The Story of ADHD

As a psychiatrist who advocates for the appropriate diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Adults, I am frustrated by the many misconceptions that seem to linger like flies at a summer barbeque. If you are one of many who have suffered from this disorder, perhaps you will relate to the story below.

A Common Story

At some point in your life you came to the realization that something just wasn’t adding up. Throughout early schooling you struggled to stay organized and motivated. But on the rare occasion that you found the energy and courage to sit down on a Saturday (rather than Sunday near midnight) and attempt your weekend homework you were probably discouraged yet again:

  • “How many times do I have to read this sentence before I understand what it means?”
  • “Why did I just read 20 pages of this book but couldn’t tell you one meaningful thing about it?”
  • “Screw it, I’m gonna play sports or video games instead.” 
This pattern gets old so you begin telling yourself that you’re just not smart enough, not good enough, not savvy enough to juggle life like everyone else. And of course the most encouraging and reassuring remarks you received were statements like “you just need to work harder” or “stop being lazy” or “do you even care about your future?” 
 
Now that your self esteem was sinking into the cold, dark abyss like the Titanic in 1912, your contagious positive spirit began drowning too. If not already feeling like a failure, you sensed actual failure was imminent.
 
As time went on, you probably took one of the following routes: Either you said “f**k it” and started drinking and doing drugs out of anger and frustration or you continued to suffer in silence pretending you were okay only to feel more drained and guilty about not telling the truth. Or maybe you developed coping skills and compensated by being overly obsessive and overly worried about everything because you’ve been told repeatedly that in order to achieve goal X you just needed to work harder. 
 
Then one day you heard someone talk about Attention Deficit Hyperactivity Disorder and you immediately felt something awaken inside you. You were so relieved to hear you weren’t the only one who relied on Spark notes to pass English class–not because you were lazy but because there wasn’t enough time in the day to read the same page more than 3 times. After all, 20 pages of reading meant 60 pages for you. 
 
So you debated whether to go to the doctor and be evaluated. You felt vulnerable and worried about opening up to someone you’ve never met. You started to worry that you might sound like a “drug seeker” or a “cheater.” Once you finally built the courage to share your story you were met with your worst nightmare–immediate invalidation. 
  • “We don’t prescribe those drugs in this clinic.” 
This is followed by urine drug testing and a referral for a $1,500 Neuropsychological test that only worsens your preexisting anxiety and obsessive thinking. So you go to the testing center and sit there in a quiet room clicking buttons and solving puzzles for hours as if that accurately captures the work-life of someone struggling with ADHD symptoms. 
 
There are many points to this story. Humans are complex and the brain is by far the most complicated system in our universe. Neuropsychological tests for ADHD are NOT something I routinely order and the reasoning is simple: How does sitting at a computer in a quiet exam room or solving boring puzzles for hours in a controlled environment confirm that my patient really is experiencing distress and dysfunction? How does a neuropsychology test with inconsistent validity help my patient who can clearly articulate how they are feeling and what they are experiencing?

Science Speaks

Despite numerous attempts by the uninformed to delegitimize the diagnosis of ADHD, the science speaks loud and clear: Attention Deficit Hyperactivity Disorder (ADHD) is a real disorder that can occur in children and adults. It isn’t uncommon to hear people offer opinions such as “ADHD is an excuse to medicate misbehaving children to appease parents” or “everyone has ADHD and would benefit from psychostimulants.” When I hear these things, I take a deep breath and remind myself that these opinions are just what they are…opinions.

The belief that ADHD is an excuse to medicate misbehaving children or the notion that adults seek an ADHD diagnosis to obtain stimulants to “cheat the system” is not supported by any legitimate scientific evidence. Do people abuse prescription stimulants? Yes, they do. Are some children misdiagnosed with ADHD? Yes, some are. Do some adults “fake” the diagnosis to obtain stimulants? Yes, some do. But let’s leave the blanket statements and unsubstantiated beliefs in the box labeled “99% of political arguments” (the label included). If anything, ADHD is not recognized nearly enough in adults. The possible reasons for this are beyond the scope of this post.

Disclaimer

If you’re the one spreading rumors that street methamphetamine is just like Adderall then you’re also the one who believes that illicit methamphetamine purchased on the street has the same pharmacokinetic and pharmacodynamic effects as prescription stimulants at therapeutic doses simply because both are amphetamines. In which case I’ll go ahead and whip up some methanol martinis for you. Don’t worry, ethanol and methanol are both alcohols. If you go blind, you’ll understand my point.

References

  1. Young, Joel. ADHD Grown Up: A Guide to Adolescent and Adult ADHD .(2007)
  2. Gil Zalsman & Tal Shilton (2016) Adult ADHD: A new disease?, International Journal of Psychiatry in Clinical Practice, 20:2, 70-76, DOI: 10.3109/13651501.2016.1149197
  3. Stewart, T. D., & Reed, M. B. (2015). Lifetime nonmedical use of prescription medications and socioeconomic status among young adults in the United States. The American journal of drug and alcohol abuse41(5), 458–464. doi:10.3109/00952990.2015.1060242
  4. Psychiatric Times. 7 Evidence-Based Insights About ADHDhttps://www.psychiatrictimes.com/adhd/7-evidence-based-insights-about-adhd
  5. Higgins, E.S. & George, M.S. The Neuroscience of Clinical Psychiatry: The Pathophysiology of Behavior and Mental Illness. 3rd Edition. 2018.
  6. Blumenfeld, Hal., MD, PhD. Neuroanatomy Through Clinical Cases. 2nd Edition. 2010.
  7. Sadock, Benjamin J., and Harold I. Kaplan. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/clinical Psychiatry. 10th ed. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print.
  8. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association, 2013. Print.
  9. Stahl’s Essential Psychopharmacology, 4th Edition. Cambridge University Press. 2013
  10. Schatzberg & Nemeroff. The American Psychiatric Association Publishing Textbook of Psychopharmacology. 5th Edition. 2017.

