Narcissism

Narcissism

Screen Shot 2017-07-14 at 9.07.51 PMThe legend is that Narcissus was a handsome Greek youth who rejected the desperate advances of the nymph Echo. As a punishment, he was doomed to fall in love with his own reflection in a pool of water. Unable to consummate his love Narcissus was said to stare at his image in the pool hour after hour and finally pined away and changed into a flower that bears his name Narcissus.Screen Shot 2017-07-14 at 9.12.22 PM

Screen Shot 2017-07-14 at 9.10.21 PMIn 1911, Otto Rank, a prominent psychiatrist, spoke of narcissism as being related to vanity and self-admiration. A few years later, Sigmund Freud thought narcissism was not necessarily abnormal. He distinguished between primary narcissism with self-love which is linked to self-preservation and secondary narcissism where there becomes limited ability to love others and the problematic development of megalomania.

In the 1970’s, Otto Kernberg wrote extensively on this subject and felt that there was a group of people who have an unusual degree of self-reverence in their interactions with other people. He noted that Screen Shot 2017-07-14 at 9.16.57 PMin these individuals, there was a great need to be loved and admired by others and a curious apparent contradiction between a very inflated concept of themselves and an inordinate need for tribute from others. He believed that their emotional life is usually shallow and that they tend to experience little empathy for the feelings of others. Such people obtain very little enjoyment from life other than from the tributes they received from other people or from their own grandiose fantasies and they feel restless and bored when external glory wears off. Dr. Kernberg wrote about techniques for approaching such patients in psychotherapy.

 

Screen Shot 2017-07-15 at 10.54.33 AMThe latest version of the Diagnostic Criteria Manual (DSM-5) from the American Psychiatric Association stated that a Narcissistic Personality Disorder is a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and a lack of empathy beginning by early adulthood and present in a variety of contexts as indicated by five or more of the following.

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognize as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is “special” and unique and can only be understood by, or should associated with, other special or high status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
  6. Is interpersonally exploitative (i.e. takes advantage of others to achieve his or her own ends).
  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviors or attitudes.

It is possible and in fact is often the case that other mental health conditions may be simultaneously occurring along with a narcissistic personality. This might be depression or other mood conditions, or variations of psychosis, et cetera. The criteria stated above are provided for mental health professionals to make a psychiatric diagnosis. Different professionals may disagree whether an individual meets a particular criteria. Also, it should be obvious that only five criteria are necessary to make the diagnosis. Therefore, people with the same diagnosis might be quite different from each other. For example, an individual theoretically could be quite empathic and not be arrogant or have haughty behavior and still meet the criteria.

Any diagnosis should not be a derogatory value judgment of an individual. It is true that some of the above-criteria deal with being self-centered and not relating well to others which usually makes a person unlikeable. This is not always the case, sometimes a person with these characteristics may be quite charming and liked by others, as well as having other positive and endearing characteristics.

From my experience, it is true that people with narcissistic personality do not seek therapy as much as others do. But certainly that is not always the case. In fact, such a person may be particularly susceptible and even devastated by a “narcissistic injury” which would be circumstances which gives the person insight into their weakness, faults and vulnerabilities. Such a person may very well feel that he or she need help in dealing with these overwhelming feelings. Nevertheless, it still requires a set of specific circumstances for a person with narcissistic personality to decide to seek psychotherapy. Treatment of such of individual is often difficult and requires special techniques.

 

 

Psychiatric Ethical Position on Role of Psychiatrists in the Interrogation and Torture of Prisoners

The ethical position of the American Psychiatric ( APA) Association and the code of ethics for psychiatrists about torture came to prominence about 10 years ago when I was Speaker of the Assembly of the American Psychiatric Association. At this time the Assembly endorsed the position of the Board of Trustees of the APA about this issue. Recently this topic has surfaced again as described in the article below in the the APA News . I would suggest that this article should be read  and then for further clarification I would like to present a video interview that I had  in 2009   with the late Dr. Abraham Halpern. Dr. Halpern was a prominent American psychiatrist who was leading spokesperson  on number of ethical issues.

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And now please view the interview that I did with Dr. Halpern on this subject in October 2009.     https://www.youtube.com/watch?v=oULhHzC8E_8

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Please feel free to add any comments that you have about this subject in the comment section below and they will be published shortly.

