, the negative introject. Negative introjects are unconscious, self-defeating thoughts that often stem from disturbing messages received in childhood, which interfere with mental health, happiness, and success. Dr. Berman illustrates with colorful case reports how negative introjects underlie many common psychiatric disorders, such as anxiety, depression, eating disorders, obsessive-compulsive disorder, hypochondriasis, posttraumatic stress disorder, and body dysmorphic disorder. She describes ways to diminish these negative perceptions with multiple modalities, including medication and psychotherapy. The book includes tables with practical suggestions on ways to counteract negative introjects with positive ideas and behaviors, such as exercise, listening to music, interacting with pets, conversations with positive people, and meditation. Dr. Berman seamlessly blends psychoanalytic thought with behavioral psychology and psychopharmacology in a clear, straightforward manner, which only a seasoned psychiatrist with decades of clinical experience could do. This book is a must read for patients and clinicians alike!” Barbara Bartlik, M.D., Psychiatrist, private practice, New York, New York; Distinguished Fellow, American Psychiatric Association; Assistant Clinical Professor of Psychiatry, Weill Cornell Medical College; past President, Women’s Medical Association of New York City “What an interesting and insightful book! Dr. Berman’s Taming the Negative Introject is truly a cogent and a comprehensive guide to psychological defense and confronting the negative introjection in the patient. She does this with wit, wisdom, and profound sensitivity. You know she wrote this book based on her long clinical insight and her service with her patients. This is a beautifully written and organized book with a great reservoir of information and deep sensitivity and empathy for her patients. This invaluable book provides us with the information and knowledge we need to make rational and healthy choices.” Jose P. Vito, M.D., DFAPA, Clinical Assistant Professor, N.Y.U. School of Medicine; Forensic Telepsychiatry, Central New York Psychiatric Center; Director, Medical Education and Training, Outpatient Clinic, Office of Mental Health State of New York; past President, New York Psychiatric Society District Branch of the APA; assembly representative of New York, American Psychiatric Association

Taming the Negative Introject Empowering Patients to Take Control of Their Mental Health

CAROL W. BERMAN

First published 2019 by Routledge 52 Vanderbilt Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2019 Carol W. Berman The right of Carol W. Berman to be identified as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data A catalog record for this book has been requested ISBN: 978-1-138-58458-7 (hbk) ISBN: 978-1-138-58459-4 (pbk) ISBN: 978-0-429-50592-8 (ebk) Typeset in Dante and Avenir by Apex CoVantage, LLC

To Marty and Barbara for their unending support

Contents

Foreword (by Dr. Phyllis F. Cohen)

ix

  1 What is the Negative Introject?

1

  2 Anxiety and the Negative Introject

7

  3 Hypochondria, PTSD, OCD, and the Negative Introject

19

  4 Major Depression, Bipolar Disorder, and the Negative Introject

33

  5 Psychosis and the Negative Introject

51

  6 Personality Disorders and the Negative Introject

65

  7 Addictions and the Negative Introject

79

  8 Denial of the Negative Introject

97

  9 Negative Introject in the Group

105

10 Dreams and the Negative Introject

115

11 Happiness and the Negative Introject

121

Index

125

Foreword

About a year ago, Dr. Berman and I were sitting and talking about patients. The subject turned to the pains that many of those who see us experience, so much of which is caused by the negative ghosts that haunt their heads: those voices in there that criticize, degrade, deny opportunity, belittle, and see only the worthless and bad in the person. I commented, “Oh, that’s what we in the Modern Analytic school call the ‘Negative Introject’.” “How would you define that?” she asked, and I responded: “The piece of an early critical voice that we took in an early developmental stage. We believe that they are our own thoughts, but in reality, it is an alien implant incorporated into us.” With that, Dr. Berman’s curiosity was fully aroused. Her fine research skills went into action, accompanied by her collector’s instinct. It inspired me to go back and locate when and by whom I  had first become aware of the phenomena of the negative introject and of the important role it plays in our work. In 1992, Dr. Lou R. Ormont wrote a book called “The Group Therapy Experience: From Theory to Practice.” Dr. Ormont, a modern analyst, had been at the forefront of advocating the value of group. As he did so, he formulated new methods, new concepts, and the reworkings of old ones. In his chapter titled “What the Therapist Feels,” he delineates as an unconscious block, what as therapists we must recognize before we can have insights on the path to formulating treatment.

x  Foreword

We are, almost surely, dealing with what psychoanalyst Eduardo Weiss, back in 1932, first called an “introject.” An introject is a part object, a piece of some significant figure of the person’s past, that remains incorporated in the psyche but has never been assimilated into the person’s adult ego. It operates as a feeling, an attitude, a voice urging others to act in the role of the patient himself. In some sense, the person remains a victim of this voice, which lives by its own rules. Dr. Berman takes this concept to the next level. Writing with sensitivity and directness, she describes the many forms this strange malady takes through the medium of patient stories. In 11 chapters, it covers the gamut of psychiatric illnesses from anxiety, bipolar disorders, major psychoses, and everything in between, and maps out the part that the negative introject played in each. With candor, we are presented with personal narratives in case studies. The stories of these real people do make clear, the why, the who and the what of each affliction. Even more, for those of us who like happy endings, by so doing, we are given evidence as to how positive resolutions may be achieved in many of these lives. To round out the picture, in some instances we are let into the thoughts and reactive feelings of the therapist and can follow the course of the treatment from both sides. In conclusion, I believe this book fills a need for a simple comprehensive presentation of a complicated, often confusing alien piece of the psyche. Dr. Berman has offered us a clear verbal picture of this enigma; the ways it may look and the ways it may act and affect patient lives. We are left with illustrations and possible applications of therapeutic methods to take on the enemy of maturation progress. I offer my thanks and appreciation to the author. Accompanying the engrossing tales, Dr. Berman has provided a series of tables which includes agnostic definitions of the different disorders from the DSM-V and others we might call practical “How to. . . ’s.” Accompanying one of the chapters is a surprise gift, a tenminute play, that captures a particular view of that negative voice in action. Phyllis F. Cohen, Ph.D., Psy.D., CGP, FAGPA New York, NY

What is the Negative Introject?

1

The negative introject is an old psychoanalytical concept that needs to be revived. Simply put, it is the negative voice in a person’s mental panorama. This is the voice that tells you that you’re stupid, ugly, and incompetent. It is different than the superego, ego, or id, Freud’s trifecta. The superego keeps us under control with its morals, axioms, and warnings, but it’s not necessarily negative or harsh. The ego is the functioning self, mediating between the superego and the id. The id is all the suppressed aggression, sexuality, and impulses in a person’s consciousness. The id can be negative at times, but it can also be positive, pushing a person on to fulfill necessary instincts. The purpose of this book is to introduce awareness of the negative introject to give people some control over this disturbing aspect of the mind. Whenever we name an enemy, we can begin to formulate defenses and plans to subdue it. In Lewis Carroll’s Through the Looking Glass, Alice must pass through the “wood where things have no names.” There she forgets all nouns, including her own name. With the help of a fawn who has also forgotten his identity, she makes it to the other side, where they both remember everything. Realizing that he is a fawn, she is a human, and that fawns are afraid of humans, he runs off. The fawn is protecting itself by remembering the names of things. We humans can protect ourselves by naming the negative introject and learning about the various ways it sabotages us. In many fairy tales,

2  What Is the Negative Introject?

naming the monster or the witch allows the protagonist to have power over these creatures. Here is a good illustration of a person unconsciously controlled by her negative introject: Lydia was fortunate to be found cancer-free after each six-month checkup she had with her oncologist. Three years before, the surgeon had removed cancer from her breast. Since then, all her mammograms were fine. She should have been celebrating her cancer-free diagnosis, but she never did. Lydia hated having a mammogram. She shuddered, remembering that horrible day three years before when the radiologist had discovered the malignant spot on her breast. Sitting in a hot waiting room with all the other frightened women, sweating and shaking, would have been a nightmare of fear and anticipation for anyone. But for Lydia it was the worst because she actually had the dreaded disease they all feared. And she kept believing it would recur. Why didn’t she celebrate being cancer-free? Lydia unconsciously believed that such a celebration would jinx her and make her cancer return. She felt she somehow warded it off by not being happy, by not celebrating. In her Italian family, there was a superstition known as the “evil eye.” Lydia felt that someone had given her an evil eye to cause the cancer in the first place, and she could easily be subjected to that condition once again if she rejoiced in her cancer-free state. Three years before, when she’d been diagnosed with breast cancer, she’d been wearing a sexy red dress that made men stare at her. Unconsciously, she felt guilty about looking so desirable. Lydia had never had psychotherapy to understand herself fully, so she never realized what she was feeling or believing underneath her everyday thoughts. Even people who have been psychoanalyzed may not be aware of their deepest belief systems, which may be sabotaging them. The “evil eye” is a curse cast by a malevolent look, usually given when the victim is unaware. Many cultures believe that receiving the evil eye will cause misfortune or injury. Talismans, often with a counteracting eye, are created to protect the wearer against the evil eye. The “evil eye” causes many different cultures to pursue protective measures

What Is the Negative Introject?  3

against it. The concept and its significance vary widely among different cultures, but can be found in Jewish, Indian, Greek, Italian, and Ethiopian peoples. The idea appears frequently over the centuries in Jewish religious writings and literature. Lydia thought her best bet was not to tempt any evil eye directed toward her, so she never celebrated being cancer-free. Consequently, she wasn’t happy. She didn’t allow herself to be in a positive state of mind. Instead, she kept herself in a negative state that easily dropped into depression. Of course, she didn’t do this consciously. If anyone asked her how she was feeling, she would answer “fine.” But she didn’t feel fine. By playing it safe and not celebrating, Lydia was depriving herself of happiness. Underneath all these worries about the “evil eye” was a malignant part of her psyche, one that she had never considered. This part of her mind constantly brought up the “evil eye” as well as many other superstitions and negative thoughts. In psychiatry, we call this part of the psyche the “negative introject.” Introjection is a psychological defense that normally takes place early in a child’s narcissistic stage of development (around age 2 to 3 years).1 Before that time, the child sees its mother as one with itself. When the child differentiates from the mother, then the child has absorbed the care-taking object into itself. If this part of the psyche is negative and critical, it will be a source of problems for the person’s entire life. Therapists usually must confront this “negative introject” in their patients at some point in the therapy. Often in these cases, a negative transference to the therapist occurs, and this makes it simpler for the therapist to identify the malignant part of the patient’s psyche. The difficult part is when the therapist must point out the “negative introject” to the patient. A therapist cannot simply say, “You have a negative introject, and we’re going to work on that.” Of course, if the patient is familiar with psychology and all its terminology, this is possible. For most patients and people in general, the negative introject will lead to self-sabotage. In Lydia’s case, the self-sabotage was in the realm of denying her happiness. Self-sabotage is a concept with which the general public is familiar. Most people have undermined themselves at some time or another. “Self-saboteurs” are constantly defeating

4  What Is the Negative Introject?

themselves. Think of an intelligent student who can never bring himself to study until the last possible moment before an exam. Of course, he’ll fail. Or the dancer who keeps telling herself that she’s a klutz, until her prophecy comes true, and she is clumsy. Behind all of these instances is the “negative introject.” Patients, and the public in general, enjoy believing that they are completely in control of themselves and are consciously making decisions, but, of course, we know they’re not. Their unconscious minds are making far more decisions than they realize. We therapists spend our time with them attempting to make their unconscious conscious. Back in the early part of the twentieth century, Sigmund Freud differentiated the conscious mind from the unconscious. He wasn’t the first one to make this distinction, but he popularized it more than anyone.2 Dr. Freud called the unconscious the “unbewusst,” which simply means the “unknown” in German. After Freud, psychoanalysts and psychotherapists developed treatments to reveal patients’ “unbewusst.” Carl Jung described the collective unconscious as a universal unconscious mind that all beings of the same species share. We humans have instincts and archetypes. Archetypes are concepts such as the Great Mother, the Wise Old Man, and the Tree of Life.3 Instincts, again, according to Jung, are hunger, sex, activity, reflection, and creativity. Freud thought the unconscious was totally unique and personal to each individual. These two opposing points of view are essential to understand how the two psychoanalysts differed from each other and how these contrasting concepts contribute to modern psychoanalytical practice. If Jung were considering the negative introject, he probably would think of this force as part of the collective unconscious. The negative introject could manifest as an archetype, such as the devil. Superstition is rampant among humans. Often if someone does something against his better judgment, he will say, “The devil made me do it.” Superstitions exist in every society. Usually, they have to do with luck, prophecy, and supernatural beings. It is part of our collective unconscious to believe in them. For instance, many people believe that it is bad luck to walk under a ladder, or to have their path crossed by a black cat, or to break a mirror. The universal presence of the negative introject propagates these beliefs.

What Is the Negative Introject?  5

The “breaking the mirror and getting years of bad luck” superstition was supposed to have originated with the Romans, who believed that life renewed itself every seven years and that breaking a mirror would thus cause damage to the soul that it was reflecting during that time. Mirrors would be used in magical rituals for scrying (remotely viewing a person or place) or fortune-telling. I’m a psychiatrist who has been in practice for 30 years, helping patients make their unconscious minds more conscious. The reason we therapists attempt this difficult task is to give people more control over themselves, which will help them with depression, anxiety, eating disorders, sexual dysfunction, and many other problems. Every day, I see people acting out against themselves. It’s painful to witness some of the most horrendous and bizarre acts against the self. There are the most obvious ones—i.e., suicide attempts, drug and alcohol addictions, eating disorders—and the least obvious, such as ruining a newly cooked meal or saying horrible things to loved ones. The self-sabotaging element in us has been called variously the punitive superego, the negative introject, the hurt child. A patient of mine referred to her negative self as “the thing with claws” that crawls out of its dark cave to attack her when she is most vulnerable. Another patient asked me, “Is the negative introject necessary? Why did we ever develop it?” I explained that the negative introject is like our appendix: it developed as a helpful element in the past, but it can be useless or destructive in the present. For example, an appendix might have been helpful to digest roughage when we were living in the forest as early primates, but nowadays, it can become infected and even kill a person if, as in appendicitis, it bursts and causes peritonitis. In the same way, the negative introject might have been useful for the young child to learn boundaries, but in adults, it can be malicious and selfsabotaging. Table 1.1 shows some practical approaches to combating the negative introject. In a way, the negative introject can be seen as a psychic form of autoimmunity in which the self turns against itself and destroys itself. In rheumatoid arthritis, Hashimoto’s thyroiditis, multiple sclerosis, lupus, and celiac disease, just to mention a few of the more than 80 autoimmune diseases, the body does not recognize its own cells and thus attacks itself. The white blood cells that are responsible for destroying

6  What Is the Negative Introject?

Table 1.1  How to Counteract the Negative Introject, or an Armatorium Against the Negative Introject An Arsenal of Practical Approaches to Helping Patients Deal With the Influences of Their Negative Introject: (1) Visualization of beautiful images—such as beaches, forests, lakes, waterfalls, fantasy images (2) Music, including classical, rock and pop, jazz, folk, and New Age (3) Physical exercises, such as yoga, Tai Chi, Chi Gong. Participation in sports, weight training, and anaerobic workouts (4) Religious participation, prayer, rituals, meditation, chanting, drumming, dancing (5) Conversations with positive people, including psychotherapy, group therapy, 12-step programs (6) Animal therapy, relating to horses, dogs, cats, and other species to alleviate anxiety and induce positive emotional states (7) Community service and involvement

invaders—i.e., viruses and bacteria—destroy healthy cells instead. Likewise, a person’s negative introject does not recognize its own effect— namely, that it is destroying a healthy psyche when it attacks! This book is designed to help all kinds of psychotherapists, from psychiatrists to social workers and psychologists, identify the negative introject in all its varied forms and then to tame it.

Notes 1. Freud, S. (1953–1966). Standard edition of the complete psychological works of Sigmund Freud. London: Hogarth Press. 2. Ibid. 3. Jung, C. G. (1972). 1916 essay, ‘The structure of the unconscious’. In Collected works of C.G. Jung, Vol. 7. Princeton, NJ: Princeton University Press.

Anxiety and the Negative Introject

2

Even though Mary Ann had been free of panic attacks for a year, she was still afraid she’d get one any minute. The 23-year-old nurse was taking 100 mg of sertraline every day. She had few side effects—e.g., sometimes a headache or stomachache—but she was still worried. At the beginning, when the diagnosis of panic disorder was made and she started taking the medicine, the psychiatrist had also prescribed 0.5 mg of Xanax if she did get a panic attack. At that time, she would keep one or two Xanax in a locket around her neck, but once the sertraline started working, she never needed them. The funny thing was she still wore that locket a year later because the negative part of her kept telling her that she wasn’t safe, and she could panic at any time. Logically, she knew this wasn’t true. As a nurse, Mary Ann understood the science behind panic disorder, but that did her little good when she was out in the world. She was afraid to ride the bus or get in the subway, and sometimes she would have agoraphobia, during which she was afraid to leave her apartment. Mary Ann discussed her fears with her psychologist, whom she saw once a week for psychotherapy. Her therapist was able to zero in on Mary Ann’s internal negative voice that told her she was always in danger. As a child, she remembered that her mother was constantly afraid that something would happen to Mary Ann. Her mother would say, “Don’t talk to strangers”; “look both ways when crossing”; “watch out

8  Anxiety and the Negative Introject

for strange men inviting you into their cars,” etc. All good practical advice that many mothers give to their children. Somehow, Mary Ann internalized these warnings into a malignant, negative introject. Why did she do this, and other people don’t? The answer is probably a combination of Mary Ann’s particular biology, chemistry, and psychology, which together create a certain dysfunction of her nervous system. We know that panic attacks are caused by a misfiring of the locus coeruleus, which is an alarm system in the brain.1 In the panic attack patient, the locus coeruleus fires off when nothing is wrong, triggering adrenaline to shoot throughout the person’s body. In people without panic disorder, this system fires when the “fight or flight” response is needed—e.g., to run away from a fire in a building. We don’t know how the negative introject is connected to the nervous system, but we can see the harmful effects in patients like Mary Ann. She has a faulty nervous system that causes panic attacks. She takes a medicine that gets rid of these attacks, but she is left phobic and fearful, nonetheless. Through psychotherapy, Mary Ann was able to largely conquer her fears—go outside, ride a bus, take the subway—even though the negative part of her told her not to do these things. When the negative introject reared its head, Mary Ann recalled her therapist’s advice, which is outlined in Table 2.1. If this sounds easy, it isn’t. Taming her negative introject took an enormous effort on Mary Ann’s part and many hours of psychotherapy. Sometimes it didn’t work, and Mary Ann wound up trapped by her fears again. Maureen was a 43-year-old pharmacist who prided herself on never needing medication. The one exception was in her 20s when she’d suffered from panic attacks after graduating college, and she’d briefly taken Table 2.1  How to Get Rid of Your Negative Introject 1.  Identify that the negative introject is active. 2. Call it by its name. In Mary Ann’s case, its name was “Cory” (a take on her mother’s name “Corrina.”) 3.  Fight it and reduce it in your mind. 4.  Remember you are more powerful than your negative introject.

Anxiety and the Negative Introject  9

imipramine, a tricyclic antidepressant (TCA) antidepressant. From the ages of 25–43, she’d been panic attack free and without medication. She was health conscious to the point of being insufferable to family and friends. She did daily workouts, ate a vegetarian diet, and bombarded her pharmacy customers with unsolicited medical information. Her husband arranged for the two of them and their children to go on a so-called dream vacation that proved to be a nightmare for her. It was a cruise to four Caribbean islands. Maureen had never wanted to go on a cruise, although she’d heard many people bragging about their trips. Being confined to a boat crowded with strangers and exposed to a lot of non-vegetarian food didn’t sound like fun. During the ten-day cruise, she didn’t feel seasick, but she resented the crowds of 3,000 passengers; hated their small cabin, which made her feel claustrophobic; and was repulsed by the unhealthy food. However, she didn’t want to complain because the vacation was her husband’s anniversary present to her. Also, her two children seemed to be enjoying themselves, swimming and playing the many games available on board. Once on shore and back to work, she expected her resentments to disappear and life to return to normal. Unfortunately, even though she was on solid land, she still felt as if she were rocking back and forth. She couldn’t believe it. Even if she held perfectly still, she had the sensation of moving. Her internist examined her and found nothing wrong. Then her Ear Nose and Throat specialist checked her ears and throat and assured her she was fine. She didn’t feel fine. She was upset and waited anxiously for a return to her normal state. She consulted three other doctors before they came up with the name for her problem, Mal de debarquement (see Table 2.2), or literally, sickness of disembarking. The condition is common, even in professional sailors. This illusion of movement felt after travel by ship or train or airplane usually stops after a few hours. Unfortunately, in some individuals, especially in females in their 40s and 50s, it can last for months to years or never stop. One explanation for the disorder is that the brain adapts to the movement of the ship or vehicle, but once the movement stops, the brain is unable to readapt. There are many treatments, including medications such as benzodiazepines, Klonopin or Valium, or selective serotonin reuptake inhibitors (SSRIs) like Prozac or Lexapro. Medications for motion sickness, such as meclizine

10  Anxiety and the Negative Introject

25 mg or dimenhydrinate 50 mg, may be used, but they are seldom helpful. Maureen did not want to use any of these medicines, but she was glad she had a diagnosis. At first, she thought she would just wait and hope to be one of the lucky ones in which the disorder simply stops. Then to her horror, after an 18-year hiatus, she began to have panic attacks again. They woke her from a sound sleep. She felt as if the bed were rocking. Her heart pounded; she sweated and shook, had a sensation of choking, and feared that she would die. She was only too familiar with the symptoms of a panic attack.2 After college, she’d been terrorized by panic disorder. She knew she could become more and more fearful and even agoraphobic, so she decided to consult a psychiatrist. From the first visit, she was very directive, telling Dr. Gold that the only medication she would take would be Klonopin. Dr. Gold agreed to put her on 1 mg once per day temporarily but informed her that in the long-run, she’d be better off with an SSRI—e.g., Lexapro. Dr. Gold saw Maureen as a small, slender white woman with sandy brown hair. Her speech was fast and eloquent, her mood anxious. She was oriented to person, place, and time. There were no hallucinations or delusions. No suicidal ideation. Dr. Gold’s impression was panic disorder 300.01(F41.0) (diagnosis category from the DSMV and ICD 10) and mal de debarquement. The doctor suggested that Maureen start psychotherapy once a week to deal with her worries about mal de debarquement and panic attacks. She agreed, relieved to have someone with whom to talk about her concerns. During the course of her six-month treatment, she understood that her usual style of never complaining and trying to “put on a happy face” worked against her, since her negative introject was let loose with a vengeance. Her husband didn’t even know that she had suffered from panic attacks in the past. He wanted to help, but she excluded him. The psychiatrist encouraged her to disclose her feelings to him. Her laissez-faire attitude with her children was also counterproductive. She learned to place appropriate boundaries with them. Panic attack patients often have difficulties setting limits with significant people in their lives. Their negative introjects tell them to just let people do whatever, even though that frightens them. Klonopin stopped her panic attacks. She refused to try an SSRI or take imipramine again. She was fearful about stopping

Anxiety and the Negative Introject  11

Klonopin, which helped her movement problem as well as the panic attacks. Very gradually, Dr. Gold tapered the Klonopin, and she was fine. At the end of treatment, she was panic attack free and only experienced mal de debarquement symptoms occasionally. Maureen’s case illustrates how panic disorder can be triggered by physical conditions, even after many years. Patients like her would do well to maintain some form of psychotherapy, even once to twice a year, to explore various inhibitions and remain aware of problems that could trigger panic disorder. Rachel, a 24-year-old, worked as a waitress in a night club. When she was 20, Rachel was raped in a park. She had experienced numbing and feelings of detachment from others afterward. She described herself as unloving, and she was not able to get close in relationships. Rachel did not expect to marry or have children. Her boss was attracted to her and often asked her out, even with the “Me Too” movement happening. Rachel did not care for him and refused to date him. One evening, in the early morning hours when they were closing up the night club, the boss grabbed and hugged her. She screamed and started punching him. Her exaggerated response was out of proportion to the offense, but Rachel was having a flashback to her rape scene. In her mind, she superimposed the rapist’s face onto her boss’s face. She cried and started trembling so violently that the boss was worried about her. Rachel couldn’t calm herself down. Finally, the boss and another worker had to escort her to a psychiatric emergency room for treatment. There Rachel was able to talk to the doctor about how she had been avoiding all thoughts and feelings regarding the rape. Table 2.2  Mal de Debarquement Syndrome 1. A common condition in people who have been on a boat or airplane or space flight or other moving vehicle. 2. Dizziness, swinging, swaying, unsteadiness and/or rocking sensation after disembarking a moving vehicle. 3. The symptoms usually resolve in several hours, months, or years, or in some people, especially women in their 40s and 50s, they may never end. 4.  The symptoms are not alleviated by anti-motion sickness drugs.

