Sunday, August 14, 2011

'Having an Empathy Problem' Versus 'Having Zero Empathy'

Stuart K. Hayashi

What I am about to say is a generalization about persons suffering from currently-untreated Borderline Personality Disorder (BPD). Naturally, these generalizations do not necessarily apply to all people with BPD at all times. This assessment is based on what I have observed in my own experiences, plus what some persons diagnosed with BPD have written to me. Bear in mind that those persons do not necessarily agree with everything written on this blog. Anyhow, I will sometimes refer to persons with currently-untreated BPD as "Borderlines." This should not be taken as a pejorative; the locution is used for the purpose of making my blog post easier to read. Likewise, the loved ones of Borderlines will sometime be called "Non-Borderlines," "Nons" for short. When discussing a Borderline, I will switch between the pronouns "him" and "her."

Their Aloof Pose Does Not Prove That They Never Think About You
Love ones have often been on the receiving end of very inconsiderate treatment from the Borderlines in their lives. And when currently-untreated Borderlines are confronted with this fact, their loved ones are often horrified by the currently-untreated Borderlines' evident refusal to show remorse for this treatment, or to even make any sincere promise to change it. Based on the Borderlines' blase-at-best reaction, many loved ones often conclude that Borderlines are sociopaths who have zero capacity to empathize. I can see why such loved ones would infer as much. However, such a conclusion is misleading. If you have someone in your life who has undiagnosed, untreated BPD -- and refrains from exhibiting any real remorse for mistreatment of you -- chances are that this person does have genuine remorse for this mistreatment . . . but would be loathe to admit it to you.

Even as prestigious a research psychologist as Simon Baron-Cohen (cousin to the famous actor who plays Borat and Bruno) grievously equivocates Borderlines with sociopaths. A news article about Baron-Cohen's latest book summarizes Baron-Cohen's conclusion this way:

...the pathological group. These are people with borderline personality disorder, antisocial personality disorder and narcissistic personality disorder. They are capable of inflicting physical and psychological harm on others and are unmoved by the plight of those they hurt. Baron-Cohen says people with these conditions all have one thing in common: zero empathy.

The news article's author is not putting words into Baron-Cohen's mouth. Direct quotations from Baron-Cohen indicate the accuracy of the prior paragraph's description of Baron-Cohen's view. Baron-Cohen himself says that he equates every "personality disorder" with "a lack of empathy because many of the personality disorders, like the psychopath, or people with borderline personality disorder are just operating on a totally self-centred mode."

Both Simon Baron-Cohen and the newspaper writer fallaciously equate ethics with "social interaction," the implication being that you would have no need for morality if you were stranded on a desert island all by yourself. As you know that I support a humane and considerate Ethical Egoism, you know I reject the "zero-empathy-equals-evil" presumptions of Baron-Cohen and that newspaper writer. But as this blog concerns itself merely with explanations of BPD and Body Dysmorphia, I will not digress into a long discussion about the ethics of rational self-interest. I will merely continue about BPD.

This ABC News piece likewise cites a psychologist as it equates BPD with a sociopathic paucity of empathy:

Two of the potential issues [Casey] Anthony could suffer from are borderline personality disorder and psychopathology, the experts said. The main thing these issues have in common is a total lack of empathy, according to LeslieBeth Wish, a psychologist and licensed social worker in Sarasota, Fla.

Once, a person with a beautifully high level of empathy had seriously told me, "I wonder if I'm a sociopath. When other people want me to cry about the things I do to them, they get no such response. I just go numb; I don't have a ability to feel."

Knowing this person very well, I replied, "I don't think you lack such a capacity; I have seen and felt your warmth and caring. I think what's really going on is that you feel so strongly, that it it causes a strain and hurt more severe than that experienced by others. It's not that you feel less than they, but more. To defend you against too much pain, the emotional parts of you go numb so as to protect you."

Then this person made a really weird blank look (more of this will be described later). The person then said something very quickly, and the tone would have sounded cocky if it weren't full of obvious defensiveness. What was said was, "No, I don't go numb at all. I'm just logical."

