Psychiatric Annals 20:7/July 1990

Group psychotherapy offers a unique format in which some of the more intractable features of bulimia nervosa are amenable to change.

The 1964 edition of "The Abnormal Personality" has little mention of eating disorders as we know them today. Anorexia nervosa and bulimia nervosa are subsumed under gastrointestinal disturbances, with the author stating:

Digestive and eliminative processes are subject to many kinds of disorder. There are disorders of appetite and eating: at one extreme stands bulimia, marked by inordinate appetite and excessive eating; at the other extreme, anorexia nervosa, a loss of appetite so exaggerated that it sometimes threatens life.

In a mere two decades, with the cultural sway toward slimness, eating disorders have become a major health problem. Eating disorders have become so prevalent that they are included in the DSM-III-R as discrete clinical phenomena.

Bulimia nervosa is a compulsive eating syndrome characterized by uncontrolled binges followed by self-induced vomiting, laxatives, or diuretic abuse. Ambivalence, dysphoria, and self-deprecating thoughts accompanied by an over-concern with slimness are yet other features of this disease. The vast majority of those afflicted with this disorder are young women between the ages of 14 and 42, with the majority falling in the adolescent and young adult age ranges. Currently, 8% of all females and 1% of males are diagnosed as bulimic, according to DSM-III-R criteria.² The prevalence of the disorder under-scores the need to examine treatment successes critically and to continue to develop viable methods that combine the best of group, individual, and pharmacotherapy strategies. Although comparative studies have vet to demonstrate the superior efficacy of group psychotherapy, a considerable body of literature suggests many of the symptoms of the bulimic patient may be reduced through this modality.³

Group psychotherapy offers a unique format in which some of the more intractable features of bulimia nervosa are amenable to change. In particular, intense feelings of alienation and shame are reduced by sharing the secret of the binge-purge cycle. Perfectionism, unrealistic expectations, and negative beliefs about the body and the self may be challenged by other group members. Identification of feelings may take place in an atmosphere conducive to interpersonal learning.^3-18 Moreover, in a medium in which trust develops, the myth of personal incompetence-the belief that an individual has no value apart from her slimness-can be challenged.

Because the group symbolically represents the nuclear family, childhood traumas can be reworked and resolved in the group setting. As such, group psychotherapy offers a viable modality for patient recovery.

LONG-TERM VERSUS SHORT-TERM GROUP PSYCHOTHERAPY

For the specific issues of the eating-disordered patient, a long-term, open-ended psychotherapy group may represent the most effective form of treatment. While a short-term group may deal well with symptom management and support, the long-term group provides fairly predictable stages of development in which core dysfunctional beliefs may begin to emerge safely. The long-term group allows for the reestablishment of trust that has somehow been shattered in the patients' formative years. As patients begin to interact, doubts, misperceptions, and fear of intimate contact emerge. Honest feedback can be offered in a way that is new and different for the patient who has been accustomed to criticism. Within the "in vivo"⁵ culture of the group, the total personality and modus operandi of each individual can be understood, analyzed, and corrected.

Intense feelings of alienation and shame are reduced by sharing the secret of the binge-purge cycle.

The consistency and stability of a long-term group allows for the development of group cohesiveness, which provides a foundation for the maturation of trust-a crucial factor in the recovery of the eating-disordered patient. Members may begin to shift the focus of their concern from symptoms to the sharing of their true selves. It is particularly within the context of long-term group treatment that the eating-disordered patient develops her social skills and tentatively ventures forth into interpersonal intimacy.

BULIMIC PROFILE

In understanding the impact of group psychotherapy on the bulimic patient, a representative personality profile, illustrated by the following vignette, is useful.

Vignette

Lauren, a woman in her mid-20s, has a 5-year history of bulimia. From a prominent family, her parents placed a high premium on appearance, conformity, and achievement. Lauren was an appealing, but chubby, child who was often nagged about weight by her intrusive mother. She recalls her preteen years as uneventful, although they were punctuated by several efforts at dieting. When she was 17, her parent's separated-a traumatic event. One year later, she left home to attend a highly competitive university. She did well as an undergraduate, but her confidence was shattered when her college boyfriend left her. At that time, she began binging and purging. She was able to go on to law school and graduated in good standing despite her illness.

Shortly thereafter, she presented for treatment: attractive, composed, and well groomed. Beneath her veneer of success lay crippling self-doubt - her slim body was her only proof of adequacy. She complained of loneliness and of being unable to form new relationships, particularly with men. To avoid pain, she avoided contact. Food became her intimate companion and purging a desperate attempt to feel in control of her life.

Women such as Lauren enter treatment possessed by an ego-alien compulsion. Isolated by their symptoms, they join together in group therapy to share, support, and enrich each other in a way different from any other previous experience. This point was illustrated when one patient asked another to describe a binge episode. As the patient described her odyssey from one restaurant to the next, the first patient admitted, "I thought I was the only person in the world who did that." For the bulimic patient, this universality of experience may exist only in the group.

Instillation of hope, interpersonal learning, and identification are among the most important therapeutic factors operative in the change process.⁴ When an experienced patient states to the neophyte patient, "I was once where you are now," the experienced patient becomes, at once, guide, inspiration and teacher. The following case studies illustrate this.

