Think about this the next time someone cuts you off in traffic or in a grocery store line: Anger can bring on a heart attack or stroke.
That’s the conclusion of several studies at Harvard Medical School and elsewhere. One study of 1,305 men with an average age of 62 revealed that the angriest men were three times more likely to develop heart disease than the most placid ones.
Angry older men, as stereotypes go, are most vulnerable. But excessive ire can take a toll at any age. Researchers at Johns Hopkins School of Medicine tracked 1,055 medical students for 36 years. Compared with cooler heads, the hotheads were six times more likely to suffer heart attacks by age 55 and three times more likely to develop any form of heart or blood vessel disease.
The conclusion is clear: Anger is bad for you at any age. “Among young adults, it’s a predictor of premature heart disease later in life,” says Harvey Simon, an associate professor of medicine at Harvard Medical School.
Most anger research has focused on men, so whether the same risk applies to women remains unknown. One study, published in 1995, found that, during two hours after an angry outburst, a individual’s risk of having a heart attack was more than twice that of someone who had not lost their cool. Out of 1,623 people in that study, 501 were women.
“Almost all the anger research I’m familiar with has focused on men,” notes Simon. “However, based on a 2006 study of road rage, I would guess that women are less prone to severe anger and thus to its deleterious effects, which include heart attack, stroke, and even impaired lung function.”
A Harvard study, published in August, concluded that men who showed high hostility at the start of the eight-year investigation exhibited significantly poorer lung function at the end of it. “This research shows that hostility is associated with poorer [lung] function and more rapid rates of decline among older men,” notes Rosalind Wright, an assistant professor at the Harvard School of Public Health.
Strokes of anger
Over the years, then, anger increases a man’s and, probably less so, a woman’s chances of heart disease. But, what about a single burst of rage, the guy who cuts in front of you just before the exit ramp? The answer apparently is “yes.” In the Harvard study of 1,623 patients, which included 501 women, intensive anger more than doubled their risk of heart attack if the emotion occurred in the two hours previous to the heart attack.
In an evaluation of 200 stroke patients in Israel, researchers linked a bout of intense anger to a 14-fold increase in risk of stroke within two hours of the emotional incident.
Results from a study published this year found that of more than 2,500 patients treated in emergency rooms in Missouri hospitals, about 500 of them were torn by anger just before the injury. The greater the anger, the higher the risk, researchers concluded.
Anger comes in many doses: annoyance, irritability, frustration, vexation, resentment, animosity, ire, indignation, wrath, and rage, for example. Most people know when they’re mad. If not, someone is bound to tell them so, sooner or later.
Psychologists have developed a scale that rates anger levels. It’s a true-or-false test that presents statements like: “At times I feel like smashing things.” “I easily become impatient with people,” “I’ve been so angry at times that I’ve hurt someone in a physical fight.”
Once you decide how irate you are, you need to decide what to do about it. For a start you can see your family doctor about the wisdom of taking an aspirin a day. Harvard researchers recently found that a single low-dose (81 mg) pill can reduce anger-caused heart attacks by 40 percent. In other words, a daily aspirin may cut the risk of breaking an angry heart by almost half.
How to be cool
Simon adds more advice in the September issue of Harvard Men’s Health Watch, which he edits. “Try to identify the things that bother you most and do your best to change them,” he suggests. “Learn to recognize warning signs of building tension, such as a racing pulse, fast breathing, or a jumpy, restless feeling. When you recognize such signals, take steps to relieve the tension. Often something as simple as a walk can cool things down.”
Don’t boil in silence. Talk out your feelings with your spouse, partner, or a good friend. If that doesn’t work, write down your feelings. Try to explain to yourself why you are so irritated or vexed.
Simon also suggests learning to meditate, or experimenting with deep breathing exercises. Also, you can, with practice, change behaviors that light your fuse. Here are some examples: Don’t always try to have the last word. Try not to raise your voice. Don’t curse. Wait a few seconds when you feel on outburst coming on then try to express yourself calmly. Don’t grimace or clench your teeth. Practice smiling.
If all such efforts fail, angry people can seek professional help. A 2002 study reported that stress management classes can protect men from anger-induced heart problems, and individual counseling may be even better.Read Full Post | Make a Comment ( None so far )
Like other emotions, anger is experienced in our bodies as well as in our minds. In fact, there is a complex series of physiological (body) events that occurs as we become angry.
Emotions more or less begin inside two almond-shaped structures in our brains which are called the amygdala. The amygdala is the part of the brain responsible for identifying threats to our well-being, and for sending out an alarm when threats are identified that results in us taking steps to protect ourselves. The amygdala is so efficient at warning us about threats, that it gets us reacting before the cortex (the part of the brain responsible for thought and judgment) is able to check on the reasonableness of our reaction. In other words, our brains are wired in such a way as to influence us to act before we can properly consider the consequences of our actions. This is not an excuse for behaving badly – people can and do control their aggressive impulses and you can too with some practice. Instead, it means that learning to manage anger properly is a skill that has to be learned, instead of something we are born knowing how to do instinctually.
As you become angry your body’s muscles tense up. Inside your brain, neurotransmitter chemicals known as catecholamines are released causing you to experience a burst of energy lasting up to several minutes. This burst of energy is behind the common angry desire to take immediate protective action. At the same time your heart rate accelerates, your blood pressure rises, and your rate of breathing increases. Your face may flush as increased blood flow enters your limbs and extremities in preparation for physical action. Your attention narrows and becomes locked onto the target of your anger. Soon you can pay attention to nothing else. In quick succession, additional brain neurotransmitters and hormones (among them adrenaline and noradrenaline) are released which trigger a lasting state of arousal. You’re now ready to fight.
Although it is possible for your emotions to rage out of control, the prefrontal cortex of your brain, which is located just behind your forehead, can keep your emotions in proportion. If the amygdala handles emotion, the prefrontal cortex handles judgment. The left prefrontal cortex can switch off your emotions. It serves in an executive role to keep things under control. Getting control over your anger means learning ways to help your prefrontal cortex get the upper hand over your amygdala so that you have control over how you react to anger feelings. Among the many ways to make this happen are relaxation techniques (which reduce your arousal and decrease your amygdala activity) and the use of cognitive control techniques which help you practice using your judgment to override your emotional reactions.
If anger has a physiological preparation phase during which our resources are mobilized for a fight, it also has a wind-down phase as well. We start to relax back towards our resting state when the target of our anger is no longer accessible or an immediate threat. It is difficult to relax from an angry state, however. The adrenaline-caused arousal that occurs during anger lasts a very long time (many hours, sometimes days), and lowers our anger threshold, making it easier for us to get angry again later on. Though we do calm down, it takes a very long time for us to return to our resting state. During this slow cool-down period we are more likely to get very angry in response to minor irritations that normally would not bother us.
The same lingering arousal that keeps us primed for more anger also can interfere with our ability to clearly remember details of our angry outburst. Arousal is vital for efficient remembering. As any student knows, it is difficult to learn new material while sleepy. Moderate arousal levels help the brain to learn and enhance memory, concentration, and performance. There is an optimum level of arousal that benefits memory, however, and when arousal exceeds that optimum level, it makes it more difficult for new memories to be formed. High levels of arousal (such as are present when we are angry) significantly decrease your ability to concentrate. This is why it is difficult to remember details of really explosive arguments.Read Full Post | Make a Comment ( None so far )
After every act of incomprehensible violence, the world asks whether the killer could have been identified ahead of time. It’s as automatic as the call for more gun control and better mental health services.
