Depression and Spiritual Growth

B. A Spiritual Model of Healing and Wellness

Major depression and bipolar disorder are among the most searing experiences of life. I have known people who have had an episode of major depression, and also have had a serious heart attack. When asked which they would choose if they had to go through one or the other again, most of them said they would choose the heart attack! It is therefore wise to try to obtain some kind of framework and perspective in which to view the illness and the progression back to wellness.

The initial phases of the model offered here resembles somewhat the model of dying developed by Dr. Elizabeth Kubler-Ross in her famous book "On Death and Dying". But I want to point out right away an essential difference: in Kubler-Ross's model the end state is that you die; in this model the end state is that you get to live, perhaps for the first time ever.

When one comes to the full realization that he/she has a chronic mental illness, the most common natural reaction is denial: the insistence that "there must be a mistake; this can't be true!" The trouble with denial is that it doesn't accomplish anything. It neither retards the course of the illness, nor facilitates its cure (quite the contrary, it typically delays meaningful treatment). How long this state lasts depends on how severe the illness is: if it's mild, denial can be sustained for a long time; but once grinding, crushing, mind-breaking major depression sets in, the luxury of denial falls by the way, and survival becomes the issue of the day.

In the Kubler-Ross model of dying, the next stage is often anger: "Why me?!". In contrast, strong anger is not typically a part of the progression of events in severe depression. Some psychiatric theories attribute special significance to its absence, and go so far as to say that depression is actually caused by ``suppressed anger''. From my own experience and contacts with many severely depressed people, I dismiss those ideas. The fact is that the scientific evidence shows severe chronic depression is biochemical, and requires treatment with medication. Also, it is unreasonable to expect depressed people show anger because they are in misery; rather than angry, they are passive. Furthermore, they often feel guilty about everything in their lives, and even believe, in some tortured sense, that they ``deserve'' their illness.

Manic people tend to become controlling rather than angry. They will often be very arrogant, and openly manipulative of the people around them. If the manic state is severe enough, they may even resort to violence to retain this ``control''.

As one comes finally to acknowledge the indisputable presence of the illness, one feels a sense of loss, grief, and mourning. One senses that life may never be the same (aside: it may actually become better, but one usually can't believe that at this stage). That some of the opportunities we thought we had may not be there any more; that we may not have, or do, all the things we had hoped to, and believed we would -- this is loss. As the loss sinks in, we feel grief: grief for that part of our own life that seems likely to be dead now; grief for the loss of ourselves as terrible as the grief we experience for the loss of others. And then we mourn. This can be a painful, tearful time, in which there is no consolation.

But the human spirit is amazing; it can survive, singing, under the most adverse circumstances. And the will to survive leads us to a new position: acceptance. This is the most important step in the process of healing! It is literally impossible to overemphasize how important acceptance is: it can be the choice between life and death. To illustrate, suppose some terrible disaster befalls you: your beloved spouse dies, or your child dies, or you are permanently injured and scarred in an accident. These are events that you really don't like; but you don't control them, and therefore cannot change them; nor are they going to change by themselves or by someone else's intervention. So you have a choice: you can forevermore be caught up in your loss, grief, and mourning, or you can say (out loud if it helps!) "I don't like this situation one little bit! I never will; but I can't change it, so I must accept it so that I can get on with living."

Once we can do that, once we can simply acknowledge what is, even if we don't like it, a wonderful thing happens. We begin to experience release. That is, the loss is still there, and we still don't like it; we acknowledge and accept its existence; but now we refuse to have it dominate every waking moment of our lives. In effect we say "Yes, you are there. And I have dealt with your presence as well I can. But I have other things to do now.'' This cuts the string that otherwise would have you jumping like a puppet for the rest of your life, and allows you to move forward again.

Once you are released, healing can begin. You gain the insight and courage to carry out your decision to continue living. You grow stronger. The ugly scars are still there; but they aren't painful any more when you press on them, even hard.

I remember, as a kid in junior high-school, seeing a friend naked in the shower after gym class who had a gigantic keloid scar reaching from the top of his left shoulder down past his left breast. It looked horrible. Not being a diplomat, I ingenuously said to him ``That looks really terrible. What happened?" He replied ``I was once burned severely in a fire." Still practicing my "diplomac"' I said "Wow, that must have really hurt!" And he returned "Yes it did. It was extremely painful." Then he did something remarkable, which I still remember 50 years later: he clenched his right fist, and he hit himself in the middle of the scar as hard as he could, saying "It hurt terribly then, but it is healed now, so it doesn't hurt any more".

I have thought about that ever since. It is true for a person with CMI as well; once we heal, very ugly ``scars'' may be there, but they won't hurt any more!

You will be different then. Healing has changed your environment and changed you. There is no going back to what was before.

You might conclude that the process I have described leads only to a state in which there is permanent loss, or some aspect of your life is permanently degraded. But here the analogy with a friend dying or a permanent physical injury breaks down. In those cases, your friend will remain dead; the limb you lost is gone. Whether your life is degraded or not depends on how you deal with these losses. But in the case of mental illness radically different outcomes are possible. For example, if one experiences a strong remission, then one can look back at the period of severe illness with an awareness of the loss of some things, which, with the help of successful psychotherapy we can replace with other things (habits, beliefs, insights, stance towards life, and so on) which we like better. My own experience, and that of other people with CMI who I have known, is that the trip through the "fire'' of depression or mania can be purifying, burning away the worst of us, creating new openings through which we can proceed into the future. I recall someone once saying to me "It is when your iron is thrust into the white-hot flame, and hammered, hammered, and hammered, that it becomes steel."