Case 1

Melody, an aging debutante in her 50s, was married with one small daughter. She presented for treatment with the complaint that she 'eats for three." She spent the major portion of her life worrying about her body size and the appearances of her home and child. Her activities revolved around exercise, charitable functions, and teas. She complained of dysphoria and free-floating anxiety bordering on panic.

In the group, she painfully described how badly she felt inside. She believed her life would he perfect if only she could lose 20 pounds. She had great difficulty understanding that the next bite of food would not magically obliterate the bad feelings and that fixing the outside would not alter the inner emptiness. She continued to focus on externals until one member gently confronted her, "We've heard a lot about your body, but we've not heard anything about your mind." The group accurately identified that her hunger was for a feeling of value. She painfully confessed her belief in her personal incompetence that she couldn't be anything but slim and beautiful. Her self-doubts were expressed in the following poem:

I am no good
I have no brain
Anything J achieve is by mistake
Therefore secretly
I VOMIT my achievements
I live through my body
My body is my only worth
No wonder I have so many
problems.

The group challenged this myth based on her active and intelligent participation with them. Melody became an important and respected group member. As the feeling of incompetence gave way to a more solid sense of self, she was transformed into a person with talents and ideas She helped the neophyte members work through their own feelings of incompetence and became a role model with whom others identified. At the time she left the group, she planned to return to school to pursue a graduate degree in design a sublimation of her concern with externals.

According to Yalom,4 the group recapitulates the nuclear family in ways that could never be accomplished in individual treatment precisely because the group feels like a family. Unconsciously, members take on the same role in the group that they assumed in their family-of-origin. The pathologic behavior is reactivated and reworked when the therapist and the patients, who symbolically represent the parents and siblings, foster the resolution of unconscious conflicts. Dysfunctional communication and pathologic behaviors can be identified; new behaviors can be practiced, and change can occur as the patient undergoes a corrective emotional experience. The following case illustrates this point.

Case 2

Nancy was a 42-year-old white married female who sought treatment for bulimia. Her parents died in a car accident when she was 6. Nancy was reared somewhat resentfully by her oldest brother and his wife. Despite the fact that she was physically cared for, her presence was barely tolerated. Sensing this reaction, she tried to be the nicest little girl in the world although she never felt loved.

Instillation of hope, interpersonal learning, and identification are among the most important therapeutic factors operative in the change process.

Nancy entered a stable and cohesive group 6 months after its inception. Although the group was prepared for a new member, they were not prepared for Nancy. During her first session in the group, Nancy began talking in a singsong fashion about her eating, her early life experiences, and then, tangentially, her philosophies. During the second session she continued to drone on. The experienced members of the group shifted uncomfortably until the leader interrupted Nancy's monologue to comment on the discomfort in the room. Annie a warm and verbal schoolteacher turned to Nancy. You know, you're acting like a 10 year old kid who doesn't know what's going on and who's trying to get the attention of the adults in the family by making nice. Maybe this is how you've coped since your parents died, but you don't have to make nice to be accepted here. We accept you because you, like me, have an eating disorder and you, like me, are in pain. That's enough."

Nancy was shaken by the gentle but constructive confrontation and threatened never to return to the group. In the next meeting, the therapist and members were able to help her process this valuable information. She was able to understand that being the "youngest person in the "family-group" had triggered regression, reactivating feelings of the frightened, abandoned child As she worked through these feelings Nancy came to acknowledge that binging had warded off her sadness for many years.

Several weeks after this confrontation, Nancy began behaving in an appropriate adult manner. Her speech became direct and forceful. She reported a decrease in the desire to binge and purge. Clearly this dramatic encounter was enabled by the group's ability to symbolically reconstitute the family-of-origin and rework the original trauma.

It may take years for each person to learn to share her deepest feelings and years for the core personality to change. For the eating-disordered patient whose trust has been compromised, group psychotherapy provides many opportunities to renegotiate this basic issue. As a result of this ruptured trust, the patient's life stance is basically one of pessimism and impending doom. Among the beliefs that color her world view is the conviction that she is not allowed to feel good, that she does not deserve happiness, that she is intrinsically bad.

In being nurtured and reciprocally being able to nurture others, the patient becomes allied with her own sense of competence and the competence of others. The constant reassurance of personal acceptance at last allows her to begin to reach out authentically to others. The axiom that the best way to help oneself is to help another is lived in the group. The goal of treatment for bulimia is not that the patient never binge and purge again. The goal of treatment for bulimia is that the patient feel like a complete person, profoundly connected to other human beings.

REFERENCES

• White RW. The Abnormal Personality. 3rd Ed. New York, NY. Ronald Press Co; 1964.
• Johnson C, Conners ME. The Etiolo;gy and Treatment of Bulimia Nervosa. New York, NY: Basic Books Inc; 1987:29-30
• Hendren RL, Atkins DM, Sumner CR, Barber JK. Model for the group treatment of eating disorders. Int. J. Group Psychother. 1987; 37:589-601.
• Yalom ID. The Theory and Practice of Group Psychotherapy. 3rd ed. New York, NY: Basic Books Inc; 1985.
• Roth DM Ross DR long term cognitive interpersonal group therapy for eating disorders Int J Group Psychother. 1988; 38: 491-509

Ms. Asner is Director, The Eating Disorders Foundation, Chevy Chase, Maryland.