12  Anxiety and the Negative Introject

Rachel had been trying not to date or to get into any situations that made her think of the rape. But when her boss had touched her that night, a flood of feelings and thoughts of the rape had bombarded her consciousness. Her negative introject slapped her in the face with the very thing she had been denying. Rachel was given the telephone number of a clinic where she could go for psychotherapy sessions. Posttraumatic stress reactions at work are the most intensive type of stress because they reinvoke an excessive stress that was previously overwhelming to the individual. The best way to cope with these extreme reactions is for workers and supervisors to become aware of the possibility that someone who has been traumatized might be triggered again. Once the reactions have happened, medical intervention and psychiatric care are usually necessary. Another type of attack by the negative introject can result from workers’ interactions with machines used in the workplace. Jay, a 32-year-old hairdresser, is the owner of a salon. When Jay talks on the telephone, he clutches the cell so tightly that his knuckles turn white. He is only making an appointment for a client whom he knows well, but just talking to anyone on the phone causes him to have a large amount of anxiety. On the other end, the client is hesitating about what day would be best for her to come for an appointment. Jay feels himself sweating and trembling as he waits. He also feels a need to move his bowels. There’s nothing particularly frightening about this client. He is always intimidated when he is on the phone with anyone. When he handles the other instruments of his profession, he has the same reactions of anxiety. It doesn’t matter if he’s using the hairdryer or curling iron, he still feels as if the machine is in control, and he’s not. Jay was brought up in a strict family in which his father constantly yelled at him and disciplined him harshly for every minor infraction. Jay has internalized his father’s harshness and developed an unyielding negative introject that punishes him for any imagined mistakes. Whenever Jay talks on the phone, he has transference to the machine and unconsciously imagines the disembodied voice over the telephone line to be his father’s voice. Thus, he sweats and trembles and has an activation of his entire autonomic nervous system when talking on the phone. He

Anxiety and the Negative Introject  13

grips the phone (and other machines, like the hairdryer) so tightly until his hands ache. Jay has recently developed an unusual arthritic condition in his hands that may be due to this inordinate tension. The effect on Jay’s clients is adverse as well. Some people believe that Jay dislikes them and that is why he is cold and abrupt on the phone. Others think he is impolite or even rude, and they look elsewhere for a hairdresser. In addition to problems with machines in the workplace, many drivers get their negative introjects activated in the vehicles they operate. In some cases, the introjects are positive, such as when a pilot has a pet name for his small plane, or a male automobile owner may call his car “she.” This can have a good effect and cause the driver to take special care of the car or plane. But in other cases, the driver may view the vehicle as a malicious creature with a will of “her” own. In those cases, the driver works against himself and his ability to operate the machinery with his negative introject. Many of these irate drivers will be found to have had bad relationships with their mothers or other female caretakers. People can also have negative reactions to their computers. Some can even develop paranoid feelings toward computers and believe these machines are trying to harm them. Others can feel tense and stressed by machines they may believe are superior to them. Many people may be threatened or believe they are inadequate compared to their computers. The negative introject reactions to computers tends to run in the negative direction. George, a 30-year-old accountant, had always felt shy in groups. He was a wallflower, hanging back when others were enjoying socializing at parties. His colleague at work suggested that he try psychotherapy. George had always believed therapy was for “crazy” types, and he thought of himself, an accountant, as the sanest of people. However, his enlightened workplace was offering private counseling sessions with social workers to enhance work production. Despite his initial hesitancy, George decided to try it. His therapist discussed work issues with him, but then George opened up about his social phobia and how he couldn’t even get a date because he was too shy to ask anyone out. The therapist had treated many people with social phobia, and she could see how George’s condition also stopped him from talking to colleagues about work issues. In discussing George’s early history, his

14  Anxiety and the Negative Introject

therapist discovered that his father had berated him for most things when he was about 4 or 5 years old. George remembered standing in front of his angry father who admonished him for going out in the rain without an umbrella and ruining his new clothes. “You are a stupid, incompetent, disobedient wimp,” his father had yelled. George didn’t know what “incompetent” or “disobedient” meant at that time, but he knew that to be called stupid and a wimp was bad. George’s internalized negative voice would say the same things to him when he was with other people. It was almost impossible to get this severely critical voice out of his head, and it was especially difficult in groups. As a result, George shied away from interacting with people. His therapist suggested identifying this voice when he was trying to socialize with people. George couldn’t do it at first, but he kept trying, and eventually he was able to hear the critical part of him saying, “You’re a creep, stupid, and shy. So why should anyone want to deal with you?” He reported back to the therapist that finally (after many attempts) he was distinguishing that negative voice from all his other thoughts. They kept working on this issue until George felt more comfortable talking to other people. Betty was a beautiful woman in her late 40s who worked as a minor executive in a big corporation. Men flirted with her constantly. She’d had several relationships lasting at most a few years. Surprisingly, Betty considered herself ugly and grotesque. She couldn’t understand why men even bothered with her and thought they’d go after any woman for sex. She was the youngest of three sisters with a narcissistic mother and an alcoholic, workaholic father. Her mother had considered her oldest sister, Darlene, a beauty (although she wasn’t in reality) and spoiled her, inducing narcissism. The second sister, Trudi, was supposed to be the brains in the family, although Betty was actually the smartest and had obtained an MBA from a prestigious university, and Trudi had barely graduated from a city college. Betty was treated like Cinderella, having to cater to the two older sisters and her mother. All negativity rolled downhill onto Betty’s head. Her two sisters mocked her and called her ugly and fat. Betty became insecure about her looks, her intelligence, and her place in the world. When her therapist tried to understand why Betty felt so bad about herself, Betty showed her a picture of an old, toothless hag. Betty said

Anxiety and the Negative Introject  15

that the image reminded her of herself. The therapist couldn’t believe that Betty could even relate to this elderly woman, let alone consider herself like her. No wonder she felt ugly and inadequate. Betty’s therapist asked her to name the image. Betty called her “the mole,” and they were off and running with a picture and title for Betty’s negative introject. In body dysmorphic disorder, the patient is preoccupied with imagined defects in his/her appearance. This preoccupation (and obsession in some cases) causes significant impairment in the patient’s life— socially and occupationally, as well as in other important areas of functioning. Betty’s horrible view of herself caused her to date men who were inferior to her in many ways. The relationships always broke up because the men were so inadequate compared to her, but she would blame herself. She took a lower salary and positions that were beneath her at work. Whenever she’d get together with the family, her mother would insult Betty and exalt her two sisters. Her therapist recommended less frequent family gatherings. Her therapist also advised intensely picturing “the mole” when dealing with her mother or sisters. Betty had to constantly remind herself that she wasn’t ugly or grotesque. Patients with anorexia nervosa who refuse to maintain a minimum normal body weight and are intensely afraid of gaining weight also have a distorted view of the shape and size of their bodies. They see themselves as fat when they are actually emaciated. Tina wore three sweaters to appointments with her therapist, even in the sweltering heat of summer. She was pale and small and shriveled looking, even though she was in her late 20s. She had been hospitalized twice in her early 20s for being so underweight. She had anemia and very low energy. In the hospital, Tina was told that they wouldn’t discharge her unless she could get her weight up to 100 lbs. She was desperate to leave. A friend with anorexia suggested that Tina put stones in her pocket to make herself appear heavier. She did so, fooled the nurses and doctors, and was sent home. Tina promptly went back online to a site for anorexics called Ana, where other people with the condition posted suggestions on how to eat less, starve yourself, and generally survive as an anorexic. Tina’s therapist asked her what she saw in the mirror when she looked at herself. Tina replied, “A big, fat horse.” Again, the therapist was

16  Anxiety and the Negative Introject

shocked at the reply because, contrary to her patient’s self-description, what she saw was a small, starved white woman bundled up in three sweaters. All other aspects of Tina’s reality testing were intact. She knew the date, where she was, her name, etc. She didn’t hallucinate or have any delusions, other than that she was fat. Her negative introject concentrated only on her body image. Tina and her therapist called her negative introject “Hammer the horse” because it hammered Tina. Tina’s therapist found it extremely difficult to get through to Tina. Even though they had agreed intellectually that Tina was too skinny, and “Hammer” was sending her false images of her body, Tina continued to restrict her food intake and to be anorexic. With an anorexic patient, even if the patient aligns herself with her therapist, stopping the cycle of not eating is one of the toughest projects a therapist will ever attempt. The intense fear of gaining weight or becoming fat is so powerful for these patients that many times, if their weight is dangerously low and their Body Mass Index (BMI) falls below 15, they may need to be hospitalized like Tina. On the other hand, we have overweight patients who detest the way they look and who are able to see themselves as obese, but who continue to overeat. They tell themselves that they are disgustingly fat, but then to comfort themselves from the negative introject who is saying nasty things about their bodies, they eat tremendous amounts of food. Some of these patients and some of the anorexic patients also have bulimia. These people will binge eat huge amounts of food (usually junk food, e.g., pizza, cakes, French fries) in a short period of time and then force themselves to vomit or consume laxatives or diuretics or do excessive exercise. Eating disorders are characterized by severe disturbances in eating behavior because the negative introject interferes with normal thinking and functioning. The negative introject in anorexia tells a person that she is overweight and will project this image in the mirror, even though the person is clearly underweight to any observer. Usually, this condition develops during childhood or early adolescence. According to ICD-10 (International Classification of Diseases, 10th Edition) criteria, a person needs a BMI of 17.5kg/m2 or less to be diagnosed with anorexia nervosa.

Anxiety and the Negative Introject  17

Agnes was a 46-year-old translator who had been anorexic since her late teens, although she refused to acknowledge this as a problem. She also would binge and then purge by vomiting. She belonged to a health club that she would attend daily and sit in the sauna for hours. She felt she was sweating out toxins or fat. Most club members averted their eyes when they saw Agnes. It was painful to look at such a skinny woman who resembled a walking skeleton with a bit of flesh spread thinly over her bones. However, when Agnes looked at herself in the many mirrors around the club, she saw lumps of fat on her belly and upper arms. Her negative introject told her she must restrict her eating to rid herself of these fat lumps. She was vegan and on a special raw diet of her own invention. If she altered her diet, the negative introject instructed her to throw up. Most of the time after bingeing, she would vomit. The other women in the club heard her throwing up all the time and reported her to management. When confronted, she denied that she was vomiting. Her intense fear of gaining weight was constantly hanging over her. She had only menstruated briefly in her 20s, and then with such a low body weight, her periods stopped. She was glad she didn’t have to go through the mess of menstruating. She didn’t want to date, have sex, or have a family either. Agnes’s negative introject kept her emaciated and depressed, but she refused medical treatment, claiming that most medical doctors in the West were quacks. Randi, a 32-year-old, was 5’2” and weighed 250 pounds. She knew she was fat and wanted to lose weight. As a result, she’d been on every diet that she could find. Nothing worked because Randy would eat enormous amounts of food—e.g., a loaf of bread, a box of cookies, a box of donuts in one sitting. Her negative introject would take a break while she ate and then insult her after she finished eating. She did binge eat—i.e., take in a large amount of food in a short period of time. Randi would not vomit or purge with laxatives. She kept all the food in her system, and so it accumulated as fat. She was embarrassed by how big she was because she couldn’t fit into clothes that she wanted or didn’t have the energy to walk around or work out. She wanted to get her stomach stapled to lose weight. Her psychiatrist prescribed 5 mg of Ritalin to try to control her bingeing. Randi tried to take it as directed, once per day in the morning, but she continued to binge, and her negative introject continued to beat her up.

18  Anxiety and the Negative Introject

In summary, all of these anxiety disorders (panic attacks, mal de debarquement, posttraumatic stress disorder (PTSD), and body dysmorphic disorders, including anorexia nervosa and bulimia) are infiltrated by the negative introject of the patients depicted here. The suffering caused in these cases could possibly be alleviated by concentrated attention to the role that their negative introjects play in the pathologies exhibited.

Notes 1. Berman, C. W. (2010). 100 questions & answers about panic disorder (2nd ed.). Sudbury, MA: Jones and Bartlett Publishers. 2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.), p. 214. Washington, DC: American Psychiatric Publishing.

Hypochondria, PTSD, OCD, and the Negative Introject

3

Janet would feel terrible if she had the slightest injury. One day, she bumped her head on the locker in the gym, which caused a bang as if a drum had been pounded. She winced and ran to look at her face in the mirror. Of course, the right side above her eye looked red, and later she would have a bruise. Most people would have put some ice on it and forgotten the incident. Not Janet. She obsessed about it for the rest of the night, causing herself to be miserable and frightened. She could hardly eat dinner because she worried that if she did have a concussion, she would vomit the food back up. She told all her friends about it. They all reassured her that they had banged their heads with few consequences. She looked up “concussions” and then “hematomas” on the Internet. When she tried to lie down to go to sleep, she felt her body stiffen and realized how anxious she was. She knew that with a concussion, she was supposed to stay awake or at least have someone watch her for 24 hours, but she was all alone. Janet didn’t feel she could impose on any friend to watch her for all those hours. What was really going on with Janet? With any slight injury, her negative introject was triggered. Her parents had been quite abusive, smacking her around at the smallest provocation. Her only defense was to let her strong superego take control and punish her before they did. This didn’t stop them from hurting her, but it gave her some feeling of control. When she hit her head, her negative introject awakened.

20  Hypochondria, PTSD, and OCD

With Janet, this would involve obsessing about the injury, considering all the bad consequences, and then worrying incessantly about them. In psychotherapy, her therapist pointed out that she was causing herself more harm by obsessing about minor injuries than the injuries themselves. Janet and her therapist worked on decreasing Janet’s obsessions by using cognitive behavioral techniques (CBT)1—i.e., focusing on the reality of the situation. When she banged her head slightly, the probability that anything was wrong was so small that it wasn’t worth Janet’s time to think about it. CBT helped only slightly, so Janet’s therapist sent her to a psychopharmacologist for medication. The psychiatrist prescribed sertraline. It took four weeks to kick in, and Janet had to raise the medication to 400 mg/day, but then, finally, she felt she didn’t have to think she was dying every time she sustained the smallest injury. At that point, her therapist was able to work with her on reducing the impact of her negative introject. Obsessive-compulsive disorder (OCD) is definitely caused by a reduced amount of serotonin in certain parts of the brain. Animals— e.g., dogs and horses—have been found to have OCD. When given SSRIs, such as sertraline or fluoxetine, canines are able to stop obsessively licking their paws to the point of bleeding, and horses can stop such compulsive behaviors as circling over and over again. So how does the “negative introject” affect chemistry or brain circuits? We don’t have any studies on this, but we do know that many OCD patients like Janet benefit from a combination of CBT therapy and medication. Maggie could hardly tolerate any criticism because it triggered her negative introject. A co-worker one step down from her at her company implied that Maggie was inadequate and really shouldn’t be in her position as an assistant to the vice president of their company. The co-worker was clearly trying to usurp Maggie and take her job. Although Maggie understood what was happening intellectually, emotionally she was devastated at the barbs aimed at her. She went home that night and kept obsessing about what the other woman had said about her. She couldn’t let go of the negativity because the negative part of herself (the introject) had seized on the co-worker’s comments. Maggie’s mother had always degraded her in many ways. Her mother’s voice formed the basis of her negative introject. If she obsessed

Hypochondria, PTSD, and OCD  21

about the critical things people said, it softened and decreased the impact of the criticism. Maggie was not the type to go to a psychiatrist, so she never identified her negative introject, and she never stopped obsessing. Of course, all of this made her miserable. Gail was a 35-year-old middle school teacher who was excessively polite to everyone. Her mother and father were working-class people who spoke plainly about everything. She considered them crude and inappropriate most of the time in the middle-class neighborhood they’d moved into. Gail was the first one in her family to attend college and then become a teacher. Whenever she had skirmishes with anyone, she tried to control her temper and her language. Her first impulse was to curse her opponent as she’d seen her parents do, but she usually didn’t. One day, Gail had finally had enough of a fellow teacher who told her what to do and bullied her in general. At the end of the argument, Gail said, “Will you please SHUT UP!!!” The other teacher looked shocked because she’d never heard Gail speak up for herself like that. Gail walked away feeling victorious at first, but then she felt guilty and uneasy. Would the other teacher report her? Had she taken advantage of a person less powerful and less intelligent? How crude had she been by descending to the other teacher’s level? Speaking up like that triggered Gail’s negative introject, which in her case was like a punitive superego. Her parents taught her to be polite, unlike themselves. Gail was reprimanded by her parents every time she burst out with curse words or a bad temper. They wanted her to function on a higher level, and she had incorporated their values, even to the point of looking down on them. That night, Gail kept obsessing about her bad behavior. She wished she could take back what she’d said. She felt that she had hurt the other teacher unnecessarily. Gail forgot that the other woman had been mean and unkind to her for over a year. She could only think of her own offensive language. She vowed to apologize the next time she saw her colleague in the cafeteria at lunchtime. When she did see the other teacher, Gail approached her ready with an apology, but the other woman turned her back and walked off in a huff. Suddenly, Gail felt relieved and justified. Why would she ever apologize to that monstrous woman? Gail’s behavior had actually been a good solution to rid herself of a bully.

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In PTSD, the patient keeps reexperiencing a traumatic event. Bob, a 30-year-old musician, had been raped when he stayed overnight in a homeless shelter. Two men had held him down while a third violated him. He wound up with lacerations around his face and an anal fissure, but the worst part was that he kept remembering the trauma repeatedly. He also had nightmares about being raped. The “negative introject” sadistically held up pictures of the rape in Bob’s mind. Bob sought treatment in the emergency room nearest the shelter. The psychiatrist who saw him was very sympathetic and gave him an SSRI and a tranquilizer to decrease his symptoms. Bob needed psychotherapy as well, but he couldn’t afford it. He had to wait until his symptoms subsided by themselves. It took several months before Bob stopped thinking about the trauma, and his nightmares finally subsided. Bob’s father had always warned him to be careful about his money and to take good care of himself. He had considered Bob “a flake,” and he criticized him whenever he would lose money or his possessions. As a result of not paying attention to bills and payments that needed to be made for his apartment, he’d lost it and had to live in the shelter. He heard his father’s voice calling him “a flake.” Of course, that was Bob’s negative introject acting up whenever he did anything wrong. In order to have a diagnosis of PTSD, a person has to (1) directly experience the traumatic event, or (2) witness it in person if it occurs to someone else, or (3) learn about it from close family members or friends, or (4) be bombarded by aversive details. Then the following intrusive symptoms occur: recurring memories, nightmares, and dissociative reactions such as flashbacks. People try to avoid the memories or dreams. Many will become irritable and angry, have reckless behaviors, hypervigilance, and sleep disturbances.2 While meditating, Carrie, a 23-year-old librarian, would see the most horrendous images: a girl getting raped, a man getting his ear cut off. Carrie realized the images were from movies or TV shows she’d seen. Why did she get them when she was trying to quiet her mind and meditate? Her negative introject was most active when she wanted to silence her active mind. Her unconscious had a chance to display horrible images that had flashed in front of her that she hadn’t really “digested.” Moreover, she hadn’t dealt with her psychological baggage.

Hypochondria, PTSD, and OCD  23

The short play that follows is a good example of how the negative introject can interfere with a person trying to meditate.

QUIET MIND A ten-minute play by Carol W. Berman Characters JAN: ANTI-JAN: BOBBY:

F, 35, practices yoga F, 35, the negative part of JAN—she looks like JAN M, 60s, JAN’s superego, distinguished looking

Setting:

JAN’S bedroom in New York City Present time.

At Rise: JAN pours a bottle of vodka down the drain and then goes into full lotus position, trying to meditate. She’s sitting quietly, center stage, in yoga top and pants, barefoot for a few seconds. Then two other characters, ANTI-JAN and BOBBY, from her mind, enter and distract her from quiet mind meditation practice. ANTIJAN looks similar to JAN, but she’s angrier. BOBBY is an older, regal man. Things start off slowly and escalate. ANTI-JAN (entering and addressing JAN) It’s hot in here. You should open the window. She bounces around the stage, showing that she’s hot. JAN sits quietly, trying not to hear or see her. That was really bad with your boss yesterday. I don’t know what you should do, but you better do something. I’m worried. Maybe he’ll fire you. You’ll never get that raise. JAN (speaking with her eyes closed because she wants to stay in her meditative state) Ssssh. Go away! I’m trying not to. . . ANTI-JAN Don’t ignore me. I’m just giving you important points that you need to know. By the way, your stomach is really hurting on the left side. Maybe you have ovarian cancer like your aunt or appendicitis. . . JAN Monkey mind be gone. I banish you from my mind. I need to meditate. Go away. I don’t want to. . .

24  Hypochondria, PTSD, and OCD ANTI-JAN You need me. You almost fell down on that broken sidewalk yesterday. If it weren’t for me watching out for you, you’d have broken your ankle again like you did. . . JAN Shut up! ANTI-JAN No! I’ll talk as much as I want. JAN (gets up and starts pushing ANTI-JAN) Get out of here once and for all! ANTI-JAN I won’t leave! They fight in a push-pull battle. BOBBY (entering and standing behind them with his arms crossed on his chest) Stop it! Ladies! Ladies! JAN (stopping the fight) She won’t shut up. It’s one thing after another. Blah! Blah! Blah! All negative stuff. I’m working on the sixth step, and I don’t need her shit. ANTI-JAN She needs me to tell her what’s what. JAN I don’t. ANTI-JAN You do. Otherwise, you’d be in some fantasy land. BOBBY (to JAN) Are you supposed to battle negative thoughts or just let them pass through your mind? JAN I know I’m supposed to let them pass, but. . . ANTI-JAN I don’t want you to let me pass through. I want. . .

Hypochondria, PTSD, and OCD  25 BOBBY Jan, just acknowledge that she’s there and let her pass. JAN It’s really hard, because she’s so insistent, and she never shuts up. ANTI-JAN Bullshit! BOBBY Try again. Bobby stands at attention behind Jan as she resumes full lotus. Anti-Jan scowls and steps to the side. Jan breathes deeply. ANTI-JAN (after a few seconds runs over to Jan and flicks her in the head with her fingers) Wake up, moron! The whole world is out there, and you’re sitting here on your butt. You’re ready to have God remove your defects of character but. . . BOBBY (grabs Anti-Jan’s hand) What did she just tell you? Jan tries to stay in full lotus while Bobby and AntiJan fight. ANTI-JAN What does it matter what she said? She needs me to tell her where it’s at. Also, I quoted the sixth step for her. BOBBY She’s got me, thank you. ANTI-JAN You’re in an ivory tower. The realistic thing. . . BOBBY We’re not into realistic now. Jan, you might have noticed, is trying to suspend herself without thought in meditation. ANTI-JAN What the hell does that mean? How is she going to stay sober without me?

26  Hypochondria, PTSD, and OCD BOBBY Leave her alone! I’m helping with all the steps! Suddenly an alarm goes off. They all freeze, and then Jan jumps up. JAN What is that? ANTI-JAN It must be a fire! Run! BOBBY Take it easy, everyone! JAN I’ll be right back. She exits for a few seconds, leaving Anti-Jan and Bobby glaring at each other. ANTI-JAN You see what I mean? Was she supposed to ignore that and just keep meditating? BOBBY She went to investigate, as she should. ANTI-JAN You’re so calm because you don’t care what happens to her. BOBBY Of course, I care, but I have a more measured attitude than you. JAN (reentering) It was just my egg timer. I forgot to turn it off when they were done. ANTI-JAN You see, you have to stay alert and not go into some Zen state. What if you have an emergency? BOBBY It was nothing—a good meditator would have stayed in position throughout that.

Hypochondria, PTSD, and OCD  27 JAN (resumes her lotus position and starts breathing deeply) OK, let’s try again. A few seconds pass as Anti-Jan scowls around the stage. BOBBY I’m warning you. Keep away. ANTI-JAN I’ll do and say whatever I feel like, big guy! BOBBY I am a big guy and the control around here! ANTI-JAN You’re not controlling me! Maybe you can be her superego, but. . . JAN Shut up! Everyone! I’m so disturbed I can’t meditate. ANTI-JAN Let’s go for a walk. You need some fresh air. BOBBY (crosses his arms and glares at Anti-Jan) I’m leaving if you don’t leave. ANTI-JAN I don’t care what you do. Leave! I’m here to stay. BOBBY I’m warning you! JAN Oh no, not you too. All of you get out of here! BOBBY If I leave, you know what will happen. Do you want that? ANTI-JAN He’s going to let you . . . He wants you to . . . What kind of superego is that? JAN I’m trying not to, but you both are driving me to it.

28  Hypochondria, PTSD, and OCD BOBBY Good-bye! He stomps out. JAN Bobby! Come back! Don’t leave me now! ANTI-JAN See! He left you just when you needed him. JAN (gets up from meditation) Girl, you’re gone too. Watch this! She gets up and grabs the bottle of vodka (which was not fully emptied at the start) and takes a big slug. ANTI-JAN Not that. Not now. Go to a meeting, Jan! She runs off stage, yelling. Bobby! Bobby! Come back. JAN Finally! They’re gone! She sits down on a chair with a sigh of relief and takes another swig.

THE END Anti-Jan represents the negative introject and bobby the superego of Jan.

***** Carrie had been abused sexually and emotionally by unstable parents. She had never addressed these issues and suppressed them until she joined a meditation group. In the group, they would sit in a circle for 30 minutes and discuss events of the day. Then they’d break up and sit individually and meditate with a leader giving them timings and images. While meditating, Carrie would see the most horrendous images. She asked other people in the group if they had experienced similar unnerving visions. No one else had. The leader

Hypochondria, PTSD, and OCD  29

suggested that Carrie try individual psychotherapy to deal with the disturbing images. When Carrie went to therapy, her psychologist dug around in her history until she discovered Carrie’s abuse. Like many people, Carrie thought what she’d experienced was normal. She had showered with her father until she was 15. He’d touched her sexually and even asked her to hold his penis. She’d complied, and her mother had mostly ignored their behavior. At other times, Carrie’s mother would slap her and scream at her, calling her a “whore.” Carrie had acted out sexually starting at age 15, dating inappropriate men who were sexually aggressive. Her parents had criticized and punished her for this behavior, so she had moved out at 17 to live with a man who was 37. He’d encouraged her to go to college and to get a degree in engineering, for which she had a predilection. She sought out the meditation group to calm her nerves. Since adolescence, Carrie had had irritable bowel syndrome and migraines. Her family was not the kind who sought medical treatment, or she would have gone to psychotherapy much sooner. Her negative introject was formed at an early age when she was trying to cope with two crazy parents. In PTSD, the flashing of negative images while a person is meditating is common. Penny was a 33-year-old IT expert who shied away from most people. She had terrible fear of being in social situations, such as parties, conferences, and even classrooms. When she was a child, she dreaded being called on by the teacher, even though she was very smart and knew most of the answers. At those times, she couldn’t find her voice. She would stutter or completely freeze if the teacher wanted her to speak. Her main fear was humiliating herself in front of other people. At the age of five, her father had demanded that she learn to recite the poetry he provided for her to read. She had difficulty reading at such an early age, but her father would take no excuse. He yelled at her and even spanked her if she wouldn’t do what he asked of her. Many times, before she had to recite for him, she would throw up or have diarrhea. These fears carried into her teens and 20s. Her negative introject sounded like her father: cruel and insistent and degrading. If she

30  Hypochondria, PTSD, and OCD

was standing around at a party (she hated them, but sometimes would be forced to attend because of work), her negative introject would be hyperactive, telling her how stupid she was that she couldn’t open her mouth and socialize. She would drink excessively to counteract her fears and then run out of the party as soon as she could. Tricia was a 40-year-old writer. One morning, she found that she couldn’t swallow anymore. She felt a lump in her throat at all times. In an attempt to dislodge it, she forced food down her throat. Some food must have been going down, because in the several weeks that she experienced the lump in her throat, she lost only a few pounds. Tricia could not afford to lose any weight. During her teen years, she had been diagnosed with anorexia nervosa, and afterward, she’d always been too thin. At work, her company downsized, which left her with two of her co-workers’ duties without any salary increase. Previously, she had been too timid to complain about the work overload, but now she was positively silenced by the fear of losing her job. Every day, she’d wake up with dread about her burden of work. Her throat seemed to close off more and more. She skipped breakfast and usually lunch. For dinner, she managed to get down a little rice and some finely chopped vegetables. She grew weaker day by day. Co-workers commented about her paleness and lack of energy. She was frightened to tell anyone what she was experiencing. Finally, she mentioned the throat lump to a girlfriend who wanted to have lunch with her. Her friend insisted that she consult a gastroenterologist (G.I. doctor). When Tricia went to the G.I. specialist, he ran several tests and discovered nothing wrong. He sent her to me, and I diagnosed major depression. Besides weight loss, she had insomnia, suicidal ideation, depressed mood for greater than two weeks, inability to enjoy anything, and crying spells. I recommended that she take the antidepressant, Effexor, which she started at 37.5 mg for one week and then gradually increased up to 150 mg. Tricia also began psychotherapy with me. I learned that she had lost her father when she was 10 and her mother when she was 17. An older, married half-brother had taken her into his household after both her parents died. He turned his sexual attention toward Tricia when his wife was pregnant. Tricia couldn’t tolerate his advances, and so

Hypochondria, PTSD, and OCD  31

she moved out at 18. Throughout her life, she had focused on men who either ignored or rejected her. If any man actually liked her, she avoided him. She’d been socially reclusive for most of her life, but she was able to work regularly. After four weeks on Effexor, Tricia felt better about herself. She was not overwhelmed at work nor did she feel so disadvantaged in general. Her throat still had a lump in it, but she slept better, and her suicidal ideation was eliminated. She no longer wanted to cry for the slightest reason. Tricia’s condition is called globus hystericus, or psychogenic dysphagia. This diagnosis is made when a patient feels a lump or fullness in the throat, but there is no true dysphagia; in other words, the person can actually swallow. The diagnosis should be made with caution and only after a thorough examination by a G.I. doctor, who must rule out organic disease. The exact mechanism causing globus hystericus is not known, and it is not associated with any specific psychiatric disorder, although it may be the harbinger of many different conditions. Tricia can also be considered to have conversion disorder. This condition was called hysteria even before Freud, who studied it in great detail. The ancient Greeks associated hysteria with women and believed it originated from a “wandering uterus,” hence the term hysteria from the Greek word “hysterus,” or womb. Freud’s case of Rosalie H., who complained of choking and constriction in her throat, is similar to Tricia’s case. Freud’s patient was sexually approached by an uncle in much the same way that Tricia was approached by her half-brother. Both women were frightened and traumatized by these events, but not consciously. In each case, they repressed the events. These days, we don’t like to use the term hysteria because we think it represents a prejudice against women. Tricia and Rosalie were both able to work out their feelings in psychotherapy and ameliorate their globus hystericus. Tricia had the added advantage of modern medication. After eight weeks of treatment, Tricia complained of globus hystericus only a few times a week. She was much improved and was able to enjoy life and work better. I suggested she stay on Effexor for another six months and continue psychotherapy for at least as long. It is unusual for depression to first present as globus hystericus, but it’s not all that uncommon. When her depression was finally treated, her dysphagia improved as well. Many times, depression begins with

32  Hypochondria, PTSD, and OCD

somatic complaints. After organic conditions are ruled out, then major depression can be treated, which often eliminates the original somatic problem.

