This is typical and often pathognomonic of Social Anxiety Disorder. It can also be seen in some people with Avoidant Personality Disorder. But with Social Anxiety Disorder, this symptom is always present.
Category Archives: Anxiety Disorders
Is Overthinking about Personal Interactions in a Social Setting Part of Dependent Personality Disorder?
Answered on Quora. A lot of the other answers are also very good if you are interested in psychiatry.
I work for the most part only with persons with OCD. I don’t even claim to be able to treat any other mental disorders. When I get people with other disorders, I refer them out, especially if they badly need help.
OCD seems to be poorly diagnosed. I get people who obviously have OCD who have been misdiagnosed as something other than OCD all the time. A lot of the time, the clinician simply does not know what is wrong with the person. At other times, they diagnosis is simply something like “anxiety,” which is not very helpful, as there is a lot more to OCD than just anxiety. The people given a diagnosis of “anxiety” in general were not being properly treated.
The second one I get a lot of is some form of psychosis. It is very common for people with OCD to get a misdiagnosis of some form of psychosis. I see a lot of “psychosis”, “mild psychosis”, “mild schizophrenia”, “psychotic depression”, “schizophrenia”, “manic psychosis”.
Almost all of these people are being treated with antipsychotic drugs, and in almost all cases, the drugs are not working or are even making them worse. I simply tell them that they are not psychotic, the diagnosis is in error, please fire your psychiatrist, and look around for another one until you find one who figures out that this is OCD.
The problem is that people with OCD quite commonly appear psychotic when the illness is bad. They “appear” psychotic, but if you examine them very closely, it becomes glaringly obviously that they are in fact not psychotic at all!
In addition there is a form of OCD called by its sufferers “Schiz OCD” in which the person worries and obsesses that they are going psychotic. They often worry that they are developing schizophrenia. I have seen more people with this problem than I can count. Some of them were properly diagnosed, especially by clinical psychologists, but many others were not.
The condition is further muddled by the fact that the person will start to develop a number of “psychotic-like” symptoms that can even include perceptual alterations. They develop “fake auditory hallucinations” where they think they are hearing voices but actually they are not. They are just misinterpreting ordinary sounds in the environment as hallucinations. They also develop “fake delusions” in which they worry that they believe crazy things when in fact they do not.
I am now very good at differentiating fake hallucinations from real ones and fake delusions from real ones and worrying that someone is psychotic from actually being psychotic. But it took me a long time to figure it out, and it’s not clear or obvious at all unless you are very good at diagnosing this particular condition.
Also the obsessions themselves or the illness itself can simply look like a psychosis. I could give you some examples, but space is limited here. Suffice to say that OCD can be a very strange, weird illness and the obsessions can look like delusions. You have to be good at differentiating between an obsession and a delusion, and the distinction is not clear at all.
However, an obsession that looks like a delusion has a particular “feel” about it that an actual delusion simply does not have. It’s more of a Gestalt, intuitive or impressionistic conclusion than a logical one.
Suffice to say that people with OCD often have a certain sameness about them. I like to say “they are all reading off the same script.” After you have seen enough of them, you can practically spot them 1/2 a mile away blindfolded at night, but few clinicians see that many people with OCD.
When OCD is extremely bad, it does indeed look like a psychosis, and the difference between severe OCD and “psychotic OCD” (which actually exists) is not clear at all. I had people who I mulled over for months whether they were actually psychotic. However out there they are though, generally reality testing is still somewhat intact.
You can start getting into the territory of some truly bizarre symptoms. I remember describing one girl’s symptoms to a retired LCSW with decades of experience. She said, “Well, this person is psychotic. That’s all there is to it.” I actually now believe that she was not, but if I told you the very weird ideas going through her head, you would probably immediately say psychosis too.
The problem is that in order to get good at this sort of micro-diagnosis, you have to see a lot of people with the disorder. After a while, you start seeing a common syndrome and a diagnostic picture develops. But a clinician who only sees people with those symptoms rarely if at all has little opportunity to hone his diagnostic skills.
If any clinicians are reading this, you can see that I am complaining that many clinicians do not understand this condition well, hence it is often poorly diagnosed and treated. I believe it is important for clinicians to understand this poorly understood disorder better. How to go about doing that, I do not know. That is for you to decide.
Do People with OCD Enjoy Thinking about Their Obsessions, or Is It Always an Involuntary/Unpleasant Experience?