Address reprint requests to Judith Asner, MSW, BCD, The Eating Disorders Foundation, The Barlow Building Suite 1435, 5454 Wisconsin Avenue, Chevy Chase, MD 20815

next:Depression Precedes Eating Disorder in Some Women
~ all Beat Bulimia articles
~ eating disorders library
~ all articles on eating disorders

Help for coping with anorexia, bulimia and binge eating disorder

Note: if you have even the smallest suspicion you are in medical danger, consult a physician immediately. Eating disorders can kill, and if you are already in trouble, you need medical attention, not self-help tips.

In the U.S. we live in a thin-obsessed society. The cultural ideals held up for us to emulate are either stick thin with surgically enhanced breasts (female) or powerful with clear muscle definition (male). It's no wonder that so many people develop eating disorders when they try to achieve these unrealistic -- and often unhealthy -- images of "perfection."

Almost always professional help is required to recover from an eating disorder, but if you want to try to help yourself, here are some suggestions. If you are not in medical danger, try them for a week. If, after seven days, you can't shake your preoccupations with food and weight, and especially if you don't make any progress towards changing harmful behaviors, get help from a resource person -- a parent, school nurse, school counselor, family physician, or mental health counselor. These people can be great allies in your struggle for health and happiness. Don't avoid being honest with them because of guilt or embarrassment.

Anorexia nervosa

• Don't diet. Never ever. Instead design a meal plan that gives your body all the nutrition it needs for health and growth. Also get 30 to 60 minutes of exercise or physical activity three to five days a week. More than that is too much.
• Ask someone you trust for an honest, objective opinion of your weight. If they say you are normal weight or thin, believe them.
• When you start to get overwhelmed by "feeling fat," push beyond the anxiety and ask yourself what you are really afraid of. Then take steps to deal with the threat, if it is real, or dismiss it if it is not real.

Bulimia nervosa and binge eating disorder

• Don't let yourself get too hungry, too angry, too lonely, too tired, or too bored. All these states are powerful binge eating triggers. Watch for them, and when they first appear, deal with them in a healthy manner instead of letting the tension build until bingeing and purging become the release of choice.
• Stay busy and avoid unstructured time. Empty time is too easily filled with binge food.
• Make sure that every day you touch base with friends and loved ones. Enjoy being with them. It sounds corny, but hugs really are healing.
• Take control of your life. Make choices thoughtfully and deliberately. Make your living situation safe and comfortable.
• Every day do something fun, something relaxing, something energizing.
• Keep tabs on your feelings. Several times a day ask yourself how you feel. If you get off track, do whatever the situation requires to get back to your comfort zone.

next: Eating Disorders: Treating Anorexia Like Addiction
~ eating disorders library
~ all articles on eating disorders

Self-Therapy For People Who ENJOY Learning About Themselves

Throughout 95 percent of human history, staying safe was something we did!
Now, since most of us have pretty safe lives, it is something we want to feel.

PROTECTING YOURSELF IN THE REAL WORLD

If there is a real threat in your life (an abusive family member, someone making threats, etc.), you need to protect yourself. Line up the police, some strong and kind friends, and whatever else you need so you can overcome the scary person in your life and to get away from the danger immediately. That's the whole story on real fear.

If you are living under such a real threat right now, don't read further. This topic is not for you. Go do what you need to do, and come back when you are safe. We'll be waiting for you.

Safety IS first!

PROTECTING YOURSELF IN THE UNREAL WORLD

If there is no real threat in your life but you still feel fear, this topic is for you. Like all of us, you need protection from believing your own thoughts!

HOW TO EVALUATE YOUR FEARS

This is how to evaluate your fears:

1) Decide if the fear is real or imagined.

2) If it is imagined, take a "feeling check" to see if you are still afraid or if you just let it go.

3) Know that your ability to think will be there for you in the future.

And if you wait to do your thinking in the future, you will be dealing with reality. Reality problems are a lot easier to deal with than fantasy problems!

Enjoy Your Changes!

Everything here is designed to help you do just that

next: Clients and Success In Therapy

Self-Therapy For People Who ENJOY Learning About Themselves

There has been a lot in the media about "false memory syndrome." There's even an organization devoted to helping people who have been falsely accused of sexual abuse.

As a therapist, I have some very strong views about this, of course. This article is a statement of those views.

ARE SOME PEOPLE FALSELY ACCUSED?
I'm sure they are.

Some therapists are incompetent. Some "clients" are cruel manipulators. So some false memories probably do occur.

But the key word here is "some" and, if you were sitting in my chair, you'd have to believe that this must happen very, very seldom!

Why would someone falsely accuse someone of sexual abuse? What would they have to gain?

If I can see any way that the accuser believes she can benefit from making such accusations, I do wonder if they might be making it all up.

But in my own experience, and in the experience of most other therapists, we seldom see people who can even magine any gain at all from believing they were treated this way.

Initially, at least, clients can't imagine anything good coming from facing their abuse. Victims feel intense fear and deep dread as soon as they even wonder if they were abused. Fear and dread are not feelings that come from someone intent on being cruel or vengeful.

Later articles in this series will tell you a lot about the intense emotion, self-doubt, humiliation, and hard work the average sexual abuse "accuser" goes through to get her life back.

I'm sure you will see that nobody could fake their way through all of that!

False accusations of sexual abuse, then, are rare
but for the falsely accused person they are devastating.

