Lisa Find Love

In the Spring of 2018 my daughter began to want to “eat healthy.” There is nothing wrong with eating healthy, I thought. After all, I am a certified health coach and am a huge advocate of eating healthy.

My daughter began reading food labels on some things and I thought, I’ll keep an eye on that. This went on for a few months with no other signs of anything unusual. Until, one day we were riding in the van with my daughter and her two  younger siblings and the two littles asked if we could grab some lunch. I happened to look in the rearview mirror at the same time. My daughter had a look of fear come over her face. That’s the instant I knew that something more serious was going on. I made a mental note to talk to her later that day.

Later on I asked her, “Are you just wanting to eat healthy or do you feel guilt or shame when you aren’t able to eat a certain way?” She burst into tears. Yep, this was more serious than I had originally thought. I told her that I was going to get her professional help and not to worry. We would handle this, and it was going to be ok.

At this time, said that she didn’t feel fat, but she was afraid to eat certain foods and she wasn’t sure what was happening. She said she would feel out of control sometimes with food and feel the need to exercise in her room to make up for it. I knew these feelings all too well as I had battled an eating disorder myself.

I googled professional help in the area and the closest I could find that looked like an appropriate place that also took our insurance was a center in northern Virginia, about an hour and a half from our house. I made an appointment right away. It took a few weeks to get my daughter seen, and in the weeks leading up to the appointment I found out there were days that she was only eating cucumbers and blueberries. I began to sit with her at every meal to make sure that she was in-taking food. At this time my daughter obliged as long as I was there sitting with her.

Finally, our appointment came and after several hours of many thorough questions my daughter was admitted to an intensive outpatient program, which was an all-day program 6 days per week. It was exhausting with the traffic and long drive on top of work, but of course it was worth it.

My daughter was there for about a month, however, things began to snowball as the eating disorder became stronger, and my daughter’s weight dropped as she ate less and less. At this time she was admitted to Children’s National Hospital in Washington D.C. and a feeding tube was put in place. My husband and I took turns staying overnight with her. She was there for about 5 days and transferred from there to a treatment center in North Carolina where she remained for four months.

During her time in N.C., she was on a rigid meal plan with goals put in place by her team. If she didn’t meet those goals with food intake, she would be presented with an Ensure supplement. If she didn’t intake enough by mouth of the food and/or Ensure, then the feeding tube would be put back in place. The tube went in and out at various times during the four months and even though we knew she needed this level of care, including a therapist, psychiatrist, primary care doctor, around the clock nursing staff, dietician and around the clock therapist assistants, she also unfortunately picked up other behaviors from being around other patients including self-harm. Maybe this would have happened anyway. There is no way to tell. But some of the other patients there were engaging in self-harm, and my daughter hadn’t engaged in this previously.

My husband and I took turns traveling to N.C. every weekend. We took off work most Fridays to be down there as much as we could. We got special permission from her team to eat as many meals with her as possible, and I coached her through as many meals as I could, battling the lies of the ED with her.

However, once observing these new behaviors (self harm for example), we decided it was time to move towards getting her home more quickly in order to get her away from the environment so that she wouldn’t pick up any more behaviors. We also thought home would be the best environment for her. Unfortunately, this plan backfired.

Although we had come home with a meal plan and were trying to put an outpatient team in place, it wasn’t’ enough. Once we saw that she had lost 10lbs in two weeks we knew something was up. We asked and she told us that she had been hiding and throwing away food without us knowing. This was partly our fault as parents for not watching her closely enough. However, there also needs to be responsibility and trust on the child’s part or it will never work. They need to want recovery or it will never be lasting.

At this point we had to admit her back to Children’s Hospital. While at Children’s Hospital they reinserted the feeding tube and said that she would not be allowed to return home until she was eating 100% of all meals and snacks. She hated it at the hospital so she obliged and was home in a week.

Unfortunately, it didn’t end there. she stopped eating again as soon as she got home and we had to re-admit her back to the treatment center in N.C. She stayed there for 7 months with a feeding tube the entire time other than two weeks with no food intake at all other than a couple snacks. She seemed to have lost all motivation, and the ED was stronger than ever. She shut down emotionally as well. She no longer wanted to talk to us as parents and didn’t see any point in talking to her therapist. It was devastating and hopeless.

We had family therapy and group therapy, but we weren’t getting anywhere. My husband and I were exhausted from the traveling and I was emotionally exhausted from worrying and feeling hopeless. It was draining on the entire family. The other kids were tired of mommy and daddy being gone and didn’t understand why she couldn’t just get better. We all knew it wasn’t her fault but it was hard to hear her say things like, “I don’t want to recover,” when we were trying so hard.  

After around month 5, her team said that they could no longer help her and they wanted to transfer her to another facility. This was like a punch in the stomach. How long would this go on? They wanted to transfer her to another state even further away. How would we handle that? It was already so stressful on the family. We have three other children.

Although the 2-month process of submitting applications to one treatment center after another was long and difficult, we are overall thankful that one door closed after another as far as the long-distance facilities were concerned. After the long wait, a spot opened up closer to home in northern Virginia, only a little over an hour away. The transfer was not easy and there were many adjustments that had to be made, but we are thankful that she has opened up to us again and gained some motivation. We are thankful that she began to take in food in by mouth again.

It wasn’t all rainbows and sunshine. After only one day in the ED unit, she had a self-harm episode and had to be transferred to the mental health unit for 2 weeks. Thankfully she hated this unit so much that it was enough motivation for her to stop the self-harm, at least for now. We are again, thankful for this improvement. This facility is not perfect. We have had some issues with the nurses and director not being kind, and we have had to address this. However, there have been positive things that have come out of it, like my daughter getting some motivation back and her clicking with her therapist.

