Wednesday, July 14, 2010

Psychiatry Residents: Can't Live With Them -- Can't Get Benefits Without Them

I had a session with a psychiatry resident, Benjamin Bregman, M.D., at the McClendon Center in Washington, D.C. on Monday July 12, 2010.  Dr. Bregman is a psychiatry resident in training at the George Washington University Medical Center.

I told Dr. Bregman that I suffered from Schizoid Personality Disorder.  Dr. Bregman asked me if I wanted to have relationships or whether I was satisfied in life being a loner.  I interjected, "Doctor, the DSM, the Diagnostic and Statistical Manual, is wrong about schizoid disorder."  Before I could explain, Dr. Bregman launched into a lecture about the DSM -- as if he felt personally attacked.  "The DSM is a work in progress," he said.  "Each person is an individual.  DSM diagnoses don't necessarily apply in whole to every patient."  Yada, yada, yada.  Dr. Bregman went on and on, defending the DSM instead of inquiring into what I meant specifically.

The doctor's comments were totally inapposite; yes, the DSM is a work in progress, but that misses the point.  The DSM is in error with respect to the following diagnostic criterion of Schizoid Personality Disorder: "1. neither desires nor enjoys close relationships, including being part of a family."  It is true that many schizoids report that they do not desire relationships.  However,  analysis of these patients has disclosed that these patients have a strong desire for relationships, but that desire is buried, unconscious; the desire for relationships is outside their conscious awareness.

Salman Akhtar, M.D., a psychoanalyst associated with Jefferson University in Philadelphia, found that although schizoids present as withdrawn, socially isolated, impervious to others' emotions, and afraid of intimacy, they nonetheless have a covert side that is exquisitely sensitive, deeply curious about others, hungry for love, envious of others' spontaneity, intensely needy of involvement with others and capable of excitement with carefully selected intimates.

The authors of the DSM accepted, without further investigation, the initial presentation of schizoid patients who, on first acquaintance, frequently lack insight into their social neediness.

The authors of the DSM based the criterion on interviews with patients diagnosed as "schizoid." The authors of the DSM did not look at the literature on patients in psychoanalysis or psychodynamic psychotherapy. Such patients almost invariably disclose a hidden psychological world in which they yearn for connections with people.

Dr. Bregman also suggested that I might have Aspergers Syndrome.  That is probably highly unlikely.

My final verdict on Dr. Bregman?  I found him to be a very likable and affable chappie.  But as a psychiatry resident he was a total nincompoop -- which is typical of his kind.  Most psychiatry residents are nincompoops.  It was psychiatry residents -- at GW, I might add -- who diagnosed me first with bipolar disorder and then with paranoid schizophrenia.

Norman Doidge, M.D., a psychoanalyst, has written the following about the Schizoid Personality Disorder.

I here use the diagnosis of schizoid as it was first used by British Object Relations theorists, called schizoid because of 'schisms' in the personality. Because the disorder involves an often skilled role play at ordinary social relations, clinicians often misdiagnose these patients as obsessional or higher level narcissistic characters. Akhtar has observed that these 'schisms' are based not only upon the conscious versus unconscious oppositions, but also overt and covert descriptive features. Thus the schizoid may be 'covertly' detached, self-sufficient, absentminded, uninteresting, asexual, and idiosyncratically moral, while 'covertly' exquisitely sensitive, emotionally needy, acutely vigilant, creative, often perverse, and vulnerable to corruption.'

Such patients display a 'moral unevenness; [are] occasionally strikingly amoral and vulnerable to odd crimes, at other times altruistically self-sacrificing.' Guntrip argued that the key schizoid characteristics are introversion, withdrawness, narcissism, self-sufficiency, a sense of superiority, loss of affect, loneliness, depersonalization, and regression.Affects. Even though a schizoid person's affect is constricted, he is not without affective investments. One schizoid patient, who seemed Spock-like talking to people, had a passionate fascination with machines. His experience of emotions when dealing with people was almost digital: he was on or off, without the analogical crescendos and decrescendos of passion. The smallest surge of emotion is like a bomb going off.