Notes 1. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York, NY: The Guilford Press. 2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

Major Depression, Bipolar Disorder, and the Negative Introject

4

Trishi hated to wake up early every morning because that was when she felt the worst. Not that she felt so wonderful during the day or night either, but mornings were particularly difficult. As soon as she opened her eyes, she started feeling horrible about herself. She told herself she was worthless, lazy, self-indulgent, stupid. As a result, it was a major ordeal to drag herself out of bed. She was a freelance writer and had no set schedule. When she finally did wake up, sometimes not until 11 a.m., she felt better, but she had low energy. She didn’t feel like eating very much and had lost five pounds in the last few months. Usually that would make her happy. Like everyone else she knew, she could stand to lose five pounds. She was only 28, but she felt like she was 88. At night, it was hard to fall asleep, so she stayed up looking at Facebook or her favorite Internet sites. She knew she shouldn’t because viewing computer screens before bed made it harder to sleep. Her mother made an appointment for her at a psychiatrist’s office. Trishi didn’t want to go, but she didn’t want to disappoint her mother, who promised to accompany her. The doctor was kind and gentle when Trishi and her mother met with her. Dr. Lane said, “You have all the classical symptoms of depression—insomnia, poor appetite, anhedonia, blue mood. I think you should take an antidepressant.” Trishi’s mother revealed that her mother and uncle had had major depression

34  Major Depression and Bipolar Disorder

too. Trishi reluctantly agreed to take sertraline, which the doctor said would take several weeks to kick in. We can see the criteria Dr. Lane used to diagnose depression in Trishi if we refer to the DSM-V (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition).1 In the third week after starting the antidepressant, Trishi felt a little better in terms of her energy level, sleeping, and eating, but mornings were still terrible. There was a part of her that she couldn’t shut up that kept telling her how worthless and stupid she was. Trishi decided to take all her pills at once and end her life. She really couldn’t take it anymore. Her mother had a key to her apartment, and when she couldn’t reach her daughter, she went over and found her daughter unconscious. The ambulance that she called rushed Trishi to the hospital, where she was admitted to the psychiatric ward. Dr. Lane, the psychiatrist who had given her medication was her treating physician. When Trishi was well enough (she didn’t have any lasting consequences from the overdose), she attended group sessions with other depressed patients on the ward. Trishi revealed that she was exhausted from an inner voice that kept degrading her and that’s why she had attempted suicide. Two other patients said they had the same problem. Then the doctor talked about a negative introject “that had to be tamed.” She gave suggestions to name it, address it, and be aware of it. Trishi named hers “the dragon,” because it was monstrously large, and it breathed fire at her. All the patients had colorful names for their introjects. In art therapy later that afternoon, they drew pictures of the introject. Trishi created a green creature with red fire pouring from its mouth. The next morning, when “the dragon” roared her awake, Trishi imagined herself wearing armor and wielding a big hose that drenched the creature in water. She chuckled at her image and felt much better. How is it that a mental construction, a mere idea, can cause a person to attempt suicide? It seems strange and uncanny that one’s mind can have so much power over one, but it does. We psychiatrists admit patients to psychiatry wards every day after suicide attempts. Depression and suicide are linked. It is often the case that when a patient feels a little better from antidepressants, he/she may attempt suicide. Depression is not the only cause of suicide, although it is an important

Major Depression and Bipolar Disorder  35

one of which we must be aware. Patients with delirium, addictions, schizophrenia, or bipolar disorder often consider and attempt suicide. Every morning, Karen woke up thinking the most mundane but depressing thoughts: “I must find a way to get those spots out of the carpet.” “How will I be able to juggle seeing both friends Saturday afternoon?” “I won’t be able to finish my work today.” The spots in the carpet bothered her because she was a perfectionist and didn’t like to see dirt anywhere, any time. She knew that the cleaning woman would take them out in a few days, but her mind constantly returned to those red dots on her carpet. What a stupid and annoying thing to dwell on. Karen would be able to see one friend in the morning and then the other friend in the afternoon on Saturday. She was used to juggling different people in the same day. She always found a way because she was clever and knew how to keep certain friends who hated each other away from each other. Why did she worry about that at all? In addition, Karen was very industrious and always finished her work, no matter what. Waking up with these useless and annoying thoughts every day kept Karen anxious and depressed. She could have thought, “Thank God I’m alive.” “It’s a gorgeous day, and I can go on my favorite trip to the park today.” “I’m lucky that I don’t have to work today.” These positive and life-enhancing thoughts didn’t occur to her. They were true, but not the first things that came to her mind. Table 4.1  Chart of Positive Thoughts to Substitute for Negative Ones 1. When you feel irrational anxiety or fear without cause: counteraction = be realistic. Is there really anything happening? If not, concentrate on being here now. 2. When you feel depressed without cause: counteraction = what is actually wrong? Move on to positive thoughts and visualization of beautiful moments. 3. When you feel obsessive: counteraction = break into new activities, forcing yourself to try things you haven’t tried before. Note: None of these suggestions will work if you have a chemical imbalance—i.e., an anxiety disorder, major depression, or OCD. These need to be diagnosed by a professional.

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Karen had grown up in a lower middle-class family in upper New York State. Her parents both worked at menial jobs to support her and her sister. Karen respected them because they were hardworking and tried their best to give their children a decent life, but the first words she heard out of her parents’ mouths in the morning were complaints about their jobs and situations in life. Her father would say over his cornflakes, “My boss is so mean to me. I’m thinking of quitting tomorrow.” He worked in the sanitation department and had a good salary and benefits, but his back was always hurting from lifting cans, and he often felt humiliated by his job. Karen’s mother, who worked in a factory on the assembly line, would argue with him and complain about her job and how the other women in the factory ostracized her because of some of her radical leftist opinions. Karen and her sister, who was two years younger, would kick each other under the table and send special hand signals to each other during meals, criticizing their parents. When they were older, they would simply tell their parents to be quiet. Karen went on to college and became a dentist, while her sister became a lab technician. Their parents were proud that their children had risen to the middle class. Even though Karen had done well, her early years with her negative parents were responsible for forming a virulent introject. She didn’t know how to escape her depressing, unnecessary obsessive thoughts about carpets and work until she went to psychotherapy. Karen didn’t even realize she was being so negative as soon as she awakened until her therapist asked her what she thought about first thing in the morning. Karen was pleasantly surprised to think that she could change her mind-set and become more positive. Karen was able to suppress her negative introject and substitute positive thoughts for the negative ones with the help of her psychotherapist. At 35, Beth finally decided to try an antidepressant. She felt that her life had been a continuous cycle of “up” or “down,” and she was tired of it. “Up” wasn’t so bad. In fact, she enjoyed the euphoria. On her daily walks when she was “up,” she’d notice the sun shining so brightly that every leaf glowed as the birds in the trees produced an opera. Sleep was unnecessary in this state. She could stay up all night on her shift sorting mail in the post office and then stay up the entire day too.

Major Depression and Bipolar Disorder  37

Eventually, she’d burn out and “crash,” feeling so “down” for 12 to 17 hours that she’d take to her bed. When she awoke, she felt short-tempered and irritable. She’d cry and wish she were dead. Her kind husband, whom she’d been married to for 15 years, would cook dinner for himself and their two young sons. Beth didn’t touch his healthy dinner. Instead, she would binge on cake and other sweets, as opposed to when she was “up” and didn’t need food at all. With encouragement from her husband, Beth revealed her problems to the family doctor. Dr. Smith had known and treated Beth, her husband, and their parents for years. He pulled out samples of an antidepressant, Lexapro, from his cabinet. Beth was afraid that the antidepressant would change her in some vital way, but she knew she couldn’t go on as she had. After breakfast, she dutifully swallowed a 10 mg Lexapro pill. She didn’t feel any different for three weeks. Finally, at the beginning of the fourth week, Beth felt a jolt of energy. She impulsively spread cookbooks all around her kitchen. Then she poured flour into three different bowls, intending to make a batch of brownies, oatmeal cookies, and a chocolate cake simultaneously. A TV program distracted her. She stopped to watch the show and never made any dessert. Thoughts raced through her mind. At 10 p.m. when she had to go to work, she decided to run in the park first. Her husband reached home an hour later and picked up her phone when her supervisor called. He was worried that Beth wasn’t at work and had left her cell in the kitchen. He promised the supervisor that he would try to find her. His attempts failed. Beth limped home at 3 a.m., bedraggled and rain soaked. Her husband hardly understood her confused explanation of where she’d been and what had happened. Since her leg was bleeding, he took her to the emergency room. They waited until 9 a.m., and then Dr. Smith appeared. He patched up her leg and gave her the number of a psychiatrist who worked with his patients. “But why should I go to a psychiatrist? Can’t you continue to help me?” Beth felt like Dr. Smith was abandoning her for no reason. “You might have something more complicated than just regular depression. Only a psychiatrist would be able to help if you have bipolar disorder.” “What’s that?” Beth didn’t want to have anything worse than she already had.

38  Major Depression and Bipolar Disorder

“Bipolar disorder is also called manic depression. Have you heard of that?” Dr. Smith looked concerned, the furrows between his brows deepened as he observed Beth through his bifocals. “I guess I have. Sylvia Plath and Virginia Woolf had manic depression, didn’t they?” “Yes, I believe they did.” Beth followed his advice and visited the psychiatrist. Dr. Katz was even shorter and stouter than Beth, who was 5’1” and 150 pounds, which made Beth relax. After taking her history, the psychiatrist agreed with Dr. Smith and said Beth probably did have what Virginia Woolf had— i.e., bipolar disorder—but a milder version called bipolar disorder II.2 In addition to Lexapro, which Beth would stay on, Dr. Katz wanted her to take 25 mg of Topamax for one week. Then Beth had to increase to 50 mg for one week and then 75 mg. Beth took the prescription for Topamax and went home. Unfortunately, Topamax did not agree with her. Beth felt lethargic and more depressed. Even though she hadn’t had a migraine headache for months, she had a terrible one the second day of taking the medicine. She tried to tolerate the side effects, trusting that she’d feel better soon. Dr. Katz seemed surprised that Beth had had a migraine (since Topamax is often used to treat migraines) and that she felt more depressed, but she told Beth to discontinue Topamax. Instead, she wrote her a prescription for 250 mg of Depakote for one week to be followed by 500 mg for two weeks. Again, Beth did not feel well on the new mood stabilizer. She was tired and blue after three days. Dr. Katz told Beth to stop Depakote when she called up complaining about it. At the next session, Dr. Katz gave Beth samples of 2 mg of Abilify tablets to take with 10 mg of Lexapro. After her prior negative experiences, Beth was reluctant to start Abilify, but the doctor explained that this medicine was in a different category than the other two. She thought she couldn’t get any worse, since her mood swings had become extreme and her temper unbearable. Beth swallowed the pills as directed. In a few days, Beth felt much improved. She was finally “up” without being euphoric. The sun was bright, not glowing. The birds chirped pleasantly without producing an opera. And Beth didn’t feel “down.” Her sleep regulated to seven hours per day (she was still on the night shift), and she ate salads and vegetables, instead of gorging on cakes

Major Depression and Bipolar Disorder  39

and cookies. Her husband smiled. “You’re back to yourself,” he said, hugging and kissing her. Psychiatrists are often called on to repair the “damage” done when general practitioners and internists give antidepressants without consideration of the patient’s diagnosis. To a non-psychiatrist physician, most depressions look unipolar. Bipolar disorder is usually not considered. When a bipolar patient goes into hypomania or mania, which can happen any time an antidepressant is given (like with Beth), the doctor knows something is wrong and a psychiatrist is consulted. Psychiatrists usually take a more thorough history and are able to pick out patterns of cycling, poor sleeping habits, and eating problems. A psychiatrist might start a bipolar patient like Beth on an antidepressant without a mood stabilizer but would be watchful for hypomania or manic symptoms. As soon as they occurred, lithium, Depakote, Tegretol, or another mood stabilizer could be given, saving the patient a lot of suffering. Beth could not tolerate Topamax or Depakote, so Dr. Katz gave her Abilify, which worked well. It is preferable to use a mood stabilizer first (which is usually an anticonvulsant) and then an antipsychotic (e.g., Abilify, Risperdal, or Seroquel). Although the newest atypical antipsychotics are believed to be at low risk for tardive dyskinesia (t.d.), t.d. cannot be ruled out with their use, so mood stabilizers (e.g., lithium, Topamax, Depakote, Tegretol) are first-line agents. Lithium can have toxic effects on the kidneys and thyroid gland, but it is the most studied medication for bipolar disorder and the most recommended. More studies are needed to prove that the anticonvulsants are just as effective and less toxic. Lithium has also been shown to act against suicidal ideation and attempts. The negative introject in bipolar disorder insults the patient during depression and then gives a delusion that everything is fine during mania. Table 4.2 exhibits some medications that are commonly used to treat bipolar disorder. Holidays prove to be a problem for many people, especially those whose negative introject remains unknown to the person. Janet had invited friends, her sister, her brother, and his family to Thanksgiving

40  Major Depression and Bipolar Disorder

Table 4.2  Medications Used to Treat Bipolar Disorder 1.  Mood Stabilizers   Lithium   Depakote   Tegretol   Topamax   Lamictal 2.  Second-Generation Antipsychotics   Abilify   Risperdal   Zyprexa   Geodon 3.  Antidepressants   SSRIs (Lexapro, Zoloft, etc.)   TCAs (Tofranil, Elavil)

dinner. Since she was the youngest, she’d never attempted to prepare the meal herself before. She felt it was her turn to have everyone over. She was happy planning everything, buying a turkey, fresh cranberries, broccoli, and all the trimmings. Janet was an excellent cook, organized and efficient. Two days before the special day, she started to have problems. First, she cut her thumb so deeply with a knife that she had to go to the emergency room. That was totally unlike her since she usually was very handy with kitchen utensils. Then while carrying groceries into the house, she slipped and hurt her knee badly. Her doctor examined her and assured her nothing was broken, but he gave her a brace to wear to stabilize the joint. So limping around and with a bandaged hand, she managed to prepare Thanksgiving dinner. When the day came, everyone sat around enjoying the delicious meal. Janet tried to get into the holiday spirit, but her mind kept dwelling on her injuries. She’d never had anything like that happen to her before. Janet’s brother, Tom, a social worker therapist, said, “Well, you had to practically kill yourself, but you did a magnificent job.” “Tell me, Tom,” Janet said, “why would I suddenly become a complete klutz when I’m usually so competent?”

Major Depression and Bipolar Disorder  41

“Did you really want to do all this work?” he asked. “I was looking forward to it, or so I thought,” she said. “Do you remember mom used to say you couldn’t do anything right?” Suddenly, memories of her mother flooded back into Janet’s mind. Tom was right. Their mother always made her feel inadequate, especially around the holidays. Janet hadn’t thought about that for a long time, because she was so good at work, sports, and most things she chose to do. And Janet had never attempted to have holidays at her home. In fact, she realized that she usually was depressed around Thanksgiving and Christmas. The holiday had triggered old feelings of inadequacy, but Janet hadn’t been conscious of these feelings or of her depressed state. Since she’d done so well in her life, she believed she no longer felt inadequate. Her clumsiness was a way that her unconscious mind reminded her of her mother’s negative view of her. Janet was amazed that these old feelings of inadequacy were able to control her behavior. Be aware of your negative introject by watching for these signs: 1. Unusual physical clumsiness—e.g., tripping, cutting oneself, dropping things, especially if you are usually limber and not clumsy 2. Saying wrong, inappropriate things when you are usually right on target in your conversations 3. Drinking to excess or drug taking when you usually know your limits and are not a substance abuser 4. Being late or not showing up at all to important events when you usually are punctual to appointments 5. Not being able to remember important dates, people’s names, or where an essential item, such as your diary, is 6. Oversleeping or staying up too late when you usually have an accurate internal clock In these instances, our negative introjects are making more decisions for us than we realize. After Freud, psychoanalysts and psychotherapists of every sort developed treatments to make the unconscious mind more conscious. The self-sabotaging element, the negative introject, the punitive superego, the hurt child! The negative introject goes by many names

42  Major Depression and Bipolar Disorder

throughout psychological literature. The most basic way to stop selfsabotage is to do psychotherapy, which makes the unconscious mind conscious. If Janet had been aware of her feelings of depression and inadequacy around the holidays, she wouldn’t have cut herself or fallen. Another way to stop the self-sabotage process would be to practice mindfulness meditation, which makes a person slow down and consider every movement made. Once we are able to stop self-sabotage, we can enjoy ourselves and our holidays. Ray, a 59-year-old ex-showgirl and dance teacher, decided to retire early since she was constantly exhausted and unable to keep up with her energetic students. She believed that she was perfectly fine, except for her weariness, which plagued her night and day. Her 62-year-old husband, who was her lifelong love and dance partner, suffered from Alzheimer’s disease. She spent most of her time indoors in symbiotic involvement with him. Her disturbed sleep was blamed exclusively on her husband, who slept in the same bed and woke at least four times per night to urinate, wander, and mumble. Ray would wake up too and follow him around the apartment to make sure he was safe. When her son called, he more often than not would find her crying or too lethargic to speak. Her appetite was diminished. Her internist found her to be in fine physical shape, without signs of a recurrence of her bowel carcinoma that she had endured two years before. “If I could just get enough rest, I’m sure I’d be fine,” she would say. Her constant zest for life, however, was gone, and her negative introject was activated. One day, she surprised her family by announcing that she wished she had died during her surgery for bowel cancer. Her son suspected that she was depressed and urged her to get treatment. Ray thought that her depression was due exclusively to her husband’s condition, which, if relieved, would alleviate her problems. After much discussion, Ray agreed to visit a psychopharmacologist. The psychiatrist obtained a careful history and found out that this was actually Ray’s third untreated episode of depression. The psychiatrist prescribed 10 mg of Paxil (paroxetine hydrochloride) to be taken at night for seven days; then the dosage was increased to 20 mg. Ray took the medicine as directed and, to her surprise, experienced just one side

Major Depression and Bipolar Disorder  43

effect, drowsiness, that helped her sleep. After four weeks, she regained her appetite, slept better, regained her vigor for life, and was “ready to dance.” Her usually rational perspective on difficult matters returned, and she was able to hire a nurse’s aide to help care for her husband without feeling guilty. The usual belief that clinical depression is something bizarre or foreign to most people is inaccurate. Depression strikes 15% to 30% of adults at some point in their lives.3 Everyone has felt sad at times, and the familiarity of these feelings may allow depressed individuals to deny their illness. Ray was in denial about her depression, thinking that her husband’s condition was at fault. Most people believe that if they are coping with a tragic event or difficult situation, they have a right to be depressed. Moreover, they think that their depression will be relieved as soon as the tragedy is alleviated and that the depression is dependent on the event. This is untrue; if the depression is ongoing for six months, then that individual’s brain chemistry may have changed, and he/she could be clinically depressed. The inadequacy of the word “depression” becomes apparent here. Major depression, the kind that requires treatment, is different from the everyday blues people regularly experience. Depression is one of the most common psychiatric disorders.4 Yet because it is so common, many people feel that if they ignore the depression, it will disappear. If the condition reaches a clinical level, then decreased or increased appetite and either insomnia or hypersomnia may develop. At this point, treatment is needed. Most people with depression also have a “blue” mood on a daily basis, anhedonia (loss of pleasure); either agitation or fatigue; poor concentration; increased self-criticism; and excessive guilt. If left untreated, depression may lead to suicidal ideation or an attempt. Suicide is a real threat in depression. Women in Ray’s age group are susceptible. Her comment about wishing she had died during surgery was particularly worrisome and an indication of the negative introject reigning supreme in depression. Depression is very treatable with medication. SSRIs, TCAs, and monoamine oxidase inhibitors (MAOIs) are commonly used. Various psychotherapies, trans-magnetic stimulation (TMS), and electroconvulsive therapy (ECT) may be employed. Despite a bad reputation, ECT is a safe and effective therapy for depression. The patient avoids side

44  Major Depression and Bipolar Disorder

effects that are frequently encountered with antidepressants, although amnesia and/or dizziness and confusion are possible. Many people who cannot tolerate any other form of treatment may respond well to ECT. Tod is a 24-year-old musician. He attended one of the most prestigious music schools in the country. His teachers all told him that his talent was abundant and that he only needed to practice to perfect his technique. Whenever winter came, Tod would fall into the doldrums and his negative introject would start in. He would practically hibernate by sleeping 12–14 hours a day after eating huge meals of starchy foods. Last winter, Tod was more adversely affected by his depression than he had ever been before. His hypersomnia extended to 15 hours of sleep a day. He gained ten pounds and continued to eat too much every day. He was too exhausted and lethargic to play his piano. Piles of clothes covered the top of his piano at home, and he claimed that he had no energy to take them off to practice. Tod forced himself to show up for rehearsals with the orchestra that employed him. On the job, he would play by necessity, but he was so self-critical that it was a tremendous strain for him just to press down the piano keys. His confidence in his abilities had evaporated along with his interest, pleasure, and ability to concentrate. Other orchestra members commented on Tod’s depression. If he were playing a melancholic piece, he performed quite well, but if he needed to play a light, airy melody, he was incapacitated. No matter what he played, it sounded gloomy. Several co-workers nicknamed Tod the “gloom machine.” Many orchestra members didn’t even like to approach Tod’s piano. Karen, a violinist, said, “It’s as if Tod sits in warped space where everything falls under a blue light.” People avoided Tod and criticized him without realizing that his problem had a name—i.e., depression. Tod was isolated from others, and this increased his feelings of self-loathing and unworthiness. His negative introject told him he was a complete failure. The conductor thought that Tod was being lazy. He gave Tod several warnings to shape up, since Tod was often late or totally absent. When Tod began to talk about suicide at his parent’s dinner table, they took him seriously. He was referred to a psychopharmacologist who gave Tod an antidepressant medication. After four weeks on the medicine, Tod

Major Depression and Bipolar Disorder  45

began to sleep and eat normally. His confidence returned, and he was able to practice again. Fellow orchestra members couldn’t believe the change in Tod. His “blue-light space” was dissolved, and he became approachable and friendly. He was able to practice again and play cheerful music. Tod’s depressions usually came in winter. Tod had what is known as seasonal affective disorder (SAD). For these people, depression arrives in winter and either mania or at least alleviation of depression may follow in spring. Tod never experienced mania; otherwise, he would have had a bipolar disorder. However, he did experience unipolar depression. Last winter, he was even worse than usual because he had the vegetative symptoms of hypersomnia and hyperphagia with a weight gain. His exhaustion and lethargy made him incapable of practicing and just barely able to crank out enough music to keep from being fired. Before his depression, Tod was able to concentrate on his playing as well as enjoy his music, but last winter, he was just barely able to force himself to continue working. Laziness had nothing to do with Tod’s inabilities. In SAD, the problem is thought to be due to an imbalance in the hormone melatonin, which is produced in the dark. Psychiatrists have been treating SAD patients with exposure to special fluorescent light or with medicines.5 Depression, which is thought to be associated with a decrease in neurotransmitters, causes fatigability, sometimes to the point of inaction. Co-workers were sensitive to Tod’s condition, but instead of being sympathetic, they nicknamed him a “gloom machine” or saw him in a warped “blue-light” space. He had a negative effect on the music made by his orchestra because the orchestra had to function as a group. If the orchestra members could have been educated to understand that Tod was not willfully being gloomy, the entire group would have benefited. The problem with mental illness is that it is largely invisible, and uneducated individuals around the mentally ill person may incorrectly assume that this person is willfully acting depressed or strange. As a consequence, the mentally ill are blamed for their behavior more than any other diseased group. These accusations lead to further guilt and self-criticism, as in Tod’s case. If people are able to recognize depression, then they can also help an individual like Tod get treatment. Mental patients are often the last ones themselves to understand that they are suffering from a treatable

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disease. Tod was fortunate to have parents who took his suicidal talk seriously. If they had denied his illness along with him, Tod might have continued to be so miserable that he would have killed himself. Instead, he was treated with good results. Clara is a 34-year old nurse who worked in the pediatric unit in the hospital. When her depression came on, she lost her appetite and dropped ten pounds. Then she developed insomnia and slept only two to three hours per night, even if she had just left a 12-hour work shift. Every morning she woke up too early and too exhausted. The little sleep she got was insufficient, but she found she couldn’t sleep longer than three hours. She felt miserable and blamed herself for everything. Her desire for sex was completely gone, along with her ability to enjoy herself in any way. Her boyfriend felt rejected by her and kept trying to cheer her up, but she didn’t respond. Whenever he wanted to have sex, Clara would refuse. They finally broke up. At work on the pediatric ward, the other nurses would try to give Clara the happiest and healthiest children to work with, since they saw how sad she was around the sickest ones. This didn’t help Clara either. Her depression would not improve, even under the best working conditions. The children who were patients on the pediatric unit as well as the staff of nurses, attendants, and doctors were all affected by Clara’s depression. The more sensitive children felt guilty around Clara. They felt that their sickness had somehow caused Clara to feel so depressed. The children who were very ill or in pain felt that Clara was not responding to their needs, which made them feel hopeless and more distressed. Clara wanted to reach out to her patients, but her depression put her in “isolation behind a glass wall,” as she put it. Co-worker nurses felt alternately angry, guilty, or depressed by her presence. Clara always dragged herself to work every day, even if she felt completely miserable. Attendants who assisted her felt that she was aloof and gave too strict orders. The doctors who required her help found her slow in responding to requests, and some even considered her passive-aggressive. Her illness decreased her normal efficiency. Clara had been trained to recognize depression in pediatric patients, but she refused to believe this about herself. She felt guilty about not being able to perform in her usual way

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and blamed herself for losing her strength. Her negative introject made her withdraw from others and blame herself. As a nurse, Clara had access to many pills. Instead of going to a psychiatrist, Clara decided to take treatment into her own hands. She started popping downers at night to sleep and uppers in the morning to perk up. She became addicted to pills. In addition to her problem with depression, she had to worry about obtaining uppers and downers to keep up with her habit (see Chapter 7 for details about drug addiction). The head nurse could no longer ignore the poor quality of Clara’s work. She called her in for a talk and told Clara that she had admired her work and dedication for eight years, but she could not understand Clara’s present behavior. Patients had been ignored or even given the wrong medicines by Clara. The children’s parents had complained to the head nurse. Clara took everything her supervisor told her very much to heart, and it triggered her negative introject. She hated herself for acting like this and felt she was an unworthy, malicious creature who didn’t even deserve to live. That night, she wrote a note explaining herself and then swallowed a bottle full of downers. Her body was found along with the suicide note two days later. The head nurse read about her employee in the newspaper and felt devastated. All the staff in the pediatric ward who had known Clara and worked with her for years were stunned by her death. Everyone felt guilty, as well as hopeless and helpless. Staff members were frightened to talk with each other about the topic, since each felt that he or she had done something wrong. This hidden topic caused the staff to feel increased stress, and the work on the unit slowed down. The pediatric patients felt frightened as their caretakers withdrew from them emotionally. Clara’s co-workers were numb in the aftermath of her suicide. One of the pediatric doctors called in a psychiatric consultant to sit down with the staff and help them resolve their feelings. Once people aired their ideas in a group, they were relieved of the heavy burden caused by Clara’s suicide. Work returned to normal in a week or so, even though no one would ever forget what had happened to Clara. Clara’s depression was obvious to everyone except herself. She kept trying to deny her illness, even though she had the most typical symptoms of weight loss and insomnia. She had a decreased sex drive, as well as fatigue and anhedonia.