What can be done to almost guarantee that false accusations cannot occur?

The therapist and the person they are working with can both act responsibly.

Here is my personal list of some of the most important responsibilities therapists have regarding sexual abuse. They are stated in the form of advice for therapists...

1) Know that sexual abuse does happen to many children and that it wounds very deeply.

The lowest estimate I've ever heard is that about 10% of all children are sexually abused by someone in childhood. Even if this low estimate is true, what would be your best guess as to the percent of sexually abused people on an average therapist's caseload? - Twenty percent? - Fifty percent??

2) Don't tell anyone they were sexually abused, but don't be afraid to ask.

3) If she says she was sexually abused, believe her.

If you have strong reasons to believe she is lying and has much to gain from it, be open with her and tell her so. You owe her that much.

4) For your sake and for your clients, don't use hypnosis or any other such techniques.

Some very good therapists use hypnosis to uncover memories. But I believe they are making a mistake. They are leaving themselves vulnerable and they are greatly increasing the likelihood that their client will doubt her own memories some day. (If the memories are that hard to uncover, they need time to surface on their own.)

5) Be aware of the potential for "leading" the client.

Be aware that therapists can and do lead clients toward their own preconceived opinions and guesses. It is only human that some of this will occur, but be diligent in limiting the degree to which it occurs in your office. When you have a hunch about something so important, keep it to yourself unless it keeps coming back for a long while (3 meetings?). Then, if you do decide to mention it, convey your own doubts about it. Say strongly that it is only a hunch and that you have no proof of it's validity. (If the client disregards your hunch and it still won't go away, talk to your own therapist about it.)

6) Be very aware of all boundaries.

A violation of any boundary can undermine all treatment with people whose boundaries were so terribly violated as children. And just because the person acts like something you propose is OK, don't assume that it is OK unless they have specifically said so. (People who were abused tend to give in to intrusions very easily, often without even recognizing that's what they are doing.)

7) If you are not confident about how to handle flashbacks and repressed memories, don't try.

Make an appropriate referral instead. And go get the training you need. This is no place for amateurs.

ALL of the client's responsibilities come down to this: LEARN HOW TO IDENTIFY YOUR FEELINGS AND THEN TRUST WHAT YOU FEEL!

1) If it feels like you might have been sexually abused but your aren't sure, believe your feeling until you CAN be sure!

2) If it feels like someone is trying to talk you into something, say so (and consider getting out of there).

3) Notice your need for protection. Learn how to become your own best "protective parent." If your therapist doesn't feel "safe enough" (compared to everyone else you've known as an adult), you need to find a better one.

4) Honor all your feelings, even the "irrational" ones!

You may know you are more afraid, sad, and angry than there is reason to be in your adult world but these feelings are still trustable. Honor them.

That's the little girl talking to you.

She needs the grownup, powerful you to take care of her while she recovers from these horrors

Enjoy Your Changes!

Everything here is designed to help you do just that!

next: Fantasy and Reality

When You Want To Take Care Of The Other Person.

CRUCIAL MOMENTS

It's an amazingly simple concept, yet most people are shocked to learn that their relationship problems happen at a certain SPECIFIC MOMENT!

They are also amazed when they learn that WHAT HAPPENS IN THAT SPECIFIC MOMENT usually determines how bad the whole problem is gong to get!

WHAT TO DO ABOUT YOUR MOMENT OF GREATEST STRESS

The next MOMENT that you have the IMPULSE to take care of your partner

NOTICE THINGS LIKE THIS:

1. What YOU actually DO when you feel this urge. (Do you go ahead with your urge and touch your partner caringly, do you hold back, ...What?)
2. What your partner actually did the split-second BEFORE you had the urge. (Was your urge to take care of them "triggered" by something they did?)
3. What YOU do next.
4. What THEY do next.
5. Where you are. (Are the physical surroundings "fitting" for this impulse? Do they "trigger" it?)
6. How you feel when you act on the impulse (or when you don't).
7. How your action (or lack of action) effects your partner.
8. How good were you at COMMUNICATING the message to them that you wanted to take care of them?
9. How good were they at RECEIVING your message?
10. How else could you have tried to communicate this message to your partner?

If you don't learn much from noticing these ten things the first time, do it again and again until you think you have a pretty good idea why things go wrong.

Remember, we are talking about THE worst problem in your relationship here. It's got to be WORTH the time it takes to figure it out!

This is the "data gathering" phase. The only thing left after the data gathering is take action. Here's what I suggest....

If your theory ONLY has to do with YOU, it's time for some "self-therapy."

Ask yourself questions like this:

"Why do I stop myself from taking action when I want to take care of my partner?"

"Why do I keep doing the same old things over and over again when I have this impulse?"

"Why do I keep hoping these things will work despite so much evidence to the contrary?"

Then make a lengthy list of all of the OTHER things you could do when you act on this impulse (besides the things you do that don't work). All you need to do then is EXPERIMENT with your list of these other things to do. Most of them WILL AUTOMATICALLY WORK BETTER than what you've been doing! Some of them may even work wonderfully for both of you!

If your theory is that YOUR PARTNER causes the problem or that somehow it takes BOTH of you to create the problem, it's time for a discussion with your partner.