Answered on Quora:
Do people with OCD enjoy thinking about their obsessions, or is it always an involuntary/unpleasant experience?
Actually enjoying your obsessions (or repetitive thoughts) is a rule-out for OCD. If you enjoy your repetitive thoughts, OCD is literally ruled out. I sometimes come across people who enjoy their repetitive thoughts and think they had OCD. I told them that they did not.
Most common differential diagnoses were Prodromal Psychopathy (person is developing psychopathy but does not yet have it), Pedophilia, GAD and Obsessive Compulsive Personality Disorder. Also things like Homosexuality which are not even illnesses. None of them are common. The only one I have seen more than once was Pedophilia.
But by and large, people who come to me suspecting they have OCD are correct almost all (98%) of the time. Clinicians despise self-diagnosis and say it has no credibility, but with OCD at least, many persons are quite certain that they have it, and they are correct in their self-diagnosis.
Usually what happens is they get symptoms and cannot figure out what is wrong with them, so they start doing research. They come across articles that describe OCD in great detail or are case histories of OCD’ers. They read that, and something instantly clicks. They say, “That’s me exactly! The person who wrote that could have been crawling around in my brain reading my thoughts.”
Pure O OCD symptoms are remarkably similar. I also like to say I can spot Pure O OCD symptoms half a mile away, blindfolded, at night. That’s not true, but you get the picture. It’s like they are all “reading off the same script.”
The symptoms are so clockwork-like that it has led me to think there is something wrong with a person’s brain who has OCD. The symptoms are classic, almost all of them display the same core symptoms and you can go down a checklist to figure out who has it, or just recognize it by sheer intuition. In that sense it is very much like how physician diagnoses a physical illness he is familiar with quite quickly via sheer intuition. In that sense, OCD resembles a typical physical illness very much.
Can OCD Be the Root Cause of Other Mental Disorders? If So, Can It Possibly Be the Cause of Schizophrenia in Some People?
There are definitely some other disorders you can get as a consequence of having OCD, such as Depression, Panic Disorder, Social Anxiety, and suicidality. However, schizophrenia and psychosis is not one of them.
But many OCD’ers worry that they may get schizophrenia or that they are in the process of getting it. Sufferers call this S-OCD, Schiz OCD or better yet OCD with the Schizophrenia or Psychosis Theme. This is simply someone with OCD who has adopted the theme of a fear of going psychotic. As with most other forms of OCD, the fear can cause symptoms that seem to mimic the fear itself. In this case, it can cause symptoms that mimic schizophrenia or other psychoses on the surface, however, careful prodding and questioning generally makes a differential diagnosis between OCD and Schizophrenia fairly straightforward.
Nevertheless, many S-OCD’ers sadly get diagnosed with schizophrenia or other psychoses by ignorant clinicians and as a result are medicated inappropriately. This subtype of OCD is very poorly known and often misdiagnosed.
I run into S-OCD’ers with incorrect diagnoses of Psychotic Depression, Schizoaffective Disorder, Schizophrenia, etc. on a fairly regular basis. The fact that when OCD is very bad, OCD’ers appear psychotic on the surface (but are not psychotic) confuses matters even more. It takes an experienced clinician to figure out what is OCD appearing psychotic and what is an actual psychosis.
At times the two illnesses are found in the same person, and sometimes in these cases it can be hard to figure out where the OCD ends and the schizophrenia begins or figuring out if a given symptom is best seen as one illness or the other. When the illnesses occur in the same person, it is sometimes called schizo-obsessive disorder. These people, who have much better insight than other schizophrenics, sometimes have a tendency to hide symptoms, which makes diagnosis even more confusing.
But having OCD is not going to give you schizophrenia. That’s not possible.
Psychopaths don’t have intrusive thoughts about violence or much of anything else for that matter. Intrusive thoughts about committing acts of violence tends to rule out sociopathy right there because sociopaths don’t experience these thoughts as intrusive. Rather they just like them. If they want to think them, they think them. If they don’t want to think them, they don’t think them. But they are not going to experience intrusive violent thoughts in my opinion.
OCD and sociopathy pretty much rule each other out. You have one or the other and it would be very hard to have both. These disorders are the opposite of each other. OCD’ers experience tremendous guilt and never commit any irrational acts of violence and sociopaths experience no guilt and commit an incredible amount of violence. So you see we are dealing with two things that are the polar opposite of each other.