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The risk of suicide is often a problem with depressed individuals. Women usually make more attempts at suicide than men, but they will often fail to kill themselves.6 Men make fewer attempts, but they are more likely to die from their suicide attempts. However, in Clara’s case, she was a nurse and therefore more knowledgeable about an effective, lethal dose of pills. Medical professionals often make the mistake of thinking that they can treat themselves. Clara tried to do this with her use of uppers and downers, but she just added drug addiction to her list of problems. Clara gave many clues to her impending suicide: she was depressed with a recent loss—her boyfriend had left her. She had the typical sense of hopelessness, helplessness, loneliness, and exhaustion, with active abuse of drugs. Another risk factor that would have been discovered if anyone had interviewed her was a former suicide attempt in her teenage years, also with a drug overdose. Clara had lost her father when she was 10 years old, which also increased her risk of suicide. Her external support system, which could have included her workplace, but didn’t, was limited. A death by suicide in the workplace can cause crippling guilt among the survivors. Each person can feel that he or she did not do enough to help the person who died. When this guilt is not expressed, it can immobilize the entire system. On Clara’s pediatric ward, her co-workers were bewildered by her suicide. Her supervisor, who had admonished her one day before her death, was especially disturbed. When the psychiatrist first came in to give the staff a group session, people were reluctant and skeptical. The supervisor insisted that everyone attend. In the group, people were able to share their feelings of horror, guilt, helplessness, anger, and, finally, acceptance of Clara’s death. They asked the group leader to come back to conduct other group sessions. Once they ventilated their feelings in the groups, the staff was ready to carry on its difficult functions of caring for others on the pediatric ward.

Notes 1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.), pp. 160–162. Washington, DC: American Psychiatric Publishing.

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2. Ibid., pp. 132–135. 3. NIMH, U.S. Department of Health and Human Services, National Institute of Health. Retrieved from www.nimh.nih.gov 4. Klein, D., Gittleman, R., Quitkin, F., & Rifkin, A. (1980). Diagnosis and drug treatment of psychiatric disorders: Adults and children. Baltimore, MD: Williams and Wilkins. 5. Retrieved from www.mayoclinic.org; www.mayoclinic.org/tests-procedures/ light-therapy/about/pac-20384604 6. Kaplan, H., & Sadock, B. (1994). Synopsis of psychiatry (7th ed.). Baltimore, MD: Williams and Wilkins.

Psychosis and the Negative Introject

5

Muriel, a 55-year-old paralegal, had been working at her law firm for 20 years. Everyone admired her efficiency and no-nonsense attitude. If lawyers wanted something done quickly and accurately, they went to Muriel. Then the law firm had to downsize. They were losing clients rapidly because their “rainmaker” had suddenly taken ill with an aggressive brain cancer. Unfortunately, Muriel was one of the first employees to be let go. The firm had three other paralegals. Muriel was the most senior and highly paid, and the partners decided they could cut costs by eliminating her job. Muriel had never revealed that she was on a mixture of antipsychotics that kept her sane. She had been diagnosed with schizoaffective disorder in her 30s, which led to several hospitalizations. She’d finally found a good psychiatrist and an excellent combination of medications. She was able to study to be a paralegal and then land a stable job with the firm for 20 years. When she was fired suddenly, it jolted her out of her usual world. At first, Muriel thought she would be okay. She had some money saved in the bank. She owned her co-op apartment. What could go wrong? Yet without her usual schedule, she would wake up in the morning, wander around her apartment, and try to figure out what to do with herself. She was unaccustomed to not working.

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While holding down her job, Muriel had been religious about taking her two different antipsychotic medications every day. As a consequence, her negative introject had been reduced to a tiny, squeaky voice in the back of her head that would come up with weird ideas or an occasional snide remark. But without her work-related activities, she stopped taking her meds on a daily basis. Muriel felt better without those horrid medications that caused her to salivate too much, become constipated, and sometimes feel like a zombie. She felt liberated without them. However, with no meds, her negative introject expanded back into the mega-monstrous force that it had been before. The force that had landed her in the hospital all those times was back, now stronger than ever. Without her meds stabilizing her, suddenly Muriel recognized so many patterns that she hadn’t seen before. Her former boss, the head of the firm, must be in love with her. She was sure of that, even though he had seemed to be happily married with two children. That’s why he had to fire her. His love was so overwhelming that he couldn’t tolerate looking at her every day and not consummating their love. Inside her apartment, Muriel heard him calling her name. She desperately searched for the source of his voice. Were there speakers in the wall, or was his voice projected by tiny cells imbedded in the wall? She took a pick and hammer and started destroying the walls in her frantic search for the source. Of course, with her negative introject, the voice was coming from her own mind. Muriel was experiencing auditory hallucinations and having delusions about her boss. She had what we call erotomania. Erotomania is a delusional disorder in which the patient believes another person of higher status is in love with him or her. A French psychiatrist, Dr. de Clérambault, published a comprehensive paper on this condition in 1921, so erotomania is sometimes called de Clérambault’s syndrome.1 Muriel had this unshakable belief that her boss loved her. By now, her negative introject had taken over her entire mental system, supplying delusions and hallucinations instead of operating as a mere squeaky voice now and then. Muriel’s neighbors were disturbed by her constant banging on the walls. One neighbor gently knocked on her door. Muriel didn’t answer. Her hallucinations were drowning out the outside world. Eventually,

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the neighbors gathered together, compared notes, and decided to call the police. The police had to break down her door to get in. Muriel was taken to the hospital and admitted to the psychiatric ward. It took several weeks to get her medications to kick in again. Unfortunately, she was discharged prematurely, before her negative introject could be relegated to its former position in the background of her psyche. At home, Muriel felt that she didn’t need those medications. After all, what was the problem if her boss loved her? Why did she have to deny his love by snowing herself under with heavy tranquilizers? She stopped taking them and started excavating the walls again with a hammer and pick. Imagine her surprise one morning when she broke through the wall between herself and her neighbor and found herself staring at him while he tried to eat his oatmeal! Needless to say, Muriel was hospitalized again. This time she willingly accepted her medications. She was discharged after a few weeks, much shaken about what she’d been through. Back in her psychiatrist’s office, Muriel finally explained what had been happening to her. Muriel had missed two sessions, and the psychiatrist had called her many times trying to figure out why his patient disappeared from treatment. She had ignored the doctor when she was psychotic. Muriel now realized that her boss didn’t love her at all and that there were no hidden speakers in her walls. She acknowledged that the sounds were emanating from her own mind, as were the delusions. Another case of psychosis and erotomania occurred with Becky. At 50, Becky was still an attractive woman who could pass for someone ten years younger. She worked as a clerk in the radiology department of a hospital. Co-workers wondered why she didn’t have a significant other, a husband, a boyfriend, or anyone. She mostly kept to herself, but she would go out for lunch now and then. At lunch, she’d complain that “so and so” exploited her or “such and such” happened that proved how untrustworthy and malicious people really were. Her companions inevitably would assure her that things weren’t that bad, but Becky never believed them. Then one day, a man she thought of as the possible “love of her life” started flirting with her. He was a radiologist who deigned to talk to the clerks and other workers. Whenever he saw Becky, he winked,

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and twice he touched her hand when she handed him an x-ray. After his touch, her fantasies, which had been simple ones of dating him, expanded to seeing herself in a romantic Hawaiian fling with him and then marrying the doctor. One afternoon, she gathered all her courage and passed him a note with her phone number. To her horror, he avoided her after that. No more flirtation, no more touching. Then Becky started hearing the doctor’s voice talking to her. At first, it was just a whisper, but then she heard full sentences in his voice, telling her she was disgusting and that he never wanted to look at her again. Becky was so humiliated that she sought counseling for the first time in her life. In the initial visit, she revealed a recurrent, troubling dream to her psychiatrist, Dr. Brown. In the dream, she was walking behind a man dressed in black leather. He had just beaten her and demanded that she follow him. He had subjugated her to the point where she was a slave to his every desire. When asked to associate to the dream, Becky talked about the radiologist and what had happened. Dr. Brown reassured her that, so far, she’d done nothing wrong and that her actual behavior was proper and logical. At the next session, Becky told Dr. Brown about the voices she heard and how she thought it was the radiologist mocking her. It was the same old story, she complained: whenever she showed her hand, someone would use the information against her. As a child, she experienced her parents as cold and withholding. They seemed to frustrate any desire she expressed. When they gathered with her aunts, uncles, and grandparents, she was always the object of their ridicule. As a young woman, she was raped by her first boyfriend, which caused her to stay away from men. She had one or two girlfriends, but she doubted their loyalty and was critical of their reactions. Becky quickly developed negative transference to Dr. Brown. She suspected that he didn’t believe her story about the radiologist. “You think I’m exaggerating our interaction and blowing the whole thing out of proportion?” she asked. “You think I’m crazy with these voices?” “Not at all,” Dr. Brown told her. “I can understand your point of view very well, but since you have these voices in your head, which we call auditory hallucinations, we might have to medicate you.” “Doctor, you can’t understand that this is extremely significant for me. I don’t flirt with men any more. This may be my last chance for a relationship.”

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No matter how much Dr. Brown reassured her, she still felt he could neither understand nor sympathize with her. He seemed like her parents, cold and withholding. She thought he might be discussing her negatively with his colleagues, and she believed she was once again an object of ridicule. Who knows what kind of weird medicine he wanted to give her? At this point, Dr. Brown realized that Becky was experiencing a psychotic episode, complete with delusions and hallucinations. Apparently, she had never had one before. Her convictions that people were against her were absolutely fixed. She was not depressed or particularly anxious. Her preoccupation with the radiologist had triggered a paranoid episode. Dr. Brown ruled out all medical conditions that could cause paranoia, such as cocaine abuse or hyperthyroidism. It was unusual for a patient to have just one psychotic episode like this with no previous history. Dr. Brown believed the best treatment for Becky was to give her an antipsychotic—e.g., Risperdal—along with psychotherapy. Becky refused the medication but agreed to psychotherapy. During sessions, Dr. Brown tried to be as straightforward with her as possible. He explained that he would never discuss her with colleagues unless he obtained her permission first. Dr. Brown did not interpret her negative transference to him because he knew that approach would get them nowhere, except into more paranoia. He was not overly warm or friendly because he knew Becky couldn’t tolerate it. If Becky accused him of lateness, which he was sometimes guilty of, he readily admitted to it and apologized. He did not recommend group therapy or behavior therapy because paranoid patients have difficulty with these modalities as well. Becky wouldn’t take Risperdal, but she did accept some sleeping medication. Dr. Brown also introduced her to the concept of the negative introject, which Becky found interesting. She even understood that the humiliating voice in her head could possibly be from her negative introject. After four months of treatment, she said she had had enough of talking about the subject. She had stopped hearing the voices and had ceased thinking about the radiologist. Becky felt so much better that she ended therapy. Dr. Brown was satisfied with the work they’d done and invited her to return any time. He thought it auspicious that she had been able to fall in love with someone, even if she was unable to handle what she perceived as rejection from the beloved.

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In the case of schizoaffective disorder, which is a psychotic disorder like schizophrenia but with an emotional, affective component, the negative introject is an interfering, powerful, unconscious force that causes the person to lose contact with reality by supplying hallucinations and delusions. The patient simply cannot identify this force nor try to diminish it with all the techniques a person who is not psychotic may use. (We have discussed depression and anxiety disorders in Chapters 3 and 4.) In patients with schizophrenia, paranoid conditions, and substance abuse disorders, identifying the presence of the negative introject in the self is almost impossible. Usually, the way to deal with the negative introject in these cases is to medicate, or use some brain stimulation, such as ECT, or wait until the person’s brain chemistry changes due to natural processes, or use some techniques we may develop in the future—i.e., virtual reality. Becky may have been an exception to the usual course of this particular disorder, although in brief psychotic episodes, patients often return to normal in a few weeks to a few months. Patients with psychosis have anosognosia, or “lack of insight,” meaning they are blind to their illness. They cannot be told that they are hallucinating or delusional. They simply cannot perceive their own illness. It is as if they are divided from their own selves. Hence, the term “schizophrenia” developed, which originally meant split (schizo) and mind (phren). Gary thought he could swim across the lake in Central Park. He was in his 30s and quite athletic. One day, he woke up and felt like the most powerful man in the world. So what if he worked in a big box store as a clerk monitoring incoming shipments? So what if he lived at home with his mother and little brother in Queens? So what if he’d dropped out of his last year of high school and never got his G.E.D.? He knew he was powerful, and strong, and clever. So that night, Gary jumped into the lake, even though it was April and still pretty chilly outside. He swam as far as he could, but the water was icy and full of debris—cans, cartons, and unidentified mushy stuff. A man saw Gary and started yelling for him to come out. Then everyone had their cell phones aimed at him to photograph his antics. He tried to show off and let them know how powerful he was, but he

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also felt tired and cold. The police dragged him out, and he was taken to the local emergency room. Gary had bipolar disorder, and he was in a manic state. In this condition of mania, patients feel extremely powerful and grandiose, as if they can do anything. Their negative introjects are crushed by excessive positive thinking to the point where they lose their judgment and think nothing is beyond their ability. Bipolar patients swing from the extremes of an exuberant state into the depths of depression, in which they feel paralyzed and unable to do anything. When they are depressed, their negative introjects kick in again and remind them that they are worthless, incompetent, and useless. With medications—e.g., valproic acid, carbamazepine, and lamotrigine—patients’ mood swings can be controlled so that the negative introject is neither completely suppressed, as in mania, nor looming large, as in depression. “Doctor, my penis is shrinking into my body! I’m afraid it will kill me!” my 23-year-old patient, Tim, complained one afternoon. Originally, he’d consulted me only about his work-performance anxiety. After giving him psychotherapy for eight months, I knew that this computer technician agonized about his penis being too small. As a result, he believed he was totally inadequate. Throughout the 30 years I’ve practiced psychiatry, I’ve encountered many men obsessed with the size of their penises, but this patient was one of the worst cases, as well as extremely delusional. Although doctors had always assured him that his penis was of normal size, he never believed them. Even in the locker room at his health club, he avoided walking around naked—although many of the men did—because he was afraid that he would be mocked. He could clearly see that he wasn’t that different from the others, but he had a fixed, false belief that he was. Male friends joked when they saw his vulnerability. “Don’t you think this has to do with your girlfriend leaving you and returning your engagement ring?” I asked, hoping to reconnect him to reality and shake his delusion. No, he was convinced that his genitals were retracting into his body, and he was dying. It has always amazed me how valid so-called outdated Freudian concepts are. I am an eclectic practitioner, who mixes a bit of Freud with Jung, Adler, etc. Nowadays, most psychiatrists employ whatever theories help in the treatment of

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their patients, but Freud’s concepts of the Oedipal complex, castration anxiety, and penis envy were all still relevant to my patient. Tim had been dating his girlfriend since his first year of high school. He had never had sex with anyone else, although he often fantasized about other women. His feelings of inadequacy kept him from attempting sex with anyone else. Rationalizing, he told himself that he was being true to his girlfriend. After he and his girlfriend became engaged, they began to fight. One Saturday night, when she failed to show up, he was frantic. He texted her all night. Finally, she answered, informing him that it was over, and she would send back his ring. He couldn’t believe that she would end the relationship so abruptly and callously. “Your penis can’t shrink into your body. It’s impossible,” I continued. I realized that he was experiencing a delusion we call “koro,”2 which is a belief that the penis and testes are shrinking into the abdomen and will lead to death. Belief in this concept has been mainly reported in Malaysia and East Asia, where it is rooted in Chinese metaphysics and cultural practices. Koro patients are troubled by fears about masturbation and what they see as sexual overindulgence. Freud would have considered them to be suffering from castration anxiety. My patient was a non-Asian man who did not have any interest in or knowledge about Chinese culture. When he explained his worry to his father, both parents took him to the family doctor. No matter how much reassurance he was given that his penis was perfectly normal and that it was not receding into his abdomen, he stuck to his false belief, or delusion, as we say in psychiatry. We explored his feelings about the breakup. Psychotherapy helped to decrease his anxiety, but his delusion remained. His negative introject was relentless in supplying him with a persistent image of his penis shrinking into his body. When his girlfriend finally returned his calls, he begged her to come with him to therapy. Once there, she expressed how oppressed she had felt by his controlling behavior. In the next session, Tim told me that he realized she reminded him of his mother and that loss of her meant loss of his mother’s affection. I thought of the Oedipal battle in which the boy loves his mother and wants to destroy his father. Only when his girlfriend returned to him and accepted his ring once again could Tim stop believing that his penis was shrinking and that he would soon die. The couple worked out compromises,

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giving her more freedom and providing him insight into what his girlfriend was feeling. They had a few more sessions before they were married, and I invited them to return if necessary. Tim’s “koro” delusion is unusual in the West, but he had always been fixated on his penis, feeling it was inadequate. His father had bullied and humbled him during his Oedipal stage (about 3 years old— at the same time that his negative introject was developing), when he was especially vulnerable to feeling inferior. When his girlfriend left, Tim believed this proved his sexual inadequacy. Her abandonment was unconsciously viewed by him as a castration, hence the development of his delusion. Ironically, it wasn’t psychotherapy that released Tim from his fears, but the actual return of his girlfriend. Sometimes reality can be stronger than therapy! Eric was a 35-year-old accountant who obsessed over his erectile dysfunction (E.D.) to such an extent that his other conditions (i.e., bipolar II disorder and PTSD) went undiagnosed for a significant period of time. Eric grew up in a disturbed family, in which he and his three brothers were molested by their biological mother, who suffered from schizophrenia and alcoholism. His father had abandoned the family when the patient was only a few months old. From the ages of 5 to 12, his mother had focused on him more than the other children. She fondled his genitals and insisted that he perform cunnilingus on her. Eric reluctantly complied until puberty at 13. Then he refused to engage in these activities, declaring himself homosexual. He felt he desired only males, but when he would try to have sex with them, he wasn’t able to maintain an erection and orgasm was rare. At age 16, Eric’s brilliance was acknowledged when he won a scholarship to a prestigious university. He gladly left home and went to live at the school. All of his sexual contacts were homosexual. He felt phobic of women. His E.D. not only upset him but also tremendously stimulated his negative introject and caused him to be promiscuous, until his senior year of college when he fell in love and lived with a boyfriend for one year. E.D. plagued him throughout the relationship. Eric abhorred drugs or alcohol after witnessing his mother’s substance abuse. After college,

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Eric studied accounting and then was hired by a large firm. At work, he was viewed as a successful, handsome overachiever. No one knew about his torment over E.D. and his nighttime prowling of bars and clubs for the perfect man who would “cure” his E.D. Needless to say, he never found this man. Then Eric consulted one urologist after another to help him with his problem. Medically, he was fine. No condition could be found that would account for his E.D. The urologist gave him prescriptions for Viagra and Cialis, which helped to some extent. Finally, one doctor, who listened carefully to Eric’s symptoms of E.D. and took note of the extent of his rage reactions, recommended a psychiatrist. When the psychiatrist first heard Eric’s history of being molested by his mother and his obsession with E.D., he thought he was dealing with a simple case of sexual dysfunction after abuse. He recommended psychotherapy once per week. As he became familiar with Eric over several months, the psychiatrist also diagnosed bipolar II disorder in consideration of the patient’s depressive episodes as well as hypomanic ones. During depression, Eric would have suicidal ideation (never acted on), insomnia, reduced appetite, and depressed feelings. When he was hypomanic, he was irritable, full of rage, grandiose, talkative, hypersexual, and he would have racing thoughts. By age 31, Eric had swung back and forth between the two poles many times. In addition to bipolar II disorder, the doctor diagnosed PTSD because his patient had repetitive and intrusive recollections of his mother molesting him. In a recurrent nightmare, his mother stood over him like a giant while he withered down to a tiny creature the size of a mushroom. (Eric associated his E.D. to this dream.) He tried to avoid women because he linked them to his trauma. When he had to deal with women at work or socially, he felt estranged, and his affect was constricted. He was hypervigilant and had an exaggerated startle response. Eric’s avoidance of women caused him significant impairment in his social and occupational functioning. The psychiatrist suggested medication to help him, and Eric gladly accepted. They began with SSRIs and then moved on to mood stabilizers. He tried Celexa, Lexapro, and Prozac, but even though he felt less depressed and anxious with these medications, his E.D. was worse. He stopped them after adequate trials of several weeks. He then tried

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Lamictal alone but felt too depressed. Next came trials of Topamax and Depakote in conjunction with Wellbutrin. Eric complained that all these medicines made him feel worse until he tried 300 mg of Lamictal and 150 mg of trazodone, which he felt helped reduce the anxiety and depression. An addition of 5 mg of Abilify helped him to sleep, increased his appetite, and decreased his anxiety. Eric wanted to use trazodone because he had read about the possible side effect of priapism and thought that this medication might help his E.D. It didn’t help, but Eric did feel less depressed. Lamictal subdued his mood swings, and the final ingredient of Abilify balanced the combination and helped his PTSD. Through therapy, Eric was finally able to understand how his mother’s abuse influenced his sexual behavior, but that interpretation didn’t eliminate his E.D., even after two years of psychotherapy. However, psychotherapy did decrease his punitive negative introject. Many a psychoanalyst would consider Eric’s homosexual behavior to be a reaction formation to his abuse. They might also interpret his E.D. as his body’s rejection of homosexuality. His erectile dysfunction occurred before he had the diagnoses of bipolar II disorder and PTSD, so his E.D. was not better accounted for by another diagnosis. Eric had difficulty learning to live with E.D. and continued to consult urologists, although his mood swings were stabilized once the psychiatrist gave him the appropriate medication. A 35-year-old woman, Marsha, had been considered mentally ill since her early 20s. She dropped out of her first year of college because she could not concentrate on her studies. However, instead of staying in her hometown, she went out west and worked at a succession of jobs. No matter where she was, Marsha was plagued with restlessness, irritability, mood swings, and paranoia. One day, things came to a head after she had been afraid to leave her apartment for several days. While lying on the couch watching a favorite soap opera, Marsha suddenly noticed that the characters on TV were talking about her. She also hallucinated her own face onto one of the actresses. Although she was very upset, she left her apartment and went to her job. Her boss noticed that she was disturbed. She revealed to him that the TV had been talking about her. But it was

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actually her negative introject projected onto the TV. Her boss helped her get to a local psychiatric emergency room. She was hospitalized for several weeks and diagnosed as having schizophrenia. In the hospital, she was treated with olanzapine as well as lithium. Upon discharge, Marsha returned to her parents’ house back east. Her parents were concerned and helpful to her. Throughout the following years, Marsha would have at least one hospitalization per year. She did not return to work. During one of the hospitalizations, she met her husband, Dan, who also had a diagnosis of schizophrenia. She lived with her husband, attended a day hospital, and visited her parents frequently. Marsha’s world was severely limited because no matter how many antipsychotic medications she took—and she tried practically all of them—she still hallucinated and felt paranoid. Olanzapine gave her the fewest side effects, but she still had a weight gain of 30 pounds, as well as acne, dizziness, drowsiness, and constipation. Then during one hospitalization, her new doctor decided to put her on Clozaril. Within weeks, she began to feel dramatically better. For the first time in 15 years, Marsha stopped hearing voices and feeling paranoid. She no longer had to take olanzapine, and her weight dropped back to normal. Her acne cleared up, and she was no longer tired or sleepy during her waking hours. She felt as if she were awakening from a long nightmare. She had so much energy, she wanted to work. Marsha took a part-time job in a store at a local mall. It was satisfying to her to be back at work. Her husband was still incapacitated by his illness. The major conflict in Marsha’s life continued to be dealing with Dan, who refused to take Clozaril, and was completely dominated by his negative introject. Ella, a 37-year-old woman, was able to hold down a job as an assistant to an executive for ten years. When she was on Seroquel and lithium, Ella’s schizophrenia was under better control than Marsha’s had been. When Ella had her first psychotic break at age 20, she was hospitalized for several months. After she was discharged, she was supposed to live in an adult home. Somehow things did not work out. Instead, she wound up homeless for several months. Going from one shelter to another was

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a horrible, frightening experience for Ella. Finally, through determination and great persistence on her part, Ella was able to obtain her present job. This allowed her to get off the streets. However, even though her medicines worked most of the time, she would still have psychotic episodes at least once each year. Ella lived in dread of these episodes. Finally, she was put on Clozaril because she started to have excessive weight gain from Seroquel, even though it controlled her psychosis. After discontinuing Seroquel, Ella began to feel better in a few weeks. Her mind cleared up for the first time in years, and her negative introject was significantly diminished. Ella once again enjoyed thinking logically and began to read books that she just couldn’t tackle in the past. At work, her boss complimented her profusely. She had always done an adequate job, but now she was doing a superior one. At this time, Ella is considering going to college for the first time in her life and then applying for one of the executive positions in her company. Ella is no longer filled with dread that another psychotic episode will stop her in her tracks or that her horrible negative introject will attack. In current medical thinking, psychosis is believed to be due, quite simply, to an increased amount of dopamine, a neurotransmitter in the brain. Antipsychotic drugs, such as Seroquel or olanzapine, block dopamine receptors post-synaptically and thereby reduce dopamine in the central nervous system. Of course, the process of psychosis is more complicated, and we learn more about it every day due to many research projects that are exploring the causes of psychosis. The major tranquilizers, or antipsychotics, may produce the following side effects: sedation, dry mouth, constipation, blurred vision, Parkinson’s disease–like syndrome, akathisia, and tardive dyskinesia. A Parkinson’s disease–like syndrome consists of a tremor in the upper body, cogwheel rigidity, and akinesia (decreased movement). This may be treated with a counteracting medication called benztropine. As opposed to akinesia, akathisia could be confused with anxiety, but in fact, it is an internal fidgeting that patients may experience with antipsychotics, and it is relieved with benztropine (Cogentin). The newer antipsychotics, such as Seroquel and Abilify, usually do not cause Parkinson’s disease–like syndrome or akathisia. Tardive dyskinesia was once thought to be a permanent movement disorder of the tongue or upper body brought on after the use of antipsychotics.