 

 

The American Academy of Psychoanalysis and Dynamic Psychiatry – 75 Years from Now

The following is a shortened edited version of the Presidential Address which I gave at the 2014 Annual Meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry held in New York May 2014.  This article in edited form will also appear in the next issue of the The Forum, a magazine published by the American Academy of Psychoanalysis and Dynamic Psychiatry , Any comments are welcome at the end of this article

 

The American Academy of Psychoanalysis and Dynamic Psychiatry 75 Years From Today

Michae Blumenfield, M.D.

President 2012-2014

 2089

The theme of this meeting has been 75 Years After Freud and my talk in closing this meeting is the Academy 75 Years from today

Screen Shot 2014-07-14 at 12.27.04 AMNow let us look 75 years into the future – The year is 2089. I have a fantasy that the President of our organization will be my grandson Obi, who recently turned 5 years old now but at that time he will be 80 years old….. in the PRIME OF HIS LIFE. Obi’s life expectancy is to be 79-86 by projections today but many believe with scientific advances that we will have, it will be much longer. In fact,  in an article in the Journal of Anti Aging Medicine a few years ago, 60 gerontologists from leading universities all over the world were asked for estimates regarding the development of future life expectancy for a person born in the year 2100 – 86 years from now. The median prediction was 100 years whereas the mean was 292- since 3 people predicted over 1000 years. – showing that there were some Death deniers.

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I am doing a project where I am recording an audio interview with the past Presidents of the Academy and I had the pleasure of doing interviews with Milt Zaproloupus and Mary Ann Eckhardt both over 100 year old and going strong

So perhaps 80 year old Obi in his prime will be President of the Academy and he will be standing here or perhaps he will be speaking to us via Hologram .

One of my son’s is a TV producer and he said to me why don’t you do a live demonstration and project yourself into the lecture hall. I looked into this technology which is definitely available but now costs $100,000 so I thought I would save the Academy some money and let’s wait until the cost comes down. Holographs or not – In 75 years from now our President will be here surrounded by large screens where perhaps simultaneous gatherings will be taking  place all over the world in lecture halls or in their offices watching and participating in this meeting

 I believe it is fair to say that we will be an international organization. This year during my presidency we changed the international dues schedule based on World Bank calculations so our international colleagues can afford to join. Those of you teaching in the CAPA (Chinese American Psychoanalytic Alliance) know about the nascent but growing interest in psychodynamics in China which will be full grown in 75 years. In fact I predict before 75 years we will change our name from the American Academy of Psychoanalysis and Dynamic psychiatric to just the Academy of Psychoanalysis & Dynamic Psychiatry. I believe we will still be aligned with the APA and American Psychiatry …but if we follow the trends of international psychiatry so we can also be aligned with international psychiatrists who value psychodynamic psychiatry.

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We are in the midst of a technology revolution that clearly affects the way we communicate with each other. Many of us are doing therapy using Skype or newer technology. I am treating a Chinese psychiatrist in China via this video technology 2x/week as part of the CAPA program Chinese American Psychoanalytic Alliance. I have treated college students who when they left to go to out of town college continued seeing me via Skype . Many of you are doing similar things

In 75 years from now we will also be teaching psychodynamic psychiatry via the latest technology. Many of you are already teaching and supervising via Skype or similar technology. I have had the exciting experience of teaching a class by SKYPE in psychoanalytic technique to Chinese students simultaneously in three different cities in China for CAPA

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My colleague Jim Strain and I have set up a program where we have offered long distance courses to 3rd world countries and have taught psychosomatic medicine via Skype or similar technology in Colombia South American and Rwanda.

It is also interesting to consider what role will the Academy play in providing teaching courses in psychoanalytic and psychodynamic theory and treatment in the United States. While at present this is being provided by the residency programs and psychoanalytic Institutes, there are many changes going on now in the systems of post graduate education. It may very well be that in future years the Academy will take a very important role in providing the latest teaching of psychodynamic psychiatry and will do much of it using the latest techniques delivering classes and perhaps supervision directly. 