Reasons for seeking treatment. The schizoid person tends to alternate between two painful, complex states. On the one hand 'there is a consuming need for object dependence but attachment threatens the schizoid with the loss of self.' Schizoids can function well as long as they can successfully repress intense dependence. To avoid losing himself in relations he protects himself by withdrawal and affective isolation. Without meaningful relationships, with affect shut down, he feels enervated, futile, lifeless. The chronic sense of futility, meaninglessness, and deadness are easily misdiagnosed as dysthymia, depression, or minimized as mere existential anxiety.

Buried alive. Schizoid withdrawal is not only interpersonal, i.e., away from real people; there is a kind of intrapsychic withdrawal, based upon fantasy. As treatment progresses, it is not uncommon for the schizoid to reveal fantasies of having buried his self within him, where it lies waiting until it is safe to be exposed. The fantasy that the self is buried also explains a dread of many schizoids, the fear of being buried alive. A patient dreamed, "There was a baby, it was buried alive. It was horrible and no one knew."

The intrapsychic tomb. It is worth relating this to the phenomenon of intrapsychic tombs described by the French psychoanalyst Torok. Torok began formulating this concept following a lead by Karl Abraham. Abraham wrote to Freud of patients who seemed to show manic denial, and an upsurge of libido, as opposed to melancholia, after the death of their loved one. Torok noticed that a number of her patients related stories of sexual acts and needs right after a death. She saw this as a desperate and final attempt to sustain the relationship by the fantasy of incorporation (concretely taking a person's body inside them). She described these patients as having a fantasy of 'an exquisite corpse' entombed somewhere inside them, which they hoped to revive. One dreamed, 'I committed a terrible crime. I ate someone and then buried them... For this reason I have to spend the rest of my life in prison.' Torok brilliantly observed that in many cases of complicated grief, the anguished pining that the living bereaved feel is not their own longing for their love object, but rather, the fantasized pining of the deceased love object for them. If we deny our beloved has died, the fantasy of the beloved as alive and seeking us persists. It is all too often overlooked because we are preoccupied with our more conscious longing for the lost object. But fantasized incorporation of the deceased 'eating the object (which parallels, in ways, the Christian imagery of consuming the host)' stifles mourning. 'When, in the form of imaginary or real nourishment, we ingest the love object we miss... we refuse to mourn.... .'

Petrification fears. The schizoid person is often aware that his sense of self is fragile, and built upon a fantasy. Several of my schizoid patients had the ongoing fear that this imaginary world could all blow up at a moment's notice. While the schizoid person's surface may be nondescript, decorous, emotionless, he is terrified of being revealed as human, full of hunger. He fears being petrified and turning into rock, if another person catches him in his glance, as was Medusa when she saw herself as others saw her, i.e., in all her fantastic, composite ugliness, filled with unruly sexual and aggressive desires and defects.

Typical Development. Akhtar's extensive review has shown that rejection, traumatic overstimulation, and neglect in the first two years of life are common in the history of schizoids. The schizoid condition was first described by the Scottish psychoanalyst Fairbairn in the 1940s. Fairbairn found that his patients had withdrawn from parents who were overtly rejecting. They preferred to live in a rich, imaginary world. Many fiction writers are schizoid because the ability to create a vivid inner world in one's head gives one a head start at writing fiction. The downside is that the schizoid's sense of other people is impoverished.

Core belief: Not hatred, but love is the problem. Fairbairn observed that the child with the rejecting or disappointing parent develops an internalized image of the rejecting parent, called the anti-libidinal object, to which he is desperately attached. The rejecting parent is often incapable of loving, or preoccupied with his or her own needs. The child is rewarded when he is not demanding, and devalued or ridiculed as needy when he expresses his dependent longings Thus the schizoid's picture of 'good' behavior is distorted. The child learns never to nag or even yearn for love, because it makes the parent more distant and censorious. The child then may cover over the incredible loneliness, emptiness and ineptness he feels with a fantasy (often unconscious) that he is self-sufficient. Love and anger get hopelessly intertwined. Fairbairn argued that the tragedy of the schizoid child is that his conscience has been warped: he believes his love, not his hatred is the destructive force within. Love consumes. Hence the schizoid child's chief mental operation is to repress his or her normal wish to be loved.