It is at the end of such a journey that one can begin to understand fully the meaning of the following quote, which once appeared on the cover of the Friends Journal:

The crucible is for silver.
But the fire is for gold.
And so God tries the hearts of men.

Those who have felt this Fire, and realize how it authenticates the depth and reality of their experience, and their experiential knowledge of God, are on the road which leads beyond healing to Grace, a subject to which we shall return.

next: Stigma of Having A Mental Illness
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In my work, I sometimes feel that there is an epidemic of low self-esteem. Even people who seem to be very sure of themselves will admit to having low self-esteem, a feeling that often makes them unhappy and keeps them from doing some of the things they want to do and being the kind of person they want to be. In fact, they may say that low self-esteem causes, or worsens, their bouts with depression and anxiety.

I know this has been a big factor in my life. I feel that I am always working on raising my self-esteem and that I will always need to do that.

There is no single way to build self-esteem. There are many different things you can do to work on this issue, and I, myself, am always on the lookout for new ways to raise self-esteem. This article will describe some of what I have learned to date.

Get Involved

Right now you have an opportunity to do something that will help you to raise your self-esteem. Once every four years, you can vote for the person you would like to be the next President of the United States. You also have the opportunity to vote for other national, state and local officials. Irrespective of the outcome of the election, informing yourself about the candidates and voting for the ones who support issues that are important to you can make you feel good about yourself, raising your self-esteem.

Begin the process by thinking about the issues that are most important to your education, health care, the environment, taxes, defense spending, etc. If you don't know how you feel about these issues, read some related articles and talk with people who have the information you need. Then, when you know how you feel, find out which candidates support your views. Then vote for those candidates. If you feel strongly about certain candidates and have the time, you may want to volunteer to help them with their campaigns. Activism will give your self-esteem another boost.

Take Good Care of Yourself

Another way you can build your self-esteem is to take very good care of yourself. You may take very good care of others and put your own personal care last. Or your life may be so busy that you don't take the time to do the things you need to do to stay healthy. You may feel so badly about yourself that you don't bother to take good care of yourself.

Some of the things you can do to take good care of yourself include:

• Eating three meals a day that are focused on healthy foods, fresh fruit and vegetables, as well as whole grain foods and rich sources of protein like chicken and fish.
• Avoiding foods that contain large amounts of sugar, caffeine and food additives. If you can't pronounce the ingredients, you may want to avoid it.
• Getting outside and exercising every day.
• Spending some time each day doing something you really enjoy.
• Spending time each day with people who make you feel good about yourself.
• Having regular check-ups with your health care providers.

Change Negative Thoughts About Yourself to Positive Ones

Work on changing negative thoughts about yourself to positive ones. You may give yourself lots of negative self-talk. Many people do. This negative self-talk increases your low self-esteem.

You can decide now not to do this to yourself. That's great if you can do it. However, negative self-talk is often a habit that is hard to break. You may need to work on it more directly by changing negative statements about yourself to positive ones.

Begin this process by making a list of the negative statements you often say to yourself. Some of the most common ones are:

• Nobody likes me.
• I am ugly.
• I never do anything right.
• I am a failure.
• I am dumb.
• Everyone is better than I am.
• I'm not worth anything.
• I've never accomplished anything worthwhile.

Then develop a positive statement that refutes the negative one. For instance, instead of saying to yourself, "Nobody likes me," you could say, "Many people like me." You could even make a list of the people who like you. Instead of saying, "I am ugly," you could say, "I look fine." Instead of saying, "I never do anything right," you could say "I have done many things right." You could even make a list of things you have done right. It helps to do this work in a special notebook or journal.

When you have developed positive statements that refute your negative statements, read them over and over to yourself. Read them before you go to bed at night and when you first get up in the morning. Read them aloud to your partner, a close friend or your counselor. Make signs that express positive statements about you and post them where you will see them - like on the mirror in your bathroom. Then read them aloud every time you see them. Think about some other ways to reinforce these positive statements about yourself.

Get Something Done

Low self-esteem is often accompanied by lack of motivation. It may feel very hard to do anything. It will help you to feel better about yourself if you do something, even if it is a very small thing. You may want to keep a list of possibilities on hand for those times when you can't think of anything to do. Things like: cleaning out one drawer, washing the outside of your refrigerator, putting a few pictures in a photo album, reading an article you have been wanting to read, taking a picture of a beautiful flower or a person you love, making the bed, doing a load of laundry, cooking yourself something healthy, sending someone a card, hanging a picture or taking a short walk.

Make a List of Your Accomplishments

You may not give yourself credit for all that you have achieved in your life. Making a list of your accomplishments will help you become more aware of these accomplishments. It will also help change the focus of your self-thoughts to positive ones. You can do this exercise again and again, whenever you notice your self-esteem is low.