If you are excited about your theory and almost sure that it is true: JUST TELL THEM WHAT YOU'VE FIGURED OUT! But be ready for them to disagree. There are two reasons your partner might disagree:

1. They may know more about the situation than you do and need to explain some things to you.
2. They might be shocked that you were even thinking about it and that you came up with such a good solution! (It's only human nature to disbelieve someone else's claim that they have figured out an answer to something that seemed "unsolvable" just a few seconds before!)

If you aren't so sure about your theory:

JUST TELL THEM WHAT YOU'VE BEEN THINKING ABOUT AND WHAT YOU'VE COME UP WITH SO FAR.

THEN ASK THEM TO DO THEIR BEST THINKING SO YOU CAN FIGURE OUT MORE TOGETHER.

EVENTUALLY, THE TWO OF YOU WILL COME UP WITH A PLAN. TRY IT OUT!

If it works, great! If it doesn't, talk again and come up with your next plan. Keep referring back to the ten things I suggested for you to notice (top of the page).

back to: Relationship Quiz Table of Contents

What is good parenting? Here are 14 things parents can do to raise a mentally healthy child.

There is no one right way to raise a child. Parenting styles vary. But it is important that all caregivers communicate clear and consistent expectations for each child.

In today's world, some parents are so busy and stressed that nurturing children may sometimes take a back seat to problems that seem more important. However, here are a few suggestions that can help parents provide for children's physical safety and emotional wellbeing.

1. Do your best to provide a safe home and community for your child, as well as nutritious meals, regular health check-ups, immunizations, and exercise.
2. Be aware of stages in child development so you don't expect too much or too little from your child.
3. Encourage your child to express his or her feelings; respect those feelings. Let your child know that everyone experiences pain, fear, anger, and anxiety. Try to learn the source of these feelings. Help your child express anger positively, without resorting to violence.
4. Promote mutual respect and trust. Keep your voice level down even when you don't agree. Keep communication channels open.
5. Listen to your child. Use words and examples your child can understand. Encourage questions. Express your willingness to talk about any subject.
6. Provide comfort and assurance. Be honest. Focus on the positives.
7. Look at your own problem-solving and coping skills. Are you setting a good example? Seek help if you are overwhelmed by your child's feelings or behaviors or if you are unable to control your own frustration or anger.
8. Encourage your child's talents and accept limitations. Set goals based on the child's abilities and interests, not someone else's expectations. Celebrate accomplishments.
9. Don't compare your child's abilities to those of other children; appreciate the uniqueness of your child.
10. Spend time regularly with your child.
11. Foster your child's independence and self-worth. Help your child deal with life's ups and downs. Show confidence in your child's ability to handle problems and tackle new experiences.
12. Discipline constructively, fairly, and consistently. (Discipline is a form of teaching, not physical punishment.) All children and families are different; learn what is effective for your child. Show approval for positive behaviors. Help your child learn from his or her mistakes.
13. Love unconditionally. Teach the value of apologies, cooperation, patience, forgiveness, and consideration for others.
14. Do not expect to be perfect; parenting is a difficult job.

This list is not meant to be complete. Many good books are available in libraries or bookstores that can help you be the parent you want to be. For free information about mental health, including publications, references, and referrals to local and national resources, call 1-800-789-2647; or access the Web site: mentalhealth.samhsa.gov/

Sources:

• This information is provided by the CARING FOR EVERY CHILD'S MENTAL HEALTH: Communities Together campaign, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

• Depression is a common, serious and costly illness that affects 1 in 10 adults in the U.S. each year, costs the Nation between $30 - $44 billion annually, and causes impairment, suffering, and disruption of personal, family, and work life.
• Though 80 percent of depressed people can be effectively treated, nearly two out of three of those suffering from this illness do not seek or receive appropriate treatment. Effective treatments include both medication and psychotherapy, which are sometimes used in combination.

Of particular significance, depression often co-occurs with medical, psychiatric, and substance abuse disorders. When this happens, the presence of both illnesses is frequently unrecognized and may lead to serious and unnecessary consequences for patients and families.

Depression Co-occurs With Medical Illnesses

The rate of major depression among those with medical illnesses is significant. In primary care, estimates range from 5 to 10 percent; among medical inpatients, the rate is 10 to 14 percent.

Depressed feelings can be a common reaction to many medical illnesses. However, depression severe enough to receive a psychiatric diagnosis is not the expected reaction to medical illness. For that reason, when present, specific treatment should be considered for clinical depression even in the presence of another disorder.

Research has shown that major depression occurs in:

• Between 40 and 65 percent of patients who have had a myocardial infarction (MI). They may also have a shorter life expectancy than non-depressed MI patients.
• Approximately 25 percent of cancer patients.
• Between 10 and 27 percent of post-stroke patients.

Failure to recognize and treat co-occurring depression may result in increased impairment and diminished improvement in the medical disorder.

Proper diagnosis and treatment of co-occurring depression may bring benefits to the patient through improved medical status, enhanced quality of life, a reduction in the degree of pain and disability, and improved treatment compliance and cooperation.

Depression Co-occurs With Psychiatric Disorders

A higher than average co-occurrence of depression with other psychiatric disorders, such as anxiety and eating disorders, has been documented.

• Concurrent depression is present in 13 percent of patients with panic disorder. In about 25 percent of these patients, the panic disorder preceded the depressive disorder.
• Between 50 and 75 percent of eating disorder patients (anorexia nervosa and bulimia) have a lifetime history of major depressive disorder.