Being smitten. In my experience, should the adult schizoid fall in love with someone who reminds him of his rejecting parent he will often describe himself as 'being smitten'; 'smitten' is the past participle of to smite, and to be smitten is to be disastrously and deeply affected as one falls in love, as though one has sustained a severe blow. The British frequently describe falling in love this way; I doubt that national partiality to that word is accidental. [The author of this article, which can be found on the internet, is a Canadian psychiatrist.]

Pickiness and Prickliness. On the other hand, when more nurturing people come along, the schizoid will often dream, guiltily, that he or she is being disloyal to the parent imago, betraying a pact. This intense, internal backlash derives from a pathological superego, which unlike that in a loved child, is anti-libidinal. The schizoid child has a conscience that has made love a crime. Conscience always incites us to scrupulously pour over events and see them in a moral light; the schizoid's conscience demands he focus on the new love interest in an active, picky, prosecutorial, fault-finding way. Love becomes about as pleasant as litigation, for both parties. To avoid feeling picky, he may try to withdraw or simply enter a defensive, turned off state, finding the potential lover 'boring' or 'a turn off'. He has gone into total affect shut-down. Or he may become prickly, and chronically irritable so that others know not to approach.Under the skin, the wish for merger or fusion. Should the love object 'get under the skin', the schizoid person feels taken over; being smitten releases his own pent-up wish to merger and cling that was appropriate in early childhood, but never satisfied at that time; his own longing gives rise to the fear that he will lose the external boundary that exists between himself and the exciting love object. He feels as if the love object is possessing him, in the sense of spirit possession.

Reversal of the values of life and death; preoccupation with the living dead, and the dead in the living. While schizoid patients may have quite conventional attitudes on the surface towards life as being something good, the fantasy life, so suffused with anti-libidinal themes, often displays a reversal of values of life and death, and an emphasis on the futility of life that one sees so frequently expressed in Beckett, for example. For instance, many of us fear that death is futile, and goes on for an unrelieved eternity; Beckett depicts not death but life as futile and going on and on without meaning. Thus there is a strong tendency towards nihilism and withdrawal that must be struggled against.

Defensive Techniques against Falling in Love: Ascetic ideals. To squelch this hunger for love the schizoid may idealize asceticism. But like the ascetic who retreats to the desert to avoid human contact and temptation, he soon begins to see the temptress in his wet dreams, sanctuary drawings, and religious stories, in a return of the repressed. He concludes, mistakenly, that desire is a bottomless pit; promiscuity and celibacy may alternate, both as attempts to deal with this perceived insatiability.

Role playing. Another anti-libidinal technique used by schizoids to preserve the pact with the bad parent is to appear to be involved with others. Thus a subset of schizoid people of the 'role playing variety' get involved in a limited way. Fairbairn showed that the schizoid can actually unconsciously disown the social role while he is playing it. A patient appeared for a long time to be free associating and involved in sessions. Only well into treatment did he disclose that he always had the omnipotent fantasy that he was controlling everything I said.

The in and out program. A related distancing technique has been described by Guntrip as 'the in and out program' and involves 'always breaking away from what one is at the same time holding on to.' This may involve 'rushing in and out of one marriage after another', or always emphasizing to one's partner that one could get along without him or her, or always fantasizing about taking a job away from the partner while staying with the partner. Such patients are 'unable to commit... in a stable... way.' They are always negotiating the optimal distance between themselves and others, saying things like 'I need my space.' But not infinite space, for the repressed hungry self is rarely completely obliterated, and it draws them back into the optimal orbit of others.

Sadomasochistic Object Relations. The belief that love consumes or destroys one's identity, and the tendency we have to repeat, make sadomasochistic object relations with a rejecting parent substitute highly likely. Sadomasochistic hurts help keep the object at a distance, which suits the schizoid's in and out program.

Attitudes toward children. In my experience, the classic schizoid is ambivalent about the 'idea' of having children, though may be surprised at how attached he or she may become towards them, should children come along. In sicker schizoids the parental instincts seem turned to pets, collecting things, or the environment which becomes animated."