The Forest

Which path are you going to choose?

Thoughts racing, heart pounding, and that feeling in our chest that something just isn’t right. The “what ifs,” the “should haves,” and the doubt that holds us hostage to a future we can’t control.

“Just be in the moment” they say.

This is the advice we can’t hear because our minds are ruminating on a past we can’t change and fearful of a future we can’t control. 

Paralyzing. Stuck. Lost.

That’s what being in this moment feels like for us. Running at high speeds on a treadmill to nowhere, we wonder why fatigue is the norm. And those short-lived moments of peace and joy scare us because we don’t want the fall to hurt us more. “It will be okay” is the type of certainty we never learned.  “Just relax” is the advice that confirms no one understands us. “You’re so strong” is the compliment we don’t feel because we don’t believe it.  

Are we good enough? What if people find out who we really are?

If the above resonates with you then we have something in common. And if that is so, then let’s imagine life as a path through a very dense and mysterious forest where the end of the path means the end of life. There are two paths we can take to reach the end. The first path is a straight line to the end (white path in image below). This path is safe, comfortable, and predictable. There is little to see on this path and there is little to experience. There are no hardships, no problems to solve, and no dangers along the way. We can hide behind social media as we show the world only the part of us we want to show lest others find out the most vulnerable yet beautiful parts we hide.

The second path is a winding maze full of mountains, quicksand, waterfalls, and who knows what else (brown path in image above). 

The second path is unpredictable, scary, and beautiful–but only if we give ourselves permission to stop and enjoy it along the way.

Now imagine that one of you takes the first path (i.e., the straight path) and the other takes the second path (i.e., the maze).

Can you imagine the conversation between both of you at the end? Can you imagine the stories, the experiences, the regrets, the wisdom, and the degree of fulfillment each of you would bring to the conversation? 

So which path are you going to choose?

Psychostimulants

The term stimulant or psychostimulant isn’t well defined. Cocaine, amphetamine, methylphenidate, modafinil, armodafinil, caffeine, and nicotine belong to this class of drugs, which are called stimulants for the marked sensorimotor activation that occurs in response to drug administration. Stimulants are characterized by their ability to increase alertness, heighten arousal, and cause behavioral excitement.

Stimulants have a rich history which is beyond the scope of this post. 

Today, psychostimulants are prescribed for the treatment of attention-deficit hyperactivity disorder (ADHD), narcolepsy, chronic fatigue, depression, and cancer-related fatigue to name a few. Stimulants are also drugs of abuse (such as cocaine, illicit methamphetamine, nicotine, and caffeine).

Let’s take a closer look at psychostimulants and how they work. 

Table of Psychostimulants

Dopamine and Norepinephrine

Dopamine (DA) and norepinephrine (NE) are monoamine neurotransmitters in the central nervous system that play very important roles in modulating the communication between neurons. DA and NE are released from synaptic vesicles into the synaptic cleft (i.e., area between communicating neurons) and recycled by reuptake into the neuron’s terminal (i.e., end of the neuron’s axon) via dopamine and norepinephrine transporters. Dopamine and norepinephrine in the cytoplasm of the neuron’s terminal are pumped into vesicles via the vesicular monoamine transporter 2 (VMAT2). After being released from the presynaptic neuron, DA and NE bind to their receptors on the postsynaptic neuron.

See the figure below.

Both amphetamine (AMPH) and methylphenidate (MPH) target the dopamine and norepinephrine systems by increasing the concentration of these neurotransmitters in the synapse. AMPH has additional properties of promoting release by reversing the dopamine and norepinephrine transporters.

Amphetamine, AMPH (Vyvanse, Dexedrine, Adderall)

Amphetamine (AMPH) has numerous mechanisms. First, it can be taken up into neurons via the dopamine transporter or norepinephrine transporter which then reverses its actions to promote the release of dopamine. AMPH also enters vesicles through VMAT2 and displaces dopamine by “forcing” dopamine out of the vesicle and into the cytoplasm. Increased cytoplasmic dopamine concentrations cause passage of dopamine through the DAT into the synapse thereby increasing the dopamine concentration in the synaptic cleft.

Methylphenidate, MPH (Ritalin, Concerta, Focalin)

Methylphenidate (MPH) acts by inhibiting the dopamine and norepinephrine transporters which increases the concentrations of dopamine and norepinephrine in the synapse. See the figure below.

 

Psychostimulants Reduce Noise and Enhance Signals

In individuals with attention and/or concentration problems, there may be a problem with how the brain is processing sensory input. Our brains spend an enormous amount of energy (up to 20-30% of all energy used by your body) processing information below our level of awareness. In fact, only a very small percentage of brain activity contributes to our conscious awareness (roughly 15%). The rest of the activity is all the unconscious processing, integrating, and analyzing of information that ultimately results in complex behavior. Much of the brain’s energy is spent “deciding” which signals are relevant and need to be brought to conscious awareness.

Think of all the activities we do that we aren’t even aware of.

While walking down the street talking with someone, do you actively feel your left big toe? Well, no, not unless you have pain or stub your toe. We aren’t aware of our left big toe because it’s irrelevant to what we are doing. But this doesn’t mean those signals are physiologically absent.

Dopamine and norepinephrine are neurotransmitters in the brain that act like the tuners of a piano. The strings of the piano that create the sounds represent the glutamate and GABA neurons that are the primary excitatory and inhibitory neurotransmitters in the mammalian brain, respectively. Dopamine and norepinephrine are there to tighten the strings so the music sounds good. No one likes a song that’s out of tune. That is, dopamine and norepinephrine are those “tuners” of the brain–they modulate communication between neurons. They help our brain decide what to ignore and what to focus on.