PS if you were a sociopath, you would not be fussing and worrying about thoughts like this, much less going on line to try to fix them. Sociopaths don’t think there is anything wrong with thoughts of hurting and killing others. They like to think about these things.
Some people are utterly unfixable or even improvable, but they are quite rare.
There are clients who are just too far gone, and they cannot be helped at all. It is as if the person were a ceramic bowl that was dropped on a hard floor. The bowl is now in 100 pieces, and the person who dropped it is on the ground looking at the pieces and throwing up their hands. “Where do I start?” he asks in exasperation.
All sociopaths and psychopaths are unfixable by their very nature. We can’t cure the sociopathy and psychopathy because they don’t want to get better. They enjoy being antisocial, and they do not wish to change. However, we can get them to change their behavior. For instance, a homicidal sociopath may show up in the office. A good therapist may be able to convince this sociopath that acting on their homicidal fantasies would be one of the stupidest things that they could ever do. This sociopath may then be able to go through life without killing an innocent person. So we can’t fix sociopaths, but we can change their behavior somewhat, tone it down, or reduce the amount of damage they do to society.
All paraphilias are unfixable by their very nature. The paraphilia quite literally will not and cannot go away. It’s etched in stone.
Schizophrenia is largely unfixable. They need a great deal of medication, and even then in most cases, they are repeatedly hospitalized. A few can go on to lead somewhat normal or even successful lives, but these people still need continuous medication and regular psychotherapy. In addition, they need frequent interventions to stay out of the hospital.
Many illnesses such as OCD, Bipolar Disorder and Chronic Major Depression are unfixable by psychotherapy. Most of these people will need medication for the rest of their lives. However, psychotherapy can improve their conditions a lot at least in the first and last cases.
Long-term suicidality is very hard to fix. It tends to become chronic with repeated attempts over the years. The suicidal person is typically defiant and is furious with you for challenging their suicidality. You are expected to sympathize with their condition, which is actually a very bad idea. Most suicidal people are what I would call “defiantly suicidal.”
Personality disorders are generally incurable. Theoretically, they could be fixed, but these people almost never present for therapy, and when they do, it is often at the behest of others, and they do not really wish to be there or get anything done. People with personality disorders, like sociopaths, literally do not want to get better. They like their personality disorder, and they are incredibly resistant to change. There are some case reports of cures of personality disorders, but in general the prognosis is grave.
I have never been able to fix long term low self esteem, and I have tried with a few people. There is something about that condition that hammers itself into the brain as if into concrete. I do not know why, but long-term low self-esteem seems to be one of the hardest psychological problems to fix. Why this is, I have no idea. Perhaps someone else can offer some ideas.
In many cases, long-term mental disorders simply cannot be fixed or cured. However, with psychotherapy and drugs, people can often get much better than they were before. We need to stop thinking in terms of cures and start thinking in terms of amelioration.
I realize that many clinicians insist that most people can be fixed or cured of long-term conditions, but I think they are lying. They are probably trying to drum up business. Many clinicians fear that if word got out that a lot of long-term mentally ill people cannot be fixed or cured, people would stop coming in for therapy. There goes their paycheck. Therapists are a lot more money-oriented than most people believe, and don’t let anyone tell you otherwise. I know this field very well.
Clinicians have nothing to worry about. Even if a lot of conditions could only be ameliorated and not fixed, I am sure a lot of folks would show up to try to get some improvement. Some mental disorders are so painful that any improvement feels like a miracle cure to the client. A lot of people have given up on being cured anyway, just want to at least get better and are quite happy to do so.
Borderline Personality Disorder (BPD)is one of the hardest disorders of all to treat. It can be improved with some therapies, but the road is long and hard. Many seem to go on for years or decades with little or no improvement. There are reports of cures, and I am familiar with a woman whose BPD cleared up at age 55 after having come on in childhood. That’s probably a typical cure. Decades of nasty illness followed by a lifting of the illness in middle age.
Many mental disorders improve in middle age, and even many personality disorders improve during this age period.
Schizophrenia often ‘burns out” in middle age, and florid positive symptoms are replaced by more negative symptoms.
Many anxiety disorders attentuate in middle age.