Screen Shot 2014-07-14 at 12.49.32 AM After I prepared this talk, I opened the NY Times and I learned that 3D Virtual Reality will be here very shortly. Facebook has paid 2 Billion dollars for a Virtual Reality Company that will give people the illusion that they are physically present in a digital world. The translation to Long Distance Learning and Therapy sessions won’t be far behind

But the BIG question is what will our theory and therapy look like in the distant future???? 

 In order to anticipate the role of psychodynamic and psychoanalytic therapy in 75 years from now we have to try to anticipate what will the state of the art of science, medicine and general psychiatry?? Let’s remember how far psychiatry, medicine and modern technology has come in the past 75 years

 Although the effects of penicillin was discovered a few years earlier it wasn’t until 1939- 75 years ago that a usable product was developed which we would say was the first antibiotic

 In 1938 76 years ago Cerletti and Bini introduced ECT therapy

75 years ago – it would be another 10 years until Lithium therapy for bipolar was discovered by John Cade

 75 years ago it would be another 12 years before chlorpromazine the first antipsychotic medication would be introduced.

Forget about computers 75 years ago regular TV was just started in the US Bill Gates father was 14 years old and his mother was 10 years old

 We know scientific advances occur exponentially – meaning that they will occur much faster in the next 75 years then they did the previous 75 years ago.

So what clues do we have what psychiatry will be like in 75 years from now? And what predictions can we make?

 

Screen Shot 2014-07-14 at 1.00.18 AMWe will have a much more complete understanding of the genetic and biological nature of Major Depression, Schizophrenia, Bipolar Disorders, PTSD and Dementia as well as entire new sophisticated methods of treating them and preventing much of the symptoms manifestations. Just looking at the journals which come across my desk in one recent month I noted:

 The role Apolipoprotein e-4 allele gene and depressive symptoms as well as the relationship to cognitive disorders

 Psychosocial risk factors associated with elevated plasma peptide endothelium

 Genetics predicators of lithium response

 Relationship between heart disease and depression

Relationship between depression and diabetes

 Role of inflammation and psychiatric symptoms

 The Role of Transcranial Stimulation on Depressive Disorders

 Neuroimaging differences in patients with Borderline Personality Disorder

 You also may have seen a recent article the Academy Journal by Michael Stone which discussed Borderline personality related to hyper-reactivity of the Limbic System

I believe that it is fair to say that in 75 years from today, modern medicine will have extremely effective medications, injections of genetic material, brain stimulation , possibly even some type of surgery as well as techniques we have never heard of that will be effective in eliminating, controlling and preventing so much the psychiatric manifestations that we see today in our psychiatric practice. Treatment will be complicated and will require not only a understanding of the state of the art science and medicine but an understanding of human behavior and interactions. Therefore they will still be best treated by physicians who are especially trained in medicine as well as in human behavior and interaction by which I mean psychiatric specialists. Of course it is possible that some of these treatments will be relative simple and will not require specialists and many conditions may be treated by general medical physicians as they often are today.

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However- No matter how effective these treatments are, they won’t be able to eliminate the effect of human interaction especially during child development on personality development, conflictual feelings such as love, hate, guilt, empathy, object choice, positive and negative identifications, competitiveness, passiveness, creativity adaptation, maladaptation, happiness and sadness, fulfillment and lack of fulfillment.

I believe that EVIDENCE BASED Research will continue to accumulate which will show that the state of the art intensive psychodynamic psychotherapy undertaken in adulthood will be the most effective therapeutic method to bring about an emotionally full filling life. It will become known and accepted that the previously mentioned biological based treatments although immensely successful in treating major depression, OCD, bipolar, PTSD, panic disorder, perhaps social phobia, hopefully Schizophrenia , hopefully various forms of autism WILL NOT be able to address the effects of human interaction, thoughts and fantasies on the developing personality nor on the ultimate satisfaction with self and relationships and with one’s place in the world BUT a meaningful modern psychodynamic therapy will do so.