In fact, norepinephrine in the prefrontal cortex (PFC) plays a role in enhancing relevant and important signals so that we focus on relevant and important things. Low-to-moderate concentrations of norepinephrine (NE) mediate these actions by acting preferentially on postsynaptic 𝛼2A-adrenoceptors. However, as the concentration of norepinephrine increases, norepinephrine begins stimulating 𝛼1 and 𝛽-adrenoceptors. Stimulation of 𝛼1-adrenoceptors and 𝛽-adrenoceptors (which occurs in high stress states) impairs our ability to focus.

When the NE concentration is too low, the signal strength (i.e., our ability to focus on things) is low. As the NE concentration increases so does the signal strength (i.e., our ability to focus on things) until it reaches a peak. Any additional increase in NE impairs, rather than enhances, our ability to focus. This explains the inverted U shaped curves depicted below.

 

Dopamine in the prefrontal cortex (PFC) plays a role in filtering out the irrelevant stimuli. That is, dopamine D1 receptors in the prefrontal cortex reduce the “noise” or irrelevant stimuli so that we can focus on relevant and important things without being distracted.

When DA levels are too low, all incoming signals, whether they are relevant or not, are treated in the same way. Therefore, it becomes difficult to focus on a single task as there are too many distracting stimuli. However, as the concentration of DA increases to moderate levels, it will decrease ‘noise’ by stimulating D1 receptors. This results in decreased firing of neurons to irrelevant inputs in PFC networks.

When DA levels are too high, D1 receptors in the prefrontal cortex are overstimulated and the brain’s ability to filter out the noise declines. Stressful situations and illicit drug use can cause dopamine levels to be too high.

Therefore, medications like amphetamines (Vyvanse, Adderall), methylphenidates (Ritalin, Concerta, Focalin), bupropion (Wellbutrin), and atomoxetine (Strattera) alter norepinephrine and/or dopamine levels to “enhance the signal” while “reducing the noise,” respectively. 

Medications (or illicit drugs) that enhance dopamine too much in certain regions of the brain may cause us to “hyper focus” or “fixate” our attention on unproductive tasks. In addition, the euphoria and motivational reinforcement that results from overstimulation of dopamine receptors in the nucleus accumbens increases the risk for addiction and drug abuse.

In summary, we don’t want too much stimulation of dopamine (D1) receptors because this is associated with euphoria, hyper focus (like scrubbing the floor with a toothbrush), impaired attention, and drug addiction. We don’t want too little stimulation of dopamine (D1) receptors because this is associated with anhedonia, depression, lack of motivation, and apathy.

The same goes for norepinephrine. We don’t want too much norepinephrine because then we will feel symptoms associated with the fight or flight response such as anxiety, hypervigilance, racing heart, sweating, and shortness of breath. We don’t want too little norepinephrine because then we will feel symptoms like fatigue, depression, drowsiness, and weakness.

Therefore, we want our DA and NE to be not too hot and not too cold, but just right (yes, like Goldilocks). This is why controlled doses of stimulants can be very beneficial for some people. 

 

References

  • S. J. Ferrando, J. L. Levenson, & J. A. Owen (Eds.), Clinical manual of psychopharmacology in the medically ill (pp. 3-38). Arlington, VA, US: American Psychiatric Publishing, Inc.
  • Cooper, J. R., Bloom, F. E., & Roth, R. H. (2003). The biochemical basis of neuropharmacology (8th ed.). New York, NY, US: Oxford University Press.
  • Higgins, E. S., & George, M. S. (2019). The neuroscience of clinical psychiatry: the pathophysiology of behavior and mental illness. Philadelphia: Wolters Kluwer.
  • Iversen, L. L., Iversen, S. D., Bloom, F. E., & Roth, R. H. (2009). Introduction to neuropsychopharmacology. Oxford: Oxford University Press.
  • Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
  • Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  • Dale Purves, George J. Augustine, David Fitzpatrick, William C. Hall, Anthony-Samuel LaMantia, Richard D. Mooney, Michael L. Platt, and Leonard E. White. Neuroscience, Sixth Edition. Oxford University Press. 2018. 
  • Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY, US: Cambridge University Press.
  • Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). New York, NY, US: Cambridge University Press.
  • Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Lippincotts illustrated reviews: pharmacology. Philadelphia, PA: Wolters Kluwer.
  • Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 6th Ed.
  • Benjamin J. Sadock, Virginia A. Sadock. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia :Lippincott Williams & Wilkins, 2000.
  • Ebenezer, Ivor. Neuropsychopharmacology and Therapeutics. John Wiley & Sons, Ltd. 2015.
  • Meyer, Jerrold, and Quenzer, Linda. Psychopharmacology: Drugs, the Brain, and Behavior. Sinauer Associates. 2018. 

How to Hug a Porcupine

NOTE: To protect patient privacy, all names, ages, and peculiarities have been changed. The general storyline, however, remains unchanged.

Brent is a 36 year old husband and father of two who presented to my office for initial psychiatric consultation. He presents at the request of his wife, Jennifer, who recently moved out of their family home because she “just couldn’t take it anymore.” My first meeting with Brent went something like this:

Therapist: Hi Brent, what brings you in today?

Brent: Didn’t you read over my file before this? You should know the answer to that already. I’ve seen enough therapists to know how this is supposed to go.

Therapist: Can you help me understand what you mean by that?

Brent: What do you need help understanding? It’s pretty simple. I’m supposed to come here, tell you my problems, and you’re supposed to listen and say things that make me feel better. Aren’t you a therapist?
 
Therapist: Hmm, has this been your experience with therapy in the past?

Brent:
 Yep. I mean let’s be real, therapists don’t actually care. They just pretend to care so they can take my money. It’s such a scam.

Therapist:
 Wow, I am sorry this has been your experience. It sounds like you haven’t had very positive experiences with therapy in the past. It makes sense that you would be skeptical about our time together. How can I be most supportive?

Brent:
 I don’t even know. My life is falling apart. I am not sure there is anything you can do at this point.