In such cases, detection of depression can help clarify the initial diagnosis and may result in more effective treatment and better outcome for the patient.

Depression Co-occurs With Substance Abuse Disorders

Substance abuse disorders (both alcohol and other substances) frequently co-exist with depression.

• Substance abuse disorders are present in 32 percent of individuals with depressive disorders. They co-occur in 27 percent of those with major depression and 56 percent of those with bipolar disorder.

Substance use must be discontinued in order to clarify the diagnoses and maximize the effectiveness of psychiatric interventions. Treatment for depression as a separate condition is necessary if the depression remains after the substance use problem is ended.

Action Steps

DON'T IGNORE SYMPTOMS! Health care professionals should be aware of the possibility of depression co-occurring with other illnesses. Individuals or family members with concerns about the co-occurrence of depression should discuss these issues with the physician. A consultation with a psychiatrist or other mental health clinician may be recommended to clarify the diagnosis.

next: The Effects of Depression in the Workplace
~ depression library articles
~ all articles on depression

Some herbal supplements can cause serious health problems. Here's what you need to know before you take herbal supplements.

On this page

• Introduction
• For More Information

Introduction

Herbal supplements are a type of dietary supplement (see the box below) that contain herbs, either singly or in mixtures. An herb (also called a botanical) is a plant or plant part used for its scent, flavor, and/or therapeutic properties.

Many herbs have a long history of use and of claimed health benefits. However, some herbs have caused health problems for users. This fact sheet contains points you should consider for your safety if you use, or are thinking about using, herbs for health purposes. It does not discuss whether herbs work for specific diseases and conditions (for science-based information on that topic, see "For More Information").

About Dietary Supplements

Dietary supplements were defined in a law passed by Congress in 1994. A dietary supplement must meet all of the following conditions:

• It is a product (other than tobacco) intended to supplement the diet, which contains one or more of the following: vitamins; minerals; herbs or other botanicals; amino acids; or any combination of the above ingredients.

• It is intended to be taken in tablet, capsule, powder, softgel, gelcap, or liquid form.

• It is not represented for use as a conventional food or as a sole item of a meal or the diet.

• It is labeled as being a dietary supplement.

1. 
   

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   It's important to know that just because an herbal supplement is labeled "natural" does not mean it is safe or without any harmful effects. For example, the herbs kava and comfrey have been linked to serious liver damage.

2. Herbal supplements can act in the same way as drugs. Therefore, they can cause medical problems if not used correctly or if taken in large amounts. In some cases, people have experienced negative effects even though they followed the instructions on a supplement label.

3. Women who are pregnant or nursing should be especially cautious about using herbal supplements, since these products can act like drugs. This caution also applies to treating children with herbal supplements.

4. It is important to consult your health care provider before using an herbal supplement, especially if you are taking any medications (whether prescription or over-the-counter). Some herbal supplements are known to interact with medications in ways that cause health problems. Even if your provider does not know about a particular supplement, he can access the latest medical guidance on its uses, risks, and interactions.

5. If you use herbal supplements, it is best to do so under the guidance of a medical professional who has been properly trained in herbal medicine. This is especially important for herbs that are part of an alternative medical system (see the box below), such as the traditional medicines of China, Japan, or India.

Alternative medical systems are built upon complete systems of theory and practice, and have often evolved apart from and earlier than the conventional medical approach used in the United States. To find out more, see NCCAM's fact sheet "What Is Complementary and Alternative Medicine?"

1. In the United States, herbal and other dietary supplements are regulated by the U.S. Food and Drug Administration (FDA) as foods. This means that they do not have to meet the same standards as drugs and over-the-counter medications for proof of safety, effectiveness, and what the FDA calls Good Manufacturing Practices.

2. The active ingredient(s) in many herbs and herbal supplements are not known. There may be dozens, even hundreds, of such compounds in an herbal supplement. Scientists are currently working to identify these ingredients and analyze products, using sophisticated technology. Identifying the active ingredients in herbs and understanding how herbs affect the body are important research areas for the National Center for Complementary and Alternative Medicine.

1. Published analyses of herbal supplements have found differences between what's listed on the label and what's in the bottle. This means that you may be taking less--or more--of the supplement than what the label indicates. Also, the word "standardized" on a product label is no guarantee of higher product quality, since in the United States there is no legal definition of "standardized" (or "certified" or "verified") for supplements.

2. Some herbal supplements have been found to be contaminated with metals, unlabeled prescription drugs, microorganisms, or other substances.

3. There has been an increase in the number of Web sites that sell and promote herbal supplements on the Internet. The Federal Government has taken legal action against a number of company sites because they have been shown to contain incorrect statements and to be deceptive to consumers. It is important to know how to evaluate the claims that are made for supplements. Some sources are listed below.

For More Information

The NCCAM Clearinghouse provides information on CAM and on NCCAM. Services include fact sheets, other publications, and searches of Federal databases of scientific and medical literature. Publications include "Are You Considering Using Complementary and Alternative Medicine (CAM)?" and "10 Things To Know About Evaluating Medical Resources on the Web." The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

U.S. Food and Drug Administration (FDA)
Center for Food Safety and Applied Nutrition
Web site: www.cfsan.fda.gov
Toll-free in the U.S.: 1-888-723-3366

Information includes "Tips for the Savvy Supplement User: Making Informed Decisions and Evaluating Information" and updated safety information on supplements. If you have experienced an adverse effect from a supplement, you can report it to the FDA's MedWatch program, which collects and monitors such information (1-800-FDA-1088 or www.fda.gov/medwatch).