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However, new research is showing that this disorder may not be as permanent as once thought, and there is some medication to counteract tardive dyskinesia.

Notes 1. De Clérambault, G. G. (1942). Les psychoses passionelles. In De Clérambault G. G. Oeuvere Psychiatrique. Paris, France: Presses Universitaires, pp. 315–322. 2. Mattelaer, J. J., & Jilek, W. (2007). Koro ‑ The psychological disappearance of the penis. Journal of Sex Medicine, September, 4(5), 1509–15. Retrieved from www.ncbi.nlm.nih.gov/pubmed/17727356

Personality Disorders and the Negative Introject

6

People with personality disorders seem to be wearing a suit of armor that can’t be penetrated. They are each defended in their unique ways against outside influences. According to the DSM-V, a personality disorder is “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment.”1 Or I would say that the personality disordered person has a negative introject stuck in a maladaptive mode. In other words, the patient always reacts the same way and is unable to adapt to new circumstances. John, a 35-year-old steel worker, was suspicious of everyone. His negative introject told him that people were exploiting him and deceiving him at all times. He had no proof of actual harm that others were doing to him, but he felt certain that he was being abused in this way. As a result, he stayed away from most people and wasn’t able to form close relationships. John worked as a foreman in a steel mill. He argued with co-workers and forced them into compromising positions, making them admit that they were wrong about trivial matters. One day, he saw two workers snickering and looking in his direction. He immediately felt that they were talking about and conspiring against him. He singled them out and gave them the worst assignments. They reacted by reporting John to his supervisor.

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The same misunderstandings happened over and over again, making John’s life miserable. John would ask his uncle (the only person he trusted) if his perceptions were true or distorted. His uncle honestly told John that he thought he was paranoid. John wanted to believe his uncle, but his negative introject always told him otherwise and led him astray. John couldn’t change his behavior or outlook. Unfortunately, like most people suffering with his condition, John refused to seek treatment. Instead he was stuck with his paranoid personality disorder.2 Julia, a 23-year-old librarian, kept to herself and never mingled with others. She had always felt detached from everyone, including her family. Men tried to ask her out, but Julia said no to them constantly. She had no desire for sex or engaging in other activities that people her age enjoyed, such as dancing or drinking or eating out in restaurants. Her boss often congratulated Julia for her hard work and accomplishing many of the tasks that others shunned. His praise (or criticisms) seemed to have no effect on Julia. She had been a loner since her early teens. Her parents, worried that she might have depression or schizophrenia, had taken her to a psychiatrist, but the doctor had only diagnosed Julia with schizoid personality disorder. He assured Julia’s parents that she wasn’t psychotic or depressed. In schizoid personality disorder, the negative introject of these patients tells them to keep away from other people who only cause problems and that they would be better off just minding their own business. Sometimes it is hard to differentiate people with schizoid personality disorder from those with mild autism spectrum disorder. In contrast to those with schizoid personality disorder are those people with schizotypal personality disorder.3 Louise was a 45-year-old actress who supported herself with typing jobs when she couldn’t get acting work, which was frequently. Louise was a good-looking woman, but she often wore bizarre outfits for her day-to-day activities—e.g., a witch’s outfit or a catsuit. She enjoyed the attention she received while wearing these costumes. She also dyed her hair a bright red, which caused people to stare at her.

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Most people considered Louise strange. She didn’t care. She didn’t have any close friends, only casual acquaintances. When she was in her witch’s outfit, she believed she had magical powers and could put hexes and other spells on people. Her negative introject then told her that she was a powerful sorceress. Louise should have doubted the legitimacy of her negative introject because over the years, she could see that people were not harmed by her hexes or actually affected by any of her spells, but she refused to be realistic. Louise had a lot of social anxiety, but when she dressed in her costumes, she felt more confident. Louise was not like a schizoid personality because her negative introject did not tell her that she should keep away from people. Neither schizoid nor schizotypal personality disordered people are usually psychotic, although sometimes in extreme cases for short periods of time they can be. According to the DSM-V, unlike the schizoid and schizotypal personality disorders, which as a rule are not as prevalent as borderline personality disorder (BPD), BPD appears in approximately 5.9% of the world population. Betty was surprised at how quickly people in her life went from wonderful to horrible. Sometimes it happened in one day! Betty, a 26-year-old graduate student in business, noticed this extreme fluctuation of character in her professors most of all. What Betty didn’t realize was that her negative introject was projecting her own point of view onto people at different times. Betty had BPD, in which there was a “pervasive pattern of instability of inter-personal relationships, self-image, affects and marked impulsivity.”4 She alternated between seeing her professors as all wonderful to completely terrible, but she was the one imposing these images on them. They weren’t changing so rapidly. Her negative introject also gave her an unstable image of herself, so one minute she’d believe she was able to do anything, and the next she felt like a complete failure. All of this rapid change made her feel angry and empty all the time. She would shop or have sex with strangers to relieve herself of these erratic emotions. Betty easily felt rejected and abandoned by all the people she interacted with. In truth, people did not want to be with her because

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Betty could become suddenly abusive when her negative introject convinced her that she was dealing with a horrible person. Over the centuries, women have repeatedly been accused of being hysterical. In my field, “histrionic personality disorder” (HPD)5 is what this kind of behavior is called. The DSM-V describes HPD as “a pervasive pattern of excessive emotionality and attention seeking.” HPD also describes someone who has inappropriate sexually seductive behavior and who considers relationships to be more intimate than they actually are. The word “hysteria” is derived from the Greek word “hystera,” meaning a wandering of the uterus. In the past few years, females have not been targeted with a diagnosis of HPD as often as they once were. However, I’m beginning to believe that men may be the ones with hysteria these days, but we should probably call it “testosteronic personality disorder” (TPD) for the male equivalency of HPD. All of a sudden, it seems we have become obsessed with powerful men being exposed in the media as sexual predators. I believe these men are experiencing “male panic,” or TPD. When we view all this sexual behavior biologically, we can get a clearer perspective on the situation. Since at this point men cannot reproduce by themselves, they need to engage with females in whatever way they can. Their showing-off behaviors—touching women inappropriately or masturbating in front of them—all indicate “male panic.” The male instinct is to get their sperm out there at all costs. All over the world, societies set rules for male-female engagement. In the West, we usually choose someone, date, have sex, marry (maybe), and then reproduce. Although these rules are changing rapidly, the marriage unit has ensured the male that he will have a mating partner and usually that the offspring are from his sperm. The institution of marriage is a safe harbor for males, and also for females, who are most vulnerable during pregnancy and afterward. Of course, nowadays, people are reproducing in all sorts of unconventional ways: using sperm banks, surrogate mothers, etc. Eventually, humans will be able to reproduce without using women’s wombs, but then I’m sure all sorts of laws will lock us down. Males (and females) can copulate with many partners, but some of them panic unconsciously, and the negative introject makes them fear that they won’t reproduce and fulfill these compelling instincts.

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Powerful males (even unattractive ones) have the ability to mate with many females and spread their sperm to the most desirable mates. Their positions as alpha males have heretofore guaranteed that they could “get away with it.” Similarly, in most primate groups—i.e., monkeys, chimpanzees, and gorillas—the alpha male mates with the most females and produces the most offspring, no questions asked. We humans must keep in mind that we share 97% of our DNA with these animals. Why has human male “testosteronic” behavior suddenly been exposed and why only now has action been taken against the perpetrators? Again, biology can explain it. Our population is huge and growing. So perhaps unconsciously we are noticing excessive male sexual behavior in an effort to curb our population. If males are forced by society to control their excessive “testosteronic” behavior, it will result in less sex, less reproduction, and the world population will decrease accordingly. Homosexual behavior also serves to reduce the population. Current media coverage has allowed women to finally speak up about what has been happening to them for centuries. Men try to engage women while they are in their reproductive years. Sometimes women want to engage; other times they don’t. Of course, the choice should be the woman’s prerogative. I think it’s a good idea to label this behavior and thus try to control male panic. The antisocial personality disordered person has an introject that tells him (and it’s usually a male) that he doesn’t have to follow any of the laws of society. As a result, these personalities fail to conform to social norms and often wind up under arrest. They are deceitful, impulsive, irritable, and aggressive. Tom, a 23-year old wannabe rock star, was excessively charming and seductive. He’d approach older women and try to get them to date him. He had little money and, since he’d barely graduated high school, no career (although he imagined himself to have a great voice and to be rock star material). The woman would be flattered that Tom was attentive to her, but she would have to pay for the dinner or any movie they went to see. Tom tried to worm his way into the woman’s life. He would provide sex if she wanted it or sometimes help with chores. Occasionally, he would get a gig singing with a band. From the woman

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that he was seducing he would demand her attendance, and one time he asked the woman to buy him a new suit and pay his hair stylist. He got what he could from his “marks.” As soon as the woman became aware of his sociopathic nature, he would dump her and move on to the next victim. Tom had no remorse, because his negative introject told him that he was special, smarter, better-looking, and generally a superior person who could get away with anything he felt like doing. Finally, when he stole three credit cards from a woman, he wound up in jail. Tom also exhibited narcissistic behavior, but he was not just exhibiting narcissistic personality disorder (NPD); he disregarded the law and defied social norms. Those patients manifesting only NPD usually do not wind up in jail. They are mainly concerned with themselves and their aggrandizement, but their deceitfulness and exploitation of others is mainly to promote themselves. If others are harmed during their self-absorbed behavior, it is usually inadvertently. Judy was a beautiful 32-year-old actress who was sure she would be discovered as a big star any day. In the meantime, she took small roles in offoff Broadway productions. Her husband was a long-suffering businessman who catered to Judy’s whims. She spent huge amounts of their money buying beauty products to counteract the aging process. One day, her husband was in an auto accident and landed in the hospital. Instead of visiting him and being concerned with his welfare, she kept up her usual routines, claiming she couldn’t see him very often because it was too painful for her to look at her husband in that condition. Her husband’s sister visited him every day and was highly critical of Judy’s lack of concern. Judy was preoccupied with her fantasies of unlimited success that her negative introject constantly flashed in front of her imagination. The negative introject also told her she was so special that she didn’t have to participate in ordinary tasks—e.g., visiting her injured husband in the hospital. After her husband was discharged from the hospital, he moved in with his sister and filed for divorce. Judy was shocked by his behavior and unable to understand how her haughtiness and lack of empathy broke up her marriage. People with obsessive-compulsive personality disorder (OCPD) do not necessarily have the more commonly discussed OCD, although

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many individuals think the two conditions are the same. Those with OCPD generally have an inflexible pattern of thinking, feeling, and behaving, whereas those with OCD have obsessions (recurrent, persistent thoughts) and compulsions (repetitive behaviors). Sound confusing? Michael’s story is fairly typical of OCPD. By age 25, Michael had established his career as a dancer in a modern troupe. He diligently practiced dancing every evening without missing a night. By day, he worked as a waiter in a café. His co-workers knew he was finicky, and they often teased him about not being able to touch leftovers on customers’ plates. Sometimes Michael would even pick up used dishes with napkins, fearing that he would be contaminated otherwise. Michael’s negative introject told him that everything was dirty, and he needed to be extra clean and careful about touching things. He had many feather pillows around his apartment. Standard ones lined his bed, designer ones were in the living room on his couch, and a big red one was on a mat that he used to work out. After a hard day at the restaurant and stressful night of practice, he would come home, stretch out somewhere, and happily grab a pillow to put under his head. His hands would keep moving over the pillow until he found feathers to crack. Michael had the opportunity to become a lead dancer in a show that his troupe was putting on in the fall. He doubled his practice time, reduced his hours at the restaurant, and tried to lose even more weight. He was already quite fit, but he knew that the artistic director of the troupe liked his male dancers to look almost anorexic. Everyone told him to take it easy, complaining that he looked too gaunt and seemed to be straining himself. Michael ignored them. He slept only four hours a night to squeeze in more practice time and ate even less. He began to realize that something was, in fact, wrong when he found himself compelled to align the pillows perfectly on his bed and couch before he could fall asleep. Then he found it necessary to balance all his pillows. He explained his problems to his weekly psychotherapy group, which he had considered eliminating to save time. The other group members asked him if snapping the feathers and balancing his pillows gave him a sexual sensation. Michael said no. He told them that he’d been cracking feathers since childhood, but the balancing compulsion was new. The group was sympathetic and tried to offer suggestions to help. Afterward, the social worker who led the group took Michael

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aside and recommended a psychiatrist. When Michael consulted the doctor, he was given a diagnosis of OCPD. The doctor was able to identify Michael’s problem primarily because he recognized the following eight traits, which are often evident to friends and family who live with someone with OCPD.6 1. A preoccupation with details, rules, and schedules to the point that any joy in the activity is lost. If two pillows were on one side of Michael’s couch, then two would have to be on the other side. He couldn’t rest if he didn’t do this. In addition, he would sit for more than an hour and crack the feathers in his pillows, whereas earlier in his (arguably less stressful) life, he’d only spent a few minutes. The time wasted on this compulsion angered and distressed him, but he found he couldn’t stop. 2. The person’s perfectionism interferes with getting tasks accomplished. In Michael’s case, he wanted to put gloves on when he worked as a waiter, but he knew he would be mocked by other employees if he did that. Many times, he took twice as long as the other waiters to clear tables, but he wouldn’t let anyone help him. 3. Friends and family members play a secondary or tertiary role in life. A patient of mine called Emily was so involved in her fledgling photography career that her family and friendships were not considered important. Like Michael, if friends or family members wanted to visit or suggested going out, Emily would put them off—to the extent that she became reclusive. As a result, people with OCPD typically have few friends, and their family often disregards them. 4. The person is excessively rigid and stubborn. If the director told Michael to stretch his leg in a certain way, Michael would do it exactly as he was told, even if it was painful or inappropriate for the dance. The negative introject told him that if he failed to comply disaster would follow. 5. A person with OCPD is overly conscientious and inflexible about his or her values. Emily, the patient mentioned earlier, would attend church every Sunday and expect everyone else to do the same.

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6. Those with OCPD often resemble hoarders. In Michael’s case, since he had trouble throwing anything out, some of his pillows dated back to his childhood. 7. The person often can’t let others work for him or her because they often don’t meet his or her standards. Even though they needed help in their respective jobs, both Michael and Emily couldn’t let others work for them because other people didn’t meet their exacting, and often unrealistic, standards that are set by a negative introject. 8. An unhealthy use of money—often excessively hoarded. Michael had packets of money stashed around his apartment that he never used even when he needed it. When Michael was compelled to snap the feathers of his pillow for an hour, he was bordering on having OCD. However, with the psychiatrist’s help and group therapy, Michael was able to limit his feather-snapping and eventually become more social and less rigid in his thinking and behavior. People with OCD are usually not able to stop themselves so easily from their compulsions or obsessions without medications or extensive behavioral therapy, which is another clue to their difference. Even though we psychiatrists know that we can’t really change those patients with personality disorders, the case described next was my attempt to do so. Randi, a 56-year-old homemaker married 34 years, had always warned her family that she would kill herself if her husband ever left her. She had never lived alone or worked outside the home. Her husband, a 58-yearold attorney, had supported her and their two children for their entire marriage. It wasn’t until he was hospitalized for severe depression himself that he decided to divorce her. Through psychotherapy in the hospital, he realized he had resented his position as sole provider for the family. As soon as he was discharged, he served his wife with divorce papers. Randi was devastated when she received them. The following week, her two sons found her sequestered at home, not eating, washing, or engaging in her usual activities. All she wanted to do was sleep, and when she woke up, she cried and bemoaned her fate. Her sons were

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frightened when she threatened to commit suicide, so they called emergency medical service. The police forced her to go with them to the emergency room, from which she was admitted to a psychiatric ward for depression. In the hospital, she was given an antidepressant. She had been depressed off and on for years and had tried most antidepressants, albeit with little results. After two weeks, her insurance coverage expired, and she was prematurely discharged with the diagnosis of major depression with psychotic features. Randi’s treatment with me began after the hospitalization. She appeared to be her stated age, was neatly dressed in casual clothes, and looked morose. She cried so hard throughout our first few meetings that it was hard for her to speak. She urgently requested to remain an outpatient since her inpatient experience had been so dreadful. I assured her that I would do everything I could to keep her out of the hospital as long as she wasn’t suicidal. However, she still distrusted her husband and imagined that he had paid the hospital staff to mistreat her. Her husband had always advised her on the tiniest details of everyday life, from what kind of pasta to cook for dinner to how to invest the few funds she controlled. She didn’t know how to live without him. Every session began with her crying hysterically about losing him. She wanted her sons to assume responsibility for her since her husband had abdicated his role. My plan was to have her take care of herself, but she was resistant. The original attraction to her husband was that he was a dominant, “take-charge” individual who left her no room for her own opinions. She told me that she was a “lady who lunched” and wondered how she would survive without her usual luxuries of manicures, buying designer dresses, and a visit to the hairdresser each week on the small income to which she had been reduced. Randi’s sons assured me that after the divorce was finalized, she would still have a considerable fortune and would never need to work. Her denial of her financial status was delusional and reinforced the diagnosis of major depression with psychotic features. Randi’s worst times were in the morning when she was totally alone and felt dreadful. She couldn’t see how she’d ever be able to care for herself. What would she do and how would she initiate anything? I suggested going back to school to study computer science since she was

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embarrassed about being barely able to operate her cell phone. In college, she had almost earned straight A’s and graduated with honors with a bachelor’s degree in business. Her IQ was higher than average, but she had never tried to improve herself. She had relied instead on her husband, her sons, and her friends for everything. She only agreed to take a computer course when a girlfriend said she would go with her. Our work consisted of structuring her time and teaching her basic skills of living. The plan was to wake up at a set hour during the week, make breakfast, and attend computer class. On most days, she would go to the gym and then have lunch or dinner with one friend or another. Once a week, she would view a movie or attend the theater. It was an enviable life not to need to work, but she couldn’t understand that since she had never experienced anything else. She was reluctant to do anything on her own since she lacked self-confidence in her abilities. I reinforced her intelligence and quickness in learning new skills. Her desire was to jump into another romantic relationship before she dealt with the loss of her husband. She wanted someone else to immediately support and infantilize her. The struggle was to make her aware of her excessive dependency needs. However, despite all efforts on my part, Randi’s negative introject told her that she was inadequate and needed someone to constantly care for her. Her father had died when she was ten: a horrible loss for her since she was very close to him. Her older brother was sent away to boarding school, while her grandmother and uncles took her mother and her under their overprotective wings. The patient and her mother were treated like babies who couldn’t do anything on their own. The family discouraged her from attending college out of state. Instead, she was forced into a local university where she immediately met her husband, who assumed control of her from the beginning of the relationship. She considered him manly and charming, and she fell in love. During their marriage, she always agreed with his decisions because she was afraid he would reject her and abandon her if she didn’t. Her sons grew to disrespect her because of her behavior with her husband and her disregard of their needs. In the end, her husband divorced her because he couldn’t tolerate her dependent behavior any longer. In therapy, Randi attempted to place me in the same caretaker role her husband had just vacated. Consequently, I was supposed to make

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all her important decisions for her and tell her what to do. Of course, I resisted this role and helped her initiate projects on her own. I knew that her self-confidence needed to be built up and that she needed the experience of assuming responsibility for herself. By now, it was clear to me that she had dependent personality disorder (DPD)7 in addition to major depression disorder with psychotic features. Randi was afraid to get angry with others for fear of alienating them and having them abandon her the way she perceived her father did when he died prematurely. When Randi’s husband finally did leave her, at first it seemed a tragedy; on the other hand, having to cope with the divorce opened Randi to new ways of behavior, although making these changes was extremely difficult for her. Next, we have a case of avoidant personality disorder (APD). Her co-workers at the theater wondered how Leanne was so satisfied working mainly backstage as a prop person for ten years. In stark contrast, most of them were aspiring actors stuck in the box office or behind the scenes when they longed to be onstage. Once, when Leanne had been accidentally caught in the bright lights as she crossed the stage to place a teapot on a table, she had nearly fainted. Her father, an accountant, had been the one to get her the job right after she graduated from high school. She had tried a few classes at the local college, but she was too ashamed of herself to compete with classmates or turn in assignments. Leanne knew she feared people and rejection. Since her father’s death, Leanne lived at home with her mother. She rarely ventured out on dates or with friends. When she did go out, she felt awkward and inferior. Her mother tried to encourage her to interact with other people, but Leanne was always resistant. Then a new stage manager was hired at work. With his movie-star good looks, a “Brad Pitt double” everyone said, and his polite manner, most of the women were attracted to him. Leanne tried hard to avoid him, because she found him so handsome and feared he would think that she was ugly as a troll because her negative introject informed her opinion of herself. On the contrary, everyone said that he admired Leanne and attempted to befriend her. “If only I knew he would accept me and never reject me,” she told her mother, “then maybe I could go to lunch with him as he requested.”

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“You can’t ask for a guarantee,” her mother replied. “Just try it. Go out with him once.” Leanne remembered how her mother always belittled her as a child and pushed her to join clubs or take classes that made her feel terrible. If she said no, her mother would slap her face. Her father had also mocked her for her timidity. Her negative introject told her to hide, that she was unworthy of being with other people. Every day, Leanne thought about dating the stage manager. She finally bolstered her confidence to the point where she was about to approach him, when she dropped a small radio that she was supposed to place onstage. It seemed to her that the stage manager scowled at her. After that, she couldn’t force herself to speak to him about lunch. She scurried away quickly if he came near her. Everyone told Leanne she was ridiculous to be so sensitive, but she couldn’t help herself. People with APD8 are seen by others as extremely shy. They fear rejection so much that they choose to be lonely rather than risk involvement. Leanne’s job as a prop person is a perfect occupation for an individual with APD. She can be behind the scenes and avoid contact with others. In Leanne’s case, she was not just an only child but also a fearful and isolated one. In adolescence, she stayed away from her peers. Because of her disorder, she was also unable to finish college. Oftentimes, people with this disorder can marry and have children, but they have to be protected and supported by loved ones. It is believed that 1% of the population is affected by APD, much like Laura Wingfield in Tennessee Williams’s The Glass Menagerie. In that play, Laura is so shy that she never dates, and when her brother Tom brings a “gentleman caller” to visit, she chooses to play with her collection of glass animals rather than interact with her visitor. Treatment for APD may consist of individual or group therapy. In individual psychotherapy, the therapist must develop a solid alliance with the patient, maintaining an accepting attitude. However, Leanne never had the benefit of any type of therapy. Her mother’s encouragement to attempt dating the stage manager just once was sound advice that probably would be given by a therapist. Leanne has to overcome or tolerate a world that she perceives as humiliating and rejecting, with a negative introject constantly belittling her. Group therapy helps

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patients to understand how other people really see them and encourages them to maintain a more realistic view of the world. The medications that may be used include SSRIs—e.g., Lexapro. β-blockers—e.g., propranolol—may be tried as well to decrease autonomic hyperactivity. Some psychiatrists recommend benzodiazepines— i.e., Ativan or Klonopin, but these medications must be used with caution due to their addictive potential. As with any personality disorder, APD is pervasive, generally inflexible, and leads to multilayered social and occupational problems.

Notes 1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing. 2. Berman, C. (2009). Personality disorders: A practical guide. Philadelphia, PA: Lippincott Williams and Wilkins. 3. Sometimes the two are mixed up. 4. APA, DSM-V, p. 663. Retrieved from www.minddisorders.com/Flu-Inv/Histrionic-personality5. disorder.html 6. APA, DSM V, p. 667. 7. Ibid. 8. Ibid.

