Marin County Psychological Association (MCPA)

Arrogance is Not the Same as High Self-Esteem

by Steve Orma, Psy.D.

In a recent Psychology Today article entitled “Foolish Arrogance: When High Self-Esteem Blinds You to Risk,” developmental psychologist Stephen Greenspan, Ph.D. argues that “excessive self-regard” or “arrogance” leads people to disregard important facts and make decisions that are destructive to themselves and others. He also states, “people with violent, criminal or racist tendencies tend to have overly high self-esteem.”

This is a huge problem in my field of mental health—equating arrogance and self-destructive behaviors with high self-esteem.

A person with high self-esteem greatly respects him or herself (that’s what “esteem” means). Self-esteem, essentially, is confidence in one’s ability to think, make choices, and act on those choices, as well as feeling deserving of happiness and benefiting from one’s hard work and accomplishments.  Above all, it means valuing the facts of reality and reason to guide one’s life over the course of many years.

Arrogance (or narcissism) is the exact opposite of self-esteem. Arrogant people act as if they know everything, and anything that contradicts what they believe is either evaded or rejected out of hand. They’re not interested in facts that contradict what they feel or want to be true, because that would be admitting (in their minds) they aren’t as good or worthy as the person who knows something they don’t.

The primary error with narcissists or arrogant people is they feel they must be right all the time or there’s something wrong with them. This is a huge error, as no matter how smart we are, we can make mistakes in our thinking or actions. The healthy person knows this and doesn’t let a lapse in knowledge or a mistake threaten his self-esteem. In fact, he embraces facts, whether those facts come from himself or someone else, because he knows that knowledge will help him in his life.

Criminals and racists don’t have high self-esteem, if they have any at all. Criminals (falsely) believe they can obtain self-esteem by exploiting, deceiving, assaulting, or taking advantage of others. When they get away with it, they feel “good” about themselves because they’ve put something over on others, and they feel “superior” as a result. But, this is a completely false sense of superiority or “self-esteem,” because it’s based on faking reality (i.e., lying and evasion).  One cannot achieve or maintain self-esteem by this means.

Racists lack self-esteem as well. They try to make themselves feel better than others based on non-essential physical characteristics— such as skin color or nationality. This is a distortion of reality, as a person’s self-worth is not based on skin color but on his or her character (i.e., chosen actions).

The arrogant person, criminal, and racist do not esteem themselves (at any level), which is why they evade, deny, lie, reject, and twist facts—to avoid this realization. People with high-self esteem rarely (if ever) evade facts or rational advice because they know reality is their survival tool and means of achieving and maintaining happiness.

Dr. Greenspan provides several case examples of arrogance, such as:

An “example of Bob Smith’s arrogance came when he took his 12-year-old grandson and another adult up in his plane for a late afternoon flight over the Rockies. Coming back into a small airport south of Denver just after dark, Smith was told by the tower operator that he was coming in too low and needed to increase his altitude. He responded in his usual style, by rejecting the controller’s warning, and flew his plane into a hill, killing himself and both of his passengers.”

This example is certainly illustrative of arrogance; however, it’s not an example of high self-esteem (or any self-esteem). Unfortunately, professionals in my field often equate high-self esteem with things like arrogance or narcissism, when these concepts are completely antithetical.

In the example, Bob Smith rejects the air traffic controller’s warning, without reason, and crashes the plane as a result. What makes this arrogant (or just plain stupid) is Bob doesn’t consider the advice of a professional whose expertise is guiding pilots safely to the ground. Bob does it his way to show what a big man he is. He evades vital information that would have helped him land safely, and instead, he crashes the plane and kills himself and two passengers.

A person with high self-esteem (let’s call her Amelia) would’ve handled this situation much differently. Amelia would have gathered all the data she needed to make a safe landing, including checking her instruments, using her vision, and checking in with the air traffic controller for guidance. When the controller told her she was coming in too low, she would neither ignore this information nor act on it blindly, but rather consider it with the facts she already had (e.g., her altitude, experience in landing, etc.), and then either decide to heed the controller’s warning, or make a different decision if she assessed the facts differently. Amelia, being a person who respects herself and the lives of her passengers, would never ignore advice from a controller, because she knows it could lead to a serious accident.

Amelia’s actions reflect her self-esteem, while Bob’s proves his arrogance. The problem here is the concept self-esteem is being used incorrectly by Dr. Greenspan and many other mental health professionals. The danger with equating arrogance, criminality, and racism with “high” self-esteem, is to corrupt the concept of self-esteem.

Self-esteem means confidence in one’s ability to use one’s mind, i.e., to identify the facts of reality and use logic to guide oneself safely and prosperously through life, and feel deserving of happiness. A person can’t have too much reason, knowledge, logic, acceptance of reality and of one’s limitations, or self-respect. In fact, the higher amount of these qualities, the better.

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For more about Steve Orma, Psy.D., visit: www.drorma.com .

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Presidential Blog – by Barbara Nova, Ph.D.

Happy New Year to ALL!! I am honored to take on the role of President of our wonderful organization and I extend warm thanks to those who came before me and a very warm welcome to those who are joining me in this new year of adventure! MCPA has felt like my family ever since I joined as an undergraduate student. I remember polling all of the seasoned members looking for a psych assistantship during grad school. I remember Diane Suffridge extending a vote of confidence by inviting me to be the first student member of the MCPA Board. As many of you know, Fred Rozendal, our esteemed treasurer and my beloved Husband, and I met in MCPA over 10 years ago. Life brings many surprises, as we all know, and I feel I have been very blessed with the camaraderie and support of all my MCPA colleagues and buddies over this last decade. I pledge to offer you my very best efforts and support in the role as president.