It has been a long journey. It is so hard when the eating disorder takes over and you have to hear your child say they don’t want recovery. My heart would break when I spoke to my daughter and I couldn’t fix it for her. My heart breaks when she is sad and overwhelmed and scared and hopeless — and I can’t make it all better. My heart breaks that there are treatment centers all over the U.S. and even worldwide because our children are suffering with this — and even more, there are children out there not getting the help they need.

If you have a child who is suffering, please get them professional help and know that you are not alone as a parent either. They need you. They need to know that you are there for them without judgment. They need to know that it isn’t their fault because they didn’t ask for it and they don’t know what is happening to them. There are times that I am not proud of. There are times that I let my frustration and exhaustion get the best of me. There are times I forgot that it was the eating disorder speaking and acting out and not my daughter. Looking back I wish at those times I would have had more patience. So, for you, get help. See a therapist. You need support, too. It wasn’t until towards the end that I realized I needed that support, too. Hugs, my friend. You can do this.

Thankfully, after numerous medications, 30mg of Lexapro was what did the trick for my daughter. She is finally home and living and eating freely. We are SO thankful to have her home again and to be able to witness the freedom she is enjoying with food. We know that chance for relapse is high, and I know that from my own experience as well. Like I said, I battled my own ED. Mine started in college, and I relapsed multiple times as an adult. I didn’t get control of mine until my mid-thirties when I was put on 20mg of Lexapro. For more on my eating disorder story and recovery, you can find my book, Though the Mountains Be
Shaken, on Amazon and Barnes & Noble.

One of the benefits of adulthood is the opportunity to make choices. Children often bemoan the lack of control they have over their lives. Parents, teachers, coaches, clergy, police, even strangers they encounter tell them what to do on a daily basis and they are expected to comply or face consequences. Of course, some chafe against authority and others lower their heads and succumb reluctantly. A third group evaluates the guidance and decides for themselves which path to take.

Adults who offer choices, such as, “Would you like to wear the blue pants or red pants?” or “Would you like oatmeal or pancakes for breakfast?” give them a sense of autonomy, even while providing structure.

I recall a conversation with a child many years ago who complained that: “Adults get to do whatever they want. It’s easy for them.” I smiled and reminded him that while adults have greater freedom, along with that comes additional responsibility for their decisions. Now, as an adult, he understands that dynamic and is more mindful of his choices. He has learned the art, as his wife states, of “adulting.”

Sound decision-making is a skill that can be learned, regardless of whether it is modeled for children by their elders. There is a story about two men who grew up with an alcoholic father. One followed in his father’s footsteps and the other abstained completely. When asked what prompted their behavior, both replied, “I watched my father.” On some level, the man who chose the path of sobriety knew he didn’t want to end up with the consequences of drinking that he observed his father and brother experiencing. 

As adults, we are faced with choices throughout the day, from how late to stay up, to what time to rouse ourselves from bed, and what to eat for breakfast, from what to wear, to what route to take to work. We choose whether to engage in health-inducing habits or high-risk behaviors. 

On a deeper level, we choose what to believe spiritually and who we can trust. We enter into dating, mating, and relating based on our personal criteria. We have the right to determine our career options and follow our passion and purpose into a job that suits us. 

What is the impact of a sense of autonomy?

On the NPR podcast called The Hidden Brain, a recent topic was “The Choices Before Us: Can Fewer Options Lead To Better Decisions?” The host, Shankar Vedantam, spoke with Columbia professor of psychology Sheena Iyengar, author of The Art of Choosing. She expressed with certainty, that we feel happy when we believe we have control and can exhibit a sense of autonomy, which is true whether our choices are minor or major in terms of the impact on our lives.

Iyengar cites her famous “Jam Experiment” in which shoppers were presented with two different tables filled with luscious jam. One had six flavors, the other had 24 from which they could sample. More people stopped to taste test from the second table, but a higher percentage of people, (30% vs. 3%) actually purchased the product from the table that contained six option. The findings indicated that when presented with too many choices, people get overwhelmed.

A humorous scene from the movie called Moscow on the Hudson highlights that dilemma. The film takes place during The Cold War. Robin Williams plays a Russian saxophone player named Vladimir Ivanoff who, while on a trip to New York decides to seek asylum and defects. While acclimating himself to American culture, he enters a supermarket where he discovers, to his surprise, that not only is there no line to wait to purchase coffee as he is accustomed to in his home country, but there are so many options that he falls to the floor, after reading the labels aloud and cries out, “Coffee, coffee, coffee.”

Do we want people to run our lives, so we don’t have to make choices? 

In my work as a therapist, I have encountered clients who would prefer that others make their determinations for them, since they don’t trust their own discernment. They become dependent on parents, partners, and friends to tell them what to do. It can become a quandary for them since they often end up resenting what they perceive as the source of their emotional sustenance. Their fear of negative results causes them to procrastinate or experience ‘analysis paralysis’ as they contemplate which way to turn. Like the Scarecrow in The Wizard of Oz, they would tie themselves in knots, pointing in two directions. My role as a therapist is to empower them to make informed choices.

To encourage them to step up and claim their right to choose, I ask them to do a cost-benefit analysis. I have them inquire:

1. What will it cost me in time, money, energy, relationship, job, or health if I choose this option?
2. How will it enhance my life in all of the aforementioned realms if I choose this option?
3. Can I envision a life in which I have chosen door #1 or door #2?

I remind them that they can choose again, if what they are doing doesn’t serve them.

Enter COVID-19 and our choices become limited. At the moment, we can’t come and go casually. Leaving the house can become an ordeal, that involves girding ourselves with gloves, masks, and hand sanitizer. Physical distancing has become important, as we are reminded that it helps to prevent the spread of the virus. At a time when we are most in need of human contact, it has become something to fear. Even so, we have a choice of whether to ignore medical advice or adhere to the guidance and minimize risk. 