Addictions and the Negative Introject

7

One of our biggest problems in psychiatry is dealing with and treating addicts. Most of them have giant negative introjects that they are constantly trying to suppress. They silence their negative introjects by using their substances. It’s a temporary solution that leads to use, abuse, withdrawal, and then the cycle starts all over again. Thomas, a 42-year-old businessman, started using alcohol as a teen. He’d seen his father and mother abuse alcohol since he was a young child. They’d go out most nights to drink and socialize, leaving Thomas alone. He’d have terrible panic attacks most nights when they were out. There was no one to comfort or help him. When he finally told his mother what was happening to him, she cried and promised to stay home to help him. However, when his father said, “Let’s go out,” she went. Thomas developed bad sleeping habits. As a teen, he discovered that if he took a slug of alcohol before bed, it calmed him. Then if he had a panic attack during the day, he would feel better if he had a drink. There was also a negative voice in his mind telling him he was “a no-good, stupid slug, who was bad at everything.” If he drank, the voice would be quiet for a while. Thomas was a hard worker. He inherited a business from his father, who was a wine import purveyor. Thomas was constantly around alcohol. His cycle of use, abuse, and withdrawal went on until he was 41. Then some friends suggested he go to Alcoholics Anonymous (AA) with them. He was so discouraged

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with his alcoholism that he went to an AA meeting in a church. He prayed with the group and felt so much better. His parents had been religious, and Thomas easily absorbed the “higher power” messages. Then he became sober. First, it was one week and then a month. Then six months. Then a year! He couldn’t believe it. It wasn’t easy. He had many temptations to drink, but he resisted them. The only trouble was that he still had panic attacks. In fact, they came back with a vengeance. Also, the negative voice in his mind was constantly degrading him, saying, “You are a worthless piece of crap. How long can you keep up this AA charade?” Thomas decided to get professional help at this point because he knew he couldn’t drink anymore to silence the negative introject. The psychiatrist he consulted started him on sertraline, which kicked in after a few weeks and relieved him of his panic attacks. The negative voice was harder to combat, but he worked with the doctor to identify when the voice bothered him. Whenever it came up, he was supposed to fight it and counteract its negativity with positive statements. Thomas has maintained his sobriety for years, thanks to AA, his psychiatrist, and his hard work. Addiction to alcohol is due to a complicated array of factors, including genetic predisposition and environmental conditions. It has been found that the sons of alcoholics metabolize alcohol differently than the sons of non-alcoholics. They are able to tolerate larger doses of alcohol without feeling inebriated. The alcoholic tends to be a “people pleaser,” an AA term. This is also consistent with the alcoholic as a dependent personality and one with many unresolved oral features. Low frustration tolerance and the inability to deal with anger and other intense feelings are part of the psychological makeup of the alcoholic. Marvin, a 45-year-old IT expert in a large company, was a family man with two children and a wife whom he’d been married to for over 20 years. Most of the conflict with his wife had been due to his alcohol use. He stayed out too late and drank indiscriminately with business associates in restaurants and bars. On weekends, he completely disappointed his wife by sleeping off his hangovers to the exclusion of all other activities. His negative introject could only be drowned out by sitting and watching sports on TV with a few six packs or highballs. He

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completely withdrew from his family on Sunday. As is often the case with alcoholics’ wives, Marvin’s wife did not drink. She was deeply religious and Marvin’s “enabler.” Marvin was in a state of complete denial before he went into a detox program. He didn’t believe he had a problem with his drinking. If he became a little shaky when he stopped his daily intake of alcohol, he ignored it. One time, he had a convulsion after stopping for two days. He told himself that he was working too hard and decided to rest more. His doctor told him his liver was enlarged and asked if he drank a lot of alcohol. Marvin denied everything. He knew he was perfectly OK. His ethnic group considered drinking “manly” and a social necessity. At work, he became famous for sitting around with his head in his hands and staring at the computer screen. When he designed computer programs, he was excellent, and so he kept his job for many years. His supervisor usually noticed alcohol on his breath after lunch. This wasn’t so unusual since his colleagues all had a few drinks at lunch, but Marvin smelled like alcohol every day. He would often miss work on Monday mornings, complaining of stomachaches or any other symptom rather than his hangovers. A younger computer analyst applied for Marvin’s position. This was just the opportunity his boss needed. He called Marvin into his office and told him to take care of the alcohol problem or leave the company. While he was taking care of himself, the supervisor said he would train a new analyst, just in case. Marvin was furious with the ultimatum, but he had no choice but to comply. He checked himself into the recommended detox program at one of the local hospitals. The doctor gave him Valium to stop his shaking and other withdrawal symptoms. He attended AA meetings on the ward. When he heard all the stories around him, he realized that he was similar to the men and women on his ward. He couldn’t stop drinking, and alcohol had become the center of his life. This was Marvin’s first detox after 20 years of drinking. He didn’t handle the confrontations with the other patients well. He tried to use his old defenses of denial and rationalization, but the counselors, recovering alcoholics themselves, broke through to him time after time. They kept showing him how foolish and wrong he was. Marvin couldn’t stand being treated like a 10-year-old, which was his interpretation of group therapies and exercises. He felt he was a grown man and wanted to be treated like one. One day, when a counselor told him to ventilate his feelings, he exploded

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with rage. This embarrassed him, and he quickly checked himself out of the hospital against medical advice. The doctor pleaded with him not to go and warned that stopping Valium suddenly was dangerous since his detoxification was still in progress. Considering the condition of his heart and liver, the doctor said it was a big mistake to leave precipitously. Marvin didn’t care what the doctor or anyone else said. He wanted out. Impulsivity had always been one of his characteristics, along with intolerance of his anger. He went home and locked himself in his bedroom with three six packs of beer and a bottle of vodka. The next morning, his wife knocked and knocked. There was no answer. When she finally broke the door down, she found Marvin dead, surrounded by empty cans of beer. The negative introject had won this battle. Patty had been called moody since her teen years. She didn’t find it unpleasant since she was so familiar with being up one day and down the next. However, at 42, the constant variations were wearing her down. Besides having two children to raise, she worked full time as a legal secretary, which was exhausting. Her ex-husband had been disturbed by her mood swings, especially when she used drugs. When they were together, they’d both abused cocaine by smoking crack. After her children were born, Patty refused to partake of any drugs, especially cocaine. However, her husband said he couldn’t tolerate her anymore, and he left her and then the state. Consequently, she had to support the children by herself. Her son was now ten and her daughter eight. During the years that Patty abused cocaine, she had enjoyed the highs when she felt completely in control and exuberant about life. These highs were similar to what she experienced naturally every few days, but they were more intense. The lows or “crashes” after the drug abuse were unbearable. The natural lows she experienced were never that bad: she felt blue, slept too much, and overate, but these depressed states never lasted longer than a day or so. And sometimes if she was lucky, she’d have months when she felt completely normal. One time, she was so distraught, she felt like jumping off the subway platform, but fortunately, her husband had talked her out of it. These suicidal impulses were caused by a virulent negative introject. She was concerned about her children’s welfare, which gave her a reason to quit drugs. Patty wouldn’t just quit for herself.

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Patty’s father had been diagnosed with bipolar disorder. She remembered him raging and screaming at her and her brother. One time, when he believed that she was a devil, he had tried to hit her over the head with a hammer. She’d escaped. He was even worse when he drank, which was frequently. Her mother was always mildly depressed. Patty’s work as a legal secretary was time-consuming. She often worked ten-hour days. Her mother would take the children home from school and cook their dinners. By the time Patty came home, she was exhausted. She’d tuck the children into bed and then lie down to go to sleep. Sometimes when she was in an “up” mood, she’d go on a date or stay up late at a party. She was often low on funds, because during the “up” moods, she’d go on shopping sprees and spend far too much. Her mother heard of another woman in the neighborhood who took antidepressants and was “cured” of her moodiness and exhaustion. Patty went to see the doctor at her mother’s encouragement. The psychiatrist questioned Patty extensively and then told her that she had cyclothymic disorder. He said she could try an antidepressant called Lexapro. Patty did, and after five days, she was “flying high.” It felt to her like cocaine. She went out with a complete stranger she met at the office and the next day she “maxed out” her remaining credit card. She’d given up the other cards to control her spending. Patty’s mother demanded that Patty go back to the doctor and report these results. Patty didn’t want to, but she did go to please her mother, who’d been right so many other times. The psychiatrist wasn’t surprised. He said, she had mania and gave her 50 mg of Seroquel to add to her 10 mg of Lexapro. In a day or so, she calmed down. Patty was glad she didn’t have to give up the antidepressant. She continued taking the two medications for six more months on the doctor’s advice. To her it was an excellent “cure,” and she was relieved of her up and down cycling. Both her mother and her children complimented her on her stability. Most patients with cyclothymia begin to experience mood swings in adolescence. After Kraepelin,1 it was believed that cyclothymia is a mild form of bipolar disorder. Now that we have the categories of bipolar I, II, and even III, cyclothymia can be viewed as part of the spectrum. The mood swings of hypomania and depression are not intense enough and do not last long enough to be considered bipolar disorder. Many cyclothymic patients have relatives with affective disorder, like Patty’s father who had bipolar I disorder and her mother who had depression.

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Many patients enhance their moods with drug abuse, especially cocaine2 and amphetamines. Patty, fortunately, was able to stop her cocaine abuse, but many patients remain addicted. Cyclothymic patients may also suffer from personality disorders, such as histrionic, antisocial, and sociopathic (see Chapter 6). Patty did not, even though she grew up in a traumatic environment with her often psychotic and abusive father. Her mother was able to provide a safe and “good enough” environment. The use of antidepressants in these patients is often helpful, but they can trigger hypomanic episodes. This does not mean the patient is necessarily bipolar. It is still worth using antidepressants, and they can be modulated with the addition of mood stabilizers, such as Depakote or Tegretol. A good psychopharmacologist will be able to help cyclothymic patients deal with these problems. Psychotherapy is also recommended for optimal care. Different drugs induce different states. Cocaine makes those with a degraded self-image, or decreased self-worth, or a powerful negative introject, believe that they are at least adequate and sometimes powerful. Many depressed individuals will abuse cocaine, which masks depression. Cocaine has a similar effect to antidepressant medications. However, cocaine depletes the nervous system of vital neurotransmitters, while antidepressants allow those same chemicals to remain for a longer time in neuronal synapses, thereby improving the chemical functioning of the nervous system. Many cocaine users become even more depressed than before they started drug use. They may use increasing quantities of cocaine in an attempt to alleviate their blue feelings. They find temporary relief, but then feel worse. Cocaine can be injected, sniffed through the nasal passages, or smoked in the freebase form and as crack. Studies have found that many former cocaine-abusing patients benefit from antidepressant medication. This helps them to remain drug-free. Those who have smoked the drug have the least success in decreasing their craving for it, even after antidepressant therapy. Doris is a 26-year-old administrative assistant in the motion picture industry. She is the youngest of six siblings. The older five were all brothers. Her father had made it quite clear that six sons would have been fine with him. A girl was an embarrassment and a burden to him, so young Doris did her best to try and be like a boy. As she grew

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older, she played baseball with her brothers and tried to blend in with the guys. Her mother was a quiet, frightened woman who let her husband dominate and control her. Doris wound up feeling less than adequate since she never achieved the acceptance from her father that she wanted, and she identified with her mother. Even though she attended a good college and did very well in school, she thought of herself as not too bright. Her negative introject was so powerful. Doris is attractive with sea-green eyes and sandy-colored hair cut in the latest style, but whenever she looks in the mirror, she focuses on the asymmetry of her face or any other imperfection without seeing her beauty. When co-workers passed the “white stuff ” around in the office, Doris decided to try some. This gave her a bond with the other employees. It was the “thing to do.” After the drug use, she would find herself with lots of confidence. Before using cocaine, she meekly presented her ideas to people, afterward, she felt super sure of herself. She became “queen of the kingdom” with a few snorts of cocaine. Her negative introject was suppressed. Her social life picked up also. Men asked her out because she seemed so positive, full of energy, and less inhibited. She enjoyed her newfound popularity and confidence for a while. But problems arose quickly. She couldn’t sleep at night. In the day, she was jittery and paranoid. Her appetite was terrible, and she lost enough weight to appear gaunt. When she heard about crack, she thought it would give her a more wonderful high and help her, so she tried some. She never imagined that once she started, she wouldn’t be able stop. Her problems multiplied beyond control. She couldn’t stop smoking crack and spent $300 a day just to keep up with her habit. Her income was inadequate to support her habit, so she had to dig into her savings. Doris was addicted. Others knew this long before she did. Fortunately, her family interceded and put her into a detoxification and rehabilitation center. There she had a chance to stop drug use in a protected environment and to learn about some of her psychological problems, like low self-esteem and feelings of inadequacy. During treatment, she could see how cocaine use had been masking her degraded self-image and prominent negative introject. After discharge from the hospital, she attended Narcotics Anonymous (NA) and joined a psychotherapy group.

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Clark is a 27-year-old flight attendant. He is a handsome, affable young man who knows how to comfort nervous airline passengers. He would usually walk down the aisles with a pleasant smile on his face, even under turbulent air conditions, which inspired confidence in customers. However, last spring, Clark started looking glum. Co-workers commented on this change in him. Clark shrugged their remarks off. Then he began to have frequent absences and many unsubstantiated illnesses. One day, he had to give a urine sample during a routine physical exam. The sample came back positive for cocaine. The physician who was examining him referred him to the airline’s Employee Assistant Program (EAP), who happened to be an external EAP, a psychiatrist in this case. The psychiatrist invited Clark into his office for an interview. At first, Clark tried to deny all charges of drug use, even though the doctor had the evidence of a positive urine test. After much probing and confrontation, Clark reluctantly admitted that he was snorting cocaine and smoking crack when it was available. He had worked himself into a $500/day habit. The doctor suggested hospitalization as soon as possible since Clark had already lost a lot of weight and was abusing alcohol in between cocaine binges. At first, Clark disagreed with the psychiatrist and refused to be hospitalized. Later that evening, after he was unable to obtain cocaine, he called the doctor and requested to be put into the hospital. The next day, they met in the admissions office of a small private psychiatric hospital in the middle of the city. Clark waited in a comfortable room with five other addicts who were nervously drinking coffee and smoking cigarettes. Before Clark was sent up to the ninth floor, he left all his valuables in the safe downstairs. When he reached the floor, a male nurse searched him thoroughly, even examining his rectum for drugs. “I feel like a prisoner,” commented Clark. “Well, you should see the type of drugs patients smuggle into the wards,” said the nurse. “You can imagine what chaos we would have if people were smoking crack when no one was looking because I failed to examine someone carefully, and he smuggled the drug in.” Even though Clark was a voluntary patient (which meant he could leave anytime he requested it), he still didn’t feel that he was voluntarily

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stopping drugs. The airline made it clear that if he didn’t check himself into the detoxification and rehabilitation program, his job would be in jeopardy. Clark started his program with a bad attitude and resentment about being in the hospital. His negative introject, which he had suppressed with cocaine and alcohol, dominated his thinking. As he progressed, his attitude improved, and he learned how to control his negative introject. The counselors who provided moral support and education about drugs were ex-addicts themselves. The counselor assigned to Clark, Patrick, was an ex-cocaine addict himself. Patrick understood exactly what Clark was experiencing in terms of physical withdrawal, psychological dependence, and denial of the real issues underneath the drug problem. Physical withdrawal from cocaine consisted of sweating, nightmares, headaches, irritability, and lethargy. The psychological dependency lingered on after the seven days of withdrawal were over. Real issues underneath the drug problem included Clark’s constant feelings of inadequacy (his negative introject abusing him), his fear of social interactions, and his financial debts. A typical day in the hospital began at 6:30 a.m. Nurses came by and checked Clark’s vital signs—i.e., his blood pressure and pulse. Then he would wait his turn for the shower. There were about 35 people on the ward, 15 women and 20 men. The men had four showers and the women three showers. Clark usually had to wait ten minutes before he could shower. After that, everyone had breakfast in the main room by 8:00 a.m. Group therapy was at 9:30 a.m. until 11 a.m. Afterward, all the patients assembled in the main room for films or lectures about drug addiction, co-dependency, and family difficulties in the addicted. Lunch was at noon. In the summer and spring, early afternoon time was when the patients went downstairs for a basketball or volleyball game. In winter and fall, this time was spent in a dance or movement class. Sometimes the counselors took groups out for a walk. If that happened, one counselor led the group while another one followed behind, making sure that no one escaped for a beer or a hit of drugs from the local street dealer. Upon return from the street, each patient had to submit a urine sample 12 hours later just to be sure that no one had imbibed some substance while in the street. In this way, the patients were safeguarded

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against using drugs before they had gained inner controls against their negative introjects. Inner control against drugs was built by the AA and NA groups run on the ward. Here counselors who were in sobriety themselves led the groups from 3 to 5 p.m. NA and AA followed the 12 step programs where the patients appealed to a higher power than themselves and admitted powerlessness in the face of drugs and alcohol. Upon discharge, these patients would attend NA and AA on their own. Every third day, Clark would be seen by his psychiatrist, who gave him therapy for 15–20 minutes. Every other day, he would have individual sessions with his counselor, Patrick. Dinner was at 6 p.m. Afterward, the patients would have a community meeting where complaints about ward issues were heard and suggestions for improvements were given. Films or dances or social events were held from 9 to 10 p.m. Patients tried to be in bed by 10:30 or 11 p.m. so they would have eight hours of sleep before the six-thirty wake-up time. Clark was skeptical of the entire program when he first arrived on the ward. He tried to skip the groups and other activities. Patrick, his counselor, showed up in his room on the second day when he had gone back to bed after breakfast rather than attend Patrick’s group. Patrick didn’t waste any time. He cut right through Clark’s elaborate defense system. He said, “Get your butt out of bed, buddy, and join us in group, or I’m going to suggest that you be discharged from the ward.” “But I feel weak and shaky. I didn’t have my cocaine for two days,” complained Clark. “Big deal,” said Pat. “I’ve got guys out there who have been drinking two quarts of vodka every day of their whole lives, and now they’re sober and in group. I want you there too.” Clark couldn’t hide on the ward, so he complied superficially by physically attending groups and mentally escaping into a fantasy about taking cocaine. His negative introject hated the place. In group, his peers would confront him about daydreaming too. “Quit bullshitting us, Clark,” another patient said to him. “We know you’re really not with us, man. You’re in your own head. I just asked you a question, and you didn’t hear me at all. You just gave me one of your airline host smiles and ignored me.”

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Little by little, all the patients, Patrick, the nurses, and his psychiatrist broke through to Clark. Inside, he was a hurt child who still couldn’t get over his parents’ divorce when he was 8 years old and whose negative introject was so strong. The therapies started to work on him, and Clark began to heal himself. People really did care about him, if he would only care about himself and stop trying to escape. He cried and felt the pain he had been trying to escape. After three weeks, when his time was up on the ward, he found that he really didn’t want to leave all his new friends. The psychiatrist scheduled outpatient visits for him on a oncea-week basis. Clark would attend NA and AA on his own on a daily basis for the first 60 days after his discharge from the hospital. From the psychiatrist’s viewpoint, Clark was a typical cocaine addict with an NPD. He had a pattern of being grandiose and hypersensitive to the evaluation of others, and he had a lack of empathy toward others. Clark expected to be treated as special. Lying in bed at the beginning of his treatment and his expectation that he would be excused from groups when others were expected to attend were two examples. Clark exaggerated his achievements to get noticed on the ward. The other patients saw through his facade and didn’t treat him as special. Whenever he could, Clark would take advantage of others to achieve his own ends. The attention that the psychiatrist and counselors gave him was gratifying, so he listened to the advice of these individuals. The psychiatrist would discuss Clark’s treatment one time per week in a staff meeting, which included Patrick the counselor, a social worker, the dance therapist, a nurse, group therapist, and an outside EAP from Clark’s company. Reports from staff were unfavorable during Clark’s first week of treatment. He was uncooperative, resentful, envious, and having many side effects from his cocaine withdrawal. Clark was on the verge of checking himself out against medical advice that first week. But Patrick and one of the nurses convinced him to stay. The reports were more favorable after the first week. Clark began to realize that a habit that cost him so much of his salary per week, that sent him stealing from his mother and brother, and that caused him to pawn all his jewelry couldn’t be something desirable. He decided he really would like to give up cocaine and get control of himself once again. Clark also began to realize what an impact his parent’s divorce

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had had on him, how strong that negative voice in his head was, and how inadequate, inferior, and valueless the whole event had made him feel. The psychiatrist was able to review this childhood history with him and put the important points into perspective. There were ways to feel good besides taking cocaine. Clark learned to interact with his peers in groups and in social events completely sober. He realized that other people had some of the same feelings and problems that he had. His prognosis was not the best with his NPD, but if Clark attended AA and NA on a regular basis, in addition to being in psychotherapy one time per week, he would have a good chance to remain in recovery. Heroin sends its users into a totally tranquilized state where nothing matters, into a waking sleep where no problems exist. Many of the individuals who are addicted to heroin suffered terrible abuse in their childhoods. Their abuse might have been mental, emotional, and/or physical. Heroin is absorbed at the opiate receptors of the brain where the natural opiates of the body, endorphins, are also absorbed. These opiate receptors regulate pain. The past abuse that heroin addicts experienced may have caused damage or some malfunctioning of the opiate receptor system. Through drug use, the addict may be trying to regulate his/her system. It could be that endorphins are insufficient, and the heroin user adds artificial opiates—i.e., heroin—to modulate his/her malfunctioning. This is the theory of self-medication. “Junkies” tend to feel unworthy, but when they take heroin, they place themselves into a world where they no longer need to contend with adequacy issues. Their negative introjects are silenced. Unlike cocaine users who inflate their self-image with their drug, heroin users float away to a fantasy world where image and worth no longer matter. George is a 23-year-old rock musician who supports himself by working in a music store. He is the oldest of two brothers. His father is a controlling, abusive individual who yelled, and punched George and his mother. The mother was a meek and submissive housewife who felt she had to tolerate her husband’s violence. She had grown up in a similar type of home where her own mother had been abused by her father. George bore the brunt of the punishment in the family and often tried to defend his mother, warding off blows from his father onto himself. George’s father is an alcoholic who would drink himself into violent states at least once per week. George started using any drugs he could

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get his hands on from early adolescence. First, it was marijuana and then uppers, downers, and psychedelics, such as mescaline and lysergic acid diethylamide (LSD). When he tried heroin, he knew he had found the panacea, the perfect drug for him. One shot of heroin, and he was “in nirvana.” He would drift far away from “the pain of the world.” He believed that the drug enhanced his ability to play music. High on heroin, the notes of his lead guitar sounded ethereal and surrealistic to him. All anxiety was gone, and his fingers flew nimbly over the strings. In reality, his playing while high was not noticeably better, according to the other band members. However, when he was on heroin, George’s performance anxiety on stage was lessened. Sometimes he wouldn’t even know whether he was on stage or not. One time when he was sitting backstage, another band member shined a bright flashlight on him in fun. He picked up his guitar and started to play since the light made him believe he was on stage. His job at the music store was not that taxing. All he needed to do was to keep albums in alphabetical order and to help customers find CDs and tapes. George was often late, absent, or “nodded out” on the job. His supervisor admired George and his band, so he would cover up for him when he was late or absent. The supervisor, Dan, did most of George’s job by himself. Dan was George’s “enabler,” an NA term for a codependent person who keeps the addict addicted by taking care of him and protecting him from the consequences of his habit. This went on for some time until another supervisor became Dan’s boss. Then both Dan and George had a lot of explaining to do. The outcome was that George was fired from his job, and Dan was put on probation. Then George had no money for drugs. He was forced to go to a methadone clinic, where he obtained 80 mg of methadone/day, which gave him enough stability to find another job. His life became a recurrent pattern of returning to heroin use and then bouncing back to the methadone clinic. Heroin is a more incapacitating drug than cocaine. Instead of speeding up the worker’s progress, it slows him down almost to the point of nonfunctioning. Artists and musicians claim increased creativity and productivity, but this has not been documented or researched. Such claims are usually rationalizations for drug use. Drug abusers learn to employ devious arguments and reasons to explain their deficiencies

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due to drug use. These defenses, known as rationalization and denial, help to keep the abusers unaware of their own problems. Gregory, a 55-year-old executive, became addicted to oxycontin in the usual way: his doctor gave him painkillers and failed to monitor his use. This is one of the biggest problems we are having in the U.S.A. at this time. Gregory had back surgery for a slipped L4-L5 disc after a strenuous session of golf playing. After recovery, he was supposed to wean off the opioid, but he never did. Gregory had a very critical part of himself that would excoriate him for the slightest error. He found that when he took his opioid, he wouldn’t criticize himself, and he was relieved of back pain. A perfect solution to his problems! The only trouble was he withdrew often from the medicine and would have to keep taking it for pain relief and freedom from his negative introject voice. When his surgeon finally said that was enough of oxycontin (after six months), then Gregory went to another doctor who supplied him for a few more months. When that source dried up, he asked a colleague in his office who connected him to a man who supplied it for a price. Gregory went for it and stayed addicted for years. Gregory cycled through the typical stages of (1) tolerance, (2) physical dependence, and (3) addiction. He had the physical risk factors of being a male, white, in chronic pain, with a physical disability, and an avoidance coping style. Betty, a 65-year-old retired nurse, was addicted to Valium. Her addiction had started years ago when she worked in the hospital on a medical surgery ward. She would get the residents-on-call to prescribe her “a few Valium.” Before she knew it, she was taking ten 10 mg of Valium/day. She used this benzodiazepine at first to relax after a hard day at the hospital. The Valium also quieted her negative introject, and she used the drug to sleep. She found she needed more each month just to prevent withdrawal. Betty knew what would happen if she went into withdrawal. She could have a convulsion, so she kept herself well supplied with Valium. After she retired, she asked three different doctors (her internist, her G.I., and her gynecologist) for the medicine. Then a monitoring system was activated

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in her state, and the three doctors discovered that Betty was receiving Valium from each of them. Her internist insisted that she go into the hospital to withdraw from that huge amount of benzodiazepine. Then Betty was sent to a rehab center for a month. She had a very difficult time withdrawing and felt awful with excruciating muscle pains, headaches, and her dreaded negative introject yelling at her that “she was an idiot.” Betty had many risk factors for substance abuse: she was an older female, white, with avoidance coping style, forced retirement, living alone, and in social isolation. After the addict is drug- or alcohol-free, she/he must learn to live without substances. That is the hardest part, especially for alcoholics who’ve been using for most of their lives. AA, NA, and rehab centers offer programs to stay sober, and patients must take advantage of these programs. To deal with the negative introject, they need to have psychotherapy as well. Cannabis is a main focus in the media these days. Many states in the U.S.A. have completely legalized marijuana, and other states have permitted patients to use this substance for specific medical conditions. Tony was a stoner from his teenage years on. At 30, he was a talented guitarist who lived in his mother’s basement in San Jose, California. He smoked marijuana every day and ingested psychedelic drugs on special occasions. His mother worried about his constant use and his lack of motivation for anything except his music. Tony would play with a band on gigs here and there, but his main emphasis seemed to be on staying high. He had dropped out of high school, worked at the post office briefly, and then retreated to the basement. He had dated another stoner for a few months, but found he had no desire for sex. He would rather lounge around and watch DVDs or listen to music. His negative introject told him he was a loser, but Tony would just smoke another joint if the introject became too intrusive. Marijuana was supposed to be the harmless drug that the ’60s generation could take without ill effects. Unfortunately, reliable tests are now showing that this drug causes harmful effects in the lungs and actual damage after long-term use. It also decreases testosterone levels and, thus, produces gynecomastia and decreased sex drive. A motivation syndrome, where a person loses motivation or energy to do anything, is produced after prolonged use. A loss of goals can also occur.