In terms of a vision for the year, I see us striving to serve our Marin Community with even more excellent, effective psychological services, especially collaborative and integrative services, as well as supporting our own members in their professional endeavors. Nancy Hoffman, our new CE Chair, Meghan Harris, Past President, Haleh Kashani, President-Elect, and I are beginning to plan the CE Calendar for the year. We have some very exciting opportunities, including possible topics such as law & ethics, child & adolescent psychiatry, collaborative mediation & therapy, marketing our practices in the age of instant info, and two possible special events in May, one with Lonnie Barbach speaking about “Sex after 60”. We will be voting on some changes to the by-laws in early Spring. If anyone is interested in serving on the Board or on a Committee, please give me a call or email – we currently have an opening for our Diversity & Social Justice Chair and many committees are in need of support – either on-going or with a single event/task. I would like to extend a special welcome to all new members and I’m looking forward to seeing and meeting you at one or more of our fun-filled events. My feeling is, and I hear the sentiment echoed in many members’ comments, that the best part of belonging to MCPA is getting to know like-minded professionals who readily share their knowledge and expertise, as well as their friendship. Look for emails with details about the upcoming Annual Meeting on Feb 24 from 6-9 at the Mind Therapy Clinic in Corte Madera and MORE!!!

Also check the Calendar on the MCPA website frequently for details and updates. Please don’t hesitate to contact me with feedback, questions, and suggestions. We can serve you better if we hear what you want and need.

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

The Growing Importance Of The Family System When Conducting Individual Psychotherapy

By Beth Cooper Tabakin, Ph.D., and A. Rodney (Rod) Nurse, PhD, ABPP

We have learned in recent years the marked importance for the growing child of the earliest family system— in addition to the developing dyadic relationships with each individual “caring for” person. We have also found out much more in recent years about how these personal attachment experiences within the early family system shape adult relationships and how the initial family system forms the context for our development through life stages. In the opinion of these authors we have reached a tipping point whereby even the psychologist conducting individual psychotherapy needs to consider obtaining a direct understanding of the specific patient’s family system, not simply learning about it through the patient’s eyes, as important as it is to understand that. This is similar to how a psychologist practicing primarily couple or family therapy needs to take account of new developments in understanding the individuals.

One of the more frequent reasons for a distressed individual to seek psychotherapy stems from suffering during the difficulty of making a life transition smoothly—from home to school, into adolescence, first year in college, a new or failed relationship, a marriage, the first baby, etc. What a reasonably functioning family system can do is smooth the way and support the process of these transitions so that the individual makes the change adequately and does not need to become a patient or does so for only a short time.

Conversely, when a family system has difficulty functioning around a family member’s life transition, that suffering individual may seek help from a psychologist. Given the patient’s suffering there is little reason to assume that the patient’s view of their family is, by an objective view, accurate (nor may the family member’s view of the patient be presumed accurate).  The psychologist, to be most responsible to their individual patient, needs to obtain his or her objective view of the family through assessment procedures of interviewing the family and at least obtaining some results from application of selected inventories or tests. The argument may be made that this model may not fit all patients.

However, to discover that a particular patient and their family does not fit the model is worthwhile information itself in planning and carrying out treatment, or calling for further assessment before moving ahead. At the same time, knowing just how the individual patient and family fit together can be a tremendous advantage in planning and executing therapy, anticipating strengths and vulnerabilities.

Underpinning our thesis we suggest two books and a new journal: One book by Jeffrey J. Magnavita (2005), Personality-Guided Relational Psychotherapy; and another book, edited by James H. Bray & Mark Stanton (2009), Handbook of Family Psychology. We also point to a new development in family psychology, the American Psychological Association (APA) has collaborated with the Society for Family Psychology (Division 43) to found a new APA Journal (initial issue March 2012) titled Couple and Family Psychology: Research and Practice, with “a focus on “the intersection of research and practice” (Stanton, 2011). This APA journal “reflects original research and/or clinical innovation (our emphasis)” (Stanton, 2011). (Disclosure: Dr. Nurse is Consulting Editor for the journal).

Authors:

Beth Cooper Tabakin, Ph.D. is a psychologist in independent practice in San Anselmo, California.  She serves on the boards of Division 1, CPA, and Marin County Psychological Association (MCPA).  She is a past president of MCPA and their current GAC Representative. Her website is: http://lifeafterbreakfast.org/

A. Rodney (Rod) Nurse PhD, ABPP Clinical Psychology and in Couple and Family Psychology. He is the Immediate Past President of the American Board of Couple and Family Psychology (of ABPP) and is the author (1999) of Family Assessment: Effective Uses of Psychological Tests with Couples and Families. New York: Wiley. His website is: http://www.rodnurse.com/

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

For more about Victor Yalom, Ph.D.: http://www.psychotherapy.net

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Pride: A turbo-charge for motivation or a social nemesis?

by Mary Lamia, Ph.D.

(Originally published at PsychologyToday.com)

You may not consider emotions as a source of motivation or a fuel that helps you to attain a goal. Yet a primary purpose of emotions is to activate, direct, and motivate your efforts toward achieving objectives. Thus, emotions drive action and they are a major ally in goal directedness and accomplishment. Certainly, this is the case for the emotion of pride.

Pride ignites a positive appraisal of the self that can create feelings of optimism and worthiness. The expression of pride informs others of your value, and you can likely imagine the difference in facial expression and posture when pride is felt in contrast to an emotion such as shame. In social situations, pride alerts others to your confidence and importance, and perhaps even more so when a prideful expression is coupled with captivating humility.

Unlike self-esteem, which has more to do with a general attitude about one’s own worth, pride is triggered in response to a specific accomplishment, an achievement, an event, or a measure of performance. Such temporary bursts of positive emotion can powerfully influence us, as David Brooks (2011) has pointed out in a recent New York Times opinion piece. As a result, experiencing pride because of a success can lead you to imagine further and even larger achievements (Fredrickson & Branigan, 2001). Motivation to persevere in your attempts to achieve a long-term goal, or to sustain effort in a negative situation, can be aided by experiences that trigger the emotion of pride (Williams & DeSteno, 2008).