Get a big sheet of paper and a comfortable pen. Set the timer for 20 minutes (or as long as you'd like). Spend the time writing your accomplishments. You could never have a paper long enough or enough time to write them all. Nothing is too big or too small to go on this list. This list can include things like:

• Learning to talk, walk, read, skip, etc.;
• Planting some seeds or caring for houseplants;
• Raising a child;
• Making and keeping a good friend;
• Dealing with a major illness or disability;
• Buying your groceries;
• Driving your car or catching the subway;
• Smiling at a person who looks sad;
• Taking a difficult course;
• Getting a job;
• Doing the dishes; or
• Making the bed.

Do Something Special for Someone Else

Have you ever noticed the good feeling that washes over you when you do something nice for someone else? If so, take advantage of that good feeling by doing things that are "nice" or helpful to others as often as you can to build your self-esteem. Watch for opportunities that come up every day. Buy your partner some flowers or even one rose. Send a friend a greeting card. If someone you know is having a hard time, send them a note or give them a call. Go out of your way to congratulate people you know on their achievements. Visit a patient at a nursing home or hospital or someone who is "shut-in." Play with a child - read him a book, take her for a walk, push him on the swing. Do a chore for someone that might be hard for her or him like raking the leaves or mowing the grass. You may even want to volunteer for an organization that is helping others, like a heart association or AIDS project. I'm sure you can think of many other ideas.

Other Quick Things You Can Do to Raise Your Self-esteem

Following is a list of other things you can do to raise your self-esteem. Some of them will be right at one time, while others will work at another time. There may be some you choose not to do - ever. You may want to post this list on your refrigerator or in some other convenient place as a reminder.

• Surround yourself with people who are positive, affirming and loving.
• Wear something that makes you feel good.
• Look through old pictures, scrapbooks and photo albums.
• Make a collage of your life.
• Spend 10 minutes writing down everything good you can think of about yourself.
• Do something that makes you laugh.
• Pretend you are your own best friend.
• Repeat positive statements over and over again.

You can add more ideas to this list as you discover them for yourself.

In Conclusion

Work on raising your self-esteem may go on for the rest of your life. However, this is not a burden. The kinds of things you do to raise your self-esteem will not only help you to feel better about yourself, but will improve the quality of your life while energizing and enriching it.

next: Dealing with Trauma: 5 Beginning Steps
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Self-Therapy For People Who ENJOY Learning About Themselves

Sadness is a natural emotion or feeling.

We feel sadness whenever we LOSE something that we previously enjoyed.

It is good for us both because it offers RELIEF from the pain of the loss and because it gives us a MEASURE of the importance of what we've lost.

HOW IT WORKS

Whenever we lose something, part of our energy goes into feeling sad.

If it's a major loss (like the death of a loved one) almost all of our energy goes into sadness.

If it's a minor loss (like if we've lost a favorite shirt)it may be so small we don't even notice it.

Sadness has a natural duration. We will get over it within a certain amount of time if we admit to it and express it.

If we don't admit to it (if we deny that it's there), we can feel "uncentered" or "crazy."

If we don't express it (if we keep it inside), it takes a much longer time to get over it.

Sadness feels bad when we first notice it, it feels good as we express it (by crying if needed), and it feels much worse when it's denied or squelched.

It feels better to express our sadness with people who care about us but expressing it alone is good for us too - it just takes significantly longer that way.

Sadness is really just raw energy. After we have admitted to it and expressed it enough we often feel a major boost in our energy level.

We all have one particular set of physical sensations in our body which indicate sadness to us. People feel sadness in various ways and in various parts of their body.

The most common sensations are probably "a lump in the throat," "emptiness" in the chest, or swelling in the face and around the eyes.

Your sensation of sadness may be one of these or it may be entirely different.

FEELING YOUR SADNESS

It is vital to your emotional health to know how sadness feels to you in your body.

So, right now, take a moment to remind yourself of the worst sadness you ever felt.

As you remember this day when you lost something very important to you, ask yourself: "What Do I FEEL In My Body"?

Once you recognize your own "sad place" in your body, you can stop thinking about that bad day in your life!

Notice that you are able to let go of that memory almost as quickly as you were able to remember it!

It is very important that you admit to yourself that you are sad whenever you feel this sensation in this part of your body!

As a matter of fact, you'll need to get better and better at recognizing even very slight sensations of sadness, if you want to improve your life.

UNNATURAL SADNESS

It is possible to believe that you are sad when you aren't, and to believe you are sad when you are really angry (most common), or when you are feeling scared, or happy, or excited, or guilty.

The "Split Second" It Started: Real, necessary, natural sadness starts as an immediate response to some event. Unreal, unnecessary, unnatural sadness starts in our minds, with a thought.

If the sadness was natural you will feel better as you admit and express it. If it was unnatural you won't.

If you don't get relief from your sadness, it probably started in your mind.

It is possible to simply stop unnatural sadness (once you stop believing it's real).

If you have trouble stopping it, you are probably only believing that you are sad as part of a strategy for getting along in the world. Some people call this manipulation, but that word implies that it is done on purpose. It's really a way of coping, subconsciously, with life's difficulties.

But feeling the pain of unnatural sadness never works as a way of coping in the long run.

See "PROBLEMS WITH SADNESS" (Another Article In This Series)

Enjoy Your Changes!

Everything here is designed to help you do just that!

next: Natural Scare

Overview of relaxation therapy as an alternative treatment for depression and anxiety and whether relaxation therapy works in treating depression.

What is Relaxation Therapy?