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The reason this happens is not clear, but it may be that marijuana changes certain neurotransmitters in the brain and body—specifically serotonin. The drive to perform work disappears. Allen, a 65-year-old retired executive of a major corporation, identified with his 1960s generation. He was one of the first people in his neighborhood to smoke marijuana back when it was largely unknown and considered almost equivalent to heroin. He came from a stable, two-parent family with one younger sister. His only complaint about his parents was that they were “sickly sweet, too nice and conventional.” Allen was disappointed that they weren’t “hip,” important, or rich. At first, he’d been a high achiever, working hard to be the best basketball and football player in his high school. He had also been at the top of his class academically. In college, he was a business major with the goal of becoming a multimillionaire. After college, Allen started in the sales department of the company in which he later became vice president. When mescaline and LSD became popular in the 1960s, Allen took them. He would wear his business suit Monday through Friday and his jeans and headband on weekends. He managed to rise in the company’s ranks by limiting his drug use to weekends. Allen married an easygoing woman 15 years his junior. By the time they had two children, he was smoking marijuana every day. His job as vice president of the company bored him, and his negative introject told him he was doing nothing of importance. Although years earlier he would have been thrilled to be a top executive, he now considered the job unchallenging. He missed meetings and no longer came up with the innovative ideas for which he had once been known. Eventually, another rising star within the company replaced him. Allen rationalized and accepted the loss of his job, telling himself that he was too talented to remain in such a dead-end position. His greatest pleasure became sitting in front of the TV or computer and smoking one joint after another. He imagined that his daughters couldn’t tell what he was doing, because he smoked tobacco cigarettes in between the marijuana. One day, he saw his little daughter digging some bread crusts out of the garbage for breakfast because there was nothing to eat in the house; he felt some remorse, but then quickly lit up a joint. His wife urged him to consult a psychiatrist. He finally consented to a few sessions, but stopped after the second, during which the

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doctor suggested that he join NA and attempt a drug-free period of one month. Marijuana’s positive psychologic effects include a sense of wellbeing, relaxation, and euphoria, and best of all, reduction of the negative introject. Allen felt he could only attain these states by smoking grass. He believed that his perceptions and sensitivities were enhanced and that he heard nuances in music and saw unusual imagery in art and nature when he was high. He reported that he was able to detect flaws in his work and see it from a fresh perspective when using marijuana. Allen claimed to have deeper insight into the emotional states of others as well as improved understanding of human interactions. Marijuana is known to remove social inhibitions in some people, yet there are people like Allen who withdraw from others while high. He avoided co-workers, friends, and family. Not everyone feels mentally well after smoking marijuana; some people experience anxiety and panic. Short-term memory can be impaired, so recalling marijuana-enhanced effects may be difficult. Hyper-concentration occurs, whereas ordinary concentration is decreased. While high, a person may not be able to sit still long enough to work. Marijuana alters a person’s “internal clock” so that two seconds may seem much longer. The subjective lengthening of time could provide a false sense of how long a person works and may detract from his or her efficiency. And some people have an increase in their negative introject, not a decrease. Some individuals may have a predisposition to experiencing psychotic episodes, such as hallucinations and delusions after smoking marijuana. People with bipolar disorder, schizophrenia, or those using additional drugs, such as alcohol or cocaine, would be most likely to have psychotic episodes. Marijuana use, like the use of alcohol and other drugs, is a quick and easy way to temporarily reduce stress and perhaps the negative introject. Individuals who normally would be very obsessive, anxietyridden, or confined to a strictly rational thought process believe they can “loosen up” and access unconscious material through marijuana use. Longer-lasting and more positive stress reducers, such as psychotherapy, yoga, and meditation, can be used as stress-reducing replacements for marijuana use.

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Although marijuana is not considered a physically addictive drug, it often proves to be psychologically addictive for people like Allen. The first step in treating substance abuse is awareness of the problem. Allen, however, was not willing to acknowledge his problem—a prerequisite for addiction treatment. In his case, there was not much that could be done.

Notes 1. Kraepelin, E. (1913). Psychiatrie: Ein lehrbuch fur studiernan und artze, Vol. 3 (8th ed.). Leipzig, Germany: Barth. 2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

Denial of the Negative Introject

8

In all the previous chapters, I’ve described patients who are mostly enthusiastic to hear about and then apply the principle of “taming the negative introject.” Now we come to an entirely different group of patients who reject the concept completely, who think that it’s a bizarre theory dreamed up by crazy psychiatrists. Yet these are the very patients who are completely dominated by and identifying 100% with their negative introjects! I guess it may come as no surprise if you are one with your negative introject to reject the concept. It’s the old story of the fish who doesn’t know he’s swimming in water, or children before they gain consciousness and recognize their own individuated selves.1 Two cases are excellent examples of patients rejecting the negative introject concept and yet consumed by it. One patient is a 56-year-old woman, Clara, who has bipolar disorder. She is a writer of some renown. Her defense systems include an NPD (see Chapter 6) and snobbishness. She went to an Ivy League college and is quick to mention this in any conversation with peers. She enjoys correcting her therapist’s pronunciation and using obscure words in therapy. When the idea of a negative introject was introduced to her, she “pooh-poohed” it immediately. “You never help me with anything and then you use these technical terms that are meaningless,” she complained.

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Meanwhile, Clara would wake up every morning with her negative introject telling her, “You’re a worthless piece of crap. Why do you even exist?” She just thought this was the way life should be and wasn’t interested in eliminating her negative voice. In the past, she had attempted suicide two times and landed in the hospital. But, of course, to her, that horrible morning voice was not a “negative introject” since Clara identified with it so completely. She was finally on the right combination of a mood stabilizer (Lamictal) and an antidepressant (Lexapro), so the negative voice was not caused by depression. There was also a masochistic element to Clara’s psyche. She liked to suffer and consider herself a martyr of sorts. The morning voice made her suffer and fulfilled her idea of her role in life. Her therapist tried several times to introduce the negative introject concept to help her, but Clara always rejected it. The next case was a woman of 46, Lila, who worked in IT. She had been severely abused physically as a child and had seen her mother beaten by her father. In her 20s, Lila had been an alcoholic and cocaine addict. After AA, she cleaned up her substance abuse and finished her master’s degree. Lila loved to display her brilliance with long speeches and explanations, but of course, other people hated her displays. As a result, she had few friends and any romantic involvements ended quickly. When her therapist talked about “the negative introject,” Lila accused him of wild fantasizing. Yet her inner voice told her she was nothing, and she didn’t even deserve to live. Lila also had attempted suicide in her 20s while she was abusing alcohol and cocaine. One session after Lila had fallen into a deep depression and her psychiatrist had tried many antidepressants, she admitted that he might have a point about a negative introject. However, by the next session, she rejected the idea once again. Patients must be ready to hear about their negative introjects, especially ones that they identify completely with. It’s like any other interpretation, timing is everything. And some patients, like Clara, are never ready. Usually, we don’t consider the positive introject, that aspect of our minds that tells us positive things that may be true or false. Many patients or many people (we would not be treating these people, usually because their positive introject keeps them “healthy”) are telling

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themselves that everything is all right, “no worries” as they say. They may be deniers or simply unaware that problems exist. Jim, a 72-year-old attorney, had always been an easygoing man who believed nothing could ever go wrong with him. He had refused to get a colonoscopy, a hernia repair, a flu shot, etc. He was the older of two siblings, and his parents had absolutely adored him. He was talented musically as a child, good in school, and socially successful. He married a beautiful woman, had two children, and started his own law firm. Jim seemed to live a charmed life, until he didn’t. He started getting lost on his way back from his office, even though he only lived three blocks away. Jim had been walking this route for 20 years, and suddenly he wound up ten blocks away from his home. His wife was concerned, especially since he seemed much slower than usual in his speech and movements. Socially, he started to disengage from friends and family. His wife insisted that they go to the doctor for a checkup. Jim didn’t want to go. He said he felt fine and there was no problem. When he fell down and had to be hospitalized, the doctors informed Jim and his wife that he had dementia. His wife cried and was quite upset, but Jim took it all in stride. He didn’t seem to care whether he had a diagnosis of dementia or not. Jim even tried to continue his law practice, but his secretary informed him that he was making too many mistakes and the clients were complaining. Jim stayed in denial about his condition. His wife suffered through his illness, and she could never convince Jim that anything was really wrong. Denial is a defense we all use at times, but it is considered one of the most primitive of defenses. Anna Freud, Sigmund’s daughter, delineated these defenses in her book, The Ego and the Mechanisms of Defense.2 Denial is an unconscious mechanism that protects a person from everything: from one’s desires to confronting one’s weaknesses. A person like Jim, who is in denial, refuses to accept reality. This defense worked for Jim for most of his life. The argument could be made that it protected him from worrying about his dementia, but if he didn’t acknowledge his problem, his wife and family would have to shoulder the responsibility instead. In the case of dementia, the patient loses the capacity to help himself, so perhaps denial is not so bad in Jim’s case. We, psychiatrists, are too familiar with hypochondriacs—i.e., patients who believe everything is wrong with them when nothing is.

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However, we hardly ever treat “hyperchondriacs,” a new term I’d like to coin to cover patients who are sick but falsely believe they are excessively healthy. This term would cover those patients who are in denial about their negative introjects. The DSM-V does not contain my new term. In fact, hypochondria is demoted and subsumed under the category of complex somatic symptoms disorder in DSM-V. In the past, we have just used terms like “denial” to deal with “hyperchondriacs.” A patient is considered in denial if he/she is sick, but for unconscious reasons denies it. Those in denial could also be distracted from their sickness by hypomania, drug or alcohol abuse, or workaholism and believe they are fine. Lately, I have become aware of more and more patients who are “hyperchondriacs,” professing health when they are quite ill. My patient, Gina, a 64-year-old woman, blonde, petite, and attractive, first came to me after being discharged from the hospital that had treated her for the manic phase of her bipolar I disorder. She was heavily medicated with antipsychotics and could hardly move physically, nor could she reason as she once could. As a retired teacher, she was accustomed to an active life, attending theater performances, and traveling to many countries. “Can you please get me off these medicines? I don’t feel right,” she pleaded in her first session. She had been referred by a colleague who worked as an attending in the inpatient psychiatric unit from which she’d been recently discharged. Since I didn’t know her, I read the discharge notes and then decided to carefully and slowly lower her medicines, one by one, to see if that would help her. Patients often request to go off their medicines because of side effects—i.e., weight gain, hypersomnia, headaches. I try to accommodate them as much as I can. I have found that if I don’t try to give them the smallest amount of medicine that treats their illness, they will either drop out of treatment completely or go off their medicines by themselves. Gina came to treatment once a week, so I could monitor her progress. Each week, she felt better and better. I engaged her in supportive psychotherapy: a treatment that stays on the surface, dealing with daily events and not delving deeply into the unconscious. After one year, when she was on the lowest dose of her medicine, she politely requested that I eliminate it completely. I didn’t feel

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comfortable stopping her antipsychotic, Zyprexa. Most patients with bipolar I disorder need to be on some maintenance medicines for the rest of their lives. She seemed to agree with me when I explained that it would be better for her to stay on them. As the months progressed, she looked even better. She lost the ten pounds that she’d gained, her skin cleared, and, best of all, her mood was stable. However, by the seventh month, I noticed that she was more irritable, spoke faster, needed less sleep, and ate less food. She was becoming hypomanic. I suggested she double her dose of the antipsychotic. She refused and disappeared from treatment. Her husband called two weeks later and reported that she was hallucinating, looking disheveled, and staying up all night. She grabbed the phone to speak to me. “Nothing is wrong,” she said. “I’ve never felt better in my life. I’ve been off your medicines for six months!” I wasn’t surprised that she denied that anything was wrong. Bipolar patients in a hypomanic phase feel great until they crash. “I’ll heal myself, if you don’t mind. I have a new technique to do that!” She hung up on me. After that call, she refused to speak to me, even though I called back several times. What could I  do? I  told her husband that if she were suicidal or homicidal, we could involuntarily hospitalize her, but since she wasn’t, we could only watch and wait. She’s a perfect example of a “hyperchondriac,” a patient who clearly was ill, but who denied it. Usually, we don’t encounter these patients because they avoid doctors, unlike hypochondriacs who visit too many doctors for nothing. I lost contact with Gina and never learned what happened to her, although I suspect that she was hospitalized again and had to start all over again with another psychiatrist. Hypochondriacs do themselves harm because they might be treated for diseases they don’t have. As we all know, some medical treatments are worse than the diseases, especially if a patient is allergic to a medication or has an unnecessary surgery. “Hyperchondriacs” can do themselves harm by not being treated. My patient could run into the street in her overexcited state and be run over. Patients in a manic phase are known to lose all judgment. A “hyperchondriac” with cancer could deny his illness until the disease becomes incurable. Perhaps the number

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of “hyperchondriacs” are increasing because of lack of insurance or skepticism about Western medicine. Happiness has been a popular topic lately. There have even been entire courses given on how to obtain happiness at universities. In my opinion, happiness cannot last for long if there is no awareness of the negative introject. In the college courses, they are not addressing this issue, but they should, because just when most people are feeling happy and pleased, the negative introject tends to pop up and spoil the happiness. The negative introject will remind the happy person of a lost hat, an unpleasant conversation, or a major rupture in a relationship. Negative introjects will dig up anything from the tiniest problems to the major catastrophes of life, as long as they can knock the person out of his/her euphoric state. Our U.S. constitution even guarantees us “the pursuit of happiness” as an inalienable right, yet how many patients, colleagues, neighbors, or relatives do you know who are truly happy? And if they are happy, how long can they maintain that state of mind? Perhaps they have satisfied their economic goals for the year, so they feel good for a few hours, but the negative introject is bound to interrupt with annoying facts such as, you paid your bills but next year they’ll be higher. Can you still afford to buy all this new equipment? What about those taxes on your property? How about your daughter’s college tuition? And on and on. Even if a person has just married his loved one that he has been living with for two years, he may fall from a positive state of mind. The wedding party might have been fantastic with all his old friends there to celebrate, but his new mother-in-law was so demanding and unpleasant that she triggered his negative introject. He winds up holding his head in his hands, wondering what the marriage will be like with his mother-in-law on his back. Or a woman has just had sex for the first time in a long time with a partner she desired for months. She’s left in a post-orgasmic blissful state, but then her negative introject introduces thoughts like, “I hope he didn’t have herpes. Didn’t I see a sore on his lip a few weeks ago? I hope his condom didn’t break. I’m getting a post-coital headache.” A negative state is so much easier than a positive one for most people. It reminds me of the lowest possible energy levels in an atom that

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we learned about in basic physics. The particles drop into these lowest levels just like the mind descending into the negative level. There are exceptions of course. For example, many religious people can maintain positive states for much longer than nonreligious people, especially when they are joined together in worshiping groups. They think of their gods or a mantra or that they are being tested by “antigods,” devils, etc. Then the religious person can reject the negative introject, which might be telling them “this religion is ridiculous. I don’t want to pray. I want to be out partying. Let me break these religious commandments.”

Notes 1. Piaget, J. (1969). The psychology of the child. New York, NY: Basic Books. 2. Freud, A. (1992). The ego and the mechanisms of defence. New York, NY: Routledge [republished from the original hardback, 1936].

Negative Introject in the Group

9

Individuals are susceptible to many different situations that may trigger their negative introjects. Some people may find that a group setting is particularly disturbing to them. Libby, a 55-year-old librarian, had joined a book club. She thought as a librarian who certainly knew her books that people would respect her a lot. There were nine others in the group, eight women and one man. They discussed some of her favorite books, such as Fahrenheit 451 by Ray Bradbury. She was stimulated intellectually by discussions they had about the books, but she found herself emotionally disturbed. After each weekly session, she’d go home and obsess about what was said and not said. The one man made himself the leader of the group because he was the most organized and the one with the most available free time to e-mail lists and questions for them to contemplate for the next week. He dominated the group discussions. Libby felt excluded, insulted, paranoid, and hurt many times during and after their meetings. She made friends with one of the other women who happened to be a social worker therapist. Libby thought that her friend knew psychology and would be able to tell her what was happening. The social worker had even run groups herself in the past. She said that since this group was not supposed to be therapeutic that Libby should not voice her concerns to the group. Instead, they discussed what was happening between themselves.

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Libby felt left out of the discussions. She definitely knew what they were talking about and often had wonderful insights that she wanted to share with the group, but when she tried to speak up, she would be cut off by another group member. She’d have to fight to speak. The man and two other women dominated the group discussions. Libby’s social worker friend experienced the same thing, but she interpreted this differently. Libby felt ignored and discredited, whereas the social worker did not. Libby had grown up in a family of five. Her parents and two sisters dominated most family discussions. Libby was the middle child who was largely ignored. She tended to be quiet and bookish and withdrawn. Her parents encouraged those qualities in her, but when Libby didn’t join in family discussions, she felt inadequate. She felt “less than” her two sisters, who happened to be boisterous and extroverted in their natures. The group’s exclusion of Libby during discussions triggered her negative introject. She had felt the same inadequacy when trying to survive in her family group. Old feelings about being less than others were reignited in her. Libby had no one with whom to discuss these feelings, so she continued to feel bad about the group, which should have been a perfect place for her. She dropped out of the book group as a result. According to Yalom,1 group hostilities must be acknowledged and dealt with in order to maintain group cohesiveness. In a nontherapeutic group, aggressiveness, hostility, and triggering of the negative introjects of group members are never considered. Another group that we are all members of happens to be society at large. It seems that all over the world, we are seeing our world as worse than it was a half century ago, according to the Pew Research Center. In such books as Steven Pinker’s Enlightenment Now: The Case for Reason, Science, Humanism, and Progress,2 Pinker argues that the world is actually in a lot better shape with less poverty, superior health care, and longer life expectancy. Pinker blames the media for emphasizing negative events rather than positive ones of better health, economics, and longevity. Perhaps it would be better if we reminded ourselves of our good fortunes and if we were more aware of the negative introject attempting to paint our lives bleak. As the Beatles sang, “I read

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the news today, oh boy, about a lucky man who made the grade and though the news was rather sad. Well, I just had to laugh.”3 Grapevine sabotaging is a way for a group to express anger and aggression, and a group negative introject. Hearing or distributing information through the casual, unofficial network known as the “grapevine” is a common practice in most workplaces. Going through the grapevine allows for both covert and overt hostility declarations of aggression, and for the group negative introject to thrive. In a large group and on social media platforms, it is unlikely that the maligned individual will know who spread the word about his having done such and such. Direct expression is also possible between two confidants who can let off steam by degrading a third party and then spread the gossip to a fourth member. Sabotage comes after too many people have retold the tale, and it sticks to the unfortunate person. There have even been incidents in which students killed themselves after they experienced grapevine sabotaging through Facebook. Take the case of Karen, an executive in a large advertising agency, who has angered many of her employees with her sharp tongue and relentless pursuit of errors. Maggie gossips about Karen to Linda and then to Debra. The story is spread that she is having an affair with an executive in a competitive advertising agency. By the time the tale is told to Karen’s supervisor, it has been turned into a believable story about her providing company secrets to her lover in the other agency. Karen’s supervisor becomes suspicious of her without mentioning the story she happened to pick up having coffee in the lounge. Slowly, Karen’s hard-earned reputation dwindles away. This by itself may not cause Karen to lose her job, but it does weaken the company and her chances for advancement. Karen’s employees have sabotaged her via the grapevine. We may believe that Karen deserves this treatment because we are sympathetic to Linda, but in many other instances, an innocent, unpopular person can provoke hostility onto him/herself. And the group’s negative introject was never explored or discharged in any other way. Usually, employees can only get aggression out on employers through grapevine sabotaging or scapegoating. Direct confrontation makes them too vulnerable unless their services are so invaluable that they can’t be fired. On the other hand, most employers, like Karen, can

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get away with hostility directed at their employees. Another way for employees to redirect their hostility and negative introjects is through scapegoating. Throughout human history, scapegoating can be seen as a prime means of relieving tension in society and in groups. Scapegoating is an indication of the group negative introject in practice. In the times of the Mayans and Aztecs, human sacrifices were made to the gods supposedly to appease these deities. The actual appeasement was of the people who could scapegoat the victims of the sacrifice and kill off their own undesirable feelings (negative introjects) along with the sacrificial victim. Jesus Christ was the ultimate scapegoat who took on all sins and then died to save everyone. Witches were killed in the Middle Ages in Europe and then in America as scapegoats when life became too stressful. In modern times, we have singled out minority groups based on religious beliefs or racial differences and sacrificed them. Hitler murdered Jews and South Africans abused blacks. The human need to project blame and the negative introject onto another and then to destroy that other seems to be universally prevalent in scapegoating. Projecting blame and the negative introject onto another person rather than accepting the guilt onto one’s self is one of the oldest defenses. When a group can single out another person and say it’s his/ her fault not theirs, they experience relief. The basic psychological aspects of the scapegoating type of aggression involve four important concepts. They are projection, envy, hatred, and aggressive action, all aspects of the negative introject. Scapegoating starts when a person or group has negative feelings that cannot be acknowledged. These feelings are then projected outside the self onto another individual or group. Even though the feelings cannot be acknowledged, they represent a desire of a part of the self, which may be unconscious. When the aggressor imagines that the scapegoat has this characteristic that the aggressor has projected and cannot tolerate, then the aggressor is envious and hates this person or group. Scapegoating is completed when the aggressor then takes aggressive action toward the one with the supposed quality. For example, Hitler believed that the Jews were dirty, immoral, and of low genetic stock. He was actually projecting his own fears and

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unconscious ideas about himself onto an entire group of people. Once he had made the projection, he then proceeded to envy and hate these Jews who had the nerve to be not only dirty but also immoral. His aggressive acts toward the group are recorded in the history of the Holocaust as one the biggest genocides of our time. To narrow our scope from worldwide events to, for example, the workplace is not difficult. In the microcosm of the office or factory, group scapegoating is a common release of tension and aggression. What better way to work out anxiety than to kick a scapegoat? Who are the people who scapegoat? What characteristics do scapegoats have? The people who scapegoat are releasing sadistic aggressive drives (negative introjects) during the process of diverting the blame. Unfortunately, the person who scapegoat others can be any unaware individual at work, either employer or employee. Scapegoats tend to be masochistic individuals who have been abused in their own families. They might have been the battered child at home, and then at work they will unknowingly assume that role again and “ask” for punishment in some way. Remember Linda’s behavior with Karen? Karen is a good example of an employer who attracts scapegoating and who is easily scapegoated either by her employees or by her fellow executives. Minnie, a 32-year-old woman, was the head counselor at a rehabilitation program. She had spent many years abusing herself with drugs and alcohol, but after five years of sobriety, she took the position of head counselor. Her background included an alcoholic father who had molested her sexually as well as an indifferent mother who was a workaholic. Her parents often beat her or ignored her when she was a child. Her history of abuse made her a potential scapegoat. As head counselor, Minnie was responsible for supervising other counselors and for the overall treatment plans for all the patients in her rehabilitation program. At first, she did well, but eventually the other counselors began to believe that Minnie was drinking again and not dealing with this problem. One counselor called Bill told three other counselors that he smelled liquor on Minnie’s breath after lunch. A nurse in the program was sure that he had seen Minnie leaving one of the local bars in the neighborhood. Grapevine sabotaging was starting. None of the aforementioned accusations were actually true, but Minnie as a potential scapegoat had a way of acting guilty even when

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she was perfectly innocent. She alienated her employees by being aloof, withdrawn, and unavailable at vital times during the workday. She was quick and harsh in disciplining a counselor and slow to engage in friendly conversation around the water cooler. As a result, she was an unpopular employer and one who could be easily scapegoated. Minnie’s situation might not have escalated into scapegoating. Her ordeal might have ended at grapevine sabotaging, which may involve the first two elements of scapegoating—i.e., projection and envy. However, Minnie was not that fortunate. Her co-workers continued onto the third and fourth aspects of scapegoating: hatred and aggressive action. Before long, Minnie’s supervisor, the director of the program, called her into his office to give her a chance to explain her behavior, which he believed included drinking and long hours away from the job. Being innocent, she denied everything, but her supervisor eventually fired her when hateful complaints about her escalated. This satisfied the scapegoaters and completed the process of scapegoating. After Minnie was fired, the other counselors calmed down and a general well-being and decrease in stress was noted by all. The same situation had occurred three other times with three other head counselors, all of whom were innocent of the charges against them. No one realized this, least of all the scapegoating counselors. They just thought that all of these head counselors had succumbed to the pressures of the job and misbehaved. It is often the case that a certain position in the workplace will be unconsciously designated as the “scapegoated position.” This is the position in which the unfortunate person has negative introjects dumped on him or her. The person who is chosen for this job will be the potential scapegoat. Inevitably, this person is scapegoated over and over again and eventually fired. In the earlier example, we see all the elements of scapegoating. The counselors can no longer admit to the desire to drink or take drugs, since as ex-addicts who have been drug-free for a period of time, they want to deny their previous addictions. They project the wish to get high onto their head counselor. They even go so far as to “smell alcohol on her.” The next step is envy of her imagined drinking. Finally, they hate her and act aggressively toward her. They report her to the director and build up a case against her. They persist until she is sacrificed

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by being fired. Their negative introjects are satisfied when she is scapegoated. How can this blind ritual of scapegoating be stopped so that the next head counselor is not subjected to this treatment? The ways to avoid scapegoating in the workplace are as follows. Of primary importance is recognition of the scapegoating phenomenon and scapegoating position by employers and employees, and of course recognition of the role the negative introject plays. Next, the most likely scapegoating candidates, due to race, sex, psychopathology, religion, etc., must recognize their vulnerability and protect themselves through self-knowledge as well as various therapies. Third, the aggressive needs of the working group should be expressed in other ways more productive than scapegoating. For example, positive cathartic means, such as baseball games, picnics, and group therapy, are much more conducive to a beneficial working environment than scapegoating. Stacey, a 23-year-old who had just arrived in New York City after finishing college, landed a promising position in the publishing field. She was delighted to start her first job at a prestigious company. Her supervisor was a knowledgeable older woman who impressed Stacey easily just by reciting the list of books their company published. Stacey was basically a shy and inhibited individual who was eager to fit into whatever group she was working in. The only problem was she couldn’t seem to fit into the groups around her in the workplace. She felt as if there were invisible boundaries between her and two other co-workers whom she admired. These two, Frieda and Marge, were in perfect synchrony with their mutual supervisor. Stacey attempted to sit at a lunch table with Frieda and Marge, but she was given a cold shoulder by them. When she tried to make small talk before or after work, these women ignored her or answered her remarks with silence. The stress of not fitting in and wanting to went on for months. Stacey started to miss days at work and to feel unhappy and unproductive while there. Her negative introject became hyperactive and told her that she was a failure socially. Then one day, the reason for her exclusion from the group became clear to her. She was chatting with a friend named Marc from one of the other departments. Stacey complained to him that Marge and Frieda and her boss formed a tight little clique that excluded her. Marc laughed and said, “You’d have to be gay to join those