Screen Shot 2014-07-14 at 1.09.13 AM I believe evidence based research will show that biological based treatments mentioned previously will be extremely effective in eliminating biological and genetic psychiatric conditions and may very well be able to mitigate the emotional response to relationship issues, the emotional response to loss self esteem, PTSD   etc.  but certainly will not prevent these situations, external and internal which cause anxiety and depression,  from reoccurring. But I also believe that evidence based research will build on the existing body of knowledge that strongly suggests that meaningful intensive psychodynamic therapy – let us say for sake of discussion – about two years of psychodynamic treatment- will be the most effective for doing such and produce the best results for having the least debilitating symptoms and the opportunity for a more full filling life. In the past 10 years there has been an increasing amount of Evidence Based Research and discussion about the efficacy of Psychodynamic Therapy.

If science research shows this form of treatment is effective – People will want it and expect it! The questions remaining are who will do it, who will pay for it and how will it be different than the treatment we do today ??

 WHO WILL DO IT?

 Most likely the newer form of psychiatric treatment dealing with newer medications, genetic treatment, brain stimulation, other biological interventions yet to be conceived will be handled by physicians with special interest and training in human behavior – in other words, psychiatrists. As is often the case today- when psychotherapy is indicated the same doctor who is handling the biological forms of treatment if trained in psychotherapy is in the best position to do psychotherapy also . And that would be psychiatrists.

 Recently I have been interviewing past presidents of the Academy and asking them about the pathway of their career. Many of them as have I, were drawn into this field by first being fascinated with the working of the brain and then ultimately finding that, as challenging as the interventions we could do as physicians- it was even more interesting and rewarding to interact with patients and help them make meaningful changes through psychodynamic therapy. I can see his happening in the future, as generations of medical students will gravitate towards psychiatry as tremendous advances are made in treating mental conditions BUT ultimately they will realize that in addition to these interventions, the ultimate intervention for many people will be a period of intensive psychodynamic therapy.

 OF course as is the case now- the amount of people of wanting and needing psychodynamic psychotherapy will well exceed the number of psychiatrists available to perform this therapy. So there is every reason to believe that our colleagues in other mental health professions will continue to develop their skills in psychodynamic psychotherapy and will be performing this service as many of them are now.

 But let us imagine for a moment that time and research has determined that even after all the latest bio-genetic, brain stimulating, psychopharm forms of treatment, it has been clearly shown that an intensive psychodynamic therapy makes a big difference in people’s lives…… WHO WILL PAY FOR IT?

 

 In 75 years from now it seems clear that we will have some form universal health care program – maybe single payer or maybe more like the current health care that is being rolled out. IT most certainly will cover the biological, genetic, new medical brain stimulating, modern psychopharm treatment etc and if the scientific evidence is clear the people will demand and our universal health care could very well cover the 2 years of psychodynamic treatment I envision will be needed and wanted by so many people.  BUT what if evidence is there to prove that it is worth the time and money but the future political climate won’t allow it……?

Are there any other possibilities other than the rich shell it out and it becomes a treatment for the elite?  Remember we anticipate that median life span may very well be 100. People are going to living longer and be healthier longer. People will be working and living much longer than today.

Today, if we get a mortgage on our home it is for 20 or 30 years because people are expected to have that long of a productive working life.  That also was the basis for college and post graduate loans. It is worth it, if people correctly believe that psychodynamic therapy in their 20s 30s or 40s will make a difference in  the next 60 to 80 years of their lives,  but intensive psychodynamic therapy is going to cost them over a two year period maybe 5-10 % what their mortgage might be worth, why not take a mortgage on their psychological well being?  It could be attached to their mortgage which will will be 30 \or 40 year loans or have such loans institutionalized as education loans are these days especially since people may be living and working 10 or 15 years  longer then anyway.

How will Psychodynamic therapy be different than it is today?

 In order to anticipate this question , we would have to know how our lives will be different. How will childhood experiences be different? How will families be different ? How will technology impact our lives? What degree of poverty will IMPACT child development or lack of it . We are pretty sure that people are going to live longer and therefore people’s psychodynamics are going to be influenced by growing up in multigenerational families. There will be more great grandparents as well as grandparents interacting with the developing child . Perhaps more complicated patterns of competition and identification.

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What will we learn about children being raised by LGBT parents ?

 How will some of the assumptions and psychodynamic theory be changed and modified as we understand the kids developing in same sex families? Similarly, new understandings will emerge as in the future as  we have large numbers of people who are test tube babies perhaps genetically altered.