Psychologists and psychiatrists have been working for decades to try to figure out whether there’s a link between mental illness and violence, and if so, which people are likely to act. Using an ever-changing tool kit of theories and questionnaires, they’ve made some progress.
It’s now fairly clear, for example, that people with severe mental illness, such as schizophrenia, bipolar disorder and some personality disorders, are more likely to commit violent acts than others. But the risk is small. The vast majority of mentally ill people won’t commit assault, rape, arson or homicide, although the risk rises sharply among those who abuse drugs and alcohol.
These insights are proving useful to psychiatrists, psychologists, judges, school administrators and others who must decide whether someone seems too dangerous to be left alone. But they aren’t good enough to identify an Adam Lanza, the young man who killed 28 people, including himself, in Newtown, Conn., last month. (Lanza’s mother told friends that he had Asperger syndrome, a developmental disorder, but no evidence has emerged that Lanza was diagnosed as mentally ill.)
“There is no instrument that is specifically useful or validated for identifying potential school shooters or mass murderers,” said Stephen D. Hart, a psychologist at Simon Fraser University in Vancouver who is the co-author of a widely used evaluation tool. “There are many things in life where we have an inadequate evidence base, and this is one of them.”
Even when someone has a history of threatening behavior, the killing of innocent people can’t necessarily be prevented.
The woman accused of pushing a man to his death in front of a New York subway train on Dec. 27 had been arrested several times for assault and treated in the psychiatric wards of two hospitals. The man who fatally shot two firefighters and himself in Webster, N.Y., on Christmas Eve had killed his 92-year-old grandmother three decades earlier.
The task of identifying violence-prone individuals is even trickier with young people, who have shorter histories and whose normal development often includes a period of antisocial behavior.
The prospect that the most recent massacre, or the next one, could lead to efforts to find young men contemplating the killing of strangers worries many people. Among those expressing concern are some psychologists and former patients forcibly swept into the mental health system and treated against their will.
“I think people are going toward wanting all their kids to be screened in high school for mental illness and violence risk — and that’s a bad idea,” said Gina M. Vincent, a forensic psychologist at the University of Massachusetts Medical School. “That’s my biggest fear of what’s going to come out of this.”
“We can’t go out and lock up all the socially awkward young men in the world,” said Jeffrey W. Swanson, a professor of psychiatry and behavioral sciences at Duke University. “But we have to try to prevent the unpredicted.”
The best-known attempt to measure violence in mental patients found that mental illness by itself didn’t predict an above-average risk of being violent. People released from psychiatric wards were more violent than their neighbors only if they also had drug and alcohol problems, according to the MacArthur Violence Risk Assessment Study, which tracked almost 1,000 former patients in the early 1990s.
Other research has found a link — although not a particularly strong one — between mental illness and violence.
In a 2001 study funded by the National Institutes of Health, researchers asked 35,000 adults whether they had been diagnosed with a mental illness anytime in their lives and in the previous year. They also asked a long list of questions about the subjects’ personal histories and behaviors. Re-interviews were conducted three years later, asking about violent events in the intervening period.
People who reported that they’d had both “severe mental illness” and substance abuse problems in the year before the first interview had the highest rate of violence; 9.4 percent had committed a violent act. The next most violent were people with other types of mental illness (mostly antisocial personality disorder) accompanied by substance abuse — 7.2 percent of them reported violent behavior.
Groups with lower rates of violence included people suffering only from severe mental illness, 2.9 percent of whom reported having been violent; those only with substance abuse problems (2.5 percent); and those with other mental illnesses alone (1.4 percent). People without any of these problems had just a 0.8 percent rate of violence.
Over the years, researchers have made a particular effort to study violence and schizophrenia, a disorder that emerges in young adults and often includes paranoid thoughts.
An analysis of 20 studies published three years ago found that schizophrenia increased the risk of acting violently fourfold in men and even more in women. The risk of schizophrenics committing homicide was 0.3 percent — more than 10 times greater than the average citizen.
The evidence suggests that “there’s a modest relative risk” for violent behavior in people diagnosed with a serious mental illness, said Swanson, the Duke researcher.
If some of the mentally ill are dangerous, can they be found?
Over the years, studies have shown that psychiatrists’ accuracy in identifying patients who would become violent was slightly better than chance — “obviously not good enough, given what’s at stake for public safety as well as for civil liberties,” said John Monahan, a University of Virginia psychologist who helped direct the MacArthur study.
So Monahan and many others came up with a constellation of “risk factors” and “protective factors” for violent behavior — analogous to the risk factors for heart disease, such as age, blood pressure, smoking and cholesterol — and included them in questionnaires.
Some of those instruments rely heavily on adding up scores. Others put more emphasis on the interviewer’s clinical judgment. The most popular current strategy combines both approaches; it forces the evaluator to include any pertinent issue.
All of the approaches consider the presence of a mental disorder as only a small contributor to risk, outweighed by other factors such as age, previous violent acts, alcohol use, impulsivity, gang membership and lack of family support.
There have been numerous efforts to test these violence-predicting tools in recent decades. For example, Monahan and his colleagues incorporated 106 risk factors into a software interview program and administered it to patients being discharged from psychiatric units in Massachusetts and Pennsylvania. Of those judged to be low-risk by this tool, 90 percent committed no violence over the next six months. Of those judged to be high-risk, 49 percent committed violent acts.
“From our research, we could quickly distinguish between a patient whose chance of being violent was 1-in-10 from one whose was 1-in-2,” he said.
Last summer, a large study published in the British Medical Journal found much the same thing.
It analyzed the findings of 68 studies that involved about 25,000 people in psychiatric hospitals, prisons or court-ordered detention. (The studies used a variety of assessment tools.) Of the people predicted to “violently offend,” 41 percent did. Of those predicted to be nonviolent, 91 percent were. In practical terms, that meant that if authorities used the tools for the purposes of public health, they’d have to detain two people to prevent one from becoming violent.
The authors of the analysis concluded that “risk assessment tools in their current form can only be used to roughly classify individuals at the group level, and not to safely determine criminal prognosis in an individual case.”
Most of this research has been conducted on populations already “enriched” with the potential for violence: psychiatric patients, drug users, binge drinkers, people who have been arrested. But some mass shooters don’t fall into any of those categories.
For the general public, there’s no screening tool for violence, and nobody expects that there ever will be.
Is what’s known about the relationship between mental illness and violence of any use after events like the mass shooting in Connecticut?
People who study and provide mental health treatment generally say, “Yes.” However, that’s not because people prone to violence can be found and stopped. It’s because if psychiatrists, psychologists and judges become more aware of the relationship between social circumstance, behavior and risk factors for violence, then they might be able to exert influence long before a killer’s plans are made.
At least that’s the current thinking.
“Most people who are thinking about violence are ambivalent about it,” said Hart of Simon Fraser University. “Our job is to find people who are ambivalent and convince them that violence is a bad idea.”