In American culture, we are indoctrinated to value freedom over the good of the collective. It may be what is behind the protests about “opening up the country,” for reasons other than financial. While it is completely understandable that people are experiencing cabin fever and want to travel farther than from bedroom to dining room as I do when I work with my clients via telehealth, in order to be concerned with the impact it has on anyone else they may encounter, conscious choices need to be made.

In a recent conversation with someone who, along with her husband, contracted the virus and are now on the other side of it, she shared that she is conscientious about the steps she needs to take to protect herself and others when they leave the house. He is more cavalier in his approach, shrugging off hand sanitizer when she offers it to him. The irony is that his symptoms were far more severe. He would likely say that he wouldn’t want anyone else to suffer as he had, and yet, his actions don’t align with his feelings. Cognitive dissonance at play.

As we exercise our freedoms, a pressing question is “Do I have the right to make choices that negatively impact others?”

A friend commented that while he chooses to wear a mask when in public (particularly because he lives in New York City), he will do his best not to judge those who refuse to wear one since they feel it infringes on their rights. He added, that with choice comes responsibility. Actions always have consequences. 

The longer I have been providing therapy, the more I’m convinced that, along with acquiring the skills to walk and talk, a basic task of being human is to learn to manage our emotions. Sometimes, the ways that we regulate our feelings are helpful, while other times the way we manage them can be harmful to ourselves and others.

How We Learn to Manage our Emotions (Self-Regulate) 

As a baby, your caregivers were charged with providing comfort when you were teething, hungry, or needed changing. When you were in distress, your caregivers should have remained calm. When you looked to them, they’d essentially be saying, “Don’t worry. I got this.” You would have been soothed, which in turn would calm your caregivers further, creating a positive feedback loop of mutual regulation, and all would be well once again.

As a child, your parents were supposed to help you understand, express, and manage your feelings. Let’s say you skinned your knee. Their first words should have been, “What happened!?” And as you told your story in between sobs, they should have responded with words of understanding, like, “Oh no! You were pushed down? That must have been scary!” And then the next several minutes should have been spent providing you with a physical remedy and an emotional balm. Again, the feedback loop would occur, and you would have calmed down.

As you grew, you would have naturally internalized this repeated mutual regulation process. This is what leads to the ability to self-regulate.

But if you were met with indifference (“It’s just a scratch. Whaddya crying about?”) or with horror (like it was the worst thing in the world), the mutual regulation process — and therefore self-regulation — would have been interrupted. And if your parents abused or neglected you, learning to self-regulate would be difficult if not impossible.

What Happens if You Didn’t Learn How to Self-Regulate? 

If you didn’t learn to self-regulate, you most likely developed a particular set of coping strategies. These are unique to each person. They serve a very important function and are generally difficult to change.

Certain childhood coping mechanisms can be helpful from the get-go, such as focusing on school or participating in sports. But other coping strategies to deal with difficult emotions might be less helpful in the long run. 

Here are four examples of how you might have reacted when your parents were fighting:

• Ran into your bedroom and put in your ear buds to drown them out.
• Found solace in cake and cookies.
• “Acted out,” which is an unconscious attempt to get your parents to stop arguing by turning their attention toward you.
• Intervened by directly stepping in to get your parents to stop.

In adulthood, these same four examples from childhood can evolve into a more advanced form of the same strategies, such as a tendency to: 

• Run away from conflict, either physically or by activities such as playing video games or texting with your ex.
• Indulge in self-destructive behavior such as overeating, excessively gambling, or abusing drugs and alcohol.
• Act out in ways such as lashing out at people or trying to control others.
• Avoid conflict by going along with others’ decisions when you don’t really want to.

Ironically, your coping strategies can make your long-term circumstances worse, in part because you can become more and more overwhelmed at the mere thought of having these daunting feelings, let alone expressing them. 

What Are Your Triggers?

Even the most calm, level-headed individual may have trouble managing their feelings in periods of great uncertainty and confusion. And due to the times we’re living in, at least occasional emotional dysregulation should be expected.

In regard to learning how to better regulate your emotional responses, you need to know what your triggers are and how they originated. Knowing this can not only lead to better regulation, but you can control your anxiety and other secondary emotional responses.

Triggers exist because you have a pre-existing sensitivity (i.e., a button) to certain situations and the feelings they bring. You can discover your triggers by looking at where you “overreact” to situations. We don’t all have trouble with the same emotions. Some people have trouble with anger, others want to avoid feeling fear or helplessness, and many others don’t want to feel pain or sadness. 

To illustrate, let’s say that you’re seeing a therapist and you say, “I don’t like it when other therapists come to the waiting room to get their patients and I’m the last one to be brought in.”

The therapist should ask, “Is this feeling familiar?” Inevitably, you’ll find that it comes from past public humiliations, like always being chosen last on sports teams or your parents repeatedly forgetting to pick you up at school. You naturally want to avoid feeling humiliated or abandoned.  

Please note that you don’t need to have a “right” to your feelings. It’d be great if we could choose our emotional responses. However, you’re not responsible for your feelings, but you are responsible to them, and you can only choose how to respond to them once they come up.

Seven Ways to Learn to Self-Regulate 

This leads to seven ways that you can learn to self-regulate, respond to your emotions differently, and replace old coping strategies. 

1. Consider the “No wonder!” Goal 

To continue the above example, once you understand why you have an aversion to being chosen last, you can say, “NO WONDER why I hate being the last person in the waiting room. There’s nothing wrong with me. Our gym teacher should have never let other students pick their teams (a dumb idea in my humble opinion), and my parents should have picked me up from school on time. Furthermore, they should have helped me to understand and accept my emotions rather than dismissing me.”   

 2. Stop Trying to Get Rid of Your Unwanted Emotions 

Trying to rid yourself of uncomfortable emotions does not work. In fact, it only generates more uncomfortable feelings. As noted earlier, feelings come up — you literally have no control over them. Learn to tolerate them more. Eventually, you can accept them. 