Psychosocial Treatment -- Basic Principles: The physician should appreciate the need for privacy in a person with schizoid personality disorder and should maintain a low-key approach that focuses on the technical elements of treatment. Such a focus will enable the patient to feel the physician's concern and caring and know that caretakers will not press beyond comfortable limits. The patient should be encouraged to maintain daily routines so that a sense of "life as usual" can counteract the worry that illness will shatter the patient's efforts to remain detached and uninvolved. Knowledge of the patient's usual pattern of functioning will counteract any tendency on the part of the health care team to become personally overinvolved or be too zealously concerned with providing social supports for the patient.

Individual Psychotherapy: Long-term psychotherapy has been useful in selected cases. The course of therapy involves gradual development of trust. If this can be achieved, the patient may share long-standing fantasies of imaginary friendships and may reveal fears of depending on others. Patients are encouraged to examine the unrealistic nature of their fears and fantasies and to form actual relationships. Successful psychotherapy will produce gradual change. The patient should be provided with some sense of optimism that his or her basic needs can be met without encountering some overwhelming 'collapse or suffocation.' The most useful therapeutic interaction is consistent and supportive, with clear rules, an ability for the patient to set the therapeutic distance as necessary, and some tolerance for acting-out behaviors.

The treatment of schizoid personalities is similar to the treatment of paranoid personalities. However, the schizoid patient's tendencies toward introspection are consistent with the psychotherapist's expectations, and the schizoid patient may become a devoted if distant patient. Extensive periods of silence, however, may be hard to bear. As trust develops, the schizoid patient may, with great trepidation, reveal a plethora of fantasies, imaginary friends, and fears of unbearable dependency - even of merging with the therapist. Oscillation between fear of clinging to the therapist may be followed by fleeing through fantasy and withdrawal.

Group Therapy: Group psychotherapy may be helpful. A prolonged period of silent withdrawal may often be followed by gradual involvement in the group process. It is important for the group leader to protect the schizoid patient from criticism by other members for not participating verbally in the early affiliative phase of the group. In group therapy settings, a schizoid patient may be silent for a year or more; nonetheless, involvement does take place. The patient should be protected against aggressive attack by group members on his proclivity for silence. With time, the group may become a meaningful experience for the patient and provide social contact, as well as therapy. Group therapy is particularly useful for schizoids, who are provided with a social network in which they have the opportunity to overcome fears of closeness and feelings of isolation. They learn, in the supportive milieu of the group, to communicate their thoughts and feelings directly to others and, by so doing, move toward more normal behavioral patterns.

Aaron T. Beck, MD, a leading cognitive therapist, has written the following about the treatment of schizoid patients. "In contrast to the treatments of such Axis I disorders as depressive disorder and anxiety disorders, the therapy for personality disorders requires a long period of therapeutic work--often one or more years. Also, much more therapeutic concentration deals with transference issues, exploring childhood patterns, and even revivifying pathogenic childhood experiences. In that respect, cognitive therapy has an increasing convergence with psychodynamic therapy. The major differences are that the cognitive therapist is more active and directive, the therapeutic sessions are more structured, the content is based on exploring and testing cognitive distortions and basic beliefs, and the patient is expected to carry out homework assignments."

Such is the psychological struggle of the schizoid patient. Quite frankly, how many people out there would be willing to be friendly with someone whose need for emotional distance is as strong as his need for emotional connection? Who would be willing to befriend an emotionally distant, aloof, shallow, and vacant individual? Let's face it, I'm not exactly a fun guy.


iam said...

gary, i'm just an idiot, but honestly, i don't think true friendship is based on clean psychological records or social elegance. if i lived in dc i'd prove you wrong right now. damn...

Shiv said...

still waiting on these law school related tasks to end themselves, so i can assimilate these facts of your condition.

Gary Freedman said...

Recommendation for the Social Security Administration:

You need to adopt the following rule with regard to disability benefits--

"Under no circumstances will the Social Security Administration accept the diagnoses, clinical impressions, or clinical recommendations of medical residents. The SSA will only accept the clinical opinions of board-certified physicians."

Gary Freedman said...

Zeta Zizou said...

Gary, You are the first person that talks about Schizoids that actually makes sense......would you mind if I asked you some questions? private?