Given its involvement in self-evaluation and in the relationships you have with others, pride is considered a self-conscious and social emotion along with embarrassment, guilt, and shame. But where pride has a positive valence, embarrassment, guilt, and shame are associated with the evocation of painful feelings (see previous PT blogs on “Shame: A Concealed, Contagious, and Dangerous Emotion” and “Whatever Happened to Guilt?“).

Yet these self-conscious emotions can interact, such as when you experience embarrassment, shame, or guilt in response to pride. For example, although you may gear your efforts toward accomplishments that will trigger pride, experiencing the emotion may subsequently trigger shame about your desire for recognition, guilt about leaving others behind, or embarrassment when others acknowledge your achievement. On the other hand, the emotion of pride can be triggered simply from refraining from an activity that will otherwise trigger shame or guilt.

While pride in an achievement can instill you with confidence, it can potentially create an attitude that is overly confident. But is such overconfidence necessarily maladaptive? Actually, being overconfident can be highly adaptive or, perhaps, even profitable.  Although overconfidence can, at times, lead to flawed assessments, idealistic expectations, and risky decisions, it can encourage you to compete, rather than retreat, in situations where you are capable of winning; and it has positive effects on ambition, credibility, and morale (Johnson & Fowler, 2011).  Being confident, or even overly confident, allows you to be in the game.  Situations that potentially may lead to failure or defeat are sometimes perceived as far too risky. Yet not playing the game unless you’re going to win may be overprotecting your general sense of pride.

Overconfidence is considered to be the best strategy when there is uncertainty about the strength of an opponent and the outcome, and where the costs incurred are less than the value of competing or fighting for the resource (Johnson and Fowler, 2011). In evolutionary terms, fighting for and subsequently winning a desirable mate may be worth the risk of sustaining a serious injury. But this also can apply more broadly to the use of deception in business, such as when the potential consequences that may result from false marketing or advertising are seen as worth the value of securing consumers. Such overconfidence that weighs the costs incurred in competing as less than the value of the resource often disregards risk to others.  In this case, even though such risk can result in consumer disappointment, anger, or lawsuits, these are likely seen as less expensive then losing the competitive venture.

Pride doesn’t make you self-centered, but it can characterize narcissism. Hubristic pride, which represents a more global and overly self-confident attitude, can be a result of the narcissistic cognition that who you are translates to being precious or highly valued. Since the evolutionary purpose of self-conscious and social emotions has to do with functioning within a group, pride indicates status to others and its expression can raise social standing. However, where pride can motivate behaviors that are geared toward the attainment of status, hubris falsely promotes it and may have evolved as an attempt to convince others of success even when it is unwarranted (Tracy & Robbins, 2007). Likely you are aware of people who have falsely acquired social standing with self-confidence that lacks a portfolio. Nevertheless, spurious pride is convincing and alluring whether it’s an attribute of an adolescent who uses it to extort popularity or a trait of a narcissistic leader.

For more information about Understanding Myself: A Kid’s Guide to Intense Emotions and Strong Feelings: http://www.marylamia.com

References

Brooks, D. (2011, September 30). The Limits of Empathy. The New York Times, p. A25.

Fredrickson, B. L., & Branigan, C. (2001). Positive emotions. In T. J. Mayne & G. A. Bonanno (Eds.), Emotions: Current issues and future directions (pp. 123–151), New York: Guilford Press.

Johnson D.  & Fowler, J. (2011). The evolution of overconfidence. Nature, 477, 317–320.

Tracy, J. and Robbins, R. (2007). Emerging insights into the nature and function of pride. Current Directions in Psychological Science, 16(3), 147-150.

Williams, L. and DeSteno, D. Pride and Perseverance: The Motivational Role of Pride. Journal of Personality and Social Psychology, 94(6), 1007–1017

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

You (or your spouse) Call It Quits:  Now What?

By Ann Buscho, Ph.D.

Divorce statistics widely published on the web suggest that approximately 41% of first marriages end in divorce.  The divorce rate for second marriages is 60% and for third marriages it is 73%.

The statistics don’t reflect that on every measure of stressful life events, the events that cause us to get sick, depressed, anxious, and to feel like our worlds have collapsed, divorce is at or near the top of the list.

Most people have no idea where to turn when their marriages fall apart.  Many turn to a therapist (like me) in an eleventh-hour attempt to salvage the marriage.  John Gottman’s research tells us that many of those attempts fail, because couples are getting to therapy “six years too late.”  Well-meaning friends and family often counsel people to hire the most aggressive attorney they can find.  The children (whom I often describe as “canaries in the mine”) begin to show signs of distress, regression, anxiety, acting out, or other mental health or behavioral symptoms.

Most people have no idea what their choices are when it comes to the divorce process.  In fact, most don’t realize that they have choices about how to divorce, and therefore no sense of what process would work best for them and their families.  Unfortunately, people often find themselves in an ill-suited process that either provides too little support, or generates too much adversarial conflict.  Either way, it often costs more than they can afford, and doesn’t meet their real needs.

Some need decision-makers, like a judge or custody evaluator.  Most prefer having a hand in their decisions, but need education about finances or parenting.  Many need emotional support and to be empowered to express their needs and interests in a respectful negotiation.

During the divorce, people must make life-altering decisions at a time when even small decisions feel overwhelming.  Flooded with feelings of grief, guilt, anger, shame, or fear, they struggle with big decisions about money, property, children and parenting.  With so many people facing divorce with so little information about the process options available to them, it became apparent that a large gap exists between the availability and the need for information about divorce process options.