At the time, I scoffed at the notion that this person could be a sociopath; this person had -- and has -- a highly empathic nature. I now understand why this was said, and why very sane, normal people would accuse this person of being lacking in empathy. They would make this accusation because they do not fully understand this person's psychiatric condition. The most tragic part is that this person, too, misunderstood this person's own issues with empathy. :'-(

Two Forms of Empathy
First we should clarify that there are two types of empathy -- cognitive empathy and affective empathy. You are engaging in cognitive empathy when, on an intellectual level, you understand how someone else is feeling. By contrast, you experience affective empathy when you observe someone else's emotion and, as a direct consequence of this observation, experience the very same emotion.

If I observe that someone else is sad, but I myself do not feel sad about this, then I am experiencing cognitive empathy but not affective empathy. Conversely, if I see someone is sad, and I consequently feel sad myself, then I am having empathy on both the cognitive and affective levels.

In many cases, a functioning autistic is low on cognitive empathy but is still capable of experiencing affective empathy. That is, if your body language gives off the subtle cues about your feelings that are normally given off, the functioning autistic will comprehend none of it; he will not know what you are feeling. However, if you make it very obvious that you are sad or frightened to an extreme degree, the functioning autistic will probably likewise become sad or frightened as well.

A sociopathic con man pretty much operates in the opposite fashion -- he has high cognitive empathy but low affective empathy. He is able to manipulate and con you precisely because he can carefully read your body language and tone, and therefrom accurately infer what you are feeling. However, when he sees the pain that his actions have caused you, he is genuinely unable to feel bad along with you, or to experience authentic remorse. Insofar as he is remorseful, that remorse is shallow and will be soon forgotten.

Many people with currently-untreated, undiagnosed BPD have issues with empathy that are similar to those of functioning autistics and sociopaths. However, there are important differences.

Why Do Borderlines Appear Unsympathetic to Your Distress?
An astonishing number of currently-untreated, undiagnosed people with BPD symptoms like to pride themselves on their ability to read people; they see themselves as having high cognitive empathy. However, in my experience, the same people-with-BPD-symptoms have actually made some glaring social gaffes, oblivious to their own outlandishness. I know of one case where this person thought that she had impressed everyone in the room when, in actuality, her eccentric behavior made most of the people in the room feel awkward and uncomfortable. Sometimes this person had high cognitive empathy, but there were commensurate occasions on which her cognitive empathy was low.

When it comes to the matter of affective empathy, consider the emotional instability common to Borderlines who are currently not in treatment but ought to return to it. When the currently-untreated Borderline is feeling safe and secure, it is very easy for the Borderline to emotionally bond with you and to feel as you do. However, it may be the case that this Borderline can easily be "triggered" by some stimulus -- such as by some type of mention of sex or reproductive anatomy -- that elicits a panicky anxiety attack from the Borderline. During these panic/anxiety attacks, the Borderline is often caught in a fight-or-flight response. Even though, to you, the Borderline is getting upset about nothing, the Borderline can seriously feel something like, "Aaaaaauuuuuckk!! I'm dying!!!" (This is not hyperbole. The distress is that severe.)

BPD Anxiety
When the Borderline is triggered, the Borderline will interpret the trigger as some kind of life-or-death emergency. In those moments, the currently-untreated Borderline's concern for anyone else's feelings or well-being goes out the window. During moments of panic -- triggered by rather harmless stimuli -- the Borderline will be low on both cognitive- and affective empathy.

Recall that among the main symptoms of BPD are emotional instability, chronic emptiness, a proneness to anger, self-destructiveness, suicidal thoughts, and general anxiety. As emotional pain is something of a norm for Borderlines, too many of them develop the maladaptive practice of suppressing their emotions and trying to become emotionally numb. I recall someone very dear to me who learned to repeatedly become stoic in this way. This person often became upset at the slightest provocation. It was not initially obvious when this person became upset. When this person was triggered and became upset, this person's face suddenly became weirdly blank, with this person's mouth stiffening. It looked like some kind of "poker face," but with some resignation and tiredness, too. Although the person had learned to hide the discomfort by putting on a blank, stoic expression, you could still detect the tension at the temples.