Even psychopaths often get better or at least less destructive in middle age, as many of them also burn out in a similar fashion as schizophrenics. A number of highly antisocial psychopathic men get better in middle age as the antisocial behavior attentuates. It is often replaced by depression, heavy drinking and a pessimistic, cynical, imbittered and misanthropic person who nonetheless does little damage to society anymore.
It should be noted the clients with BPD vary widely in their symptom pathology. Some are much more functional than others. Quite a few can even function well at their jobs all day, but when they come home from work, they fall apart and shift into full BPD pathology.
However, some people with BPD are so ill that they seem nearly untreatable. It is these people who will be the subject of this post, not BPD’s in general. These people seem so far gone and broken that one wonders how anyone could ever even begin to put them back together again. I suppose some progress could be made, but the damage is so severe that I have a hard time seeing how even the best therapist could possibly fix these people in any significant way.
A typical case might be a young woman who, only in her late 20’s to early 30’s, already has 8 -13 suicide attempts and many hospitalizations behind her. She goes into the hospital on a regular basis. Therapy seems to do nothing but feed her pathology as she manipulates gullible new therapists to believe her lies, nonsense, and projections as the new therapist confuses symptom pathology with the truth. Drugs do almost nothing.
Diagnosis itself is often difficult because the BPD is so severe that the person often appears psychotic/delusional. One wonders what are delusions and what are not. Even the delusions do not seem to last for long, as they are dropped, changed around, added to or substituted in a wildly chaotic fashion.
Usually there is a lot of combativeness and involvement with the court system, as the extreme rage leads a litigious person.
Splitting is severe and textbook.
Self-image is so unstable that the person almost literally adopts the full personality and even persona of whomever is on their radar at the moment. The clinician needs to be prepared that this person will so identify with the clinician that they will adopt the therapist’s image and persona as their own. Boundaries nearly do not exist for these people, and they often fall in love with their therapists, try to seduce them, or on the other hand become furious at them to where sessions became rage attacks at the therapist, and the therapists is at odds of how to respond without violating ethics.
The client can become overtly suicidal even during sessions, and infatuation with the therapist can quickly split to where the therapist is the source of all evil. Homicidal threats and homicidal-suicidal threats against the therapist may now appear. The client then hospitalizes themselves due the “horrible trauma from the evil, incompetent therapist” and soon finds sympathetic new therapist, typically a feminist woman, to unload her story on. The new female therapist forms an alliance with the client against the “evil male” former therapist and accuses him of damaging the client.
Commonly, the therapist gets angry and tells off the client. This leads to abandonment and a vengeance agenda against the therapist, who has now “irreparably damaged” the BPD and “caused them to spiral out of control.” Be prepared to get accused of abandonment, causing severe trauma in the client and making them dramatically worse. The client may become hospitalized due to allegations of damage from an incompetent therapist.
These people are so difficult and chaotic that many clinicians refuse to see Borderline patients. Some are on the record as saying that when they say a Borderline client coming their way, they hide under their desk until they go away. For a lot of therapists, these clients are nothing but trouble, and endless parade of drama and chaos. Therapy itself is chaotic, mercurial, and wild with severe splitting and often extreme idealization of the therapist for good or ill or both, interrupted by fairly regular hospitalizations. The therapist begins to wonder what’s in it for them and thinks you could not pay them enough to suffer through such clients. These clients make an excellent argument that therapeutic abandonment is the proper choice with some clients.
Do Psychologists Make Their Patients Aware of the Diagnosis of Narcissistic Personality Disorder or Sociopathy?
I recently answered this question on Quora.
Do Psychologists Make their Patients Aware of the Diagnosis of Narcissistic Personality Disorder or Sociopathy?
These personality disorders seem to carry a lot of social stigma, therefore are patients made aware of their diagnosis or does the therapist just continue behavioral therapy to treat the symptoms rather than informing them of the diagnosis?
I am not a psychologist. I am a counselor. I only work with one disorder, OCD, and I can quite accurately diagnose that condition, I assure you. Nevertheless, I am not allowed to give out legal DSM diagnoses. However, I can obviously give out my opinion on a diagnosis. I can also tell the person my opinion on what they do not have. For instance, I have gotten many clients with OCD who have been misdiagnosed with some sort of psychosis. I am an expert at telling the two apart. I simply tell them that in my opinion, they are not psychotic. Then I tell them to fire your clinician and go get a new one that will recognize the difference between OCD and psychosis (many clinicians are very poor at telling these apart).