A volunteer group of attorneys, financial specialists and mental health professionals now offer a monthly community service program for individuals who want to learn more about the process of divorce.  These “Divorce Options” workshops help individuals learn their divorce process options and explain the legal, financial, psychological and emotional issues of divorce.

An attorney discusses the different types of divorce processes: self-representation, mediation, collaborative divorce and litigated divorce. The attorney also addresses the filing process, costs, child custody, child/spousal support and property issues.  A divorce financial specialist addresses dividing property, cash flow, real estate issues and the tax consequences of divorce.  A mental health professional addresses the emotional process of divorce, how to break the news and the impact on children.

The educational program is sponsored by Collaborative Practice California, and is offered in many locations around the state of California.  The four-hour workshop costs $45.  No one is turned away because of inability to pay.  Pre-registration is NOT required.

Workshops are repeated on the last Saturday of every month, at Family Service Agency, 555 Northgate Drive, in San Rafael.

The next workshop will be November 26^th 9 am to 1 pm.

For more information, please contact us at divorceoptionsmarin@gmail.com or visit: www.collaborativepracticemarin.com

For more information about Dr. Buscho: www.DrAnnBuscho.com

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Clinical Diagnosis: How Would You Make Sense of These Symptoms?

by Nancy Hoffman PsyD, Geriatric Neuropsychologist

Clinical Presentation

The 75-year-old patient came to my office for a neuropsychological evaluation only after much pleading by his daughter, Caroline. John Smith was a tall, striking man who still embodied the successful stockbroker he once was. He was good looking and had an air of authority about him. However, he also seemed to be lost during much of the conversation, staring out the window while Caroline and I discussed a puzzling array of symptoms.  When he would speak, he was quite tangential and required frequent redirecting.

He was fond of tennis and told Caroline he had been watching Wimbledon with his new girlfriend. She was confused by this admission. They lived side by side in a duplex in Southern Marin and she hadn’t noticed anybody coming or going from her father’s side of the house. Her husband often kept different hours than she did, but he hadn’t noticed anyone coming or going either.

After several weeks of speculation, Mr. Smith finally admitted to Caroline that his new girlfriend didn’t use the front door. Instead, she would step into his side of the house through the television once she had finished her duties as a news anchor. They would sit side by side, holding hands and watching Serena Williams humiliate her opponents on the courts of Wimbledon. They were falling in love and he hoped they would soon marry.

Mr. Smith also told Caroline that he had been playing poker with a couple of professional clowns, who also accessed his apartment through the television. However, they were not quite as charming as his lover and he wanted help from his son-in-law to get them out of the house.  The night before, he had called 911 to report intruders. However, when the police arrived they could find no sign that anyone had been in or near Mr. Smith’s apartment.

Caroline called my office in a panic. Her father had a history of alcoholism but had been sober for 20 years. Could he have resumed drinking? Was he abusing prescription pain killers or was he picking up some other type of drug during his morning walks into town? The symptoms seemed to have come on suddenly and she was at a loss as to how to understand what was happening to her father. His primary care doctor had had him psychiatrically hospitalized and he was now in the intensive outpatient program (IOP) at Marin General Hospital with a diagnosis of delusional disorder. However, the antipsychotic medications they were giving him for his visual hallucinations only seemed to be making matters worse. Caroline was wondering if a neuropsychological evaluation might shed more light on her father’s condition.

During the course of our clinical interview, Caroline told me her father’s symptoms appeared to get worse as evening came. However, by morning, he was always much better.  He also had some extrapyramidal signs and would sometimes appear to have a slight tremor in his head, shaking it back and forth as if saying repeatedly, “No. No. No.” Some days were better than others, but she never knew what to expect. Calls to the police were becoming more frequent.

Testing

Medical: Mr. Smith’s labs were all normal and a CT scan had come back “unremarkable.” Caroline did reveal her father had been diagnosed with sleep apnea, but did not use the CPAP as prescribed. Could chronic hypoxia have been the cause of hist odd constellation of symptoms?  He had also moved the mattress from the bed frame to the floor because he was so restless at night, he would sometimes fall out of bed. Other than that, his health was good, although he was beginning to show signs of Parkinson’s such as rigidity and a shuffling gait.  His physician suspected the hallucinations were due to an undiagnosed psychiatric disorder and had him hospitalized for being “gravely disabled.”

Cognitive: Mr. Smith was mildly to profoundly impaired on every neuropsychological measure  administered. He could not provided a detailed sequential personal history and he did not always respond appropriately to questions. He had difficulty following instructions and would often apply his own criteria to the task at hand. For instance, on Trail Making Test Part B, which requires a person to connect letters and numbers alternately, he decided it would make more sense to connect the numbers first in order and then connect the letters in alphabetical order separately. No amount of coaching could convince him to try to follow the standardized instructions. Most of his work was slow and on verbal recall tasks, cueing was found to elicit confabulation.

Psychological:  Testing was limited due to Mr. Smith’s inability to follow instructions or sustain attention long enough to respond appropriately to questions.  He could not understand the Personality Assessment Inventory, even though had had an advanced degree. The Geriatric Depression Scale did not indicate a mood disorder, but he appeared apathetic throughout the clinical interview.  Apathy, which is easily misdiagnosed as depression, is often an early sign of many forms of dementia.  There was no history of any psychiatric disturbance in his early life and no family history of psychosis, depression, or bipolar disorder. Mr. Smith did have a history of alcohol dependence but was active in AA and had been sober for 20 years.

How would you diagnose this patient?

Mr. Smith’s primary symptoms included significant and global cognitive decline, disturbances in REM sleep (i.e. “acting out” his dreams), fluctuations in awareness (staring into space for long periods of time vs being able to hold a conversation), extrapyramidal signs (, and visual hallucinations. The use of antipsychotics only exacerbated his symptoms but the hallucinations did not cause him any great distress.