The point is that even when this person had those panic/anxiety attacks, the person developed this blank, stone-faced expression. I suspect it is because the person misapprehends that admitting her own vulnerabilities would be some kind of show of weakness. My educated guess is that some currently-untreated Borderlines misperceive that confronting and accepting this vulnerability would be some sort of relinquishment of power and control. In fact, the opposite is true -- to let the vulnerabilities show would be the manifestation of true confidence and courage and strength. Moreover, it would not be giving up control and power but gaining the only forms of power and control that matter -- the power and control over oneself that comes with taking responsibility for one's own mental well-being.

Yes, this person easily became upset. As a maladaptive -- and ultimately unhelpful -- attempt to manage the anger or hurt, this person had become accustomed to numbing and repressing such emotions so as to not "lose cool" in public. The long-term negative effects of this emotion-suppression technique are explained by a psychologist here and by a recovered Borderline here.

And one big, panic-inducing "trigger" for many currently-untreated Borderlines is any attempt on your part to confront them on how their inconsiderate behavior is hurting you and of how you wish they would see the situation from your vantage point. When you try to very gently discuss this matter with the currently-untreated Borderline, the currently-untreated Borderline might react in one or both of these ways:

1. Become triggered and experience that sense of panic and emergency. In this very moment, the currently-untreated Borderline will only worry about her own feelings -- as if her life is on the verge of ending -- and will have low regard for your decision to express your own feelings. This definitely makes the currently-treated Borderline appear generally non-empathetic.

2. Become triggered and upset, and then immediately cope with the panic by getting all numb. To the degree that the currently-untreated Borderline succeeds in becoming numb, she will honestly be devoid of any interest in your plea that she take your feelings and well-being into account. This, too, makes the currently-untreated Borderline appear generally non-empathetic.

In those moments of confrontation, the currently-untreated Borderline probably does show a deficiency in empathy. It would be a mistake, however, to conclude from this that the currently-untreated Borderline has never felt any authentic affective empathy for you.

A sociopath is someone perpetually incapable of experiencing strong affective empathy. This applies all or at least most of the time. By contrast, a currently-untreated Borderline will very easily feel affective empathy for you when she is relaxed. But this currently-treated Borderline will, in times of stress, experience momentary -- but very brutal and crushing -- lapses in empathy for you. Simon Baron-Cohen is all mixed up. A currently-untreated Borderline's momentary lapses in affective empathy -- and stubborn refusal to be contrite with his or her victims -- should not be conflated with a sociopath's continuous and persistent absence of affective empathy.

A Vicious Cycle Going in . . . A Perfect Circle . . .
If you're a Non, and have tried to maintain a close social bond with a currently-untreated Borderline, then you might have gone through this painful cycle:

1. The currently-untreated Borderline does something to the Non that is horribly inconsiderate . . . maybe even cruel.

2. The Non very gingerly, calmly, and gently tries to explain to the currently-untreated Borderline how the Borderline's behavior has been harmful and/or disrespectful to the Non. The Non compassionately asks the Borderline for a very deliberate changes -- an improvement -- in behavior.

3. This confrontation triggers the Borderline. The currently-untreated Borderline gets that panicky fight-or-flight response -- even if he or she continues to look calm on the outside -- and gains the inaccurate-but-strong emotional sensation that it's an emergency to completely ignore and disregard the Non's tearful entreaties. The Borderline will rebuff the Non's entreaties, as if only the Borderline's feelings are important whereas the Non's feelings are immaterial.

4. The Non interprets the Borderline's rebuff as a general lack of empathy and remorse. This is offensive, horrifying, and disgusting to the Non. He now sees the Borderline as cold-hearted, and this cold-heartedness as immoral. The Non desperately pleads with the Borderline to be more caring (i.e., more moral).

5. This further aggravates the Borderline, thus impelling the Borderline to further numb him- or herself. Whether by conscious intention or by automatized practice, the Borderline refrains from making any remorse visible to the Non. (In truth, when the Borderline is out of the Non's sight, the Borderline will reflect on the matter in secret and feel guilty about it.) The Non then tries harder, further admonishing the Borderline to change.