Relaxation therapy refers to a number of techniques designed to teach someone to be able to relax voluntarily. Programs most often include training in special breathing and progressive muscle relaxation exercises designed to reduce physical and mental tension. Massage, watching relaxing videos or listening to special music for relaxation do not constitute relaxation therapy, although they are sometimes included as part of a relaxation therapy program.

How does Relaxation Therapy for Depression work?

Muscle tension is usually associated with stress and anxiety, which are strongly associated with depression. Becoming aware of the link between depressive thoughts and mental and muscle tension may help.

Is it Relaxation Therapy effective?

There have been only a few small studies looking at the effect of relaxation therapy for people with depression. In two studies, it was found to be as effective as cognitive behavior therapy or antidepressant medication in the short term. The longer term effects are uncertain.

Are there any disadvantages?

None known.

Where do you get Relaxation Therapy?

Community groups often run relaxation classes. There are also therapists who teach relaxation. These are listed in the Relaxation Therapy section of the Yellow Pages. Books and tapes giving instructions in relaxation therapy are available from bookshops and over the internet.

Recommendation

Relaxation therapy is promising as a treatment for depression, but needs further research.

Key references

Murphy GE, Carney RM, Knesevich MA, et al. Cognitive behavior therapy, relaxation training and tricyclic antidepressant medication in the treatment of depression. Psychological Reports 1995; 77:403-420

Reynolds WM and Coats KI. A comparison of cognitive behavior therapy and relaxation training for the treatment of depression in adolescents. Journal of Consulting and Clinical Psychology, 1986; 54: 653-660.

Relaxation tape: Progressive muscle relaxation WARNING. Relaxation therapy is not for everyone. Some people who are very depressed or anxious or who have other types of mental health problems find that relaxation doesn't help. It might even make them feel worse. Please check with your doctor before trying relaxation therapy.

Before you begin. Find a place where you won't be disturbed. Make sure you are not hungry or thirsty and that you haven't been drinking alcohol. It is best to do these exercise sitting rather than lying down. Lower the lights. You will find that there are periods of quietness on this tape. You will know that the tape is about to finish when you hear "Open your eyes".

Download progressive muscle relaxation tape (File format - mp3, 17.7MB)

back to: Alternative Treatments for Depression

Everything you need to know about The Psychology of Good Sex is here:

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9. The Secret to Good Sex in Marriage

10. Good Sex Is Not Just for New Lovers

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INTRODUCTION

Suyemoto and MacDonald (1995) reported that the incidence of self-mutilation occurred in adolescents and young adults between the ages of 15 and 35 at an estimated 1,800 individuals out of 100,000. The incidence among inpatient adolescents was an estimated 40%. Self-mutilation has been most commonly seen as a diagnostic indicator for Borderline Personality Disorder, a characteristic of Stereotypic Movement Disorder (associated with autism and mental retardation) and attributed to Factitious Disorders. However, practitioners have more recently observed self-harming behavior among those individuals diagnosed with bipolar disorder, obsessive-compulsive disorder, eating disorders, multiple personality disorder, borderline personality disorder, schizophrenia, and most recently, with adolescents and young adults. The increased observance of these behaviors has left many mental health professionals calling for self-mutilation to have its own diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (Zila & Kiselica, 2001). The phenomenon is often difficult to define and easily misunderstood.

DEFINITION OF SELF-MUTILATION

Several definitions of this phenomenon exist. In fact, researchers and mental health professionals have not agreed upon one term to identify the behavior. Self-harm, self-injury, and self-mutilation are often used interchangeably.

Some researchers have categorized self-mutilation as a form of self-injury. Self-injury is characterized as any sort of self-harm that involves inflicting injury or pain on one's own body. In addition to self-mutilation, examples of self-injury include: hair pulling, picking the skin, excessive or dangerous use of mind-altering substances such as alcohol (alcohol abuse), and eating disorders.

Favazza and Rosenthal (1993) identify pathological self-mutilation as the deliberate alteration or destruction of body tissue without conscious suicidal intent. A common example of self-mutilating behavior is cutting the skin with a knife or razor until pain is felt or blood has been drawn. Burning the skin with an iron, or more commonly with the ignited end of a cigarette, is also a form of self-mutilation.

Self-mutilating behavior does exist within a variety of populations. For the purpose of accurate identification, three different types of self-mutilation have been identified: superficial or moderate; stereotypic; and major. Superficial or moderate self-mutilation is seen in individuals diagnosed with personality disorders (i.e. borderline personality disorder). Stereotypic self-mutilation is often associated with mentally delayed individuals. Major self-mutilation, more rarely documented than the two previously mentioned categories, involves the amputation of the limbs or genitals. This category is most commonly associated with pathology (Favazza & Rosenthal, 1993). The remaining portion of this digest will focus on superficial or moderate self-mutilation.

Additionally, self-injurious behavior may be divided into two dimensions: nondissociative and dissociative. Self-mutilative behavior often stems from events that occur in the first six years of a child's development.

Nondissociative self-mutilators usually experience a childhood in which they are required to provide nurturing and support for parents or caretakers. If a child experiences this reversal of dependence during formative years, that child perceives that she can only feel anger toward self, but never toward others. This child experiences rage, but cannot express that rage toward anyone but him or herself. Consequently, self-mutilation will later be used as a means to express anger.