 3. Reduce the Misery Index 

The misery index is the distance between how you feel and how you think you should feel. Closing the gap means saying, “Good or bad, right or wrong, it’s how I’m responding right now.” 

Rather than falling into a shame spiral, which can lead to feeling depressed and anxious, you can validate and accept your emotions, which come from a very young part of your brain and are never ridiculous.  

4. Recognize that Your only Recourse Is to Change Your Behavior 

One way I define being a grown up is being able to separate your feelings from your behavior. It’s a lifelong process and — like self-actualization — you can never grow up 100%. But you can continue to work on it.  

Passive-aggressive coping strategies are simply a way of expressing your feelings indirectly. They include the Silent Treatment, asking numerous questions (when you’re challenging someone), and accusations. These actions may help you to self-regulate momentarily, but they also destabilize relationships. Try to be more direct. Start your communication with “When you did… I felt…”   

5. Take “The Pause”  

To self-regulate, it’s important to take the pause, also known as, “Don’t just do something, sit there!”

Before responding to emotional triggers, take a moment. Literally take a breath or two. You may need as little as five seconds. Sometimes, it’s best to take a bit longer, maybe even sleeping on it before you react. Recognize, sort out, and organize your feelings before responding. 

6. Learn to Trust 

You may be wondering why this suggestion is included. Changing your coping strategies requires something you may be most afraid of: Being vulnerable. Despite the fact that your coping mechanisms came about in response to your past, try to stretch by becoming more open with others.  

Part of why you developed coping strategies is because you think that other person might ridicule you, get mad, ignore you, or — even worse — leave you. Therefore, consider starting out small, using the words, “This makes me uncomfortable,” rather than getting into your specific feelings about something that bothers you. 

7. Be Willing to Change Your Coping Strategies

This is a tall order. I sometimes think of growth and maturing as “tool replacement.” Take a good look at your maladaptive coping mechanisms and learn how to replace them with helpful ones. Know that it took you years to develop and solidify your coping strategies, and it will take a while — as well as resources such as a 12-step program, therapy, and reading self-help books and articles — to replace them. 

I wish I could be more specific and that there was a recipe for this. But because you are unique and your combination of coping mechanisms are unique, I’m only asking you at this moment to be willing. And know that with awareness and willingness, you’re half-way toward making the changes you want to see.

Emotions are an essential and natural part of life, and as you learn the basic task of regulating them in new, healthier ways, you’ll be empowered to use new coping strategies that will make you stronger, control your anxiety, and strengthen your relationships.

Posttraumatic Stress Disorder (PTSD) is defined as a fear-based disorder with several features necessary for a formal diagnosis which include: avoidance behaviors, re-experiencing, increased arousal and negative affect and/or cognition.¹ Avoidance behaviors may include avoiding people, places or situations that could be emotionally ‘triggering’ of a traumatic event. For example, some veterans may avoid amusement parks or festivities that have fireworks or excessive noise as it may cause flashbacks or anxiety.

Re-experiencing behaviors often include emotional flashbacks, intrusive thoughts or nightmares. Someone who has experienced an assault may have trouble sleeping or experience nightmares of their assailant long after a traumatic event. Negative affect or cognitions may additionally occur with PTSD which may include feeling detached, or blaming themselves for a traumatic event. Similarly, increased arousal is common with those experiencing symptoms of PTSD which may include aggression or self-sabotaging behavior. Self-medicating or self-defeating behavior is reported as a maladaptive coping strategy or a way to distract themselves from their emotional or psychological discomfort. 

Whereas PTSD has the above features necessary for diagnosis, Complex Posttraumatic Stress Disorder (cPTSD) is often defined as a shame-based disorder, which includes the key features of PTSD plus three additional features, including emotional dysregulation, a negative self-image and interpersonal relationship issues.³ For example, those diagnosed with cPTSD may avoid relationships out of fear, have a negative self-concept, and display anger, sadness, emotional disconnection or dissociation.

Some core features of cPTSD have overlapping similarities with Borderline Personality Disorder (BPD), thus further blurring the distinctions among the three disorders. However, some key differences include a fear of abandonment that is specific to BPD and a more stable sense of self-identity seen in cPTSD that is not seen as consistently with BPD. 

BPD is identified as a pervasive personality disorder often beginning in late adolescence or early adulthood and includes symptoms of recurrent suicidal behavior, identity disturbances, chronic feelings of emptiness, emotional dysregulation, and cycles of idealization and devaluation of others and self. Symptoms specific to BPD include frantic efforts to avoid perceived or actual abandonment, an unstable sense of self-identity, marked impulsivity, and unstable and intense interpersonal relationships.²

However, while there are similarities among the disorders, such as interpersonal relationship issues and emotional dysregulation, symptoms associated with BPD are often more chronic and less transient which may make BPD more challenging to treat.  

Key Differences in Relationship Issues

All three conditions can struggle with healthy interpersonal relationships, however, there are some distinctions that separate the three disorders. 