This cycle pretty much repeats itself -- getting worse and angrier with every repetition -- until the Non finally gives up and cuts the Borderline out of his life. Years later, the Non probably believes that the Borderline still feels no remorse. In truth, when the Borderline looks back on these events -- and refrains from evasion -- the Borderline probably does regret his or her behavior . . . but he or she delusionally believes it important that the Non never learns this.

If you're a Non, then it's not realistic for you to expect your entreaties ever to be enough to persuade the Borderline to change, no matter how gentle or heartfelt or justified your entreaties are. The entreaties almost always fail because this approach is one that many currently-untreated Borderlines find intolerable.

You are, however, morally justified in your wish that the Borderline would change, if only because it would be more conducive to at least his or her own happiness. :'-(

I recommend this alternative approach. Inform the Borderline that you will always care about him or her, no matter what. To always care about and love the person, however, is not the same as tolerating all of the abusive behavior, all of the devaluation, and all of the inconsiderateness and disrespect. Make it clear to to the currently-untreated, undiagnosed-person-with-BPD-symptoms that, though you will always care about this person, you will tolerate no disrespect or devaluation. Any time the person unjustly devalues or disrespects you, withdraw yourself from the interaction, and do not comply with any irrational requests. If the inconsiderateness is very severe and persistent, you can communicate to this person that these two principles are both true at the same time and do not contradict:

1. You care about this person's well-being, and probably always will.

2. You will not interact with this person again until such time that this person is able to provide you creditable evidence that she has resolved to change for the better and is getting the professional psychiatric care that she needs.

My alternative approach cannot guarantee any change at all in the currently-untreated Borderline's behavior. However, it will spare you -- the Non -- a lot of hours or years of fruitless entreaties to the currently-untreated Borderline to change.

Perhaps you can take some small consolation in the knowledge that the currently-untreated Borderline often did have authentic affective empathy for you, and that this person's exhibitions of indifference to you do not necessarily prove that, deep down inside, this person has zero regrets about mistreating you. :'-(

Wednesday, August 10, 2011

Fragmented Personalities

Stuart K. Hayashi of Hawaii, blog at blogspot

As the mental health vlogger and recovering BPD patient MeAndMyBlackTable helpfully explains, "Borderline Personality Disorder is not a Multiple Personality Disorder. However, when you are having a conversation with someone who has BPD, it can feel like you're having a conversation with more than one person." I do know of at least one case where a psychiatrist was tempted to diagnose someone with multiple personality disorder (now known as the Dissociative Identity Disorder) when the symptoms much more closely matched BPD and Body Dysmorphia.

There are reasons for why someone with BPD would act as if she has multiple personalities. To some extent, it makes sense that people would somewhat adjust their behavior according to different situations. A normal man is expected to be solemn at church, and more jocular at a party. You wouldn't expect him to be loud and raucous at a church. . . . Well, actually, I would be, but I'm not normal. And thank goodness for that! Hee-hee! ^_^ Anyhow, that sort of adjustment is normal to some degree. However, in many cases of someone with BPD, the personality changes are often much more extreme -- to the point where they greatly interfere with domestic life.

In public, someone with undiagnosed, partially-treated, currently-untreated BPD symptoms may appear to be a tough, unemotional, invincible businesswoman. But when the guard comes down, she might start sniffling over something that you wouldn't ordinarily expect someone to cry about -- such as about someone tastefully complimenting her -- and talk to you in the voice of a lost, little girl. And this change can sometimes be very sudden and happen at the slightest provocation. If you're unfamiliar with BPD symptoms, this can seem very surprising. You may feel tempted to ask the multiple-persona person, "Which of your personalities is 'the real you'?" The truth, whether that person recognizes it or not -- is that all the different personality facets are the "real" one; it's just that they haven't been as smoothly integrated as you would expect with most people.