He cited the recent case in Vancouver of a college student who told a friend she was thinking of killing a homeless man. The friend notified authorities; the student was detained and evaluated with an assessment tool called the HCR-20. She had a “death kit” of tools in her possession and had killed a cat and dog for pleasure. She was convicted of animal cruelty but will soon be released on probation, with close supervision.
But some people warn that a more aggressive mental health system would pose its own dangers.
James B. Gottstein, a lawyer in Anchorage and head of the Law Project for Psychiatric Rights, has won four cases in his state’s Supreme Court supporting patients’ rights to refuse to take psychiatric medicines, limiting conditions for involuntary commitment and other issues. He learned firsthand what it’s like to be forcibly drugged and stigmatized by psychiatric treatment.
In June 1982, he had a manic episode that he attributes to sleep deprivation. He was working hard, suffering from jet lag after returning from Europe and living in a place where the sun didn’t set at night. He was taken by the police to a mental hospital, where he spent a month.
“One of the problems that happens when you become a psychiatric patient is that everything that you do or say can be labeled as a psychiatric symptom,” said Gottstein, 59, a graduate of Harvard Law School.
“If the police knock down your door and haul you off and you get upset, you get labeled as ‘hostile’ and ‘labile.’ If you decide that you’re not going to react to these provocations, you get labeled as having ‘a flat affect.’ If you think something is funny and you laugh to yourself, then they write down ‘responding to internal stimuli,’ ” he said.
It’s not that people don’t want help, Gottstein said, but that “the system basically forces things on them that they don’t want.” He thinks it is “entirely possible to create a system where things are voluntary.”
Essential are peer counselors — people once similarly diagnosed who might be able to connect with the mentally ill when the professionals can’t. There’s a largely unknown movement trying that approach. But he’s quite sure that’s not what people calling for “greater access to mental health services” these days are talking about.
And that worries him.Read Full Post | Make a Comment ( None so far )
No matter how old people are, they seem to believe that who they are today is essentially who they’ll be tomorrow.
That’s according to fresh research that suggests that people generally fail to appreciate how much their personality and values will change in the years ahead — even though they recognize that they have changed in the past.
Daniel Gilbert, a psychology researcher at Harvard University who did this study with two colleagues, says that he’s no exception to this rule.
“I have this deep sense that although I will physically age — I’ll have even less hair than I do and probably a few more pounds — that by and large the core of me, my identity, my values, my personality, my deepest preferences, are not going to change from here on out,” says Gilbert, who is 55.
He realized that this feeling was kind of odd, given that he knows he’s changed in the past. He wondered if this feeling was an illusion, and if it was one that other people shared: “Is it really the case that we all think that development is a process that’s brought us to this particular moment in time, but now we’re pretty much done?”
Gilbert says that he and his colleagues wanted to investigate this idea, but first they had to figure out how. The most straightforward way would be to ask people to predict how much they’d change in the next decade, then wait around to see if they were right. “The problem with that is, it takes 10 years,” says Gilbert.
So the researchers took a much quicker approach. They got more than 19,000 people to take some surveys. There were questions about their personality traits, their core values and preferences. Some people were asked to look back on how they changed over the past 10 years. Others were asked to predict how they thought they would change in the next decade.
Then the scientists crunched the data. “We’re able to determine whether, for example, 40-year-olds looking backwards remember changing more than 30-year-olds looking forwards predict that they will change,” Gilbert explains.
They found that people underestimated how much they will change in the future. People just didn’t recognize how much their seemingly essential selves would shift and grow.
And this was true whether they were in their teen years or middle-aged.
“Life is a process of growing and changing, and what our results suggest is that growth and change really never stops,” says Gilbert, “despite the fact that at every age from 18 to 68, we think it’s pretty much come to a close.”
Personality changes do take place faster when people are younger, says Gilbert, so “a person who says I’ve changed more in the past decade than I expect to change in the future is not wrong.”
But that doesn’t mean they fully understand what’s still to come. “Their estimates of how much they’ll change in the future are underestimates,” says Gilbert. “They are going to change more than they realize. Change does slow; it just doesn’t slow as much as we think it will.”
The studies, reported in the journal Science, impressed Nicholas Epley, a psychology researcher at the University of Chicago. “I think the finding that comes out of it is a really fundamentally interesting one, and in some ways, a really ironic one as well,” says Epley.
He says everyone seemed to remember change in the past just fine. “What was bad, though, was what they predicted for the future,” says Epley.
He notes that if you want to know what your next 10 years will be like, it’s probably good to look at what your past 10 years were like — even though we seem not to want to do that.
Gilbert says he doesn’t yet know why people have what he and his colleagues call the “end of history illusion.”
One possibility is that it’s just really, really hard to imagine a different, future version of yourself. Or maybe people just like themselves the way they are now, and don’t like the idea of some unknown change to come.Read Full Post | Make a Comment ( None so far )
Over the past 30 years, I’ve spent nearly 25,000 hours counseling angry men, and until about two years ago, my enthusiasm was beginning to wane. If you’ve worked with angry male clients, you can understand why. These men are generally highly reluctant clients, who are often in your office only because they’ve gotten “the ultimatum” from their wives or girlfriends or bosses or sometimes court judges: “Get therapy for your anger or get out / you’re fired / you’ll go to jail.” Many, considered by everyone who knows them to have an “anger problem,” arrive in your office convinced that they don’t have an anger problem: the real problem is their stupid coworkers, annoying girlfriends, demanding spouses, spoiled kids, or unfair probation officers. However, they arrive at your office with a shotgun at their backs, so to speak, and know they have no choice. They hate the entire situation because it makes them feel powerless.
No wonder they feel powerless: they’re being coerced to lay down their anger, the only weapon they’ve ever had against feelings of powerlessness. They often trace their reliance upon anger to a childhood history of danger, trauma, shaming, and pain. Anger is the emotion they can trust, the one that might keep danger at bay. As they grew up, they continued to use anger to make people they regard as dangerous back away. By the time you see them, they regard just about every person in their lives as “dangerous,” including loved ones. These men have become habitually angry. I liken their condition to the default option on a computer: their anger goes on automatically unless they consciously turn it off.
Of course, it isn’t easy to turn off the default option when the way to do so is hidden deep within the machine’s (our brain’s) control panel. Furthermore, men for whom anger is a default emotional response to life’s vicissitudes are often relatively untrained in experiencing and communicating other emotions. For example, one of my clients “went off”–screaming and threatening bodily harm against his father’s doctors–when his father died, to the point the police had to be summoned, because he couldn’t handle his grief. Anger was the only emotion he could call upon in time of need. Not surprisingly, when these men come to therapy, whether as individuals or in couples or groups, they’re frequently defensive, argumentative, passive-aggressive, protective of their right to be angry, and doubtful about my competence to understand or help them in any way.