Other than OCD/psychosis, I also have to make differential dx on OCD/sociopathy, violent thoughts, etc., OCD/pedophilia, pedophilic thoughts, etc. and OCD/homosexuality. In a limited number of cases, I told clients that in my opinion, they did not have OCD but instead had some psychotic disorder, or sociopathic traits, or pedophilia, or that they were homosexuals. Most of this differential dx is pretty straightforward.
I have never had any narcissistic clients, God forbid clients with NPD. One thing nice about working with OCD clients is that they are usually very nice people. Not all of them, mind you. But if they are not nice, there is often some other reason, for instance, Borderline Personality Disorder in an OCD client could possibly make them impossibly vicious, cruel, unstable, not to mention extremely crazy, far crazier than any OCD sufferer ever gets.
OCD by its very nature strikes nice people. The fact that they are so nice, meek and kind is actually one of the main reasons that they have the disorder in the first place! For the most part, only nice people get it, and the nicer you are, the more likely you are to get it. I will leave it at that for the moment and give you a chance to think of why that might be. I know why but it goes beyond the scope of this post at the moment.
But in general, I never even give my opinion on other anxiety disorders or on any mood disorders or personality disorders. I only rarely see clients who have psychotic disorders, and the two that I have seen were already diagnosed. I also very rarely see people with personality disorders, and the few that I have seen were all females with Borderline PD diagnoses. I did see one woman for two sessions with obvious Borderline Personality Disorder, but I had not figured it out yet in the first session, and by the second session, I declined to diagnose her. She has already been diagnosed by a psychiatrist from afar anyway. So apparently I am guilty of failing to dx a Borderline PD client.
The session was about her OCD, not her BPD and she was very nice through the whole session. It would have ruined the whole thing if I told her she had BPD, and I doubt if she would have accepted it anyway. At any rate, I am not allowed to give legal dx’s anyway, so it’s apparently proper for me not to diagnose someone!
That only comes up if there is differential diagnosis. I simply say that I not only can I not legally give these out but that I am not qualified to work with any condition other than OCD, which I can actually work very well with. If they want me to work on their depression or whatever, I tell them that I have no expertise or training in that area so I can guarantee nothing and it would be similar to talking to a friend or family member.
If I were able to give out diagnoses, I think I would simply give them out in most every case. Possibly if it might make a suicidal patient go over the edge, I might decline to give one out. But I will disagree with the clinicians below. In my opinion, physicians and other medical professionals in addition to all licensed clinicians should give out whatever diagnosis is appropriate. I feel it is a moral matter. The patient or client is simply owed a diagnosis on the part of the clinician or MD and I feel it would be remiss of the clinician or MD not to tell the patient what is wrong with them, and I mean everything that is wrong with them.
This is just my personal opinion and I believe there no ethical rules on the subject. Also I respect the clinicians below for not giving out diagnoses in cases where it would not be helpful. I simply feel that this is a case were morals or even the categorical imperative trumps pragmatics or even common sense.
Optimus Prime: Fair enough, he’s said what he wanted to say and has repeated it a gazillion times. As you said, the man cannot control himself. Robert, apart from NPD does he suffer from OCD as well?
Sure, I actually wish Trash well honestly. He’s just not a good fit for the site.
OCD does not = constant repetition. The thoughts repeat in the brain (definitely in my case), and some of the compulsions can be repetitive, but that is because they are trying to get it right or perfect or make perfectly sure they did it right.
That’s not what is going on here. This is different. We are looking at NPD as the primary process here.
It’s like he’s not sure you heard him the first time, so he’s saying it again or shouting it to make sure you heard. Also I think he is in love with the sound of his own voice.
I will admit that Trash is a talented and even entertaining writer. He makes this cool statement or analogy and then he repeats it in the next post because he thinks it’s such a neat little bit of prose. It often is a nice sentence or phrase, but you are not supposed to repeat it no matter how damn good the image is. You say it once and move on. He’s saying it again because he thinks it is a nice image, and he is impressed with himself, so he says it again to make sure you heard him the first time, like what people do when they say something and get no response. They often repeat it because they are not sure you heard them the first time.
I do not wish to single this man out as being “Mr. Crazy.” Face it, we’re all nuts.
And as we are dealing with a personality disorder here, I would like to point out that in my opinion, we all have disordered personalities of varying degrees. I think we all have adaptive personalities to varying degrees too.