This is related to the identity disturbances, wherein someone can take on a certain persona for several months and then "change" again, or might even change self-identified sexual orientation every few months or years (see here for an example of changes in sexual orientation). Though someone with undiagnosed, currently-untreated BPD might stress his or her repeated personality "c-h-a-n-g-e"s throughout life, there is a factor that will sadly remain constant if psychiatric care remains absent: the presence of these life-thwarting symptoms. Insofar as someone with severe, untreated, undiagnosed BPD refuses any return to psychiatric care, a very beneficent, happy, authentic change is exactly what is missing. (For a good description of the identity issues, see this essay.)

This seems to be related to the issue of "splitting." If someone is "splitting," it means she has very unbalanced, whim-based, polarized, and completely nuance-free shifts in her evaluations of other people. With greater emotional attachment to a person comes more intense shifts in these evaluations. Consider a boy ranging in age from newborn to about seven years old. When a mother is nurturing her newborn baby boy, who is confined to his cradle, he sees her as all-benevolent. But when she walks away from his cradle, it's not as if he can go after her. He cannot be sure that she will ever return to his side -- as far as he can understand it, she is abandoning him, perhaps forever. In these periods, the mother is not seen as all-benevolent but infinitely neglectful, infinitely cold-hearted, and ultimately undependable.

Likewise, consider this same boy when he is four years old. Again, when his mother is lavishing attention on his adorableness, he sees her as all-good, all-nurturing, all-loving. But when she scolds him or disciplines him, he feels humiliated. At this particular juncture, she switches to all-malevolent, all-hateful. There is no nuance in this; for many children this age, it's hard to comprehend the idea that you can approve of some aspects of your mother's personality and disapprove of other parts of her, while loving her overall.

For many people with undiagnosed, currently-untreated BPD, there is a similar phenomenon at work. This person can become fixated on you and lavish you with adulation, as if you are the all-nurturing mother this person has always wished for. You can be the most masculine man in the world, and you can still be regarded, on some level, as that much-yearned-for mother figure (I repeat: you, as a man, can be seen as a strong mother figure, not father figure). But when you disappoint this person, that vision is shattered. No matter how much this person proclaimed your supreme value, you can then instantly be cast into the dog house. In her eyes, you become something that deserves zero attention or respect. To this person, you become something beyond contempt, a speck of dust.

When you have first been idolized by such a person, and then, soon afterward, given the cold-shoulder by this same person over nothing, it can make you wonder if the prior idolization was genuine. It makes the person look shallow at best, insincere at worst. But in such cases, what often happens is that, in those moments of adulation, that person meant it. Likewise, when that person was treating you like garbage, that was what was meant, too.

It's not that the person is consciously being dishonest in either case; it's that the person is acting according to strong whims with the same psychological complexity (or shallowness) as a four-year-old boy would react to you. It's very easy for a four-year-old boy to instantly shift from seeing you as all-great to all-crummy. The same principle can apply to the emotional reactions you receive from someone with undiagnosed, currently-untreated BPD. You can find a helpful description of this "splitting" over here. And now I will quote another accurate description of "splitting":

Devaluation is when they suddenly behave as if they don't value you anymore. They become inexplicably cool toward you for no discernible rhyme or reason. And they seem to have no memory of how much they adored you yesterday.

They may be doing this as a reaction to feeling abandoned. And they may feel abandoned at the *slightest* sign of rejection from someone. It may be something as inconsequential as you showing up 10 minutes late for a date. Or they might imagine you were paying attention to someone else in a sexual way, etc. Many things can trigger their fear of abandonment.

They also typically devalue their partners at times when a relationship is becoming especially close or is about to move to a new level... this also triggers their fear of abandonment. Things have become too close, they become frightened, and they push the partner away. Often, this response is an automatic reaction, more of a reflex, and not something to which they give much conscious thought. And they truly can forget how much they cared about you yesterday... they live very much in the moment... and their mood of the moment is all encompassing, they can forget everything else.

Devaluation is usually a part of a cycle of Idealization and Devaluation. They go back and forth between these two extremes of feeling for their partner. This is the push/pull dynamic of BPD. They devalue and push the partner away until there is too much distance...