His clinical team, which included his primary care doctor, a psychiatrist, and an LCSW from the hospital’s IOP, had several hypotheses, but no one seemed to agree on a single diagnosis. Given the constellation of symptoms and his presentation, they hypotheses generated included:

   a)  Bipolar disorder

   b)  Psychotic disorder

   c)  Delusional disorder

   d)  Lewy Body Dementia

Lewy Body Dementia

There are two common problems clinicians frequently encounter when trying to differentiate Lewy Body Dementia (LBD) from other forms of cognitive decline. One problem is the overlap between LBD and other forms of dementia. The other is that some of the characteristic features of LBD don’t appear until the later stages of the disease.

Lewy Body Dementia is now considered to be the second most common type of dementia after Alzheimer’s and may account for up to 25% of all dementia cases (Hansen et al). However, because the symptoms are so confusing, it is often misdiagnosed as a psychiatric disorder. Although the diagnostic accuracy of Lewy Body Dementia is poor, visual hallucinations are an important early sign (Hohl, et al). Fluctuations in consciousness are sometimes problematic because there is no agreed upon definition and the symptom report relies heavily on the observations and opinions of family members and friends.

According to the Lewy Body Dementia Association (www.lbda.org), the clinical criteria for a diagnosis of LBD include progressive dementia as a central feature.  Memory problems may not occur until the later stages of the disease while impairments in executive function and attention are more evident early in the disease process.  The diagnostic criteria also requires one of more core features, including fluctuations in awareness, visual hallucinations, and parkinsonism.  Suggestive features include REM sleep disturbances and neuroleptic sensitivity.  Supportive features include frequent falls and/or syncope, unexplained losses of consciousness, and autonomic dysfunction.

Lewy Body Dementia and Parkinson’s disease are difficult to differentiate. A general rule of thumb to follow is Parkinson’s can progress to dementia, thereby generating a diagnosis of Parkinson’s Disease Dementia (PDD), while Lewy Body Dementia begins with signs of cognitive decline approximately one year before any signs of Parkinson’s appear.

There are also personality changes that accompany LBD. The patient may become less emotionally responsive and may tend to give up favorite hobbies.  They may also appear to be apathetic and engage in purposeless hyperactivity (Galvin et al).  Fluctuations in cognition may also be accompanied by unexplained irritability.

LBD is more common in men than in woman (2:1) with a mean age of onset of 68 (Khotianov et al). The prognosis following diagnosis is poor and most patients die within 6.4 years. The most common cause of death is aspiration pneumonia.

If you suspect LBD in a long term care patient, a thorough evaluation by a geriatric neuropsychologist or a neurologist can help to clarify the diagnosis. At this time, a definitive diagnosis can only be made at autopsy (Khotianov et al.).  Early diagnosis is important as treatment with donepezil (Aricept) can often help to increase alertness and cooperation with caregivers, while treatment with L-dopa and most neuroleptics can cause symptom exacerbation.

Mr. Smith was given a diagnosis of probably LBD, which allowed the family to make appropriate plans for his future care.  All neuroleptics were discontinued and he was started on Aricept, which he was able to tolerate. He showed improvements in awareness and some of his behavioral disturbances were relieved. By knowing the expected progression of the disease, the family was able to make appropriate plans for his future care.

For more information about Dr. Hoffman: www.collaborativeassessment.com

References:

Galvin, James E. MD, MPH; Malcolm, Heather; Johnson, David, PhD; and Morris, John C. MD. Personality Traits Distinguishing Dementia With Lewy Bodies From Alzheimer’s Disease. Neurology 2007; 68:1895-1901.

Hansen L, Salmon D, Galasko D, et al. The Lewy body variant of Alzheimer’s disease: a clinical and pathological entity. Neurology 1990; 40:1-8.

Hohl, Ursula MD; Tiraboschi, Pietro MD; Hansen, Lawrence A. MD; Thal, Leon J. MD; Corey-Bloom, Jody, MD, PhD. Diagnositc Accuracy of Dementia With Lewy Bodies. Archives of Neurology 2000; 57:347-351.

Khotianov, N., MD; Singh, R. MBBChir, MA; Singh, S., MBBChir, MA. Lewy Body Dementia: Case Report and Discussion. Journal of the American Board of Family Practice 2002;15:50-54,

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

# # #

Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Marriage Guide for the Quarter-Life Crisis Committed: A Skeptic Makes Peace with Marriage -By Elizabeth Gilbert (New York: Viking, 2010, 285 pp.)

Reviewed by Ilene Serlin

Disclaimer: I was sent this book to review. I was prepared to hate it, already had snarky comments made, and was embarrassed to be seen with it. I hadn’t seen “Eat, Pray, Love,” although I did drag my protesting spouse to see the film with Julia Roberts and confirmed it as the uber chick-flick.

Disclaimer: Because my office is in the Marina in San Francisco, everyone is 30- something. Protesting that I didn’t really believe in developmental issues, I was nonetheless struck by the similarities across my clients’ issues. They came in with panic attacks and depression, fueled by observations that all their friends were getting married, life was getting serious, they hated their work and didn’t know where to start searching   for lives of meaning and purpose. So we started a group called “30-Something” that   meets once a month to support, share and process quarter-life crisis issues. The New Yorker review of Committed was being sent around on email, so when the offer came to review the book I couldn’t resist.

Fact: I couldn’t put it down. I was entertained, and envious. Envious that she got to write in this conversational, breezy style that included research, poignant family history and insights, and a piercing intelligence and wit. What if all psychological writing could be in this accessible style? I was envious that she had the foresight and discipline to take daily notes of her journey, whereas I, along with many other baby boomers, was too busy living our geographic/psychological/spiritual/romantic journeys to take time to write. Ah…. who would play me in my film? —maybe Meryl Streep?