 I have observed and have written elsewhere on this blog about the tremendous drive of adopted, children or children raised by one biological parent to connect in some way with their both biological parents and their families whenever possible –even if adopted at birth or raised by one biological parent.

 

Screen Shot 2014-07-14 at 8.50.54 PMWe just now beginning to see the emergence of children who are digital natives. – meaning they have been using digital devices since they their earliest memory – often starting at age 2 and 3 . How will this play out in 75 years after 3 or 4 generations of this child raising component with even newer technology? How will their object relations, socializing patterns etc be impacted by this this technology in their lives?

 The latest statistics show that today 1/3 of people getting married have met online. So it is probably safe to assume in 2089 most serious relationships will be started online. Those of you who saw the movie HER realize that people are considering that it may be possible to establish a meaningful relationship with a so called person who is only a computerized program. Consider the psychodynamic implications of that!

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As therapists we are always interested in the patients emotional reactions to their thoughts and fantasies, especially when they occur during a therapy session. This is also an important aspect of transference and countertransference. We also use our own emotional reactions to what is being discussed in therapy. We know also that emotional reactions are accompanied by physiological changes throughout the body including changes in activities in various parts of the brain. All of these emotional responses   can occur before there is conscious awareness of the emotional reactions. I usually wear a fit bit on my wrist. This is wrist band which measures my heart rate and  number of steps I take – it also recognizes when I am sleeping. This is a first generation device. Similar devices are being developed that measure BP, pulse respiration rate and future devices are expected to have the capacity to measure cortisol levels and even other hormones including sexual arousal etc.  Perhaps a little band around the head would measure electrical activity of the brain.  The capacity to wirelessly project any measurements to a computer screen or projection screen already exist. So I can imagine that if the patient and the therapist each wore these devices we would have the ability to measure all these internal manifestations– ALL which could be observed by the therapist or the patient or possibly both during the therapy session.

 

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Obviously I really don’t know what is in store for our organization or the future of psychodynamic psychiatry and our profession. I do know that there is going to be lots of change. The tradition of our Academy has been one that respects the work done in the past but always has a willingness to consider new ideas. I hope we will continue to do this and that we will take steps to continually change our organization to meet the needs of our profession and embrace what is to come 75 years from now or 150 years after Freud AND BEYOND

 END

 Any comments are welcome below

 

 

 

 

 

 

 

 

 

 

 

 

Suicided Troops Family To Get Condolence Letter

Last week President Obama announced that he would begin to send letters of condolence to the families of troops who kill themselves in combat zones. This is a change in policy which has been advocated by many groups including families of soldiers who have died by suicide as well as many mental health professionals. One such family is that of Chance Keesling who died by suicide in June of 2010. Despite the accomplishment by the President of this important change it should be noted that the new policy still has some wording in it which make it inherently unfair and discriminatory.

Last week President Obama announced that he would begin sending letters of condolence to the families of troops who kill themselves in combat zones. He noted that this was a decision that was made after a difficult and exhaustive review of the former policy and he added “I did not make it lightly…This issue is emotional, painful and complicated but these Americans served our nation bravely. They didn’t die because they were weak.”

Long Campaign to Change

There has been a long standing campaign to get the President to change the previous policy, led by families who had soldiers die by suicide. Various veteran groups, members of Congress and  mental health professions, including myself have been publicly advocating that the President change the policy.

The Keesling  Family

I first wrote about this issue in my blog (Psychiatry Talk.com in December 2009) after reading a NY Times piece the previous month about the tragic loss which the Keesling family suffered when their 25 year old son Chance killed himself in Iraq in June of that year. He was in his second tour of duty when the stresses of combat combined with an argument with his girl friend over the phone led to hopelessness and suicide. Hours before his self-inflicted fatal gunshot wound the Keesling family received a rambling despondent email message from their son.