It’d be misleading to say that my most difficult clients are unmotivated. More accurately, they’re antimotivated, committed to undermining any behavioral programs or specific anger management tactics I offer. Meaningful change takes many repetitions: “Practice, practice, practice” is a hallmark of anger-management training. For example, taking the time to put a problem into perspective (“On a 1-10 point scale, Joe, how important is it for your teenage daughter to get home every night by 8 p.m.?”) works well, but only if the client is motivated enough to practice putting things into proper perspective perhaps as often as several times a day. It stands to reason that trying to argue such men out of their commitment to anger is pointless. I long ago realized I couldn’t beat them in face-to-face combat; they’re better at in-your-face challenges and making contemptuous remarks than I’ll ever be. I needed a tool that allowed me to sidestep their oppositionality and create a therapeutic alliance.
At a deeper level, chronically angry people have become lifelong victims of what’s sometimes called negative neuroplasticity. They’ve unintentionally trained their brains so well, through countless repetitions of undesired behavior (at least, undesired by the rest of the world), that they’re primed to think, feel, and say things that increase their own anger. For example, Joe may well think that if his daughter gets home after 8 p.m. it means she’s probably having sex with some male punk. That kind of thought pattern is automatic.
So now we have two major concerns. First, some of my clients enter treatment antimotivated. Second, their brains have been programmed to react automatically with anger and hostility to a wide variety of situations. What kind of therapeutic intervention can address these issues?
Focusing on the Brain to Increase Motivation
About six years ago, I stumbled across the answer when I attended a session about the brain at the Networker Symposium in Washington, D.C. The controversial brain researcher Daniel Amen was just beginning his lecture when he mentioned in passing that he’d been browsing through the books on anger in the sales area. “None of them said anything about the brain,” he noted somewhat dismissively. Now many of those anger books he was trashing were my books, so at first I was defensive. But by the end of the talk, I realized he was right, at least about the books I’d authored. I hadn’t mentioned anything about brain processes for a simple reason: I didn’t know anything about them. That led me to immerse myself in the subject of the brain, and as I did so, my enthusiasm for working with angry clients increased exponentially.
How can learning about the brain–particularly the angry brain and how it got that way–possibly influence clients who have a hard time taking in therapy or sticking with anger-management techniques? Aren’t concepts drawn from brain research simply too abstruse, too abstract, and apparently unrelated to daily life to make much difference to them? In fact, what I’ve found is just the reverse: these men are fascinated by information about how anger develops in the brain and why it’s so hard to control, and they consider it far more relevant to their lives than many standard therapy concepts. Getting to understand a bit of what happens “inside their heads” when they get angry resonates deeply with them. In one way, they can cling to their defensiveness and denial systems, since they certainly can’t be accused of deliberately messing up their minds. Sidestepping their defensiveness and emphasizing their opportunity to do something right that will retrain their brains gives them a positive direction and a possible source for well-earned personal pride. Furthermore, hearing me explain how, by regular, committed behavioral practice of various anger-management techniques, they can literally change their own brain circuits, stimulates both hope that they can change and desire to begin. For the first time in their lives, they feel they might be capable of literally using their own brains tochange their brains. It is a real revelation to many angry men.
My own enthusiasm for brain science and my belief in angry men’s inherent capacity to reorganize their own neural circuitry are probably another key to revving up their motivation to try. My “brain talk” to them isn’t just a lecture about applied neurophysiology, but in truth a kind of triggering mechanism arousing their own curiosity and interest. Clearly, my enthusiasm evokes–in their brains–a mirroring enthusiasm for this process. It may well be that my sheer enthusiasm for this endeavor, my joy and excitement about the brain, triggers left-hemisphere mirror neuronal activity that bypasses right-hemisphere negativity and cynicism.
Devron Johnson is a 40-year-old male who’s been divorced for 10 years, partly because of his anger problems. An intelligent but not highly educated man, he works as a heating and cooling technician. He has two adolescent sons, with whom he barely converses and seldom visits. He’s now in a new relationship with Sheila, a 36-year-old mother of three younger children who live with them. Although Devron has never been physically violent with the children, he often frightens them with his angry outbursts.
This man grew up in a tough part of Detroit, where survival was the name of the game. His parents separated and reconnected several times during his childhood. The family atmosphere was markedly hostile–full of negativity, accusations, and occasional violence. Devron said he hated his father because he was never there for him, not even when he became a star athlete on his high school’s baseball team.
Devron sought therapy because Sheila had threatened to end their relationship unless he became much nicer to her kids. He added that he was also in trouble at work because “I gave the finger to my boss once too often.”
Here’s how Devron described his anger: “Man, I had a bad attitude in school. I beat people up if they looked at me wrong. But I gave that up. I don’t hit nobody anymore. But Sheila says I still have a bad attitude. She says I look for problems with her kids. Then I blow because I have a really short fuse. And I have a hard time letting go of my anger, too. Once I get pissed at someone, they stay my enemy forever.” Still, Devron does want to change. He loves Sheila and even grudgingly admits he likes her children. He doesn’t want to lose them. However, he doubts whether I, or anybody else, can help him. A few years ago, he attended an anger-management program for about 10 weeks, but says, “I didn’t get nothing useful from it.”
Like many angry clients, Devron came to counseling under duress–the “get help, or get out” final call. This isn’t a formula for success, since such clients often arrive for counseling thinking that they’ll more or less passively go through the motions to get the wife/boss/law off their backs, and then they’ll be free to revert to previous behavior. By contrast, Devron was directly skeptical and dismissive–derisive, in fact. Instead of pretending to buy the package, he openly challenged me to prove I had something new to offer. It’s uncomfortable to be sneered at by your client, but I’ve learned to recognize an open challenge as a positive indicator for success. Devron’s disdain was a sign of energy that might be used in counseling, if I could develop an alliance with him.
“Actually, Devron, I do have something to offer you that you probably haven’t run into before,” I told him, “I can help you change your brain.” I proceeded to explain with the enthusiasm and energy I usually feel when talking about the brain that he was actually capable of making fundamental, long-term changes in the way he thinks. “Devron, all it takes is commitment and persistence. I know you’re capable of both of those things because you’ve told me how much you love Sheila and the kids–that’s commitment–and how you’ve stuck it out with them when it would have been easier to walk away–that’s persistence.” I emphasized to him that he’d developed lifelong habits of anger that had become deeply rooted in his brain. But I assured him that he and he alone could make changes in those habits if he so desired. However, I cautioned him that real brain change doesn’t come easy. I said he’d need to make a strong commitment to practice new behavior for at least several months, so he could build, improve, and expand new circuitry inside his brain while reducing the power of his negative brain circuits. I briefly mentioned such concepts as neuroplasticity and myleinization, but only as a tactical move, to assure him that I did, in fact, know what I was talking about. I told him I didn’t just believe this brain stuff might work, I was absolutely convinced because I’ve seen many other angry people change their brains in just this way, and because I myself had changed my brain to become much more optimistic and generous.
As I spoke, I watched Devron’s “show me” expression change to hope and wonder. “You mean I can really change the way I think?” he asked. It turned out that Devron’s oppositionality obscured a deep sense of pessimism and hopelessness. He’d believed that change was impossible, in effect dooming him to a lifelong anger career. But now, maybe because of my own sense of conviction, he began to see possibilities. We talked a little more before the hour ended, and I asked him to think about how much he wanted to change his brain and in which ways. I also asked him what positive goals he wanted to pursue–for example, what other emotions he might be willing to experience if his brain wasn’t dominated by anger. A positive goal is important with all clients, of course, but especially with angry clients, who often mistakenly set only the negative goal of being less angry. I explained to Devron that only setting a negative goal like quitting being angry was like deciding that a car that currently could only go in reverse would be just fine if you could get it to stay in neutral. The idea is to move forward in life, to get that car moving ahead. Of course this same idea applies to only quitting drinking (instead of leading a sober lifestyle) or stopping being critical (instead of giving praise).