Back to reality and the book review–Bottom Line: I heartily recommend the book for any 20-40 something year-old who is struggling with issues of commitment, the nature of love, intimacy and marriage. And I heartily recommend it for therapists who want to understand and help those struggling with these issues. And I heartily recommend it for those who need reminders to laugh about the serious issues of life and the human condition.

I then began to imagine what it would look like if this book were structured as a course, something along the lines of Maimonides “Guide for the Perplexed.” Each chapter would serve as a section, like:

I. Ambivalence—In this section, Gilbert acknowledges her own ambivalence about marriage and fear of being “caught.” She knows that there is a  “Marriage Benefit Imbalance” in which marriage is not always healthy for women: they don’t live longer, accumulate more wealth, thrive in their careers, and are more likely to get depressed or die a violent death than single women. Gilbert rightly dreads the real possibility of divorce, quoting Rebecca West’s adage that “getting a divorce is nearly always as cheerful and useful an occupation as breaking very valuable china” (p. 4). According to the Holmes Rahe stress scale, divorce is second only to the death of a spouse, and “even more anxiety-inducing than „death of a close family member’ (even the death of one’s own child)” (p. 81). Once based on societal and institutional needs, divorce began skyrocketing by the mid-nineteenth century as people exercised the right to choose their own partners.

II. Marriage choices–However, the ability to choose without the wise counsel and perspective of family and community elders left young people often-making poor choices. Eighteen-year olds have a 75% divorce rate, while the divorce rate after age 50 is “statistically almost invisible” (p. 123). In this section, Gilbert reflects on her first marriage and “flighty” and “irresponsible” behavior. Only in time for her second marriage does she come to understand the importance of “character”, “steadfastness” and “honor.”

III. Infatuation vs. Love: Exploring the universal human longing for passion, Gilbert explores Plato’s story of Aristophanes’ myth of wholeness in which we humans, originally whole but split in two, long for our other halves to feel 5 whole again. This longing is expressed in loneliness, which causes us to be infatuated with the wrong person again and again. She likens infatuation to an  “addiction” in which “you’re not really looking at that person; you’re just captivated by your own reflection, intoxicated by a dream of completion that you have projected on a virtual stranger” (pp. 99-101). Quoting Freud’s definition of infatuation as “the overvaluation of the object,” and psychologists’ definition of the “state of deluded madness” as “narcissistic love,” Gilbert admits: “I call it “my twenties.” Fortunately, she has the wisdom to acknowledge that life is often enriched by irrational passion, and that the depression that results from unmet desire can be a “friend” that brings us back to a more mature understanding of ourselves.

IV. Cultural Perspectives on Marriage: By spending time and “interviewing” members of the Hmong tribe in Vietnam, Gilbert gains valuable perspective on the role of marriage among many cultures around the world. She comes to understand that “If you are a Hmong woman…you don’t necessarily expect your husband to be your best friend, your most intimate confidant, your emotional advisor, your intellectual equal, your comfort in times of sorrow”  (p. 32).

She reviews useful facts about marriage throughout history, including the fact that marriage was not always “sacred,” even in Christianity, and was sometimes between a man and more than one woman, or between two men (in ancient Rome), between two siblings (medieval Europe), between two children born or unborn (consolidating power between families), a living woman and a dead man (China), or even a temporary 24-hour pass (Iran).

Contrasting the Old Testament requirement for priests to marry with the early Christian repudiation of sexuality, the body, and marriage. Gilbert shows how the Christian ideal impacted Western philosophy and morality. Then during the middle Ages, marriage became a means of passing wealth down through the generations and a promise of security. Only in the nineteenth century did Queen Victoria establish the custom of a white gown and traditional weddings. The notion of modern romantic marriage is indeed new! Furthermore, when marriage was established to ensure the successful passage of wealth down generations, women lost many privileges. European courts upheld the idea of “coverture,” which maintained that women’s individual civil existence disappeared when she married. Once women established the ability to earn their own incomes, however, they no longer needed the support of marriage. By 2004, “unmarried women were the fastest growing demographic in the United States” and “a thirty-year old American woman was three times more likely to be single than her counterpart in the 1970s” (p. 149).

Acknowledging the stresses that the Western ideal of the nuclear family places on modern marriages, Gilbert begins to realizes that love is being there for each other and “…there is not one special person who will make your life magically complete, but that there are any number of people (right in your community, probably) with whom you could seal a respectful bond” (p. 41).  Marriage is not found but built: “the emotional place where a marriage begins is not nearly as important as the emotional place where a marriage finds itself toward the end, after many years of partnership” (p. 41).

V. The Myth of the Pursuit of Happiness: Acknowledging that she “had always been taught that the pursuit of happiness was my natural (even national) birthright, Gilbert understands that the Western pursuit of individualism, romantic love and happiness can create unrealistic expectations, crashing disappointments, insecurity, poor self-esteem, high anxiety, depression and confusion—all symptoms I see among the beautiful 30 something year-olds in my office. She calls the “life of individualistic yearning” the “birthright of my modernity,” creating almost “an entirely new strain of woman (Homo limitlessness)”…who are in “danger of becoming paralyzed by indecision” or “compulsive comparers” in a modern world which  “has become…”a neurosis-generating machine of the highest order” (pp. 45- 46).

VI. Marriage Resilience and Tools: Gilbert summarizes other useful factors that help determine “marriage resilience” such as education, history of cohabilitation, heterogamy, social integration into a community, religiousness, and gender fairness. She looks at the importance of loving boundaries to establish trust and reduce risks of affairs, the importance of ceremony and ritual, and affirms the importance of being thoughtful and taking control of the relationship. She covers topics like fidelity, money, prenuptial agreements, having children, transparency and accepting each other’s flaws, and concludes with a view of mature marriage as a spiritual path: “Perhaps transcendence can be found not only on solitary mountaintops or in monastic settings, but also at your own kitchen table, in the daily acceptance of your partner’s most tiresome, irritating faults” (p. 131).