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women.” Then all of the little things she had noticed throughout the months fell into place for her. So that was why Frieda and Marge and her boss were always kissing, hugging, and whispering to each other. What they all had in common was their homosexuality and their sexual relationships with each other. They could sense that Stacey was basically unlike them as a heterosexual woman, and so she was excluded. Knowledge of this state of affairs helped Stacey to feel less degraded and unwanted. Her negative introject receded for a while. The negative introject had almost convinced her that the women were rejecting her because she was unworthy and inadequate in some way. Knowing that she couldn’t join their group because of her sexual preferences made her feel much better. She eventually transferred to another department in the company. There she was able to blend in with a heterosexual group of co-workers and feel more comfortable. Stacey’s situation of being excluded by co-workers who were sexually involved with each other caused a reawakening of her Oedipus complex. Here Frieda and Marge (and sometimes her boss) reminded her of her parents who also had an exclusive sexual relationship that locked her out. Stacey felt like the Oedipal loser in these triangles; she felt inadequate and unworthy, and, of course, her negative introject was activated. The fact that her fellow employees were homosexual was disturbing to her as well since Stacey tried very hard to suppress her own homosexual feelings. Witnessing others engaging in homosexual behavior stirred up her own forbidden impulses and caused her anxiety. Her negative introject told her that she was a big loser and unable to be part of a group. The homosexual group in Stacey’s workplace was able to form a powerful clique to protect its own interests. People like Stacey who were heterosexual were excluded from the group to such an extent that Stacey found it more profitable to transfer to another department. In this way, this special interest group maintained its power and predominance in the workplace. Such cliques don’t need to only be special sexual groups. They can be the old boy’s school or the married men’s league. They can also be certain religious groups or racial groups that gain power and control. Workplace laws in the U.S.A. provide for equality in race, religion, and sex, but secret cliques always exist that undermine these laws. The best way to counteract these special interest

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networks is to make them known to the workplace at large and then to confront their exclusivity and discrimination against nonmembers of the group. In Stacey’s workplace, the sexual liaisons between Frieda, Marge, and her boss proved to be advantageous for them but disadvantageous for Stacey. The overall effect on the workplace, however, was beneficial since the gay clique accomplished a great deal of work on behalf of the company. The exclusivity of the group gave them pride and helped them to be especially productive. However, it had a bad effect on Stacey who could not join the group and whose negative introject was activated by the rejection. While watching theater productions, the collective unconscious is often activated in the audience. We identify with a hero or heroine and usually follow that character on adventures. The antihero/antiheroine or villain stimulates our negative introject. Some of us will relate more to the villain than the hero, of course. For instance, in A Streetcar Named Desire by Tennessee Williams, the troubled heroine is Blanche DuBois. Most of us will identify with her and her problems, although I’ve heard some people, especially men, identify with Stanley Kowalski, the brute who rapes Blanche. He is the negative introject personified. He has no mercy on poor Blanche who is homeless, pregnant, and emotionally unstable. Group therapy is derived from individual therapy and expanded to deal with many people at once. This type of therapy is ideal for the workplace where work groups experience various psychological difficulties. The most common types of group psychotherapy include analytically oriented group therapy, supportive group therapy, transactional group therapy, and behavioral group therapy. In analytically oriented group therapy, the group meets one to three times/week, lasts for one to three years, and has a goal of moderate reconstruction of personality dynamics. Present and past life situations are considered as well as intra- and extra-group relationships. Dreams and transference are analyzed frequently. Interpretations involve unconscious conflicts. In supportive group therapy the group meets once per week for up to six months, usually with a goal of better adaptation to the environment. Primarily environmental factors—e.g., workplace issues—are considered. Interpretations strengthen existing psychological defenses,

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and the unconscious is mostly left unexplored. This is the type of group therapy that would be the most appropriate for the majority of workplaces and could be introduced into a weekly staff meeting. Transactional group therapy meets one to three times per week for one to three years with a goal of alteration of behavior through conscious control and acknowledgment of members’ negative introjects. The primary concern is intra-group relationships. Positive relationships and behavior are reinforced and negative behavior analyzed. The therapist challenges defenses and gives personal responses. This type of group would also be appropriate in the workplace. Behavioral group therapy meets one to three times per week for up to six months with a goal of relieving specific psychiatric symptoms— e.g., phobias and behavioral problems. Specific symptoms are the focus of the group, and positive relationships in the group are fostered. There is no examination of transference issues. This type of group is helpful for specific individuals with certain behavioral problems. Groups also depend on the experience, sensitivity, and charisma of the group leader, who should also have the same appropriate training described for the therapist who conducts individual therapy.

Notes 1. Yalom, I. (1975). The theory and practice of group psychotherapy. New York, NY: Basic Books. 2. Pinker, S. (2018). Enlightenment now: The case for reason, science, humanism, and progress. New York, NY: Viking Press. 3. The Beatles. (1967). A day in the life. Sergeant Pepper’s Lonely Hearts Club Band. London: EMI Studios.

Dreams and the Negative Introject

10

Since the negative introject lives mainly in the unconscious mind, it makes sense that dreams are influenced by it, especially nightmares. What better way to disturb the person than to give him/her bad dreams! Laura was a 35-year-old freelance writer who had been badly traumatized by her parents as a child. They divorced when she was ten, and she was forced to play the unpleasant game of being transferred back and forth between their homes. She wanted to stay with her mother most of the time because they would cook together and have pleasant talks. However, her mother was depressed, and often, she’d say horrible things about Laura’s father and his new wife. Her father believed in “fun, fun, fun,” even if Laura was not in the mood, and his new wife resented Laura. Laura would have terrible nightmares as a child and sometimes even night terrors, in which she’d wake up screaming and have no memory of what she had dreamed. One night as an adult, Laura dreamed that she was in a narrow hallway surrounded by seven closed doors. She knew she had to get out, but as she opened one door after another, attempting to escape, she discovered horrible things. Behind the first door was a severed head, the next a clutching hand, and the third held a dirty mop! Laura was afraid to open anymore doors, but she knew she had to get out of the hallway. She woke up screaming, but it wasn’t a night terror because she

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remembered it and told the dream to her therapist. They interpreted it together as Laura free-associated to each of the images. The narrow hallway was the tight squeeze she’d been in between her two parents. The severed head represented the severed relationship between her two parents. The clutching hand was the pressure she felt from them. The mop was what she had to do for them—i.e., mop up the dirty mess they’d made of their marriage. Laura was still dealing with her parents’ mess years after the original trauma of their divorce. Her negative introject never let her forget what she’d gone through. In one way, it was useful that she presented the material to her therapist and finally dealt with it; but in another way, it retraumatized her to experience these nightmares. Laura’s negative introject had been formed when she was little, and her parents had been arguing all the time. Her parents were individually quite kind and considerate of Laura, but taken together, when they were in battle, they were horrendous. Sleep terrors are episodes of screaming, intense fear and flailing while still asleep. Also known as night terrors, sleep terrors are considered a parasomnia—an undesired occurrence during sleep. A sleep terror episode usually lasts from seconds to a few minutes, but episodes may last longer. Sleep terrors affect about 40% of children and a much smaller percentage of adults. However frightening, sleep terrors aren’t usually a cause for concern. Most children outgrow sleep terrors by their teenage years. Sleep terrors may require treatment if they cause problems like insomnia or if they pose a safety risk. Sleep terrors differ from nightmares. In a nightmare, the person wakes up from the dream and may remember details, but a person who has a sleep terror episode remains asleep. Children usually don’t remember anything about their sleep terrors in the morning. Adults may recall a dream fragment they had during the sleep terrors. Sleep terrors generally occur in the first third to first half of the night and rarely during naps. A sleep terror may lead to sleepwalking. During a sleep terror episode, a person may do the following: • Begin with a frightening scream or shout • Sit up in bed and appear frightened • Stare wide-eyed

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• Sweat, breathe heavily, and have a racing pulse, flushed face, and dilated pupils • Kick and thrash • Be hard to awaken and be confused if awakened • Be inconsolable • Have no or little memory of the event the next morning • Possibly, get out of bed and run around the house or have aggressive behavior if blocked or restrained Occasional sleep terrors aren’t usually a cause for concern. If a child has sleep terrors, consult your doctor if they • Become more frequent, • Routinely disrupt the sleep of the person with sleep terrors or other family members, • Lead to safety concerns or injury, • Result in daytime symptoms of excessive sleepiness or problems functioning, or • Continue beyond the teen years or start in an adult. Sleep terrors are classified as a parasomnia—an undesirable behavior or experience during sleep. Sleep terrors are a disorder of arousal, meaning they occur during the deepest stage of nonrapid eye movement (NREM) sleep. Another NREM disorder is sleepwalking, which can occur together with sleep terrors. Various factors can contribute to sleep terrors, such as the following: • Sleep deprivation and extreme tiredness • Stress • Sleep schedule disruptions, travel, or sleep interruptions • Fever Sleep terrors sometimes can be triggered by underlying conditions that interfere with sleep, such as the following: • Sleep-disordered breathing—a group of disorders that include abnormal breathing patterns during sleep, the most common of which is obstructive sleep apnea

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• • • •

Restless legs syndrome Some medications Mood disorders, such as depression and anxiety In adults, alcohol use or abuse

Sleep terrors are more common if family members have a history of sleep terrors or sleepwalking. In children, sleep terrors are more common in females. Some complications that may result from experiencing sleep terrors include the following: • Excessive daytime sleepiness, which can lead to difficulties at school or work, or problems with everyday tasks • Disturbed sleep • Embarrassment about the sleep terrors or problems with relationships • The negative introject gaining the upper hand Jean, a 62-year-old widow, also had bad dreams. She’d lost her husband a few years before due to an accident. He’d been in a coma for a month before she’d finally pulled the plug on the ventilator. Jean felt guilty that she’d made that decision, but all the doctors had assured her that he had so much brain damage that he’d only be a vegetable if he ever woke up. Jean dreamed that they were in a foreign country where they couldn’t speak the language or get medical help while her husband was suffering from poisoning. Jean woke up feeling terrible that her dear husband was dead and that she couldn’t help him once again. You could argue that her negative introject wanted to torture her with more guilt, or it was trying to help her come to terms with his death. She could never decide which it was, but she hated the bad dreams. Abby, a 55-year-old artist, had lost her husband of 30 years 5 years ago, but every night, she dreamed she was looking for him. In one dream, she was in a fancy European café of seven stories and, she was searching for Tim, her deceased husband. Then she was on a trip to Cambodia in a dream, and he was somewhere; she just had to keep

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searching. In another dream, she was in a lab, and she only had to find the right room, and Tim would be there. Abby would wake up frustrated because she never found Tim in any of her dreams. Abby had tried to date other men to no avail. Tim and Abby had had a deep bond that Abby thought impossible to recreate. They’d been inseparable, traveling everywhere together, eating each meal with each other, and sleeping holding hands. They even shared a studio. Tim had been an artist too, and instead of competing with Abby, as a lot of other artists would do, he inspired her as she inspired him. They even cooperated on a painting together. When Tim was diagnosed with an astrocytoma, a horrible inoperable brain tumor, Abby was devastated. They had discovered the brain tumor late, and Tim died quickly after the diagnosis. Abby tried her best to carry on with her life after her husband passed away, but she missed him so much at home, in the studio, and in her world. She thought about Tim when she was out with other men. Her negative introject would compare the men to Tim and find them wanting. “All these men are so inadequate and incompatible compared to Tim,” her introject told her. So, of course, she dreamed about him and her negative introject never let her actually find Tim and have some time with him, even if it would only be a dream. The negative introject is an essential part of the unconscious panorama. However, because it is so primitive, at times, it goes too far, is too intense, and it attacks the person. Ed, a 40-year-old man, had just broken up with his long-term girlfriend, Liza. He thought it was about time that he ended the relationship, which had been stressful and distracting. His therapist said Liza had BPD. Ed wanted to find a woman to marry and have children with. Liza didn’t want marriage or kids. The only problem was Ed kept dreaming about Liza, even though he was dating other women. He dreamed that Liza had a party and invited all their friends, but not him. Ed came back to the apartment they’d shared and found everyone having fun. Liza acted like she didn’t even know Ed in the dream. Ed’s negative introject was painting a picture of him as an absolute loser who no one wanted to befriend. He had felt that way as a child and adolescent because his parents moved around so much that it was difficult to

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settle into a neighborhood and make friends. Liza had solved so many problems of loneliness, rejection, and isolation. She always wanted to be with him. He’d clung to her also, even when she was abusive, saying degrading things to him. But Ed longed for his own family, and she’d made it clear that wasn’t for her. His negative introject presented more dreams in which he was a lonely reject. Finally, Ed called Liza and asked her to come back. Liza refused. Ed’s negative introject relentlessly supplied the bad dreams night after night. In psychotherapy with the therapist who had encouraged him to set Liza free, he analyzed the dreams and realized why he felt so alone. His therapist kept positively reinforcing his dating other women. Ed was fortunate because he found a woman who also wanted to have children, and he dated her. Eileen, a 32-year-old filmmaker, was an only child, or so she had been told. She kept having dreams about a sister whom her mother loved more than her. In one dream, Eileen’s mother was hugging and kissing this sister and telling Eileen to leave. Eileen regretted that her mother had always been cold and rejecting of her. One day when she was visiting her mother, she shared one of her dreams about a sister. Her mother gasped and said: “Oh no, you must be psychic!” Eileen replied: “What do you mean?” After much persuasion, her mother admitted that there had been another baby born before Eileen. However, that baby had died in infancy, and Eileen’s mother tried to bury any memory of her when she buried her tiny body. Her mother despaired of having any other children, but fortunately, Eileen had been born one year later. Out of fear that anything would happen to the child, her mother had withheld her affections. Unconsciously, Eileen’s mother had worried that her negative introject would kill Eileen too, as she had imagined that it killed her first born. Thus, her mother had tried not to invest emotionally in Eileen. Eileen had sensed something that her mother didn’t tell her until then about a baby. Her negative introject supplied the dream that tortured her about a sister and her mother not loving her enough. She wrote a film about a similar situation.

Happiness and the Negative Introject

11

Happiness is an elusive concept, especially with the negative introject ever ready to destroy it. Just when a person is feeling happy and pleased, the negative introject is bound to pop up and spoil the happiness. Positive psychology, a term coined by Abraham Maslow,1 referred to a call for a balanced view of human nature. In psychiatry, we practitioners mostly concentrate on psychopathology (and the negative introject affecting every condition), as we have seen in these chapters. In Maslow’s psychology, he took the opposite view and emphasized positive conditions, such as self-actualization, or a desire to fulfill each person’s potential. Happiness is defined as a result of individuals being “reality centered,” “problem centered,” truth seeking, upright, and possessing wholeness, self-sufficiency, and many other traits he considered essential. He tried to emphasis the positive characteristics of people. Maslow never addressed the negative introject. The following is an example of how patients could be encouraged to refrain from a negative state: “Happy New Year,” I said cheerfully to my patient John. This was our first meeting after the holidays. He sat with his head down. John looked up at me sullenly and then put his head down again. He had been doing psychotherapy with me for a few months. He’d refused

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to take any antidepressants, although I’d suggested them for this 37-year-old father of two on his first visit. John was a handsome, sandy-haired, tall man stuck in a minor administrative post for the city. He’d had bigger ambitions, but after his first son was born, he settled into his job to pay all the bills. “I don’t feel so happy,” he said. “I’m in debt. My wife doesn’t listen to me anymore. My kids are always cranky. They kick me around at work. What is there to feel good about?” “You’re healthy. You have two children and a job. We’ll work on your conflicts with your wife.” “You’re overly optimistic, doctor,” he replied. “Let’s start with your goals or resolutions for the New Year.” “What goals or resolutions? I don’t believe in that,” he said. “Maybe that’s the problem. It’s always a good idea to have a purpose, to have goals for the future.” “Why is that?” John was usually skeptical of any of my suggestions. “You won’t let me give you medications, which I still think you need, but maybe you’ll let me offer some advice. After all, what are you paying me for?” “I wonder about that myself.” He smiled reluctantly. When he smiled, which wasn’t often, his face looked younger and refreshed. I saw how handsome John really was. “We all need goals and resolutions. It helps us focus on what we have to do and gives us courage to do it. For instance, my goals for the New Year are to meditate once a day, do more yoga, get my book published, and eat better.” I knew that self-revelation to a patient could be tricky, but I believed this information could inspire him. “I don’t know what I could have as a goal.” He was sitting up straighter and looking at me. I had his attention. “What about starting that writing class you saw advertised? And you wanted to learn martial arts? You said your wife bought you the digital camera you wanted for Christmas. Could you take a course in that?” “Whoa! Whoa! Hold on. You’re going too fast for me.” “OK. These are just suggestions. Pick one and put it on your list. You’ll feel better immediately.”

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“I guess I could take a class in digital photography, but. . . ” He hung his head again. “What’s wrong? That’s a great idea.” “I’m no good in these classes. You remember what happened to me when I was in college?” “You said that the other students made fun of you. You did some photographs of trash cans or something? Everyone thought that was weird, but the instructor liked your photographs.” “You have a great memory, doc. That’s it. I don’t want to sit in a classroom and have people make fun of me again. Especially at my age.” “Do you remember what I said about that incident?” “No, I can’t say I do. I just remember the pain I felt when they laughed at me.” “I said the other students were probably jealous of you. I saw a museum exhibit in which the artist had taken photos of the sides of buildings all over the world. It was a hit. What would your classmates have said about that?” “Yeah, you’re right. They would have laughed at that too.” “Exactly. I’ll give you some techniques to protect yourself against your classmates if you need to. You were in school 17 years ago. Times have changed. People laugh at different things now, but you can’t let their laughter stop you from enjoying your life.” “I guess you’re right. I would like to learn to use that camera.” John set a goal to take his digital photography class. I also convinced him to try the martial arts class. He believed he would do poorly in both endeavors, but at least he had two resolutions on his New Year’s list. I had made some headway into helping him out of his depression. Goals and resolutions can counteract the negative introject, which was quite prominent in John. Some groups can be especially happy and barricade themselves against negativity. For example, many religious people can maintain positive states for much longer than nonreligious people, especially when they are in worshiping groups. They think of their god(s) or a mantra or that they are being tested by the “antigods”; then they can repudiate their negative introjects, which might be telling them, “This

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religion is ridiculous.” “I don’t want to pray. I want to be out partying.” “Let me break these rigid commandments!” Other ways to increase one’s happiness and decrease the influence of the negative introject include the following: • Participation in athletics and team sports • Mindfulness and meditative exercises, such as tai chi, chi gong, yoga, drumming, or chanting • Making and/or viewing art • Music—listening to, performing, and creating music • Theater—attending theatrical productions, performing, writing plays, working with improv groups, etc. • Volunteering with nonprofit enterprises in various areas, including fundraising, publicity and marketing, education outreach programs, etc. • Participating in altruistic ventures, such as Doctors without Borders, animal rescue, food distribution, or literacy programs In conclusion, the struggle against the negative introject is a constant battle that we must all be aware of. In this book, we have revealed numerous ways in which the negative introject impacts various patients with psychiatric disorders, as well as the general public. In our efforts to alleviate the nefarious effects of the negative introject on human lives, we psychiatrists must be willing to branch out beyond our current areas of expertise to connect with practitioners and researchers in other related fields: neurology, artificial intelligence, alternative mindful enhancement techniques, to mention a few. We must also be willing to explore new therapeutic modalities that will emerge in the future.

Note 1. Maslow, A. (1968). Toward a psychology of being. New York, NY: Simon and Schuster.

Index

Note: Page numbers in bold indicate tables on the corresponding pages. Abilify 39, 63 addictions: alcohol 79–82, 98; cocaine 82–90, 98; heroin 91–92; marijuana 93–96; oxycontin 92; scapegoating and 109–110; Valium 92–93 akathisia 63 alcohol abuse see addictions Alcoholics Anonymous (AA) 79–80 altruism 124 anorexia nervosa 15–17, 30 antipsychotics 38, 39, 63, 101 antisocial personality disorder 69–70 anxiety disorders 18; body dysmorphic disorder 14–15; eating disorders 15–17; holidays and 39–41; mal de debarquement syndrome 9–11, 11; panic attacks 7–10; posttraumatic stress disorder (PTSD) 12–13 art and art therapy 34, 124 athletics and team sports participation 124 Ativan 78 autoimmunity 5–6 avoidant personality disorder (APD) 76–78

Beatles, The 106–107 behavioral group therapy 114 benzodiazepines 9, 78 benztropine 63 β-blockers 78 bipolar disorder 38–42, 57–58, 97–98; cyclothymic disorder compared to 83–84; denial of 100–101 bipolar disorder II 38, 61 body dysmorphic disorder 14–15 Body Mass Index (BMI) 16 borderline personality disorder (BPD) 67, 119–120 Bradbury, R. 105 bulimia 16 cannabis see marijuana Carroll, L. 1 Celexa 60 chanting 124 chi gong 124 child abuse 28–29, 60–61, 98 claustrophobia 9 cliques 111–113 Clozaril 62, 63 cocaine 82–90, 98

126  Index

Cogentin 63 cognitive behavioral therapy (CBT) 20 collective unconscious 113 conversion disorder 31 counteractions to negative introject 6, 8, 123–124 cyclothymic disorder 83–84

Glass Menagerie, The 77 globus hystericus 30–31 goals and resolutions 121–123 grapevine sabotaging 107 group settings, negative introjects in 105–114 group therapy 113–114

De Clérambault’s syndrome 52 delusions 52, 56, 58–59 dementia 99 denial of negative introject 97–103 Depakote 39, 61, 84 dependent personality disorder (DPD) 73–76 depression: denial of 46–47; globus hystericus due to 30–31; seasonal affective disorder (SAD) 45; suicide and 34–35, 47–48; symptoms of 33–37 detachment feelings 11 dimenhydrinate 10 Doctors without Borders 124 dopamine 63 dreams 115–120; group therapy and analysis of 113; guilt and 118–119; sleep terror 116–118 drumming 124 dysphagia, psychogenic 30–31

hallucinations 52, 56 happiness 102, 121–124 heroin 91–92 histrionic personality disorder (HPD) 68 Hitler, A. 108–109 holidays, anxiety over 39–41 hyperchondriacs 100, 101–102 hypochondria 19–20, 99–100

eating disorders 15–17 Effexor 30, 31 ego 1 Ego and the Mechanisms of Defense, The 99 electroconvulsive therapy (ECT) 43, 56 Enlightenment Now: The Case for Reason, Science, Humanism, and Progress 106 erectile dysfunction (E.D.) 59–61 erotomania 52–55 “evil eye” 2–3 Fahrenheit 451 105 fluoxetine 20 Freud, A. 99 Freud, S. 1, 4, 31, 41, 58, 99

ICD-10 (International Classification of Diseases, 10th Edition) 16 id 1 imipramine 9, 10 introjection 3; see also negative introject Klonopin 9, 10, 11, 78 “koro” delusion 58–59 Lamictal 98 Lexapro 9, 10, 37, 38, 60, 78, 83, 98 lithium 39, 62 lysergic acid diethylamide (LSD) 91 major depression 43; with psychotic features 74 mal de debarquement syndrome 9–11, 11 male-female engagement 68–69 “male panic” 68 manic depression 38 marijuana 91, 93–96 Maslow, A. 121 meclizine 9–10 medications: for anxiety disorders 7–11; for bipolar disorder 38, 39, 40; for cyclothymic disorder 83; for depression 30, 31–32, 34, 42–43,

Index  127

43–44; for hypochondria 20; for motion sickness 9–10, 11; for personality disorders 78; for psychosis 51–52; for schizophrenia 63 meditation 28–29, 124; negative introject interfering with 22–28 mescaline 91 migraine 38 mindfulness 124 mirrors, superstitions about 4–5 monoamine oxidase inhibitors (MAOIs) 43 motion sickness 9–10 music 124 narcissism 14 narcissistic personality disorder (NPD) 70 negative introject: additions and 79–96; in anxiety disorders 7–18; defining 1; denial of 97–103; in depression (see depression); dreams and 114, 115–120; example of unconscious control by 2; in group settings 105–114; happiness and 102, 121–124; how to counteract 6, 8, 123, 124; in hypochrondria 19–20; interfering with person trying to meditate 22–28; leading to self-sabotage 3–4; in literature 1–2; in obsessive-compulsive disorder (OCD) 20–21; in panic disorders 7–8; personality disorders and 65–78; in posttraumatic stress disorder (PTSD) 12–13, 22; psychosis and 51–64; superstitions and 2–5; watching for signs of 41 negative thoughts 35 nonrapid eye movement (NREM) sleep 117 obesity 16 obsessive-compulsive disorder (OCD) 20–21 obsessive-compulsive personality disorder (OCPD) 70–73 Oedipal stage 59 olanzapine 62, 63

overweight patients 16 oxycontin 92 panic disorder 7–10 paranoia 13 parasomnia 116–117 Paxil 42 personality disorders 65–66; antisocial 69–70; avoidant 76–78; borderline 67, 119–120; dependent 73–76; histrionic personality 67–68; narcissistic 70; obsessive-compulsive 70–73; schizoid 66–67; schizotypal 66–67; testosteronic 68–69 Pinker, S. 106 Plath, S. 38 positive introject 98–99 positive psychology 121 positive thoughts 35, 36 posttraumatic stress disorder (PTSD) 12–13, 22 projection of blame 108–109, 110 propranolol 78 Prozac 9, 60 psychogenic dysphagia 30–31 psychosis: erotomania 52–55; medications for 51–52 psychotherapy 7–8, 10, 29, 58 rape see sexual abuse religious people 103, 123–124 reproduction 68–69 sabotage: grapevine 107; self- 3–4, 41–42 scapegoating 107–111 schizoaffective disorder 51, 56 schizoid personality disorder 66–67 schizophrenia 62–63 schizotypal personality disorder 66–67 seasonal affective disorder (SAD) 45 selective serotonin reuptake inhibitors (SSRIs) 9, 11, 20, 43, 78 self-sabotage 3–4, 41–42 Seroquel 63, 83 sertraline 7, 20, 34 sexual abuse 11–12, 28–30, 60–61

128  Index

sexual dysfunction 59–61 shyness 13 sleep terrors 116–118 social phobia 13–14 Streetcar Names Desire, A 113 substance abuse see addictions suicide 34–35, 47–48 superego 1, 5; see also negative introject superstitions 2–5 tai chi 124 tardive dyskinesia 63–64 Tegretol 38, 84 testosteronic personality disorder (TPD) 68–69 theater 124 Through the Looking Glass 1

Topamax 38, 39, 61 transactional group therapy 114 transference 113 trans-magnetic stimulation (TMS) 43 tricyclic antidepressants (TCA) 9, 43 Valium 9; addiction to 92–93 volunteering 124 Williams, T. 77, 113 Woolf, V. 38 Xanax 7 Yalom, O. 106 yoga 124 Zyprexa 101