Finally, I cautioned Devron again that real brain change doesn’t come easy. I told him he’d need to make a strong commitment to practice new behavior for at least several months so he could build, improve, and expand new circuitry inside his brain while reducing the power of his negative brain circuits. I then sent him home with two pages of examples of possible brain change plans he could implement. One example was converting criticism and pessimism to praise and optimism. Another was to convert resentment into forgiveness. A third was to look for the good in people (and himself) instead of the bad.
When Devron returned a week later, he said he’d thought a lot about changing his brain and his life. He’d discussed it with Sheila, who’d told him she’d stick around for a while if she saw him really working to change his behavior. Now he was eager to make a six-month commitment to brain change. I then gave him some handouts I’ve created to help him name his brain-change plan. A person with a good brain plan has given it a name that means something at an emotional level, includes specific initial behaviors to maximize the opportunity for immediate success, and at least speculates about longer-term improvements and additions, and how achieving these changes might affect him or her. I also gave Devron the chapter on neuroplastic change from my book to reinforce the idea that changing his brain was realistic, if and only if he’d make a strong commitment to it.
Devron returned the next week in a quandary. He told me that he and Sheila had had a big disagreement about what his brain-change plan should include. She wanted him to be nicer to her children. Devron told me that he wanted to be nicer to them, but that his first concern was quitting thinking so pessimistically about the world. “If I can’t quit thinking that everyone is out to screw me over, I don’t think my changes will last,” he said. I thought Devron had hit upon a clear understanding of how he needed to change at an existential level. Brain-change plans aren’t simple behavioral alterations: they really change your brain, and in doing so, ultimately affect your connections with yourself, those you love, and the universe. So I affirmed Devron’s insight. However, I did point out that his goal and Sheila’s weren’t contradictory. Being nicer to the kids could well become one way that he altered his mindset of hostility and suspiciousness. After all, deeply held beliefs don’t change completely on their own. Devron needed to try out new behavior and receive positive rewards for doing so in order to give his brain the opportunity to be transformed.
I’d like to offer a side comment here. We often expect our angry clients to act as if they were living in a safe world, a world in which people are pleasant, trustworthy, loving, and consistent. This false belief on our part sets clients up to fail. Devron’s siblings, for instance, regularly engaged in felonious behaviors, such as drug dealing and robbery, and expected him to join them as he often had in the past. He told me during therapy that he’d begun declining these invitations. When I asked him if he’d practiced being assertive with them, he laughed. “I guess if telling my brother to go to hell when he attacked me for not going along with some scam he was into, then yes, I was very assertive.” The result of his new “good” behavior was that his family ostracized him for several months. Fortunately though, Sheila and her children were dependably in his corner, so that Devron could practice new, prosocial behavior around them without being criticized or ridiculed.
Devron named his plan “Learning to Trust.” I was tempted to add “and take in love,” but Devron would have labeled that phrase unmanly. When I asked him how he planned to begin this plan, he suggested he could go to his father to see if he could learn to trust the man he most distrusted in the world. Needless to say, this was a palpably rotten idea: in all likelihood, his father would once again have demonstrated his complete untrustworthiness, potentially undermining everything Devron was trying to do. I talked him out of it with some difficulty by pointing out that he was betting his whole stake on one roll of the dice. “Besides, it’s a bad bet,” I said. “You’d be better off investing in a smaller stake, like letting yourself trust Sheila more.” That reminded him of his real priorities.
He decided to open up emotionally a little more to both his family and a few trusted coworkers. For example, he told some of his history to two of his coworkers, the ones he felt most comfortable with, and they responded positively with their own self-disclosures. Then he took a bigger chance by admitting to Sheila that he had cheated on his first wife. Much to his shock, she told him she’d known about it for a long time–his ex-wife had thoughtfully given Sheila that information when she’d begun dating Devron–but she’d chosen not to mention it and trust that he’d be faithful to her.
Shiela’s disclosure and assertion of trust brought him to tears. At that very moment, his brain-change plan spontaneously expanded to include being trustworthy to others. Since Devron had a long history of lying by omission (“Oh, I must have forgotten to tell you that”) this expansion was quite significant. It had proved harder for him than the initial goal because he’d had to retrain himself not to leave out some of the truth “so nobody could pin me down.” He kept expanding from his core commitment to develop trust. He realized along the way that he’d been mean to Sheila’s children because he didn’t want to get close to them and then lose them. But Sheila came through by rewarding his obvious changes with reassurance that she’d stay with him.
I regularly review a client’s brain-change plan with him or her, rather than just assume it’s working fine. It’s important to challenge clients quickly if they’re letting their plan drift.
The final addition to Devron’s plan was learning how to be more empathetic. Devron acknowledged that empathy was strange territory for him: “Frankly, I never gave a damn what anybody else felt.” But now that he felt safer, he could do what safe people do: care about and take a real interest in others. Like many angry people, he has some difficulty being empathic. Empathy partly depends on automatic attunement processes usually learned in infancy through parent–infant synchronic movement. He experienced few such experiences as a child. We talked together about this deficit, a deficit he was determined to challenge. He immediately made a real effort to put himself in the shoes of others. It’s just that he had trouble first taking off his own shoes. For instance, he told his 12-year-old daughter, Amy, who was being teased by classmates, that he knew exactly how she felt, even though he’d been the bully, not the victim, when he’d been in school. But here again, the principles of neuroplasticity apply. Devron realized he’d misunderstood the situation when his daughter got mad at his reply. He then consciously took the time to listen better. Gradually, this behavior was becoming faster, smoother, and more automatic.
Devron’s plan, then, began with developing some basic trust in the world, which led to being trustworthy himself, which morphed into increased empathy and actually caring about others. He quit working with me after approximately nine months. Our last session included Sheila, who affirmed that Devron had become much less angry, more caring, and far more present in their lives. She’d previously doubted his changes would endure, “But he’s only becoming nicer,” she admitted. “I don’t doubt him any longer.” Devron added that he now felt deep inside his soul that he could trust Sheila. He felt safe in a relationship for the first time in his life. “So now I have no reason to be mad all the time.” Of course, he and Sheila still argue from time to time, as do almost all couples. But Devron controls his initial burst of anger far better than before, calms down quicker, and lets go of his anger sooner.Read Full Post | Make a Comment ( 1 so far )
It first showed up in my Facebook feed early Saturday morning, and then I saw it everywhere—in my email inbox, my texts, all over the internet: Asperger’s … Asperger’s … Did you hear???? … Asperger’s. Twenty-year-old Adam Lanza, who had killed 26 people at Sandy Hook Elementary School the day before, was allegedly on the autism spectrum. Advocates rushed to respond; many groups, including Autism Speaks, GRASP (the Global and Regional Asperger Syndrome Partnership) and Autism Rights Watch issued statements expressing sympathy for the victims while reminding a spooked public not to “scapegoat” the disorder or further “stigmatize … autistic persons and their families.”