Dissociative self-mutilation occurs when a child feels a lack of warmth or caring, or cruelty by parents or caretakers. A child in this situation feels disconnected in his/her relationships with parents and significant others. Disconnection leads to a sense of "mental disintegration." In this case, self-mutilative behavior serves to center the person (Levenkron, 1998, p. 48).

REASONS FOR SELF-MUTILATING BEHAVIOR

Individuals who self-injure often have suffered sexual, emotional, or physical abuse from someone with whom a significant connection has been established such as a parent or sibling. This often results in the literal or symbolic loss or disruption of the relationship. The behavior of superficial self-mutilation has been described as an attempt to escape from intolerable or painful feelings relating to the trauma of abuse.

The person who self-harms often has difficulty experiencing feelings of anxiety, anger, or sadness. Consequently, cutting or disfiguring the skin serves as a coping mechanism. The injury is intended to assist the individual in dissociating from immediate tension (Stanley, Gameroff, Michaelson & Mann, 2001).

CHARACTERISTICS OF INDIVIDUALS WHO SELF-MUTILATE

Self-mutilating behavior has been studied in a variety of racial, chronological, ethnic, gender, and socioeconomic populations. However, the phenomenon appears most commonly associated with middle to upper class adolescent girls or young women.

People who participate in self-injurious behavior are usually likeable, intelligent, and functional. At times of high stress, these individuals often report an inability to think, the presence of unexpressable rage, and a sense of powerlessness. An additional characteristic identified by researchers and therapists is the inability to verbally express feelings.

Some behaviors found in other populations have been mistaken for self-mutilation. Individuals who have tattoos or piercing's are often falsely accused of being self-mutilators. Although these practices have varying degrees of social acceptability, the behavior is not typical of self-mutilation. The majority of these persons tolerate pain for the purpose of attaining a finished product like a piercing or tattoo. This differs from the individual who self-mutilates for whom pain experienced from cutting or damaging the skin is sought as an escape from intolerable affect (Levenkron, 1998).

COMMON MISCONCEPTIONS OF SELF-MUTILATION

Suicide

Stanley et al., (2001) report that approximately 55%-85% of self-mutilators have made at least one attempt at suicide. Although suicide and self-mutilation appear to possess the same intended goal of pain relief, the respective desired outcomes of each of these behaviors is not entirely similar.

Those who cut or injure themselves seek to escape from intense affect or achieve some level of focus. For most members of this population, the sight of blood and intensity of pain from a superficial wound accomplish the desired effect, dissociation or management of affect. Following the act of cutting, these individuals usually report feeling better (Levenkron, 1998).

Motivation for committing suicide is not usually characterized in this manner. Feelings of hopelessness, despair, and depression predominate. For these individuals, death is the intent. Consequently, though the two behaviors possess similarities, suicidal ideation and self-mutilation may be considered distinctly different in intent.

Attention-seeking behavior

Levenkron (1998) reports that individuals who self-mutilate are often accused of "trying to gain attention." Although self-mutilation may be considered a means of communicating feelings, cutting and other self-harming behavior tends to be committed in privacy. In addition, self-harming individuals will often conceal their wounds. Revealing self-inflicted injuries will often encourage other individuals to attempt to stop the behavior. Since cutting serves to dissociate the individual from feelings, drawing attention to wounds is not typically desired. Those individuals who commit self-harm with the intent of gaining attention are conceptualized differently from those who self-mutilate.

Dangerousness to others

Another reported misconception is that those individuals who commit self-harm are a danger to others. Although self-mutilation has been identified as a characteristic of individuals suffering from a variety of diagnosed pathology, most of these individuals are functional and pose no threat to the safety of other persons.

TREATMENT OF THE INDIVIDUAL WHO SELF-MUTILATES

Methods employed to treat those persons who self-mutilate range on a continuum from successful to ineffective. Those treatment methods that have shown effectiveness in working with this population include: art therapy, activity therapy, individual counseling, and support groups. An important skill of the professional working with a self-harming individual is the ability to look at wounds without grimacing or passing judgment (Levenkron, 1998). A setting that promotes the healthy expression of emotions, and counselor patience and willingness to examine wounds is the common bond among these progressive interventions (Levenkron, 1998; Zila & Kiselica, 2001).

Source: ERIC/CASS Digest

The overall picture seems to be of:

• people who: strongly dislike/invalidate themselves
• are hypersensitive to rejection
• are chronically angry, usually at themselves tend to suppress their anger have high levels of aggressive feelings, which they disapprove of strongly and often suppress or direct inward
• are more impulsive and more lacking in impulse control tend to act in accordance with their mood of the moment
• tend not to plan for the future
• are depressed and suicidal / self-destructive
• suffer chronic anxiety
• tend toward irritability
• do not see themselves as skilled at coping
• do not have a flexible repertoire of coping skills
• do not think they have much control over how/whether they cope with life
• tend to be avoidant
• do not see themselves as empowered

People who self-injure tend not to be able to regulate their emotions well, and there seems to be a biologically-based impulsivity. They tend to be somewhat aggressive and their mood at the time of the injurious acts is likely to be a greatly intensified version of a longstanding underlying mood, according to Herpertz (1995). Similar findings appear in Simeon et al. (1992); they found that two major emotional states most commonly present in self-injurers at the time of injury -- anger and anxiety -- also appeared as longstanding personality traits. Linehan (1993a) found that most self-injurers exhibit mood-dependent behavior, acting in accordance with the demands of their current feeling state rather than considering long-term desires and goals. In another study, Herpertz et al. (1995) found, in addition to the poor affect regulation, impulsivity, and aggression noted earlier, disordered affect, a great deal of suppressed anger, high levels of self-directed hostility, and a lack of planning among self-injurers:

We may surmise that self-mutilators usually disapprove of aggressive feelings and impulses. If they fail to suppress these, our findings indicate that they direct them inwardly. . . . This is in agreement with patients' reports, where they often regard their self-mutilative acts as ways of relieving intolerable tension resulting from interpersonal stressors. (p. 70). And Dulit et al. (1994) found several common characteristics in self-injuring subjects with borderline personality disorder (as opposed to non-SI BPD subjects): more likely to be in psychotherapy or on medications more likely to have additional diagnoses of depression or bulimia nervosa more acute and chronic suicidality more lifetime suicide attempts less sexual interest and activity In a study of bulimics who self-injure (Favaro and Santonastaso, 1998), subjects whose SIB was partially or mostly impulsive had higher scores on measures of obsession-compulsion, somatization, depression, anxiety, and hostility.

Simeon et al. (1992) found that the tendency to self-injure increased as levels of impulsivity, chronic anger, and somatic anxiety increased. The higher the level of chronic inappropriate anger, the more severe the degree of self-injury. They also found a combination of high aggression and poor impulse control. Haines and Williams (1995) found that people engaging in SIB tended to use problem avoidance as a coping mechanism and perceived themselves as having less control over their coping. In addition, they had low self-esteem and low optimism about life.

Demographics Conterio and Favazza estimate that 750 per 100,000 population exhibit self-injurious behavior (more recent estimates are that 1000 per 100,000, or 1%, of Americans self-injure). In their 1986 survey, they found that 97% of respondents were female, and they compiled a "portrait" of the typical self-injurer. She is female, in her mid-20s to early 30s, and has been hurting herself since her teens. She tends to be middle- or upper-middle-class, intelligent, well-educated, and from a background of physical and/or sexual abuse or from a home with at least one alcohol addict parent. Eating disorders were often reported. Types of self-injurious behavior reported were as follows:

Cutting: 72 percent Burning: 35 percent Self-hitting: 30 percent Interference w/wound healing: 22 percent Hair pulling: 10 percent Bone breaking: 8 percent Multiple methods: 78 percent (included in above) On average, respondents admitted to 50 acts of self-mutilation; two-thirds admitted to having performed an act within the past month. It's worth noting that 57 percent had taken a drug overdose, half of those had overdosed at least four times, and a full third of the complete sample expected to be dead within five years. Half the sample had been hospitalized for the problem (the median number of days was 105 and the mean 240). Only 14% said the hospitalization had helped a lot (44 percent said it helped a little and 42 percent not at all). Outpatient therapy (75 sessions was the median, 60 the mean) had been tried by 64 percent of the sample, with 29 percent of those saying it helped a lot, 47 percent a little, and 24 percent not at all. Thirty-eight percent had been to a hospital emergency room for treatment of self-inflicted injuries (the median number of visits was 3, the mean 9.5).

Why so many women? Although the results of an informal net survey and the composition of an e-mail support mailing list for self-injurers don't show quite as strong a female bias as Conterio's numbers do (the survey population turned out to be about 85/15 percent female, and the list is closer to 67/34 percent), it is clear that women tend to resort to this behavior more often than men do. Miller (1994) is undoubtedly onto something with her theories about how women are socialized to internalize anger and men to externalize it. It is also possible that because men are socialized to repress emotion, they may have less trouble keeping things inside when overwhelmed by emotion or externalizing it in seemingly unrelated violence. As early as 1985, Barnes recognized that gender role expectations played a significant role in how self-injurious patients were treated. Her study showed only two statistically significant diagnoses among self-harmers who were seen at a general hospital in Toronto: women were much more likely to receive a diagnosis of "transient situational disturbance" and men were more likely to be diagnosed as substance abusers. Overall, about a quarter of both men and women in this study were diagnosed with a personality disorder.

Barnes suggests that men who self-injure get taken more "seriously" by physicians; only 3.4 percent of the men in the study were considered to have transient and situational problems, as compared to 11.8 percent of the women.

Self-Injury is known by many names, including self-abuse, self-mutilation, deliberate self-harm, parasuicidal behavior. It may be referred to by specific methods of self-injury such as "delicate" or "coarse" cutting, burning, or hair pulling.

Self-Injury transcends gender, age, religion, educational and income level. It may be accompanied by depression, and/or a range of psychiatric problems such as other mood disorders, obsessive-compulsive disorder, addictions, eating disorders or psychotic disorders. The longer it goes unrecognized and untreated the more disruptive it is to the sufferer's life and relationships and the more treatment-resistant it may become.