In sum, the journey that Gilbert takes the reader in her own search to understand the institution of marriage can prepare not only her, but also the rest of us in a step toward greater wisdom and mature love.

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For more information about Dr. Serlin, please visit: www.ileneserlin.com

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Maybe You Should Be Angry - Anger is a good emotion that sometimes goes badly

by Mary Lamia, Ph.D.

(Originally published at PsychologyToday.com)

Perhaps your flight is considerably delayed; the team you’ve supported for years is getting humiliated on the field; your insurance company has rejected a claim for a ridiculous reason; or, you saw a provocative text on your partner’s cell phone. In any case, you’re angry.

Anger deserves appreciation. Designed to produce action in response to the violation of social norms or to remedy situations that are wrong, anger alerts you to circumstances that are unjust and tells you that you’re having a reaction to something that should not be as it is. Often anger is conceptualized as a disruptive emotional force, but it is meant to be an adaptive internal signal that cues self-protective action. Actually, anger is a good emotion that sometimes is misunderstood or irrationally misused.

Getting caught up in how this emotion makes you feel and what it causes you to think may be part of the problem when an expression of anger goes badly. When anger is triggered, your sympathetic nervous system creates arousal in the form of physical agitation, muscle tension, and strength that prepares your body for action. Blood pressure, body temperature, and heart rate increase—you feel hot. The impulse related to what you feel is to strike out at someone or something. Situations that elicit anger demand that you are physically ready to appear aggressive. Anger is designed to protect the self, and, in doing so, results in a greater willingness to take risks (Lerner & Keltner, 2001; Lerner & Tiedens, 2006). In order to accommodate what anger makes you feel, your corresponding thoughts are negative and this cognitive restructuring helps you to carry out the actions required.

It’s important to pay attention to what exactly is triggering your anger and to protect yourself accordingly. In some situations expressing anger, rather than inhibiting it might be counterproductive. Suppose someone you love or respect is emotionally hurtful to you. Your anger might jeopardize the relationship, especially if you want to lash out, get away, or make the other person experience guilt for how they made you feel. If you express your anger the focus might then become your angry reaction and not how the other person triggered it. In such a situation your anger is simply informing you to protect yourself from someone who is hurting you. But the importance of remaining attached to the person who is hurtful may obscure the fact that the person to whom you are attached is hurtful. Your anger may be trying to tell you so. In such a situation, the expression of hurt or sadness may be more productive in resolving the issue than expressing anger.

A situation in which you experienced an offense to your sense of self may leave you with repetitively triggered anger whenever that situation comes to mind, whether you were passed over for a promotion, betrayed, cheated, or hurt in an intimate relationship, among many other possibilities. Your emotional system is simply doing its job reminding you to protect yourself or find a solution. But like a recurring nightmare, you may not be able to extract this anger from your mind until you understand why it is being triggered, figure out what you can do differently now or in the future, or simply succeed in finding a happy ending in your favor that lets you rest.

The cognitive consequence of anger in response to being morally offended is seen in the complex relationship between anger and empathy. When you are angry your empathy is automatically diminished for the person who is the object of your anger.  What your anger is doing is rallying resources, both physical and cognitive, to stop someone who is doing whatever it is that may be threatening to you. A perceived injustice requires action and necessitates that you are not inhibited about hurting someone else. Anger suppresses the inhibition to empathize so that you can carry out the necessary interaction. Empathizing with the other will keep you from doing what needs to be done in order to protect yourself, and is akin to making excuses for behavior that has hurt you. Anger will cut off your empathy for their pain and help you to focus on your own self-protection. Even so, how you express your anger is also critical to self-preservation since exaggerated, inappropriate, or maladaptive expression will not allow the recipient to accept your message

Does getting back at someone who made you angry actually help you? The emotion of anger results in a willingness to endure the consequences of punishing someone who has betrayed you (de Quervain et al., 2004; O’Gorman, Wilson, & Miller, 2005). However, researchers have found that thinking about punishing someone, or even punishing them, will cause you to continue focusing on your anger towards that person (Carlsmith, Wilson, & Gilbert, 2008). So wanting revenge or seeking it can keep you from moving on and truly regaining the sense of yourself that was lost in the betrayal. It is highly likely that wanting revenge when you are wronged is a result of humiliation or shame that accompanies an injustice (see a previous blog on “Shame: A Concealed, Contagious, and Dangerous Emotion”). Although the relationship between anger and shame is widely recognized, recent research has considered when anger is shame-related and when it is not (Hejdenberg, J. & Andrews, B., 2011). Although it is often assumed that having an angry temperament is related to shame, the study disconfirmed that effect across genders. According to the findings, shame is related to anger that is felt after specific provocation, such as criticism. Thus it is important to determine what triggered your angry response, consider other emotions that may be hiding behind your anger, and recognize that, ultimately, you determine your own sense of self.

Any emotion taken to an unhealthy level is dysfunctional, whether it’s sadness, guilt, or even excitement. Anger management has to do with having sensible reactions to situations that elicit anger, and an ability to sublimate or deal in ways that are healthy. It is not that you shouldn’t feel anger, but anger does not have to result in expressed aggression. Being able to cognitively consider consequences, recognize a course of action that would resolve the situation, and respond in healthy, regulated ways are essential to using your emotions for the self-protective and informational purpose for which they are intended.

For more information about Understanding Myself: A Kid’s Guide to Intense Emotions and Strong Feelings: http://www.marylamia.com

References

Carlsmith, K. M., Wilson, T. D., & Gilbert, D. T. (2008). The paradoxical consequences of revenge. Journal of Personality and Social Psychology, 95, 1316-1324.