Although Lanza’s diagnosis has yet to be confirmed, he is only the latest mass murderer whose autism-spectrum status has been speculated about, including Colorado movie shooter James Holmes and Anders Behring Breivik, the Norwegian who killed 77 people in 2011. Even serial killer Jeffrey Dahmer and Unabomber Ted Kaczynski have been retroactively labeled autistic, with the same diagnosis-happy fervor that has caused other activists to claim Albert Einstein and Thomas Edison as members of the Asperger’s nation. But the legitimacy of these diagnoses is less interesting than the question they imply: Did autism make them do it?
As president of EASI Foundation: Ending Aggression and Self-Injury in the Developmentally Disabled, I work with many families struggling to manage their autistic children’s dangerous behaviors. There was a time when my own son Jonah, now 13, was prone to such violent rages that I feared I might end up like Trudy Steuernagel, who was bludgeoned in 2009 by her 19-year-old autistic son Sky Walker, or Linda Foley, who was also beaten to death by her 18-year-old stepson, Henry Cozad. But I was never afraid Jonah would massacre 20 kids with a semi-automatic rifle.
Researchers distinguish between two types of aggression: affective and predatory. Affective aggression is the most common; it occurs when an individual reacts to stimuli in the environment—or, as was the case for my son, internal neuropsychiatric events. These are short but very emotional episodes, accompanied by the increased heart rate and flushed skin of autonomic system arousal. The vast majority of violent crimes committed by individuals with an autism spectrum diagnosis fall in this category, and the details reveal a marked lack of premeditation. A 2006 Swedish study comparing autistic murderers with those who had been diagnosed with antisocial personality disorder found that more than 70 percent of antisocial killers used a weapon, whereas only 25 percent of the autistic killers did—and, I should note, this group was very small, consisting of eight autistic individuals who had been convicted of homicide or manslaughter in Sweden from 1996 to 2001, compared with 27 who had been diagnosed with anti-social personality disorder. As many autism advocates have pointed out over this past weekend, the autistic population has a lower rate of criminal activity than that of neurotypicals; in all likelihood this is because those who are prone to the most violent rages—like Sky Walker and Henry Cozad—are identified at a very young age. In the best-case scenario, they respond, as Jonah did, to psychiatric intervention. But this population is notoriously difficult to treat. Many end up in residential treatment facilities.
Predatory aggression is very different. Cool, detached, and controlled, it is primarily a cognitive experience of planning and execution. When Adam Lanza donned black fatigues and a military vest, drove to Sandy Hook Elementary School with three of his mother’s guns, and ruthlessly gunned down everyone he found—this was an example of predatory aggression that is generally not seen in the autistic population.
Still, this distinction doesn’t explain why so many autistics are prone to aggression of any kind. Studies have found that up to a staggering 30 percent suffer from aggressive and/or self-injurious behaviors of varying degrees. But it turns out this might not have much to do with autism at all—the primary impairments of which, according to the Diagnostic and Statistical Manual of Mental Disorders, involve socialization and communication, not violence. The violence has and more to do with psychiatric conditions that many people on the spectrum suffer from. One 2008 study by scientists at King’s College London found that 70 percent of their young autistic subjects had at least one co-morbid disorder, such as childhood anxiety disorder, depressive disorder, oppositional defiant and conduct disorder, or ADHD. Forty-one percent had two or more co-morbid disorders.
It is this combination of developmental delay and psychiatric disorders that pops up again and again in the literature on autism and violent crime. A 2008 review by Stewart S. Newman and Mohammad Ghaziuddin reported that “an overwhelming number of violent cases had co-existing psychiatric disorders at the time of committing the offence”—84 percent, to be precise. And Newman and Ghaziuddin couldn’t rule out personality disorders, such as anti-social personality disorder, in the remaining subjects. They conclude, “co-existing mental disorders raise the risk of offending behavior in this group, as it does in the general population.” This academic paper echoes the practical experience of those working with autistic youth; Roma Vasa, child psychiatrist in Kennedy Krieger Institute’s Center for Autism & Related Disorders, states that children with Asperger’s “usually only exhibit intense anger if they have additional psychiatric disorders.” Even then, “their anger does not typically result in these types of massive violent attacks [like the Sandy Hook shooting].”
It’s no surprise to find the real culprit is mental illness, not autism. As Katherine S. Newman, author of the 2004 book Rampage: The Social Roots of School Shootings observed in a CNN editorial Monday morning, school shooters such as Adam Lanza “are almost always mentally or emotionally ill.” Still, there is a lesson for those of us who care for a person on the autism spectrum: We need to watch for those secondary psychiatric disorders our loved ones are vulnerable to. Often, parents and clinicians assume that patients are anxious or depressed or manic or aggressive because of their autism, when in fact those symptoms may have a different etiology. It isn’t easy to tease them apart, especially in lower-functioning individuals who can’t articulate their feelings well. But it was only once my son was diagnosed with bipolar disorder and treated accordingly that the frequent, unpredictable, and intense rages that characterized his childhood finally subsided.
Going forward, we may or may not find out more about Adam Lanza’s alleged Asperger’s diagnosis. But his social awkwardness, his genius IQ, his ability to build a computer from parts—these are all red herrings, reasons why autistic individuals are more likely to be victims of crime. These factors are not even remotely relevant explanations of why Lanza committed this crime. And every time we conflate his developmental disorder with whatever psychiatric or personality disorders he may also have suffered from, we harm the entire autism community.Read Full Post | Make a Comment ( None so far )
Human empathy depends on the ability to share the emotions of others—to “feel” what other people feel. It is regarded by many people as the foundation of moral behavior. But to some, the concept seems rather airy-fairy. What does it mean to say “I feel your pain”? Isn’t that just a fanciful flight of the imagination?
Well, not really. For one thing, it turns out nonhuman animals—-even rodents-—show evidence of empathy. For another, it appears that empathy has a neurological basis.
The same brain regions that process our first-hand experiences of pain are also activated when we observe other people in pain. Moreover, when we observe the emotional signals of others, we recruit brain regions associated with theory of mind, the mechanism that permits us to take the perspective of another person. This theory of mind mechanism-—along with the ability to keep our own emotional reactions under control-—may be of crucial importance for showing empathic concern, or sympathy.
A person who lacked theory of mind or the ability to self-regulate emotions might focus solely on her own emotional reactions to another person’s plight. She might respond aversively to the victim, or–absorbed by her own emotional agitation–she might even become aggressive. Empathy, then, involves a package of abilities. Here’s a quick guide to the biology of empathy, including information about the development of empathy in children.
In one experiment, 15 rhesus monkeys were trained to get food by pulling chains. Monkeys quickly learned that one chain delivered twice as much food than the other. But then the rules changed. If a monkey pulled the chain associated with the bigger reward, another “bystander” monkey received an electric shock. After seeing their conspecific get a shock, 10 of the monkeys switched their preferences to the chain associated with the lesser food reward. Two other monkeys stopped pulling either chain—preferring to starve rather than see another monkey in pain.