More information about the relationship between self-injury and clinical depression

• Study of Patients Who Exhibited Cutting Behavior and Suicidality

• Depression: Suicide and Self Injury

• Psychological Characteristics Common in Self-Injurers

• Depression is Common in People Who Self-Injure: Therapist's Comments

• Cutting: Self Mutilating to Release Emotional Stress

• Self Mutilation: Self-Injurers Often Suffered Sexual or Emotional Abuse

Treatment

• Teen-Depression Treatment Teaches Kids to Handle Anxiety

• Can Caviar Cure Depression? Fishing for Health

• Eye Movement Desensitization Reprocessing to Treat PTSD

• Coping with Feelings and Thoughts of Suicide - Transcript

Psychologists encourage parents to help teens find healthy ways to deal with frustration. Many teens feel like there's something wrong with them and don't understand why they're depressed. Doctors say parents should tell teens feelings like that are natural and consider counseling to help them.

Some doctors call it the new anorexia nervosa -- a dangerous addiction that's catching on with large groups of local teens. It's called Cutting. Teens taking blades to their bodies trying desperately to take their minds off emotional stress. Kids First reporter Kendall Tenney talked with one teen who almost lost her life because she was trying to cut away the pain.

Warning: graphic/disturbing description follows

"I was with that razor in the bathroom cutting and slicing away."

"I had these feelings and depression and I didn't know how to deal with it."

"I needed a release and that's what it was."

A release that almost took Marie's life last September when she cut too deeply and almost bled to death. "When you're cutting and you go into that trance you don't feel the pain you don't realize how deep you're going."

"How often were you doing this?"

"Once every other month I'd hit bottom for myself and I'd break out the razor."

"It helps take their mind away from the fact that they're depressed."

Doctor Mark Chambers has treated several local teen cutters. "It's almost always the result of depression and very often these kids don't know how to deal with it."

It's something they discover on their own. It might start with just the scratching of the skin and then they realize hey that feels better than what I'm feeling and then it tends to build and magnify from there.

"There can be cases where the cutting is done multiple times, every day."

"How were you able to hide this from people?"

"I did it in places where they couldn't see it like my upper arms."

That lasted 3 years until Marie's boyfriend told her mother what was going on.

"I was just devastated because I couldn't understand why she would do something like that."

"You feel remorse, you feel guilt, you feel like a freak, you're not supposed to be doing this."

Twice a week, the 23-year-old goes to support groups at her church and mental health facilities to control those urges. "I've had setbacks. I'm still going through it, I still cut."

"The thoughts go through my head. This isn't working out... go and cut yourself. You can't deal, go and cut yourself. I don't want to go through life with all these scars on my body."

Marie and her mom are trying to start a local support group for cutters. "Kids First" logged on to teen cutting websites. We found several teens in Nevada admitting to self-mutilation -- all looking for help to stop their addiction.

Psychologists encourage parents to help teens find healthy ways to deal with frustration. Many teens feel like there's something wrong with them and don't understand why they're depressed. Doctors say parents should tell teens feelings like that are natural and consider counseling to help them.

Excerpts from the Archives of the Narcissism List Part 22

1. Narcissists and Sexual Perversions
2. I Hate Birthdays
3. Hysteroid Disphoria
4. Narcissists and Control
5. Meaningful to Who?
6. Is Narcissism Learned? Can it be Unlearned?

1. Narcissists and Sexual Perversions

Graphic descriptions aside, Narcissism has long been thought to be a form of paraphilia (sexual deviation or perversion). It has been closely associated with incest (research supports this) and paedophilia (which research does not, as yet, support).

I raised the possibility that incest was AUTO-EROTIC and, therefore, narcissistic in: The Offspring of Aeolus On the Incest Taboo

In other words:

When a father makes love to his daughter - he is making love to himself because she IS 50% himself. It is a form of masturbation and reassertion of control over oneself.

Homosexuality is NOT a sexual perversion. I analyzed the relationship between narcissism and homosexuality in FAQ 19.

2. I Hate Birthdays

I hate holidays and birthdays, including my birthday. It is because I hate it when other people are happy if I am not the cause of it. I have to be the prime mover and shaker of EVERYONE's moods. And no one will tell me HOW I should feel. I am my own master.

I feel that their happiness is false, fake, forced. I feel that they are hypocrites, dissimulating joy where there is none. I feel envious, humiliated by my envy, and enraged by my humiliation. I feel that they are the recipients of a gift I will never have: the ability to enjoy life and to feel joy.

And then I do my best to destroy their mood:

I bring bad news.
Provoke a fight.
Make a disparaging remark.
Project a dire future.
Sow uncertainty in the relationship.

And when the other person is sour and sad, I feel relieved.

It's back to normal.

My mood improves dramatically and I try to cheer her up.

Now if she does cheer up - it is REAL. It is my doing. I controlled it.

And I controlled HER.

3. Hysteroid Disphoria

XXX: Sam, you're describing here what the empirical-descriptive folks have called "hysteroid dysphoria" (among other things).