Chance Keesling (Photo from the Keesling family)

His father Gregg commented on my blog and we began a correspondence about this issue. He and his wife had decided to share some of their grief with the public in order to try to bring about a change in the Presidential policy, which was so hurtful to his, and other families who suffered similar losses.  They would receive a folded flag, a letter from the Army praising their son, a rifle salute at his burial and financial death benefits. But the letter of condolence from the President of the United States, which is the symbol of the voice of the people of our country, which is sent to every other fallen soldier in war since the presidency of Abraham Lincoln, was conspicuously absent. There was an increasing frequency of articles touching on this subject in the media. I wrote about it again in my blog and in the Huffington Post and received more comments than any other pieces that I have written. The House of Representatives voted in May 2010 to add an amendment sponsored by Representatives Burton and Napolitano to the Defense Authorization (HR 5136) that urged that the policy be overturned. The only response from the President was that this policy was being evaluated.

Why There Was Resistance to Change ?

It was difficult to say exactly why there was resistance to changing this policy. It appeared to come from certain factions within the military who had the misguided idea that such recognition would encourage suicide or would be rewarding those who were “weak” and couldn’t deal with stresses compared to those who did. These ideas were antithetical to the fact that there were so many accounts of the comrades of these soldiers who did die from suicide who were quite devastated by these losses and very supportive to the families of their fallen comrades and to their memories. There also was no psychological basis for such theories. I could not help but feel this was another example of the stigmatization of mental illness.

American Psychiatric Association Weighs In

As a Past Speaker of the Assembly of the American Psychiatric Association (APA) I believed that it was important that American Psychiatry speak out on this issue. I wrote an Action Paper (a resolution) with Dr. Roger Peele of Washington D.C. which was also co-authored by Drs. Catherine May, Eliot Sorel, Hind Benjelloun and Joseph Napoli which was voted upon and approved by the APA Assembly in May of 2010. The Board of Trustees of the American Psychiatric Association then approved it. In July 2010 James H. Scully Jr. M.D., CEO and Medical Director of the American Psychiatric Association wrote to President Obama representing the 37,000 psychiatric physicians. He called upon the President to eliminate the stigma and shame associated with suicide for families and survivors by reversing current policy and forwarding Presidential condolence messages to families of individuals who complete suicide while in military service. In October of 2010  the APA issued a public statement urging President Obama to reverse the policy of barring such letters. A number of other mental health groups including the American Foundation for Suicide Prevention and the Mental Health America had officially come out in favor of this policy change. APA President Carol Bernstein, M.D. issued a statement in which she noted, “ The contributions of these men and women to their country are not less for having suffered a mental illness. A reversal of this policy to allow condolence letters to family members will not only help to honor the contributions and lives of the service men of women, but will also send a message that discriminating against those with mental illness is not acceptable.”

The Long Awaited Change

The number of suicides in the military continued to go up either approaching or in some analyses exceeding the number of combat deaths. The problem of PTSD and the mental health of our combat troops became a high priority of the military but there was still no change in the Presidential policy.

Last month (June 2010) I met with Gregg Keesling for breakfast as he was in Los Angeles for a business meeting. He had received some indication that the President was reconsidering his policy but nothing had come down yet. Senator Barbara Boxer had just sent a letter to the President, which was made public.  We reflected in our discussion whether this issue might come to a head sooner if fate had led to a high profile family to lose a military family member to suicide rather than unknown but valiant people such as Gregg and his wife. It was clear that he and others like them in memory of their lost loved ones were not giving up the fight and were continuing to push for a change in the Presidential policy.

The Keeslings were notified in advance of the official announcement that henceforth the families of soldiers who die in a combat zone by suicide will receive a Presidential letter of Condolence. They understood that this would not be retroactive but were nevertheless overjoyed that the battle that they had fought in memory of their son was won. While there is nothing that relieves the pain of the loss of a child, hopefully the significance of this accomplishment will help in a small way.

I certainly am very pleased that the President has seen fit to make this change in his policy. I imagine that it was not an easy thing to do since there apparently was strong resistance in the military.

Still Unfair Discrimination

Coming Home (Photo from the Keesling family)

However, it should also be pointed out that there is still something inherently unfair and discriminatory about the new policy. As I understand it, letters of condolence will only be sent to families of troops who have killed themselves in a war zone. I am certain that if a soldier is critically injured by an explosive device but does not die until he or she is back in the United States receiving treatment, his family would not be denied a letter of condolence from the President. Similarly what if a soldier develops a mental disorder related to the stresses which he or she is experiencing in a combat zone and is transferred to the US to be treated but unfortunately succumbs to this condition and commits suicide? Shouldn’t this soldier also be considered to be a combat victim and shouldn’t his or her family also receive a letter of condolence.  Sometimes changes come in small increments and perhaps this important step and the attention to this issue will help the destigmatization of all mental disorders.