Mice, too, respond to the display of pain by their companions. Researchers at McGill University put pairs of mice together and injected one or both of them with a substance that induces mild stomach ache. Mice reacted to the pain by wriggling and stretching their legs. But the intensity of the reaction depended on social cues. Mice wriggled and stretched more when their companions were also in pain. Moreover, mice exposed to the sight of a suffering cage mate were quicker to back away from an unpleasant heat source—suggesting that witnessing their companion’s discomfort made mice more sensitive to their own pain.
So there is nothing particularly human about finding the painful experiences of others unpleasant. But why is “second-hand” pain unpleasant or upsetting?
New research by neuroscientist Jean Decety suggests a fascinating neurological link between our own, first-hand experience of pain and our perception of pain in other people. When typically developing kids (aged 7 to 12 years) were presented with images of people getting hurt, the kids experienced more activity in the same neural circuits that process first-hand experiences of pain. This automatic response–termed “mirroring”—has also been documented in adults. The phenomenon may reflect the activation of mirror neurons, nerve cells that fire both when a person performs an action and he sees that action being performed by others. To date, researchers have identified specific neurons involved in the mirroring of hand movements. No one yet has isolated specific mirror neurons for pain or emotion.
Mirror neurons may explain how we can experience “second-hand” pain or emotion. But to respond with empathic concern, we need other information, too. We need to understand the perspectives of other people. We also need to overcome our own negative reactions to the display of another person’s pain or distress.
Brain-imaging research seems to confirm this link between theory of mind and empathy. For instance, when people have been asked to evaluate the emotional facial expressions of others, they showed activation in the brain regions associated with theory of mind tasks. And theory of mind is probably important in other ways. For instance, Jean Decety and his colleagues have investigated how the brain distinguishes between the victims of accidents and victims of aggression.
To better understand how theory of mind contributes to the perception of “second hand” pain, Decety’s team showed kids two sets of images. One set depicted people experiencing painful accidents. The other set showed people who were being victimized by aggressors. In both scenarios, functional magnetic resonance imaging (fMRI) revealed that merely looking at images activated brain regions associated with the first-hand experience of pain. But when kids watched images of one person deliberately inflicting pain on another person, additional brain regions (in the orbital medial frontal cortex and the paracingulate cortex) were activated.
Brain imaging research and studies of brain-damaged patients suggest that these regions are associated with social interaction, emotional self-control, and moral reasoning. Were the additional brain regions activated because the kids were engaged in social and moral thinking? It seems very plausible.
The activation wasn’t caused by the mere presence of multiple people in the images, because researchers controlled for that. And, when kids were debriefed at the end of the experiment, most of them commented on the unfairness with which the victims had been treated.
The study mentioned above measured the responses of normally-developing kids. What about kids who show a cruel streak? Decety’s group conducted a similar fMRI study on teenage boys with conduct disorder, or CD.
This disorder is a serious psychiatric condition linked with behaviors like physical aggression, manipulative lying, sexual assault, cruelty to animals, vandalism, and bullying. It’s also a precursor to antisocial personality disorder in adulthood (Lahey et al 2005). Researchers screened boys (aged 16-18) for CD, and showed them the same types of images of accidents and assaults mentioned above.
The results were very interesting. I feel your pain…and it makes me lash out
In some respects, the boys with CD responded like boys in the control group. In particular, the mirror neuron system for pain was activated in both groups.
But there were dramatic differences.
First, the boys with conduct disorder experienced less activation in brain regions associated with self-regulation, theory of mind, and moral reasoning.
Second, the boys with CD actually exhibited a stronger “mirror” response to accidentally-caused pain.
And, unlike controls, the boys with conduct disorder experienced strong, bilateral activation in the amygdala and striatum.
What does this mean? It’s not clear. The amygdala processes emotion. And the striatum is activated by strong stimuli—both pleasurable and aversive. So there are at least two possibilities.
The aggressive boys might have gotten a pleasurable “kick” out of viewing the pain of others.
But given that their own pain centers were strongly activated, it’s also possible that observing second-hand pain triggered negative emotions—emotions that make the boys behave more aggressively. As Decety and his colleagues point out, negative emotions—particularly in people with poor emotional control—can cause agitation and outbursts of aggression (Berkowitz 2003). This effect may be magnified in kids who have trouble distinguishing their own first-hand pain from the pain of others.
Decety and colleagues speculate that boys with conduct disorder may experience high levels of agitation or distress when they experience second-hand pain. When this distress is combined with poor self-regulation of emotion, they lash out. But whether second-hand pain makes aggressive kids feel good or irritable, one thing seems pretty certain:
The brains of boys with conduct disorder responded more intensely to images of other people experiencing pain. And this intensity was linked with the boys’ aggressive tendencies. The more strongly a boy’s brain responded to second-hand pain, the more highly he scored on measures of daring and sadism.
Animal studies and brain scan research might make us wonder if feeling empathy is a purely automatic process. But, as noted above, empathy is really a package of abilities, and there is evidence that empathy and empathic concern can be shaped by experience.Read Full Post | Make a Comment ( None so far )
We need only to do something once to know we are capable of doing it, the more we do it the better we get, each time we do it, we gain confidence and are more capable, less fearful. The doubts we possess prevent us from trying and push our comfort zone, to step beyond what we are capable of achieving. What is familiar is comfortable, and we like to stick with what provides us comfort, but what is familiar is not always what’s better. Anything worth having in life takes some degree of effort, change is inevitable and what was once novel soon becomes familiar. We adapt to just about anything and are able to endure. We grow accustomed to what is familiar and in it we find security. We cannot necessarily control what is happening but we can adjust to the world around us, we are great at dealing with change we change our clothes, our hair, as you read this the hand on the clock are moving, the lights grow dimmer the sun sets, we cannot control the wind but we can adjust our sails. Yet we feel as powerless as a car without an engine to alter our environment, but we can be a role model to others to be an example of how we would like to be treated. If what I’m doing isn’t working, I need to change direction and find what I can alter, that being yourself, rather then fight what I cannot control.Read Full Post | Make a Comment ( None so far )
I like to say that the heart is where emotions come from. Yet, the heart has no judgment at all. We are all born as emotional beings, which we use to help us survive. Our brains are not fully developed, so our logic is not always logical or rationally based on facts. We seek to avoid pain and cry out for pleasure. When an infant hears his parent’s arguing and yelling he will cry. Infants are emotional being that use their emotional radar to pick up on the feelings of those around them to survive. Historically, teenagers have always seemed to make illogical and irrational decisions. This is partly due to the limitations in their logic and reliance upon their emotions. Adolescents seek out pleasure, are unable to delay gratification, and pursue impulsive actions. As we age our brain fully develops and our logic takes over. Yet our emotional memories are strong and trump our rational decisions. Can we logically explain all the things we do for love? The time and money we invest in caring for others, beyond evolutionary theories, there is no logical explanation other then it feels good to love. Emotional memories become emotional reflexes as we age. We no longer even think of these motivations, we just react. Yet, below the surface our fears of pain lead us to defend ourselves to avoid the misery we once were exposed to. This pain may be from our own direct experience or it may be vicariously through witnessing another’s pain. Still these emotional memories were so strong and even traumatic that we have spent a great deal of our lives acting in ways to avoid reliving them. The longer we act to avoid these experiences the more these emotional memories turn into strong emotional reflexes. Eventually reaching the point where we no longer question where they come from but feel obliged to act in accordance with them out of internal discomfort. Emotions cause us physical discomfort in the form of headaches, muscle tension, nausea, sweating, shortness of breath, or an increased heartbeat just to name a few. These are ways our body communicates with us and lets us know that we are neglecting ourselves. So we seek to release this pain by lashing out with exaggerated emotional reactions and dump our pain onto someone else. Typically these are safe targets, who are people that love us because we know that they will forgive us and tolerant our outbursts.Read Full Post | Make a Comment ( None so far )
Do you bite your nails? For 30 years, I did. We nail biters can be “pathological groomers” — people for whom normal grooming behaviors, like skin picking or hair pulling, have become virtually uncontrollable.