Therapist:
 Sounds like life has been really difficult. I am wondering what you mean when you say your life is falling apart. 
 
Brent: Well, my wife left me, my kids don’t want to see me, and I might lose my job. I just don’t understand what I’m doing wrong. [Brent becomes tearful]
 
Therapist: [I remain silent but attentive to encourage Brent to continue]

Brent:
 I’m sure you’re rolling your eyes inside, ‘here we go, another drama queen.’

Therapist:
 What makes you say that?
 
Brent: I can just tell. You must get so tired of listening to people like me.

Therapist:
 [I make note of Brent’s assumption because it could provide insight into how he feels about sharing his emotions with important people in his life. However, I don’t immediately reply with an overly validating remark that might stymie the therapeutic dialog]. Sharing our emotions can be really scary sometimes. Can you tell me a little more what you mean by ‘people like me?’

Brent:
 I can’t tell you how many times I’ve been told I’m too sensitive or overly dramatic or that I read into things too much.

Therapist:
 How does it feel when others say those things?
 
Brent: [Brent becomes tearful again]. It hurts so much. No one gets it. I care so much but that just ends up biting me in the ass. It would be so much easier if I just didn’t give a shit about anyone.

Therapist:
 [I remain silent and refrain from offering an automatic reassuring remark but I use body language to show Brent that I am attentive and concerned].

Brent:
 When I love someone, I love them with all my heart. I go out of my way to make sure people feel special. That’s just who I am. But what about me? What about my needs?
 
Therapist: [I nod]
 
[Brent’s body language communicates to me that he is angry and unsatisfied.]

Brent: This is stupid, you just sit there and nod like you know what I’m going through. How dare you pretend to care! I came here because I needed help. Just sitting there staring at me and nodding isn’t helping, it is making things worse! I knew I should have stayed home!

Therapist: [I begin to feel frustrated by my inability to meet Brent’s expectations and I feel insulted and disrespected by his comments. At the same time I begin to feel anxious, ashamed, and insecure as I start to believe Brent is right.] I am sorry you feel that way. Nodding is my way of showing attentiveness and interest in what you’re sharing with me. 

Brent: [Looks away and shakes his head]

Therapist:
 [I begin to question by abilities. Maybe I’m not good enough to be a therapist. Maybe Brent is right. I decide to share my feelings with Brent.] I’m frustrated with my inability to help you. It hurts me when I see others suffering. [I share with Brent how this situation is affecting me and I validate his emotions by letting him know I can see he is in pain. I show compassion by remaining calm and concerned so Brent doesn’t feel I am abandoning him]. 

Brent: [Brent becomes tearful.] I am in so much pain. I get so angry because I feel like no one cares about me. [Brent begins to shift his anger away from me. His defenses begin to lift now that he feels validated and unabandoned. He opens up a little more as the session continues].

How To Support Someone Like Brent

Validation, Validation, Validation.

If you’re a compassionate human being, it is normal to feel uncomfortable when someone you care about is suffering emotionally. Imagine a close relative expressing the following sentiment: 

“I am such a loser. No one will ever understand me.” 

Our gut reaction might be to offer reassurance by saying something like:

“That’s not true!” 

While this might be well intentioned, it is rarely effective. Reassurance is usually not the way to go because it isn’t as supportive as validating the emotion. It is easy to get caught up in the content and forget about the underlying emotion. Has a close friend or relative ever said something like:

“You don’t even care about me!” 

We might become defensive and push back with “yes I do!” But again, this is probably not helpful. Instead, try validating the underlying emotion. Consider the following alternative response: 

“It hurts me to hear that. I can’t imagine how painful it must be to feel that way.” 

We all know our thoughts can be irrational and untrue sometimes, but our emotions are ALWAYS real regardless of whether we believe they are justified. By validating the emotion, we avoid getting caught up trying to “convince” someone like Brent that his thoughts are irrational (which is not validating at all and will ultimately lead to frustration and anger for everyone involved). 

Be Concise, Direct, and Matter of Fact

This can be challenging as many of us feel the need to explain ourselves when others challenge our views, opinions, or beliefs. Unfortunately, when we do this, we become susceptible to manipulation. That is, the more words we use and the longer we take to explain or share something, the greater the likelihood those words and explanations will be distorted or misinterpreted. In fact, this is often the unconscious strategy employed by those with Cluster B traits. Consider the following example where someone like Brent is interacting with a friend who did not return his phone calls (i.e., did not do what Brent demanded):

Someone like Brent: Where the hell are you? I called you 14 times and you never picked up. I was in a crisis, and you weren’t there for me! How could you do this to me? Do you even give a shit about me? Or anyone else for that matter? You are so selfish!

Supportive Friend: I am so sorry I didn’t get back to you. I was at the office and had to take care of some important work and then my son called because he needed a ride home from school. By the time I got home I was exhausted, and it completed escaped my mind. I am trying to be as supportive as I can. I am not selfish at all!

Someone like Brent: What work could have been more important than helping a friend who was in so much pain. Feeling exhausted is my normal. If you really cared, you would have called me back. It only takes 2 minutes. Am I not worth two extra minutes of your time??

You can see the pickle of a situation this is becoming. It is important to set limits and remind yourself that your needs matter as well. Don’t fall into the trap of believing we can’t be compassionate and supportive unless we explain ourselves entirely and/or allow others to walk all over us. Being concise and direct does not mean being unsupportive. Consider the following alternative response:

Someone like Brent: Where the hell are you? I called you 14 times and you never picked up. I was in a crisis, and you weren’t there for me! How could you do this to me? Do you even give a shit about me? Or anyone else for that matter? You are so selfish!

Supportive Friend: I am so sorry to hear you were in crisis. Unfortunately, something personal had come up that required my immediate attention. I hope you are okay.

In the alternative approach, the supportive friend did not “bite the bait” (i.e., become offended and feel the need to explain). The supportive friend also did not acknowledge or address the irrational and hurtful accusations/comments. When in doubt, try to respond as concisely and matter of fact as possible.