Psychological Problems Expected After Japanese Disaster

Psychological problems are expected after the recent earthquake and tsunami in Japan. In the past American psychiatrists with experience in disaster psychiatry have offered assistance to colleagues in other countries who are dealing with a catastrophic event and it is expected that this will occur with the current incident. In the initial phase psychological first aid will be given to the survivors and then symptoms of acute stress will be addressed. Between 10-50% of those impacted can be expected to develop symptoms of post traumatic stress disorder. Expertise in risk communication will also be helpful in dealing with the task of informing the public. This becomes especially relevant with the threat of radiation contamination from damaged nuclear reactors.

As the earthquake and tsunami disaster in Japan unfolds, we cannot help but feeling helpless and overwhelmed as we learn of the increasing death and injury toll and see the tremendous destruction. Even though some of us as psychiatrists and other mental health professionals have worked in disaster situations, very few of us have witnessed the magnitude of the events taking place in Japan.

Mental Health Experts will Offer Help

Edited by M. Blumenfield & R. Ursano

I am sure that there will be mental health specialists from the United States and elsewhere offering their assistance to our colleagues in Japan as has been the case with other major catastrophes. During the Kobe earthquake in Japan in 1995, I was a member of the Committee on Disasters of the American Psychiatric Association and we arranged to translate a good part of our mental health written materials for disaster into Japanese so I am sure they will be made available again  at this time. In that event and during subsequent events, American psychiatrists held conference calls with mental health professionals in impacted areas to offer the benefit of experience which we had from working in various events including plane crashes, The World Trade Center bombing, Oklahoma City, Katrina, 9/11 and other events. An organization called Disaster Psychiatry Outreach was formed by a group of young psychiatrists from New York who trained many psychiatrists who then participated in the mental health efforts in various locations throughout the world. For several years I participated with my colleagues in  teaching courses at the annual meeting of the American Psychiatric Association about disaster psychiatry. I am sure there will be many mental health professionals joining other volunteers  to assist the Japanese in dealing with this traumatic event.

I would like to briefly review some of the anticipated mental health issues in a disaster such as this one.

Psychological First Aid

Needless to say – the first effort is always rescue and attempt to save as many as lives as possible. All resources will be directed  towards  searching and finding the victims of this tragedy. First Aid to the victims should always have priority over mental health support but it should be given with Psychological First Aid.   this means that  food, water and shelter should be provided in a compassionate manner. An essential part of this effort is to communicate in efficiently and humanely  with families and loved ones who have survived.   Another part of this psychological first aid is going to be some kind of continued support to those who have suffered so many losses personal and material loses. The role of insurance, government support and foreign aid along with that of friends and family will be very meaningful and psychologically supportive.

Actual treatment might be better than a support group for some patients who have undergone severe trauma.

Not Just Grieving But Complicated Grieving

Edited by Fred Stoddard, Jr., Craig Katz, and Joseph Merlino

Whenever there is loss of life there is grieving by family, friends and I am sure by the entire country. Grieving is a universal process and while it is influenced by culture and religion, there are certain physical and emotional components of it that are well know by physicians, ministers, mental health professionals and anyone who has been around long enough to see such responses in themselves and others. There will be waves of emotions whenever anything reminds them of the loss, tears and depressive symptoms. While the lost person may never be forgotten, the severity of the symptoms and inability to function as before will usually improve over time with normal grieving. However a situation like this is one which falls into a different category usually named complicated grieving. Such a designation  is made when there is the death of large numbers of people especially when children are killed or large numbers of children are grieving, unexpected death often of horrible and bizarre circumstances. ( This designation also applies when there is murder or suicide which doesn’t apply here ).It is more likely to occur when the body has not been located and given a ceremonial funeral.  Complicated grieving usually is prolonged for at least a few years, sometimes longer. It is complicated by symptoms of severe depression and may lead to substance abuse and suicidal behavior. There is often a need of the  bereaved to to find an explanation for the event or seek some type of restitution. This may lead to tremendous anger directed towards the government and public officials even in a situation where there was a natural disaster. These feelings can  also get directed towards God and towards one’s religion. It becomes very meaningful for the government, and society to recognize the loss of lives. Memorial and commemorative services at anniversaries of the event as well as monuments and dedicated rebuilding becomes part of the healing process.