But psychiatry is changing the way it thinks about pathological grooming, and these changes will be reflected in the American Psychiatric Association’s DSM, short for Diagnostic and Statistical Manual of Mental Disorders. A new version is coming out early next year, and it puts pathological grooming in the same category as another disorder you’ve probably heard of: obsessive compulsive disorder, or OCD.
This rethinking gives pathological groomers some new ways to think about those behaviors.
I can tell you the exact moment I became a nail biter. I was 6 years old, watching my mom get dressed for work. She paused to mull something over, chewing on a nail. My reaction: “How cool! How grown-up! I think I’ll try it.”
I never stopped. It was embarrassing — like wearing your neuroses on your sleeve. At parties, I learned to wrap my fingers all the way around my wine glass, so that my nails faced my chest. I hated filling out forms in public places.
Recently, something happened that made me finally quit biting my nails. I’ll get to that in a bit. But I was feeling quite pleased with myself when I showed them to Carol Mathews, a psychiatrist at the University of California, San Francisco. “Your cuticles are pushed back. It’s not bad. Looks like you’re a recovered nail biter is what I’d say,” she pointed out.
“They are behaviors that stem from normal grooming — the kind of thing that most animals do and is evolutionarily adaptive, right?” says Mathews.
But in pathological groomers, those behaviors go haywire. Instead of being triggered by, say, a hangnail, the pathological nail biter is triggered by driving, reading or feeling stressed out. “After a while, the behavior becomes untriggered,” says Mathews. “It becomes just an automatic behavior that has no relationship to external stimuli at all.”
Until recently, the DSM treated pathological grooming a bit like an afterthought and put it in a catch-all category called “not otherwise classified.” But the new DSM proposes to lump together pathological groomers and those with mental disorders like OCD. That includes people who wash their hands compulsively or have to line up their shoes a certain way.
These behaviors have a lot in common. In both cases, it’s taking a behavior that’s normal and healthy and putting it into overdrive, doing it to the point of being excessive. But in at least one way, OCD and pathological grooming are also very different.
“In OCD, the compulsion is really unwanted,” says Mathews. People with OCD don’t want to be washing their hands or checking the stove over and over again. There is no fun in it. There’s fear — fear that if they don’t do something, something else that’s very bad will happen to them.
But from her pathological grooming patients, Mathews hears a very different story: They enjoy it. “It’s rewarding. It feels good. When you get the right nail, it feels good. It’s kind of a funny sense of reward, but it’s a reward,” she says.
I can relate to that. And in my household, I’m not the only one. My daughter Cora is 3, and she’s why I decided to quit. I didn’t want Cora to learn to bite from me, the same way I learned from my mom. So for three months, I wore acrylic fingernails and spent many long hours at the manicurist maintaining them.
And it worked. I lost the urge. But apparently, it was too late.
“I don’t want to put my fingers in my mouth. I just [do] it even though I don’t want to,” Cora explained to me. But was she just mimicking me, or was there something else going on — something deep and strong enough to make nail biters out of at least four generations of women in my family, including my grandmother?
That’s where Francis Lee, a psychiatrist and neuroscientist at Weill Cornell Medical College in New York, comes in. A few years ago, a colleague came to Lee with a mystery: A mouse — bred with a specific gene mutation — was behaving very oddly. “I was dumbstruck,” recalls Lee. “It was just repetitively moving its front paws over its eyes and ears,” — a behavior he instantly recognized from studying people.
Mice bred with this mutation groom so much, they give themselves bald spots. “They’ve removed the hair around their eyes, they actually look like they have little white rings around their eyes,” says Lee.
In these mice, the genome is destiny. Every mouse that has this particular mutation — even if it’s separated from its mother early on — eventually will become a pathological groomer. And the grooming isn’t all. Lee says these are some of the most anxious mice he’s ever seen. He even said to his colleague at the time, “That is one crazy mouse.”
People, of course, are a lot more complicated. There are some genetic mutations that seem to crop up in people with OCD and in people who groom pathologically. But just because you have the mutation doesn’t mean you get the behavior.
In fact, with OCD, it’s more likely you won’t, says Mathews. “As genetically determined as OCD is, the risk to a family member for someone who has OCD is only 20 percent. So it’s 80 percent chance of not getting it,” she says.
Which brings me back to my own crazy mouse.
As a parent, there are ways I could lower the chances that Cora will grow into a biter. When Mathews works with young kids, she does things like put Band-Aids on their fingers to help them notice when they’re biting or pulling. Then she sets up reward systems to try to steer them away from the behavior.
I’d already started to do a clumsier version of this, gently batting Cora’s hand away from her mouth whenever she started to bite. But it had come at a price, one I wasn’t entirely comfortable with. I had to decide what was worse: making Cora feel bad about herself for something she couldn’t help, or just letting her grow into a nail biter, which, while certainly not the worst thing in the world, had given me some grief.
Tracy Foose, a psychiatrist in San Francisco who specializes in anxiety disorders, seemed to offer a third option. She bites her nails, and, like me, she has a 3-year-old daughter. Foose has a whole different take on it — probably a much better one. Nail biting is just part of who she is. She’s even proud of it. “You know, my mom bites her nails. She was an artist. So, I think I associate it with being cool and being older and working on something important,” she says.
During her residency, Foose met a patient at the ER one night. “A lovely, middle-aged mother of several kids who came in and looked scared out of her wits,” she recalls. This woman had become fixated on a perceived blemish on her face. “She had picked at her cheek to a level where she was bleeding profusely,” says Foose.
It was dermatillomania, to be specific.
“She truly could not control herself, despite the pain that it was causing, despite the disfigurement. And nail biting sort of forever fell off my radar,” says Foose.
Nail biting is not life threatening. On the scale of human failings, it barely lifts the needle. It’s not to say Cora wouldn’t be better off not biting her nails. But, says Foose, there may be a better way to talk about it. Just as Foose had removed the stigma and guilt for herself, maybe I could do that for my daughter.
“You can go to the place of giving kids information. Like, ‘Oh, I see you biting your nails. Mommy bites her nails, too. You know why we shouldn’t bite our nails? Because there are germs that live under our nails,’ ” explains Foose.
A way that frames it, in other words, as a choice. One that’s hers to make — even if it takes having her own kids one day to make it.Read Full Post | Make a Comment ( None so far )
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