Set Strict Boundaries

This cannot be overstated. It is vital to set boundaries for yourself. When a difficult patient, loved one, close friend, or colleague begins attacking with hurtful comments, it is easy to become immediately defensive and then insecure later on. We might begin questioning our abilities and our intentions. It is easy to mistakenly internalize emotions that aren’t ours and this is when we become vulnerable to manipulation. It is important to set limits and boundaries for yourself. Your needs matter as well. It’s when we begin losing our sense of self that we become resentful, angry, and lost. 

Don’t fall into the trap of believing we can’t be compassionate and supportive unless we allow others to walk all over us. This way of thinking is very unhealthy for everyone involved. 

It is important to let Brent’s problems remain his problems. 

Stay Consistent

If you say 11:30am, be sure you are ready at 11:30am. Try to be consistent in how you respond. If one day you respond one way and then another day you respond differently, someone like Brent will never learn from the responses. It is the consistency in response that promotes learning. Someone like Brent will begin to learn that his behavior must change if he seeks a particular outcome. 

Don’t Be Afraid to Share Your Feelings

If we hide our feelings, it is impossible for others to know how we feel. This is particularly important for supporting someone like Brent. When Brent says something hurtful, make it known. Tell him. Allowing yourself to be emotionally vulnerable and share exactly how you feel does two things–it validates your own feelings, so you don’t neglect yourself and it provides important feedback to someone like Brent. Sometimes it can even de-escalate the situation. 

Seek Reassurance from a Colleague or Friend When Needed

It is normal to question yourself. But when you begin believing the irrational accusations others make, it is important to keep yourself grounded in reality and run things by people you trust and respect. This is ESSENTIAL. Learn all about Projective Identification here.
 
To learn more about Borderline Personality Disorder, click here.

What is ERP Therapy?

Exposure Response Prevention (ERP) Therapy is a type of exposure therapy that uses the same principles as Cognitive Behavioral Therapy. In ERP, we expose ourselves to distressing situations and then prevent our immediate urge to respond with a compulsive act. Over time, we learn to tolerate anxiety-provoking thoughts and situations in a more productive way.

ERP is about facing your fears and learning that it isn’t that bad (even though it feels bad in the moment).

For example, we might expose ourselves by placing our hands in dirt. Normally, we would immediately wash our hands to provide temporary relief and may continue to do so repeatedly lest they aren’t actually clean. When implementing ERP, we would refrain from washing our hands which would be very uncomfortable. We would sit with this discomfort for as long as we can.

Over time, we would become more tolerant of the discomfort as we learn that we are okay despite not washing our hands immediately and repeatedly. Obviously, this is much easier said than done. 

For more information about Exposure Response Prevention Therapy, click here.

An Example of a Manipulator

The Scenario

You’ve recently met a new co-worker named Shannon who is very kind, caring, and compassionate. You find yourself drawn to her charismatic, charming, and energetic personality. And although you don’t agree with many of her opinions, you find her humor controversial yet hilarious. Shannon always seems to be in the know–the new fashion trends, the latest gossip, and the trendiest places to socialize. She hosts the best parties at her enormous home which is nothing shy of gorgeous. From the couches to the wine glasses to the small antique pieces arranged around her home, everything seems so intentional and thoughtful. You haven’t met her close friends but your opinion of them isn’t positive. Every day, Shannon has stories about how “awful” her friends are and how mean they can be.

One day, Shannon comes into work, and you immediately notice something is off. She is quiet, withdrawn, and doesn’t even acknowledge your existence. You grow concerned so you approach her to say hello. She gives you a forced smile and appears to be on the verge of tears. You ask her if everything is okay. At this point she begins crying. You can feel her pain, so you sit down and ask her what’s going on.

“No one gives a shit about anyone but themselves. I can’t believe I thought I had friends.”

You recognize her statements as being a bit extreme but you can tell she is suffering emotionally. You really want to be there for her. Shannon goes into a long story about her friends and how they treat her. 

“I feel so used.”

She tells you how her friends only contact her or reach out to her when they need something or want something from her. 

“If I didn’t know the bouncers at the best nightclubs or I didn’t have my beautiful home, they wouldn’t have anything to do with me.”

You sit down next to Shannon and offer her a supportive ear. She tells you all the things her friends have done to hurt her and reject her. You try to build up her self-esteem because you don’t want to see her hurting. You offer reassuring statements. Shannon immediately cheers up and tells you how amazing you are–how you’re the only person who truly understands her and listens to her. 
She then offers to have you over for a cocktail next weekend. 
 
For the next few weeks, you are excited about your friendship with Shannon. She buys you incredible gifts, takes you on fun experiences, and seems to idolize you. Shannon constantly tells you how much you have changed her life and how special you are–how you were meant to meet and how you are the one person she needed in her life during this difficult time. 
You feel good about how you’ve changed her life in a positive way–but there is also a feeling of discomfort that is hard to describe. Something is off. You start to wonder how you became the most important person in Shannon’s life. Despite your growing suspicions, you go with it.

Soon you find yourself spending more and more time with Shannon. Your family and other close friends take notice. While you want to make the time for your family and close friends, Shannon makes you feel so special and important that saying no to her becomes increasingly more difficult. The last thing you want to do is let her down or disappoint her. She has idolized you to the point where you feel trapped on a pedestal so tall that the thought of falling off scares the shit out of you. It doesn’t help that Shannon has a way of asking for things. You recall a recent text message exchange:

It doesn’t take long before you begin to feel responsible for Shannon’s feelings. When you can’t be there 24/7 or whenever she needs you, you feel guilty. You start questioning your own loyalty as a friend and you feel really mad at yourself for not being a good enough friend to her. 