Sam: No, I am not.
I am describing the narcissist's pattern of reaction to deficient narcissistic supply.
A personality disorder is a COMPLEX of hundreds of separate behaviours.
Surely, each behaviour pattern taken separately can be labeled out of context.
Moreover, the same behaviour pattern can (and often does) occur in a few mental health disorders.
For instance, "hysteroid dysphoria" (I am not a fan of this "definition") is also a part of the cyclothimic disorder.
But, in the CONTEXT of the narcissistic personality disorder what I describe in FAQ 28 is one of a group of recurrent dysphorias identified as early as 1960.
Additionally, do not forget that the Narcissistic PD has finally crystallized as a mental health diagnostic category only in 1980. "Discoveries" from 1969 - preceding Kohut, Kernberg and even early Millon - are absolutely irrelevant in view of today's understanding of narcissism.
Below, I outlines the differences based on the text you chose:

XXX: It's atypical depression (a specific subtype of non-melancholic depression) with narcissistic/histrionic/borderline "personality" features. A characterization (from "Atypical Depression" (Quitkin et al) in "Clinical Advances in Monoamine Oxidase Inhibitor Therapies", Kennedy ed.):
"In 1969, Klein and Davis described a group of patients referred to as `hysteroid dysphorics.' These patients were characterized by strong desire for attention and applause, positive response to amphetamines, and a marked rejection sensitivity (especially in romantic contexts)"

Sam: Narcissists do not react only to rejection.
They react to any input - verbal, nonverbal, social, implied, real or imagined - which is deemed by them to be incommensurate with their inflated self-image.

Often, narcissists react badly to ACCEPTANCE and LOVE rather than to rejection because they have a self-image as being mean, vicious, frightening, etc.

XXX (still quoting): "leading to frequent depressive episodes."

Sam: The narcissist is highly ego-syntonic (this is why treatment fails in most cases).
His dysphorias are so rare and "reactive" (I don't find this term particularly instructive either) that they have been classified and characterized with great ease.
The narcissist is more likely to react with narcissistic rage to rejection of the type described above.

XXX: "Features of these depressive episodes frequently included loss of ability to anticipate but not experience pleasure."

Sam: One of the major differentiating factors. 
Narcissists do not experience serious, prolonged anhedonia.
They immediately distort cognitive input to fit their self image (It was discovered that they enhance positive inputs rather than reject negative ones).

XXX: "hyperphagia or craving for sweets"

Sam: Never noted in narcissists - but research is rather lacking, I admit.

XXX: "Hypersomnolence, lethargy or inertia, and marked reactivity of mood."

Sam: These are classic depressive signs. They describe well a major depressive episode, cyclothimia, dysthimia and about a dozen other types of depressions.

XXX: Onset frequently occurred in adolescence without a history of adequate premorbid functioning.

Sam: Onset of narcissism AND its dyphorias is at age 2-4. Klein talks about age 6 months and she has a depressive construct (see FAQ 67).
True, the PD itself sets on in early adolescence.

XXX: Another interesting feature is, in addition to the general hyperphagia, specific cravings for chocolate (and amphetamines). There is a link to family history of alcoholism (not necessarily in the family of origin). It's thought to be related to a dysregulation in the systems governing reward.

Sam: No such connections have been discovered in research. Narcissists are often prone to substance abuse, though (dual diagnosis).

XXX: Personally I don't think it's useful to label these folks as personality-disordered (*especially* narcissistic), as it tends to stigmatize them, as well as depriving them of potentially useful medical interventions (response rates to MAOIs, for example, are comparable to those of melancholic depressives). I'm sure that a lot of them do have chaotic childhoods, but then again, a lot of people with chaotic childhoods *don't* grow up to become hysteroid dysphorics, so there has to be more to it than just that, even if it does play some role. The use of the word "hysteroid" emphasizes this - it *looks* like what we assume is a "personality" disorder, but it isn't safe to assume that it *is* a PD.

Sam: No one diagnoses someone as a narcissist just because he is sad.
FAQ 28 that you are referring to is one of 82 FAQs. Narcissism is a hypercomplex phenomenon.
I didn't suggest that if one matches FAQ 28 one is a narcissist (=didn't label and stigmatize them, though I do not regard a mental health diagnosis as a stigma).
I suggested that many narcissists match FAQ 28.
FIRST, one is diagnosed as a narcissist and THEN this particular type of dysphoria fits into the diagnosis. By ITSELF - of course it is insufficient to establish the existence of the NPD.

4. Narcissists and Control

Narcissists - above absolutely all else - are control freaks.

This, for instance, is why they precipitate their own abandonment. By bringing abandonment upon themselves - they feel that they control it.

To the narcissist, lack of control results in excruciating pain.

Control means alleviation, amelioration, or even annihilation of pain.

Narcissists cannot face loss of control coupled with loss of a major source of supply.

This is why they commit incest - so disproprtionately that it was once thought that narcissism is a sexual paraphilia (disorder). Through sexual union with their off spring they seek to merge with him or her and to transform him or her to be the narcissist's extension, thus never to abandon them.

This is why they sometimes stalk their ex-spouses. This is why they cripple their loved ones (always emotionally, in extreme cases physically). They thrive on the dependence and neediness of their sources of supply.

5. Meaningful to Who?

It is impossible to have a relationship with a narcissist that is meaningful to the narcissist.

It is, of course, possible to have a relationship with a narcissist that is meaningful to you (see FAQ 66).

6. Is Narcissism Learned? Can it be Unlearned?

Is narcissism LEARNED?

It is often a reactive formation, a result of unbalanced (overly negative or overly positive) reinforcements. It is some form of conditioning. It is an adaptive strategy and an amalgam of defense mechanisms.

It is all learned. Maybe not consciously - but it IS learned (it is not of genetic origin, or not predominantly so).

So, can it be UNLEARNED?

For instance, by behaving UN-narcissistically?

Some say: No, on the contrary, such an effort will REINFORCE the narcissism.

Others hold the opposite view.

Who knows?

next: Excerpts from the Archives of the Narcissism List Part 23