Perhaps you know someone who has symptoms of undiagnosed, currently-untreated BPD. Perhaps this person repeatedly proclaimed undying love for you. Then this person went through a scary phase and, a week later, started treating you like dirt. Was this person's prior declarations of love all a lie? I think you will find that, when proclaiming love, this person believed it at the time. Likewise, when this person was treating you like dirt, this person assumed it emotionally justified, at the time. This is how someone with treated, diagnosed BPD describes it [when you go to the link, it's in the margin on the right]:

Some partners of people with BPD worry the relationship was just a game, that their SO [significant other] was using them and felt nothing for them. That's not true.

I am a recovering BP [Borderline Personality].

Before, when I was in a relationship, my feelings felt genuine. I didn't have a conscious ulterior motive. There was an authentic connection; and while it may have been unhealthy and for the wrong reasons, it was, in my mind, real.

I acted as if I was in love because I thought I was.

The bond that occurred in the beginning of a relationship was incredible: there was a deep (false) sense of knowing the other person intimately, intuitively. He became my whole world and it was wonderful, rapturous. When my boyfriends left – and they invariably left – that world was anhiliated; everything fell to ashes. . . . The saddest thing about the situation was that I was the cause of my pain, yet had little idea then that it was due to my own behavior.

So yes, the love is “real”, but only in the sense of how it feels to the person with BPD: the feelings seem real, they feel like love.

This is a video that describes a more severe (to me) version of the "fragmented personalities" phenomenon.

Below is a video from the mental health vlogger and recovering BPD sufferer Dani Z. She is much more chipper and more self-aware than those whom I have known who have shown symptoms of what looks like untreated, undiagnosed BPD. But Dani Z being more chipper and self-aware is part of the fact that there is individual variation among different cases of people who have BPD.

Monday, August 08, 2011

Body Dysmorphic Disorder, a.k.a., Body Dysmorphia

Body Dysmorphic Disorder (BDD) -- also known as body dysmorphia -- is a persistent psychological condition involving a sense of alienation from one's own natural physical features. Someone with BDD can look in the mirror and be disturbed by this, saying, "Who is that? I don't recognize this person. It's all wrong. This is ugly. Everyone tells me I'm good-looking. But when I look in the mirror -- or at old photos of me -- I can see I'm ugly." This might be related -- I once read a very distressing blog entry in which the author wrote something like, "I have the urge to cut my face up."

Someone who has experienced the condition of body dysmorphia very helpfully explains it in this video.

This one is also very helpful in its description:

I appreciate the candor of these vloggers. These issues are not easy to discuss. By doing so, however, they help educate people and let other sufferers of this condition know that they are not alone.

Someone can have body dysmorphia without having Borderline Personality Disorder (BPD). Likewise, someone can have BPD without having body dysmorphia. However, as I previously mentioned, a survey of individuals diagnosed with BPD found that about half of them also reported having symptoms of body dysmorphia.

This condition is the cause of much distress. To those of who have it and are disturbed by it, please know that you do not have to suffer through this. There are effective psychiatric treatments for this. Getting that treatment is difficult to start. But, in the end, it's worth it. :'-)

As you may notice, long-term recovery from this condition does not come from an extended effort to hide one's true appearance beneath some clever disguise. Rather, long-term recovery comes with radical acceptance of one's own natural-born, metaphysically-given anatomy. Once again, a stable and lasting happiness comes from true self-acceptance. :'-)

More Treatments for BPD Available on Oahu

Earlier I blogged about BPD treatment practices in Honolulu, and noted that within Psychology Today's index of mental health care professionals on Oahu, only one was listed as a specialist for treating Borderline Personality Disorder and gender identity issues (see here). I thought there was only one such specialist on Oahu, but there is another in Kailua.

And it turns out that there is a Dialectical Behavior Therapy (DBT) clinic on Oahu. Its website's very front page mentions that the clinic's practitioners specifically aim to treat BPD symptoms.

UPDATE from Monday, January 16, 2012: Today I found another website providing contact information for other clinics and therapists in Honolulu who provide DBT. Among those professionals, though, only one mentions having a strong focus on providing DBT.

I know that, deep down, you know that it's a good idea to return to getting the help you need. Have courage. The long-range happiness possible to you is within your grasp; you only need to courageously commit to making it a reality. :'-)