Resentment starts to build as you try endlessly to be the friend you think Shannon needs. But it never seems to be enough. You begin feeling helpless, frustrated, and inadequate. But those feelings are nothing compared to the guilt that infects your soul.

Shannon’s birthday is approaching, which happens to be on the same day as the music festival you look forward to all year because you get to reunite with your closest childhood friends who you rarely get to see. You plan on inviting Shannon once you have the details because you know she will want to know all the logistics. You panic when you receive a voicemail from Shannon:

“My life is falling apart, but at least I have you. I am so grateful I get to spend my birthday with you. What do you think about having a spa day at that place you’ve always wanted to go to? I know the owner and she is giving us the deal of a lifetime!”

You begin obsessing about how you should respond. You love spa days and you have wanted to go to this place for years and you finally have the opportunity to go. You can’t believe she is picking the place YOU love. 

You feel stuck, but you think maybe she will enjoy the music festival. A few minutes pass and you see your phone light up. Shannon is calling you. You don’t pick up.

An hour later you receive a text message:

You bite. You respond with a long message about how grateful you are for the invitation and then you tell Shannon about the music festival and how you were waiting for the details before officially inviting her.

She responds:

You feel terrible. Shannon did go out of her way for you. She has given you so much over the past month and you feel embarrassed and stupid that you didn’t know she doesn’t like crowds (even though she loves nightclubs and other events she plans).  Either way, you feel like you should have known better. The pit in your stomach grows as your favorite concert approaches. You decide to go, but all you can think about is Shannon and how she is alone on her birthday. You can’t stop thinking about it. 
The guilt you feel prevents you from having a good time. You try not to take photos because you don’t want Shannon to see you having a good time on social media. But really, you feel like you don’t deserve to have fun unless Shannon is having fun too.

While at the concert you get messages from Shannon:

That hits deep. So many emotions begin to surface. You love Shannon and wish she was having fun with you, but you are angry and frustrated because you feel responsible for her pain. You vacillate between anger and guilt to the point where you start questioning things. 

Maybe Shannon is right. Maybe I am selfish. Maybe I’m not good enough. 

And you start to feel depressed and lost. Shannon blames you for all her problems and you feel terrible. You do everything to console her and gain her trust back and finally Shannon accepts your apology. But the cycle continues…
 
Soon, you learn that being happy without Shannon creates conflict. And doing or feeling anything that isn’t acceptable to Shannon also creates conflict. Before you know it, you don’t even know who you are anymore because you have worked so hard at becoming someone you aren’t just to avoid conflict with Shannon. 
 
Now you know how people with prominent cluster B personality traits can affect those around them.

The Chameleon Effect

How to be Supportive

Supporting someone through a difficult time can stir up many emotions. We might be feeling sad, worried, helpless, frustrated, awkward or even angry. This is normal.
 
As compassionate and caring humans, our natural tendency is to jump in and try to “fix” the problem. We will do anything we can to relieve the suffering of those we care deeply about. But sometimes the way we offer support has more to do with relieving our own discomfort and distress and this is where things can get a bit tricky.
 
It becomes even more difficult if the one you’re supporting lacks insight into the problem or refuses to accept that a problem exists.

So what is the best way to support someone? Is there a best way?  The answer is no, one size does not fit all. Below are a few tips. 

Don’t Make Assumptions

When we know someone really well, it is tempting to assume we know what they need at all times. But we don’t. Each of us responds differently to different situations even if the situation is similar to previous ones. Just because a loved one needed “X” in the past does not mean we should assume “X” is still relevant.

Put Your Mask on First

If you’ve ever traveled by airplane you are probably familiar with the oxygen masks. Flight attendants tell us to put on our oxygen masks first before helping others. If you’re feeling exhausted, angry, sad, overwhelmed or frustrated, take a moment or two for yourself. Close your eyes and take a few deep breaths focusing on your breathing.

Silence Is Not a Bad Thing

Many of us might feel an urge to offer reassurance or advice if silence sets in. Resist this urge. Sitting with someone in silence can send the powerful message that you are there to stay and listen whenever they are ready. Offering advice or quick reassurance can be perceived as dismissive. Have you ever cried in front of someone else? What would feel more reassuring, response number 1 or response number 2? 1) “Oh no, don’t cry, it will be okay.” 2) A silent hug or gentle back rub.

Body Language

Nonverbal communication is very important. Position yourself so your entire body is facing toward the person you are consoling. Lean forward slightly without violating personal space and make eye contact. But don’t stare if they aren’t looking at you.

When in Doubt, Ask

Sometimes we need a hug, other times we need space. Or maybe we don’t know what we need. Regardless, if you aren’t sure what your loved one needs, simply ask in a compassionate, supportive, and curious way. Example: “What can I do to support you during this really difficult time?”

Validation over Reassurance

Reassurance is okay, but validation is better. Being honest and genuine is of upmost importance. Making promises we can’t keep or offering a false sense of hope can be more hurtful than helpful. You will never go wrong with validating someone’s feelings, even if you disagree or believe they are over reacting. “It’s going to be okay” isn’t as supportive and nurturing as “I can tell this is really affecting you.”

Goldilocks Empathy

This discussion wouldn’t be complete without mentioning empathy. Empathy is the capacity to share and understand others (i.e., the ability to place oneself in another’s shoes).

Empathy can be divided into two types, cognitive empathy and emotional empathy.

  • Cognitive Empathy: Understanding another’s position from an intellectual perspective. 
  • Emotional Empathy: Understanding another’s position by sharing similar emotions. 
We can appreciate the difference with the following example:

Your best friend Sally recently found out her spouse, Dave, has been texting another women. Sally comes over to your place in tears. 

“I am so mad! I can’t believe he would do this to me! I hate him!”