DeQuervain, D.; Fischbacher, U.; Treyer, V.; Schellhammer, M.; Schnyder, U.; Buck, A.; & Fehr, E.  (2004) The neural basis of altruistic punishment.  Science, 2004, 305(5688), 1254–58.

Hejdenberg, J. & Andrews, B. (2011). The relationship between shame and different types of anger: A theory-based investigation. Personality and Individual Differences. 50(8), 1278-1282.

Lerner, J. & Keltner, D. (2001). Fear, anger, and risk. Journal of Personality and Social Psychology. 81:1, 146-159

Lerner, J. & Tiedens, L. (2006). Portrait of the angry decision maker: How appraisal tendencies shape anger’s influence on cognition. Journal of Behavioral Decision Making.19: 115–137.

O’Gorman, R.; Wilson, D.; & Miller, R. (2005). Altruistic punishing and helping differ in sensitivity to relatedness, friendship, and future interactions. Evolution and Human Behavior 26 (2005) 375–387.

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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

APA Conference Session: ”Skills-Building Session: Caregiver Satisfaction and Regeneration”

August 5, 2011

Article by Ilene A. Serlin, Ph.D.

CoChairs: Ilene A. Serlin, Ph.D, Lesley University & Kathryn L. Norsworthy, Ph.D, Rollins College

Participant: Eleanor Pardess, Ph.D, Tel Aviv University

Discussant: Charles R. Figley, Ph.D, Tulane University

Caregiver burnout and compassion fatigue are receiving significant attention from health professionals. The current literature has focused almost exclusively on the negative consequences of caregiving at the expense of exploring the whole spectrum of the caregiving experience. This workshop focused both on pathways of preventing burnout and compassion fatigue, as well as promoting caregiver satisfaction and regeneration.

The multifaceted nature of the caregiver experience calls for an integrative perspective. The Whole Person approach (Serlin, 2007a) is a particular relevant framework due to its integration of cutting-edge practices in a bio/psycho/spiritual model supporting prevention, resilience and growth. It represents a paradigm shift from an illness to a growth-oriented model. The struggle with adversity may lead to the discovery of strengths and enhancement of life’s meaning. Witnessing human suffering can take a toll on one’s resources, but can also lead to a renewed sense of purpose.

To illustrate such a multimodal approach, a model for promoting caregiver satisfaction and regeneration, was presented, drawing upon attachment theory (Mikulincer & Shaver, 2007), as well as on research on growth through adversity (Joseph & Linley, 2006) and compassion fatigue and satisfaction (Figley, 2007). Initially developed in SELAH, the Israel Crisis Management Center, for supporting a network of 600 volunteers providing emergency support in the aftermath of terrorist attacks and other crisis situations (Pardess, 2005), this model has been applied in different organizations in Israel. It offers a range of practices to enhance a sense of hopefulness, connectedness and meaning, through tapping into caregiver’ strengths, cultivating compassion and self compassion and nurturing a growth mindset. The programs include outdoor and nature-based experiential activities alongside compassion-focused strategies, and verbal and non-verbal narrative practices. Specific skills were learned and practiced during the session and implementations were illustrated.

“Caregiver Satisfaction and Regeneration: the SELAH model”

A multimodal model for promoting caregiver satisfaction and regeneration, was presented, drawing upon perspectives of attachment theory (Mikulincer & Shaver, 2007) and the “broaden and build” theory of positive emotions (Fredrickson, 2009), as well as on research on compassion fatigue and satisfaction (Figley, 2007). This approach, developed in SELAH, the Israel Crisis Management Center, aims to enhance a sense of hopefulness, connectedness and meaning, through tapping into helpers’ strengths, rather than focusing exclusively on stress management or symptom relief. Initially developed for supporting a volunteer network of 600 volunteers providing emergency support in the aftermath of terrorist attacks and other crisis situations, this model has been applied in different trauma organizations in Israel (Pardess, 2005). It uses outdoor and nature-based experiential activities with mindfulness training, narrative practices and verbal and non-verbal creative modalities, creating a wide spectrum of opportunities for self expression, cultivating compassion for self (Gilbert, 2005) and sharing.

“April 2012 Trip to Israel Trauma Centers”

By Ilene Serlin, Ph.D, BC-DMT, Lesley University & Eleanor Pardess,  Ph.D, Tel-Aviv University

All psychologists interested in promoting a constructive exchange between Israeli and American psychologists and learning about innovative methods for working with trauma and resilience in Israel were invited to the Div. 56 Hospitality Suite to learn about the upcoming trip to Israel. Dr. Ilene Serlin, Past-President of the San Francisco Psychological Association, in partnership with the Israeli Psychological Association, President Dr. Yochi Ben-Nun and Israeli psychologist Dr. Eleanor Pardess of Tel-Aviv University will lead the 10-day trip to Israel in April 2012.  Participants will have an opportunity to visit key trauma centers, witness a rich diversity of  ways of working with trauma, participate in lecture/discussion groups led by prominent Israel academics and trauma specialists, and enjoy cultural and sightseeing events around Israel. Please contact iserlin@union-street-health-associates.com for further information.

“An Israeli Woman’s Journey Toward Resiliency”

Unfortunately, many Israelis are all too familiar with trauma and they have built a compassionate network and services so people can live normal lives after having experienced extraordinary trauma and stress. In this session, a videotape interview showed a very personal conversation with a woman whose first husband and son were violently killed, and who speaks movingly about her pain and loss, yet retains her will to live, love and help others. Through hearing her story we witness inspiring resiliency and the power of the human spirit to prevail.

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For more information about Dr. Serlin, please visit: www.ileneserlin.com

# # #

Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

# # #

Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.