Office of Dietary Supplements (ODS), NIH
Web site: http://ods.od.nih.gov
E-mail: ods@nih.gov

ODS supports research and disseminates research results on dietary supplements. It produces the International Bibliographic Information on Dietary Supplements (IBIDS) database on the Web, which contains abstracts of peer-reviewed scientific literature on dietary supplements.

CAM on PubMed
Web site: www.nlm.nih.gov/nccam/camonpubmed.html

CAM on PubMed, a database on the Web developed jointly by NCCAM and the National Library of Medicine, offers abstracts of articles in scientifically based, peer-reviewed journals on complementary and alternative medicine. Some abstracts link to the full text of articles.

The Cochrane Library
Web site: www.cochrane.org/reviews/clibintro.htm

The Cochrane Library is a collection of science-based reviews from the Cochrane Collaboration, an international nonprofit organization that seeks to provide "up-to-date, accurate information about the effects of health care." Its authors analyze the results of rigorous clinical trials (research studies in people) on a given topic and prepare summaries called systematic reviews. Abstracts (brief summaries) of these reviews can be read online without charge. You can search by treatment name (such as the name of an herb) or medical condition. Subscriptions to the full text are offered at a fee and are carried by some libraries.

NCCAM has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy in this information is not an endorsement by NCCAM.

back to: Alternative Medicine Home ~ Alternative Medicine Treatments

Question:

Is the narcissist confined in his grandiose fantasies to one subject?

Answer:

This apparently simple question is more complex than it sounds. The narcissist is bound to make use of his more pronounced traits and qualities both in the design of his False Self and in the process of extraction of Narcissistic Supply from others. Thus, a cerebral narcissist is likely to emphasise his intellect, his brainpower, his analytical skills and his rich and varied fund of knowledge. A somatic narcissist accentuates his body, his physical strength, his appearance, his sex appeal and so on. But this is only one facet of the answer. It seems that narcissists engage in what could best be described as Narcissistic Hedges.

A Narcissistic Hedge is when a narcissistic colours more than one field of activity with his narcissistic hues. He infuses the selected subjects with narcissistic investment. He prepares them as auxiliary Sources of Narcissistic Supply and as backup options in case of a major system failure. These ostensibly redundant activities and interests constitute a fallback option in case a life crisis erupts. In the majority of cases, the chosen subjects or fields will all belong to the same "family". A cerebral narcissist might select mathematics and art, but not mountain climbing. A sportsman might engage in being a radio sports commentator but not a philosopher of science and so on. Still, the correlation between the various selections may not be very strong (which is why they can be used as hedges).

Experience shows that this hedging mechanism is not very effective. The narcissist reacts to events in his life as a rigid unit. His reactions are not differentiated or scaled. A failure (or a success) in one domain spreads to all the others with a contagious speed. The narcissistic contagion effect dominates the narcissist's life. The narcissist measures his personal history, in terms of fluctuations in Narcissistic Supply. He is blind to all the other aspects, angles and points of view. He is like a thermometer, which reacts to human warmth, admiration, adoration, approval, applause and attention. His life is perceived by him in gradations of narcissistic temperature. When a Source of Supply ceases to exist or is threatened or diminished, all the other parts of the narcissist's world (including his backup options) are affected. The dysphoric and euphoric moods, which are related to the absence or to the presence of Narcissistic Supply, engulf the entire personality and consume it.

A case study to illustrate these principles of the economy of the narcissist's soul:

A narcissist has a successful career as an economic commentator in several mass media. As a result of his criticism of the policies of the government, he is threatened and there are signs that a book that he was about to publish, will not be published after all. The narcissist has other subjects from which he is able to derive Narcissistic Supply. What would the likely reaction of such a narcissist be?

Being threatened endangers his feelings of omnipotence and superiority. He is "reduced to size". The special treatment that he believed himself to be entitled to has all but evaporated. This is a narcissistic injury. Worse, it looks as if the very availability and existence of his main and "serious" Narcissistic Supply Sources (the media, the book) are at risk. Dysphoria ensues. The narcissist reacts hysterically and with paranoia. The paranoid streaks in his reaction serve to re-establish the perturbed balance of his own grandiosity. Only important people are persecuted. The hysteria is the result of panic at the prospect of remaining bereft of Narcissistic Supply Sources. A drug addict would have reacted the same way to the drying up of his Supply Sources.

In theory, this would have been the perfect time to revert to the alternatives, to the hedges. But the narcissist's energy is too depleted to make this switch. He is depressed, dysphoric, anhedonic, sees no point in it all, in extreme cases, even suicidal. He jumps to radical and sweeping conclusions ("If this happened to me once, it could well happen again"). His output and achievements deteriorate. As a result, his Narcissistic Supply is further reduced and a vicious circle is set in motion.

This is the absurdity of the narcissistic mental household: the hedges can be used only when there is no need for them. Once a crisis erupts, they are no longer usable by the violently reduced narcissist, a faltering shadow of his former False Self.

next: False Modesty

• Watch the video on The Narcissist Woman

Question:

Are female narcissists any different? You seem to talk only about male narcissists! 