• Those with PTSD, cPTSD and BPD often struggle with interpersonal relationships throughout the course of their diagnosis.
• Those with cPTSD and BPD often report high incidences of childhood maltreatment which includes emotional, sexual, and physical abuse and neglect.
• The highest reported durations, types, and incidences of ongoing child abuse are often reported by those diagnosed with cPTSD.⁴
• Those diagnosed with cPTSD who have a history of childhood maltreatment and abuse are at an increased risk for being re-traumatized in adulthood, especially in intimate partner relationships.
• Those with PTSD and cPTSD usually do not have a history of a fear of abandonment whereas those with BPD usually have a very deep fear of abandonment that often has caused significant impairment and instability within their interpersonal relationships.
• Those with BPD are cyclic with idealization and devaluation within interpersonal relationships whereas this dynamic is not usually seen in those with PTSD or cPTSD.
• Interpersonal relationship trust issues are common among all three disorders however trust issues seen in BPD often surround a fear of abandonment, which is not seen in PTSD or cPTSD.
• Relationship issues are often external to those with PTSD or cPTSD, in which acts of violence, threats to their life, or situations out of their control may be a cause of their symptoms.
• Relationship issues, especially relationship with self, are internal to those with BPD which affects their ability to have a stable self-identity or stable interpersonal relationships.
• Those with PTSD may have interpersonal stressors, especially immediately following a traumatic event, however with proper intervention they may recover to baseline levels before trauma.
• Those diagnosed with cPTSD may avoid relationships or “push away” social support as threatening or fear-inducing, which may be confused with a fear of abandonment seen in BPD.
• What separates the behavior associated with relationship avoidance in cPTSD is the fear of relationships as threatening or dangerous rather than abandoning.
• Those with BPD struggle with being alone; those with cPTSD or PTSD often choose to be alone or avoid relationships.
• Those with cPTSD or PTSD may show improvement in interpersonal relationships with therapy and in learning adaptive coping strategies.

This is not an exhaustive list given the complexity and comorbidity among the disorders. If you or someone you know is struggling with symptoms relating to PTSD, cPTSD or BPD, speaking with a counselor who is trained in trauma and recovery may be helpful in building skills and assisting with coping strategies. 

References 

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
2. Cloitre, M., Garvert, D. W., Weiss, B., Carson, E. B., & Bryant, R. (2014). Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. European Journal of Psychotraumatology, 5, 1–N.PAG.
3. Frost, R., et al. (2020). Distinguishing complex PTSD from borderline personality disorder in individuals with a history of sexual trauma: A latent class analysis. European Journal of Trauma & Dissociation, 4, 1 – 8.
4. Karatzia, T., et al. (2017). Evidence of distinct profiles of posttraumatic stress disorder and complex posttraumatic stress disorder based on the new ICD-11 trauma questionnaire. Journal of Affective Disorders, 207, 181 – 187. 

I’ve always known that I don’t have complete control over my life, although, admittedly, that knowledge exists on some level deep inside of me that I scurry past and pretend not to notice. Most days, I’m content to carry on in my feigned ignorance, convincing myself that I single-handedly make the decisions that shape my future and give meaning to my life.
And then COVID-19 happened, and any shadowy illusions of control I had disappeared in the glaring light of reality — I’m fortunate if I have control over anything these days.

For all that I tell myself I am the master of my fate, I can do precious little about most things in my life right now. I can’t change the fact that I’m working from home… or that my partner is working from home… or that my stepchildren are attending school at home… or that my favorite yoga studio, bookstore, and coffee shop don’t know when or if they’ll be reopening… or that this may be a summer without sports camps, beach trips, and family vacations.

In the midst of such stress-inducing uncertainty, as I wrestle with accepting the things I’m unable to change, there is still one aspect of my life that is completely, entirely, solely under my control — writing in my journal.

We’ve probably all seen at least one article touting the benefits of journaling. Researchers have found that spending 15-20 minutes a day writing reduces anxiety and depression, improves immune system functioning, reduces symptoms of with chronic health conditions, increases our memory, and decreases symptoms of trauma. I don’t know about you, but I need all the help I can get right now. There’s never been a better time to start journaling, so if you’ve ever considered it, but weren’t sure what to write about or felt stuck getting started, consider the eight following types of journaling and see which one speaks to you:

• Gratitude Journal: A gratitude journal helps you keep track of the things you’re thankful for and the things that bring joy to your life. Simply write down the things you’re grateful for each day, using a bullet-point list or writing out complete sentences, and don’t second-guess whether something is “worth” including. Did you see a hummingbird out your window that made you smile? Jot it down. Did you master a new yoga move while sheltering-in-place? Include it. Writing down the things we’re thankful for helps us focus on the positive, which can be difficult in such unprecedented times. Check out Positive Psychology for tips and templates to get started with a gratitude journal. 
• Mood Journal: A mood journal is a way to document your thoughts and feelings, while also identifying situations or people that affect how you feel or think. Keeping track of your mood allows you understand what influences your mood, and by knowing what makes you feel anxious, happy, annoyed, embarrassed, or distressed, you’re better equipped to take action and choose how you want to respond, rather than simply reacting. Here’s an example of how to start a mood journal.
• Reading Journal: Many of us were already avid readers before the coronavirus outbreak, but whether you’ve been reading for years or started more recently to stave off boredom, you might consider keeping a reading journal. It can be as simple as recording the titles of books you’ve read, giving you a sense of accomplishment when you review them later. Alternatively, you can document specific phrases from books that impressed you, or explore your reaction to plots, characters, or that cliffhanger ending you never saw coming. Writer/blogger Alice Causarano offers helpful tips on how to start a reading journal.  
• Dream Journal: Who hasn’t been amazed (or shocked) by their dreams and wondered what they mean? By keeping a dream journal, you can often identify themes in your life, gain insight into the things that truly matter to you, and see how your mind attempt to process and make sense of what you experience during your waking hours. Psychologist Kelly Bulkeley shares tips for keeping a dream journal, as well as the unexpected benefits of doing so.
• Goal Journal: A goal journal is exactly what it sounds like — a place to write down your goals and keep track of your progress towards achieving them. Goals can be broken down into milestones you want to accomplish over the course of a day, week, month, or even year. There are as many goal-focused journals available as there are types of goals, so consider reading Bustle author Maria Cassano’s review article to see what type might work best for you. 
• One Line a Day Journal: These journals have become immensely popular over the last few years, and part of the reason might be because they’re so easy to use — you literally write one line each day. That line could consist of three words or it could be a full sentence. You can do this with any journal, or you can purchase a themed one-line-a-day journal, such as “Mom’s One Line a Day” or “Living Well One Line a Day” for those focused on health and wellness. Lifestyle writer Gyan Yankovich shares her experiences journaling one line a day and offers suggestions for getting started with this type of writing.  
• Prompt/Response Journal: Is coming up with a topic so daunting that you find yourself avoiding the blank pages of your journal? Then consider the idea of a prompt/response journal, where each day you’re provided with a different prompt in the form of a question or statement and asked to write your response to it. Prompts range from the general (“Today I feel…) to the specific (“Write about your happiest childhood memory involving a pet”). You can buy journals filled with prompts, or you can find prompts on your own, such as these from PsychCentral.