Acute Psychological Stress

By Robert Ursano, Carol S. Fullerton, Lars Weisaeth and Beverly Raphael

There are acute psychological stress symptoms which will occur in huge numbers of people in the days and weeks after the event.These will consist of extreme anxiety, depression, insomnia, bad dreams, flashbacks of the horrible events which they experienced, helplessness, numbing, detachment, feelings of unreality, depersonalization dissociative amnesia where a person can’t recall important aspects of the trauma, tendency to avoid anything or any thoughts to do with the trauma and a tendency to have an increased startle reaction or tendency to jump very easily. At this stage people are susceptible to abusing alcohol and drugs. It had been very common for peer groups and mental health professionals to organize debriefing group meetings where people who recently had been through a trauma would be encouraged to review  their experiences as well as their emotional responses including the personal meaning to them. It was thought that this approach could diminish the possibility of long term psychological symptoms. Subsequent research did not establish this as a valid approach and raised questions whether at times the group discussions created more anxiety in some individuals. While each situation is different and there are often limited psychological resources, the best psychological approach appears to be psychological first aid with warm supportive environment where the victims basic needs are met, valid information is supplied by caring people, efforts are made to connect with families, intermediate and long term planning is established and the victims are counseled about what type of psychological feelings they might be expected to have . People should be cautioned about tendency to abuse alcohol and drugs. During group meeting where information and other necessities are being provided, there should be screening for individuals who may need individual counseling, therapy with or without psychiatric medication.  People with pre-existing mental disorders may have an exacerbation of their condition although in some cases such people faced with an external catastrophic event may actually fare fairly well as they put aside their “personal demons” and actually cope better than usual. People with underlying mental conditions may need adjustment of their medication. In addition there can be an important role for the use of administering sleep medication , anti- anxiety medication of other psychotropic medication to some people during the acute phase of a trauma.

Post Traumatic Stress

By V. Alex Kehayan & Joseph C. Napoli

It is invariably that a certain number of people will go on to develop a post traumatic stress disorder where they can have persistent symptoms as described above. This can be quite distressing and incapacitating  for some people . There are several  psychological treatment techniques which may or may not include medication While the percentage is variable perhaps between 10-50% can have significant symptoms in months and years to come. We have learned that the majority of people in such situations have shown great resiliency and have a good psychological recovery over time . People closest to the areas of destruction are more likely to suffer although this is not invariably the case. Children are particularly vulnerable and should not be neglected in screening for emotional problems. Today with mass media, people watching the events can identify with their fellow countrymen and women and suffer symptoms. We now also know that there are psychological causalities among the police, fire, emergency personnel, hospital workers, morgue workers government officials and especially members of the working press who go out of their way to witness a great deal of the death and destruction.

Risk Communication

Mental health professionals can provide assistance and consultation in all phases of a disaster. There are also mental health experts who have studied the field of risk communication which is how public officials and the media provide information about potential danger. It has been shown that it is both essential for there to be a spokesperson who is trusted to deliver honest information to the public at the same time to do it in a manner to minimize fear and panic. This has been studied and there are techniques which this can be done in the most effective manner.

Psychologcial Impact of Radiation Threat

One additional thought related to the above issue of risk communication is the situation where there is the potential of radiation fallout to the communities surrounding nuclear plants which is the situation occurring as I am writing this. There was a similar situation in the United States with the Three Mile Island incident where there was a question of the accidental release of radioactive vapor into the air. Subsequent studies have shown that while there actually was no  physical danger many people suffered psychological symptoms especially women of child bearing age  and mother of small children who were highly anxious about the potential danger of radiation.

There are some excellent books on psychological issues in disasters which can be easily accessed. I have pictured  some of them in this blog. I welcome your thoughts on this very important current issue.