Answer:

I keep using the male third person singular because most narcissists (75%) are males and more so because there is no difference between the male and female narcissists except in two things.

In the manifestation of their narcissism, female and male narcissists, inevitably, do tend to differ. They emphasise different things. They transform different elements of their personality and of their life into the cornerstones of their disorder. Women concentrate on their body (as they do in eating disorders: Anorexia Nervosa and Bulimia Nervosa). They flaunt and exploit their physical charms, their sexuality, their socially and culturally determined "femininity". They secure their Narcissistic Supply through their more traditional gender role: the home, children, suitable careers, their husbands ("the wife of..."), their feminine traits, their role in society, etc. It is no wonder than narcissists - both men and women - are chauvinistic and conservative. They depend to such an extent on the opinions of people around them - that, with time, they are transformed into ultra-sensitive seismographs of public opinion, barometers of prevailing winds and guardians of conformity. Narcissists cannot afford to seriously alienate those who reflect to them their False Self. The very proper and on-going functioning of their Ego depends on the goodwill and the collaboration of their human environment.

True, besieged and consumed by pernicious guilt feelings - many a narcissist finally seek to be punished. The self-destructive narcissist then plays the role of the "bad guy" (or "bad girl"). But even then it is within the traditional socially allocated roles. To ensure social opprobrium (read: attention), the narcissist exaggerates these roles to a caricature. A woman is likely to self-label herself a "whore" and a male narcissist to self-style himself a "vicious, unrepentant criminal". Yet, these again are traditional social roles. Men are likely to emphasise intellect, power, aggression, money, or social status. Women are likely to emphasise body, looks, charm, sexuality, feminine "traits", homemaking, children and childrearing - even as they seek their masochistic punishment.

Another difference is in the way the genders react to treatment. Women are more likely to resort to therapy because they are more likely to admit to psychological problems. But while men may be less inclined to DISCLOSE or to expose their problems to others (the macho-man factor) - it does not necessarily imply that they are less prone to admit it to themselves. Women are also more likely to ask for help than men.

Yet, the prime rule of narcissism must never be forgotten: the narcissist uses everything around him or her to obtain his (or her) Narcissistic Supply. Children happen to be more available to the female narcissist due to the still prevailing prejudiced structure of our society and to the fact that women are the ones to give birth. It is easier for a woman to think of her children as her extensions because they once indeed were her physical extensions and because her on-going interaction with them is both more intensive and more extensive. This means that the male narcissist is more likely to regard his children as a nuisance than as a source of rewarding Narcissist Supply - especially as they grow and become autonomous. Devoid of the diversity of alternatives available to men - the narcissistic woman fights to maintain her most reliable Source of Supply: her children. Through insidious indoctrination, guilt formation, emotional sanctions, deprivation and other psychological mechanisms, she tries to induce in them a dependence, which cannot be easily unravelled.

But, there is no psychodynamic difference between children, money, or intellect, as Sources of Narcissistic Supply. So, there is no psychodynamic difference between male and female narcissist. The only difference is in their choices of Sources of Narcissistic Supply.

An interesting side issue relates to transsexuals.

Philosophically, there is little difference between a narcissist who seeks to avoid his True Self (and positively to become his False Self) - and a transsexual who seeks to not be his true gender. But this similarity, though superficially appealing, is questionable.

People sometimes seek sex reassignment because of advantages and opportunities which, they believe, are enjoyed by the other sex. This rather unrealistic (fantastic) view of the other is faintly narcissistic. It includes elements of idealised over-valuation, of self-preoccupation, and of objectification of one's self (THAT which have all the advantages is what we want to become). It demonstrates a deficient ability to empathise and some grandiose sense of entitlement ("I deserve to have the best opportunities/advantages") and omnipotence ("I can be whatever I want to be - despite nature/God").

This feeling of entitlement is especially manifest in some gender dysphoric individuals who aggressively pursue hormonal or surgical treatment. They feel that it is their inalienable right to receive it on demand and without any strictures or restrictions. For instance, they oftentimes refuse to undergo psychological evaluation or treatment as a condition for the hormonal or surgical treatment.

It is interesting to note that both narcissism and gender dysphoria are early childhood phenomena. This could be explained by problematic Primary Objects, dysfunctional families, or a common genetic or biochemical problem. It is too early to say which. As yet, there isn't even an agreed typology of gender identity disorders - let alone an in-depth comprehension of their sources.

There are mental disorders, which afflict a specific sex more often. This has to do with hormonal or other physiological dispositions, with social and cultural conditioning through the socialisation process, and with role assignment through the gender differentiation process. None of these seem to be strongly correlated to the formation of malignant narcissism. The Narcissistic Personality Disorder (as opposed, for instance, to the Borderline or the Histrionic Personality Disorders, which afflict women more than men) seems to conform to social mores and to the prevailing ethos of capitalism. Social thinkers like Lasch speculated that modern American culture - a narcissistic, self-centred one - increases the rate of incidence of the Narcissistic Personality Disorder. To this Kernberg answered, rightly:

"The most I would be willing to say is that society can make serious psychological abnormalities, which already exist in some percentage of the population, seem to be at least superficially appropriate."

next: Multiple Grandiosity