Journaling is for you; it’s a way to get to know yourself and a place where you can write what you want without fear of being criticized or hurting someone’s feelings. You may try one type of journaling and decide it’s not for you, but don’t let that be the end of your introspective journey — try something else. Now, perhaps more than ever, we need safe spaces to process all that’s happening around us, and journaling is a relatively easy and inexpensive way to establish at least a modicum of control in the COVID-19 chaos. Have fun and remember — there’s no wrong way to write!

References:

Writing about emotions may ease stress and trauma. [No date]. Harvard Health Publishing Healthbeat. Retrieved from https://ift.tt/2h0mVKU

Phelan, H. (2018, Oct. 20). What’s All This About Journaling? The New York Times. Retrieved from https://ift.tt/2JhWQUC

Barth, F.D. (2020, Jan 18). Journaling isn’t just good for mental health. It might also help your physical health. Letting your emotions out can reduce stress, which can boost your immune system — as long as you then process your emotions. NBC News. Retrieved from https://ift.tt/2NDNfec

Bailey, K. (2018, July 31). 5 Powerful Health Benefits of Journaling [blog post]. Retrieved from https://ift.tt/3f4qmMj

Tull, M. (2020, Feb. 19). How Journaling Can Help With PTSD [blog post]. Retrieved https://ift.tt/2BJZv9O

Narcissism is many faceted and comes in several types. Narcissists will use a variety of tactics and defenses to keep you insecure and ensure their status and that their needs are met. It’s easy to be confused, but it’s important to understand and spot which type of narcissist you’re dealing with. Recently, two research teams have identified a common trait.

The Grandiose Narcissist

Although there are different kinds and degrees of narcissism, for years research mainly focused on the familiar — exhibitionistic narcissists who seek the limelight. These are the boastful grandiose narcissists who are public figures and are recognizable in films. They’re described in the Diagnostic Statistical Manual of Mental Disorders (DSM) under narcissistic personality disorder (NPD).

We can all spot those charming, attention-seeking extraverts whose vanity and boldness are at times obnoxious and shameless. They’re self-absorbed, entitled, callous, exploitative, authoritarian, and aggressive. Some are physically abusive. These unempathetic, arrogant narcissists think highly of themselves, but spare no disdain for others.

Helped by their extraversion, they report high self-esteem and satisfaction with their lives, despite the pain they cause others. Because they outwardly seek acclaim, attention, and domination, grandiose narcissism is externalized. Even in love, they seek power by game-playing. Many do maintain relationships, notwithstanding the lack intimacy and unhappiness of their partners, who are easily seduced by their charisma and boldness.

The Vulnerable Narcissist

Lesser known are vulnerable narcissists (also referred to as covert, closet, or introverted narcissists). Like their grandiose kin, they’re self-absorbed, entitled, exploitative, unempathetic, manipulative, and aggressive, but they fear criticism so much that they shy away from attention. Individuals of both types of narcissism often lack autonomy, have imposter syndrome, a weak sense of self, are self-alienated and unable to master their environment. However, vulnerable narcissists experience these things to a markedly greater extent.

In contrast to grandiose narcissists, rather than feeling confident and self-satisfied, vulnerable narcissists are insecure and unhappy with their lives. They experience more distress, anxiety, guilt, depression, hypersensitivity, and shame. They’re conflicted, holding both inflated and negative irrational views of themselves — the latter which they project onto other people, their lives, and the future. Their negative emotionality depicts a bitter neurotic averse to personal growth. They require reinforcement for their grandiose self-image and are highly defensive when perceived criticism triggers their negative opinion of themselves.

Unlike extraverted narcissists, they lack positive relationships. Instead of boldly dominating people, they’re threat-oriented and distrustful. Their attachment style is more avoidant and anxious. They withdraw from others with hostile blame and resentment, internalizing their narcissism. Empathetic codependents feel sympathetic and want to rescue them from their misery, but end up self-sacrificing and feeling responsible for them.

The Communal Narcissist

Even more difficult to identify is a third type of narcissist only named recently — communal narcissists. They value warmth, agreeableness, and relatedness. They see themselves and want to be seen by others as the most trustworthy and supportive person and try to achieve this through friendliness and kindness. They’re outgoing like the grandiose narcissist. However, whereas the grandiose narcissist wants to be seen as the smartest and most powerful, a communal narcissist wants to be seen as the most giving and helpful. Communal narcissists’ vain selflessness is no less selfish than that of a grandiose narcissist. They both share similar motives for grandiosity, esteem, entitlement, and power, although they each employ different behaviors to achieve them. When their hypocrisy is discovered, it’s a bigger fall.

The Malignant Narcissist

Malignant narcissists are considered to be at the extreme end of the continuum of narcissism due to their cruelty and aggressiveness. They’re paranoid, immoral, and sadistic. They find pleasure in creating chaos and taking people down. These narcissists aren’t necessarily grandiose, extroverted, or neurotic, but are closely related to psychopathy, the dark triad, and anti-social personality disorder (Houlcroft, et al. 2012).