While you might understand why Sally would be angry and upset, you might not actually feel angry and upset as well. Sally reveals that she doesn’t actually know if Dave is texting someone else but suspects he is based on his recent behaviors. Sally also reveals that she didn’t receive a promotion at work recently. 
Cognitive empathy is your understanding of Sally’s reaction. It makes sense. But there are still many unanswered questions. Perhaps Sally is feeling unwanted and rejected because she didn’t receive the promotion and is now feeling insecure about her relationship with Dave. The best support for Sally is a healthy balance of both cognitive and emotional empathy, what I call Goldilocks Empathy. Too much cognitive empathy and you might come across as “too cold” and dismissive emotionally. Too much emotional empathy and you might come across as “too hot” and potentially reinforce a negative pattern of behavior. 

Final Comments

In summary, we want to share understanding on both emotional and cognitive levels as we strive for a type of empathy called Goldilocks Empathy. This doesn’t come naturally for many people and takes practice. Many of us are more prone to one type of empathy over another (i.e., some of us tend to be more emotionally empathetic and some of us tend to be more cognitively empathetic). How we achieve Goldilocks Empathy takes practice–a topic for a future post (along with how to be supportive when a loved one denies a problem exists).

Personal Boundaries

Have you ever felt like your kindness and generosity were taken for granted? Do you struggle to say what’s really on your mind?

This could be a sign that your personal boundaries need some attention.

Personal boundaries are the rules we set for ourselves within relationships. Healthy boundaries mean preventing others from projecting their beliefs and judgements onto you.

A person with healthy boundaries can say “no” to others and not feel guilty for doing so. This is not as easy as it sounds.

Many of us have “all or none thinking.” That is, we make irrational rules and conditions such as “if my wife calls me and I don’t feel like talking then I must be a bad husband who doesn’t really care.”

The “all or none” distortion in this case is the irrational belief that we can’t be loving and supportive while also doing what we want or need for our own wellbeing.

Boundaries should be based on your beliefs and values (i.e., the things that are important to you). These may not align with the beliefs and values of others–but that is okay. After all, they are YOUR boundaries.

When a client, patient, loved one, stranger, close friend, or family member begins attacking you with hurtful comments, it is only natural to become defensive, frustrated, and insecure.

We might even begin questioning our own abilities and intentions.

Our personal boundaries become violated when we allow the opinions of others to negatively influence our beliefs about ourselves. This is when we become vulnerable to manipulation.

It is essential to set limits and personal boundaries for yourself. Your needs are just as important as anyone else’s. By giving others the power to hurt us, we lose our sense of self and become resentful, angry, and lost. 

When you find yourself asking, “who am I?” it usually means your personal boundaries have faded. 

Don’t fall into the trap of believing we can’t be compassionate and supportive unless we allow others to walk all over us. This way of thinking is very unhealthy for everyone involved. 

So how do we set personal boundaries?

Be Prepared

Before entering a situation where boundaries might be violated, set boundaries for yourself explicitly. For example, if you have to interact with someone who is very critical or condescending, tell yourself “if I feel disrespected or judged then I will concisely state my feelings without having to explain and then respectfully remove myself from the conversation.”

Plan Ahead

Think about what you are going to say and how you are going to say it prior to a difficult encounter. This will help boost confidence in yourself.

Be Clear

You always have the right to express yourself. When you do, make sure it is clear and without ambiguity. YOU DO NOT HAVE TO EXPLAIN YOURSELF.

The Power of “I”

When expressing how you feel, be sure to use “I” rather than “you.” When we keep it about our feelings, it comes across much less threatening. Consider how the two examples below may be received.

(1) “You are being mean and hurtful. You don’t listen to me.”

(2) “I feel hurt by your words. I’m not feeling heard.”

They are both expressing the same thing but in very different ways. It’s often not what we say but how we say it that matters most.

Here are some examples of how to express yourself clearly:

  • “Please don’t speak to me that way.”
  • “I’ve decided not to ___”
  • “I’ve decided to ___”
  • “I feel belittled by you and that will not work for me.”
  • “I appreciate your opinion but I disagree with you.”

Use Confident Body Language and a Respectful Tone

Face the other person, make eye contact, and use an appropriate volume of speech (not too loud or too soft). Be respectful but don’t shy away from stating how you feel. Many people don’t like confrontation and they will avoid stating their beliefs lest others will get upset, angry, or defensive. Quieting your own voice is another way of saying “I don’t respect myself. My feelings don’t matter. I don’t matter.”

Compromise when appropriate

You don’t have to compromise. But consider listening to the others’ points of view and appreciate their needs as much as possible. Healthy relationships require “give and take.” But when you find yourself giving more than taking, make note of it and bring it up. Relationships are always two-way streets.
 
If you found this post helpful, check out our post on communication tips. and how to be supportive.
 

Work-Related Burnout

With the COVID-19 pandemic blurring the line separating work life and personal life, work burnout is becoming the new epidemic. In this post, we will review common signs and symptoms of work burnout and offer some strategies for managing this new epidemic. 

What is Work Burnout?

Work burnout is considered a type of work-related stress characterized by a sense of reduced accomplishment and loss of personal identity. Burnout is not a medical diagnosis by itself, but it may exacerbate, or be a nidus of, numerous health-related problems.

Interestingly, researchers propose that individual factors, such as personality traits and family life, influence who experiences work burnout. Let’s consider how to know if you are suffering from work burnout and what you can do to relieve the suffering. 

What are common signs and symptoms of work burnout?

  • Becoming cynical or critical at work
  • Dragging yourself to work and having trouble getting started
  • Irritability or impatience with co-workers, customers or clients
  • Fatigue
  • Difficulty concentrating 
  • Lacking satisfaction from your achievements
  • Using food, drugs or alcohol to feel better or to void negative feelings
  • Sleep problems
  • Unexplained headaches, stomach or bowel problems, or other physical complaints
If any of the above symptoms resonate with you then consider whether you’re suffering from work burnout. It is always recommended to talk with your healthcare provider because these symptoms can also be related to health problems such as depression.

Who is at risk of developing work burnout?