Fluctuating Ego States

If you have a hard time identifying which type of narcissist you’re dealing with, it might be because grandiose narcissists oscillate between states of grandiosity and vulnerability. For example, grandiose narcissists may show vulnerability and emotionality (usually anger) when their success is thwarted or their self-concept is under attack. Greater grandiosity indicates greater instability and likelihood of fluctuation. There’s little evidence that vulnerable narcissists exhibit grandiosity (Edershile & Wright, 2019), (Rhodewalt, et al. 1998).

The Search for the Core of Narcissism

Using new techniques, recent studies have attempted to isolate a singular, unifying trait among narcissists. Researchers examined narcissism by testing distinct personality traits. Two recent models emerged: One is based on personality and the other is an integrative, transactional approach.

The Trifurcated Model

The Trifurcated Model of Narcissism shows that narcissism centers on three personality traits: Agentic extraversion, disagreeableness, and neuroticism. (Miller, Lynam, et al., 1917) (Agentic extraverts are authoritative and bold go-getters who pursue acclaim, achievement, and leadership positions.) Of the Big Five personality traits, disagreeableness is the only one common to both types. The model illuminates the core of narcissism to be interpersonal antagonism, shared by grandiose and vulnerable narcissists alike. It’s characterized by manipulation, hostility, entitlement, callousness, and anger (Kaufman, et al., 2020). Vulnerable and grandiose narcissists express antagonism differently. The former are more hostile and distrustful, and the latter are more immodest and domineering.

The Spectrum Model

The Narcissism Spectrum Model (NSM) created by Kerzan and Herlache (2017) conceives narcissism as existing on a spectrum from grandiose to vulnerable. It demonstrates how NPD varies in severity and how traits manifest. The model reveals that both types of narcissists share a common psychological core of entitled self-importance. Narcissists believe that they and their needs are special and take precedence over those of others. This core is made up of arrogance, self-involvement, and entitlement. In fact, entitlement is reportedly the most toxic element in relationships. 

Narcissists’ differing personalities express diverse qualities at various times, this model captures a fluid, functional analysis that is more representative of real life. The greater a person’s grandiosity, the less is their vulnerability and vice versa. More entitlement and risk-taking increase professional and interpersonal difficulties. The greater the vulnerability, the further away (lower) is their grandiosity.

Takeaways

In sum, narcissism exists on a spectrum ranging from domineering and extroverted to introverted and neurotic. The core features of narcissism are antagonism, self-importance, and entitlement, making narcissists disagreeable, uncooperative partners and work associates. Because other personality types can be antagonistic, I prefer the Spectrum Model that singles out self-important entitlement as the core of narcissism, thus distinguishing it from sociopathy and borderline personality disorder, among others.

Grandiose narcissists present a mixed bag. While they feel and function better than vulnerable narcissists and can be socially engaging when they choose, their antagonism and entitlement create problems and jeopardize relationships. If they attend therapy, it should focus on their antagonism and entitlement. 

On the other hand, vulnerable narcissists need help managing their perceptions, moods, and emotions. They resemble people with borderline personality disorder and would benefit from dialectical behavioral therapy, which is effective in reducing antagonism. Schema-focused psychotherapy and cognitive behavioral therapy are helpful for both types to reduce shame and anger.

Whatever type of narcissist you care about, the relationship is hurtful. Rather than getting your needs met, you’re undermined and drained dealing with frequent criticism, callousness, hostility, demands, and entitled expectations. Don’t spend your efforts trying to please or change a narcissist. Instead, start recovery to rebuild your self-esteem and autonomy so you’re more resilient whether you stay or go. If you’re undecided, get some individual psychotherapy, and use the tools in Dealing with a Narcissist to determine the prognosis for your relationship.

References:

Edershile, E. & Wright, E. (2019). “Fluctuations in grandiose and vulnerable narcissistic states: A momentary perspective.” DOI: 10.31234/osf.io/8gkpm.

Houlcroft, L., Bore, M., & Munro, D. (2012). “Three faces of Narcissism.” Personality and Individual Differences, 53: 274-278.

Kaufman, S. B., Weiss, B., Miller J. D., & Campbell, W. K. (2020). “Clinical correlates of vulnerable and grandiose narcissism: A personality perspective,” Journal of Personality Disorders, 34 (1), 107-130.

Krizan, Z. & Herlache, A. D. (2018). “The Narcissism Spectrum Model: A synthetic view of narcissistic personality,” Personality and Social Psychology Review, 1:29. DOI: 10:1177/1088868316685018.

Miller, J. D., Lynam, D. R., Hyatt, C. S., & Campbell, W. K. (2017). Controversies in narcissism. Annual Review of Clinical Psychology, 13, 291–315.

Rhodewalt, F. & Morf, C. C. (1998). On self-aggrandizement and anger: a temporal analysis of narcissism and affective reactions to success and failure. Journal of personality and social psychology, 74(3), 672.

© Darlene Lancer 2020

When I was sixteen years old, I met every requirement in the DSM-IV criteria for Anorexia Nervosa. My Body Mass Index (BMI) hovered just below 17.5, I was obsessed with counting calories and becoming skinnier, I was terrified of gaining even a single pound of weight, and I lost my period for longer than three consecutive cycles. My iron and ferritin levels fell below normal and I was tired all of the time. Before long, I was avoiding eating with my friends and family, and I had given up my favorite sports because I was too weak to run the warm-ups. I was never diagnosed with an eating disorder, however; I refused help because I felt that I was never thin enough.

When we think of someone with Anorexia Nervosa, we might picture someone like who I just described: underweight, sickly, and perpetually exhausted. However, these physical characteristics appear only over long periods of time; in order to actually exhibit them, one needs to have been struggling mentally for a while beforehand. One does not simply go to sleep one day healthy and wake up the next underweight and malnourished. Anorexia takes hold and develops over months or even years, and it is mentally debilitating long before its physical implications begin to emerge. Why, then, does our perception of Anorexia Nervosa hinge so heavily on its physical side-effects, and tend to focus less on the mental state that precedes it? The DSM recognized this issue in part and updated the criteria for Anorexia Nervosa in the new DSM-V; no longer is it necessary to have an absent menstrual cycle or to be at a particular BMI in order to be diagnosed — although a “significantly low body weight” is still required. In theory, such an emendation allows those who are struggling with the mental aspects of Anorexia to receive diagnosis and treatment, before all of the dire physical effects set in. But why is physical appearance still being factored into the equation at all? Is it merely perpetuating the concept of being “not thin enough” to have Anorexia? 

At sixteen, I was lucky enough to eventually re-attain a healthy weight, thanks to the intervention of my family, support from close friends, and a year of veganism. My energy levels rose, my blood normalized, and I deleted the calorie-counting apps from my phone. I didn’t learn how to love my body, but I learned how to live in it.

In retrospect, I ask myself why I never felt like I deserved to get help. In fact, I was doing quite the opposite of getting help — I was actively trying to dig myself deeper into my disorder. I spent a good part of my time on MyProAna (a pro-Anorexia forum) getting advice on how to reach new “goal weights” and how to starve myself without passing out in class. I was swept into an entire community of people who I felt understood me the way that no one else did. Worst of all, I felt like I needed to lose more weight to become comfortable in my body, and eating normal quantities of food filled me with intense feelings of shame and disgust.

It seems that eating disorders have a knack for giving their victims a nasty case of Stockholm Syndrome. Could this be one of the most dangerous, but least addressed, features of Anorexia Nervosa? 

When I realized that I was slipping back into disordered eating in college, I wanted to get help as quickly as possible. My old habits took hold subtly, beginning with an effort to eat less sweets and hit the gym a few times a week; then I was looking back and realizing that I hadn’t eaten dinner with my friends in months. I was counting pistachios into tiny tupperware containers, living off yogurt and applesauce for days at a time, refusing lunches with my parents on weekends, and avoiding hangouts with my friends like the plague.

I couldn’t focus on anything other than food and calories. Schoolwork went on the backburner. My days very quickly became reduced to numbers: numbers on the backs of labels, on scales, and on tape measurers. I obsessively counted and recounted every single calorie in every morsel of food that I consumed, over and over again. I scribbled down meal plans into every notebook and onto every handout in class, and made checklist after checklist in the Notes application on my phone. The amount of calories in an ounce of walnuts, half a spoonful of peanut butter, and a cupful of blueberries became second nature to me.

As the months went on, the physical symptoms began to follow suit; I lost fifteen pounds, my collarbones and hip bones began to protrude, and my clothes sagged. I had been a healthy weight to begin with, so this was enough of a loss that the people who knew me pulled me aside to ask if I was alright. This time around, I knew that I wasn’t; what was happening was all too familiar to me. I felt afraid and unwell, and yet still I hesitated to get help. I feared that maybe, because my weight was still within the “normal” range for BMI, going to the doctor would be an overreaction. It wasn’t until a few weeks later, when I nearly fainted at a coffee shop, that I finally booked an appointment. 

My doctor checked me over and told me to come back in two weeks so that she could monitor my weight — by the time I went back, I had lost almost seven more pounds. I now scraped the bottom of the normal BMI range for my height. This time, I was told in no uncertain terms that I needed to start eating more, and that if I didn’t, my heart rate would start falling and my body would begin to shut down in response to starvation. I needed to come back that very Monday — only five days away. Monday came around and another two pounds had gone. 

I was quickly diagnosed with Anorexia Nervosa and was told to come back for weekly weigh-ins in addition to psychotherapy and appointments with a nutritionist, but, oddly enough, I no longer thought I needed help. I rejected the meal plans that I was given, refused to continue meeting with my nutritionist, shuddered at the suggestion to “restore my weight,” and brushed off my parents’ worries. I know what I’m doing, I thought with frustration. They don’t get it. 

It’s such a slippery thing to fall into the open arms of an eating disorder. It happens so quickly; you feel like you have complete control and like it’s all harmless, and then suddenly it gets away from you and becomes a monster all on its own. Even as I went through the motions of “recovery,” I mentally rejected the diagnosis. How could I have Anorexia? My weight might be a little low, but I wasn’t skeletal. I didn’t look like the poster girl for Anorexia. I didn’t look like I needed treatment.

That is the insidiousness of this eating disorder: it tricks you into thinking that you don’t need help when you do, all because of a number on a scale that will never be low enough. You tell yourself that you will be happy once you lose a certain amount more, but when you reach that amount, you will not be satisfied and you will set another goal. It will become a ceaseless game of limbo that could very well land you in a hospital bed one day, if not an early grave. Anorexia is the deadliest of all mental illnesses, with a whopping 20% mortality rate when left untreated. Death rates increase ten-fold if the individual is diagnosed between the ages of 15 and 19, and 18-fold if they are diagnosed between the ages of 20 and 29. Early treatment is critical for a better shot at recovery, but how can early treatment be provided if the DSM specifies low weight as a requirement for diagnosis? 

Listing “significant low body weight” as a criterion for Anorexia Nervosa may be seriously exacerbating sufferers’ hesitancy to get help. To a healthy mind, there is such a thing as too thin, but to a mind sickened with Anorexia, that simply doesn’t exist — and the more the disorder kicks into gear, the more it tightens its grasp.

Because Anorexia progresses rapidly and becomes increasingly more difficult to treat down the line, perhaps the point that should be driven home is this: struggling mentally is enough of an indicator that you need and deserve help. At the end of the day, eating disorders are mental illnesses that wreak havoc on your body regardless of what you weigh. Removing physical characteristics from the DSM’s diagnostic criteria may be the first step towards acknowledging this fact, and to helping sufferers understand that their body is never going to be — and never has been — a defining factor in their illness.