  • Those who have a heavy workload and work long hours
  • Those who struggle with work-life balance
  • Those who work in a helping profession, such as health care
  • Those who feel they have little or no control over their work

What are some consequences of work burnout?

Work burnout can have significant consequences, including:
  • Excessive stress
  • Fatigue
  • Insomnia
  • Sadness, anger or irritability
  • Alcohol or substance use disorders
  • Heart disease
  • High blood pressure
  • Type II diabetes
  • Vulnerability to medical problems, including infections

What are some strategies for managing work burnout?

  • Recognize the signs and symptoms of burnout and assess whether they are negatively impacting your life. This is an obvious but often neglected first step!
  • Discuss specific concerns with a supervisor (if possible). Perhaps you can reassess expectations and develop solutions together. 
  • Prioritize daily tasks (more on this later)
  • Seek support. Whether you reach out to co-workers, friends or loved ones, support and collaboration might help you cope. If you have access to an employee assistance program, take advantage of relevant services.
  • Engage in one or more stress-reducing activities for at least 20 minutes each day. This may include yoga, meditation, tai chi, martial arts, mindfulness exercises, boxing, weight training, cross-fit, running, swimming, other aerobic exercise, sports, creative writing, painting, drawing, listening to music, playing an instrument, or reading for pleasure. 
  • Get quality sleep. We spend about a third of our lives sleeping. Sleep allows our body to reset. Interestingly, sleep is important for our memory, our immune system, and our ability to regulate our emotions.
  • Healthy diet. Junk food is comforting, but it doesn’t help your cause. Having the occasional “cheat meal” is important, but limit those sweets and saturated fats as much as possible. A high protein, high fiber, moderate fat, and low carbohydrate diet can improve your energy levels, concentration, memory, and mood!
  • Set healthy work-life boundaries. Setting healthy work-life boundaries will not only improve your mental health but prevent burnout and promote more effective and efficient work!
Let’s discuss healthy work-life boundaries in a bit more detail.

Work-life boundaries

Boundaries are the rules we set for ourselves in our relationships, our work, and our personal lives. Healthy boundaries mean preventing others from projecting beliefs, judgements, or expectations onto you. A person with healthy boundaries can say “no” to others when they need to while also supporting those in need. This includes work-related tasks, home chores, or supporting those you care about. This is not as easy as it sounds.

 

Prioritize your values
Boundaries should be based on your beliefs and values–the things that are important to you. These may or may not align with others and that is okay. They are YOUR boundaries.  The first step is to make a priority list. Example below:

  • Spending time with family
  • Personal Free time/Hobbies
  • Exercise
  • Productive and Efficient work
Prioritize your time
Each day, it is important to make time for your top priorities. To do this, you will need to create a “skeleton” schedule. This does not mean scheduling your day minute by minute or hour by hour. You don’t want to become a prisoner of your own schedule! Here is an example based on the priorities listed above:

Morning 

  • Wake up at 6:30AM
  • Exercise for 30 minutes before work
  • Check and respond to emails for 30 minutes 
  • Work from 8AM-11AM with 15-minute breaks every 45 minutes 

Noon

  • Spend 30 to 45 minutes eating lunch and visiting with a friend or family member
  • Check and respond to emails for 30 minutes prior to starting afternoon work

Afternoon

  • Work from 1PM-4PM with 15-minute breaks every 45 minutes
  • End all work at 5PM and spend 30 minutes checking and responding to emails one last time for the day

Evening

  • Spend at least one (1) hour with a friend or family member
  • Spend 30 minutes playing guitar (or other hobby)
  • Get ready for bed at 10:00pm
  • Leisure reading for 30 minutes in bed
  • Lights out by 10:30PM

Checking Email
Schedule the times you plan to check your email. One of the biggest mistakes people make is obsessively checking email. This is anxiety-provoking and inefficient. It disrupts your focus and is simply unnecessary. Use the auto-respond function to inform those who email you of when you check your email. You can also instruct people to call you directly if it is urgent.

Smartphones
As with email, limit time on your phone as much as possible. When you need to focus on completing a task, silence your phone and place it facedown next to you. If answering phone calls is important for your work, place your phone on vibrate and keep it in your pocket. When not working, set a time to put your phone on silent in a drawer or out of view for at least 30 minutes. By doing this, you’ll learn that you DO NOT need to have your phone on you at all times.

Computers
Your computer should only be used for work during work hours only. When the work day is over, shut down your computer and/or put it away. If you need to use the computer for personal use, then use it for personal use ONLY. Some people find it helpful to have two devices – one for work and one for play. But this may not be possible.

Consistency
Try your best to remain consistent with your schedule! There will always be some flexibility but do your best to remain consistent. Try not to get down on yourself if you struggle at first to be consistent. Simply recognize when you’re deviating from the path and make adjustments to get back on track.

Use technology to help you
Many smartphones have reminder functions. Try setting reminders for when to take breaks, check emails, spend time with family, or exercise. There are many apps out there that can help with prioritizing your daily tasks as well!

Share your boundaries with others
It is important to share your new strategies with your family, friends, co-workers, and supervisor(s). Ask your friends and family to keep an eye on your behaviors so they can point out when you might need to make some adjustments. Inform your co-workers and supervisor(s) so they can provide input and suggestions. While it is important to maintain healthy boundaries, it is also important to know how to compromise. BUT…compromising does not mean trashing all your boundaries.

Whenever you have the urge to work during non-work hours, make a habit of asking yourself the following:

  • Is this in line with my values and priorities?
  • How important, on a scale from 1-10, is it that I complete this RIGHT NOW? (Anything 6 or below can wait).

Begin and end each day with anything BUT work
It is essential to begin and end your day with something positive. Something you enjoy. If the first thing you do each morning is check your email and the last thing you do is check your email, then you are setting yourself up for burnout. Do not let the first and last activity of each day be something work-related. 

For additional resources, check out the following articles