#18 Underground DSM-IV - Full Version

Reprinted a few times over the years.  I didn't update it much this time.

Further slight editing 10/31/11.
Addition 11/22/16, next paragraph, and then far below

Someone at work requested that I print out the whole thing in 2011, and I have had a recent request to reprint this.  It is ten years old now.  I have edited it, primarily by removing some sentences I no longer think are that defensible.   The following is a collection of empirical observations about people with various diagnoses.  Some are a bit unfair, and I plan to attend to that when I improve it and add pieces to it.  Soon, I hope. 

Uses the phrase: “Head games”= Borderline PD
“Deep” depression  =  Dependent Personality, or less often, Borderline or Histrionic.
  (“very, very” is also a bad sign. I spoke with a woman yesterday who used three "very's" a half-dozen times while describing her history. Her children are very, very, very, important to her.  Except operationally they aren't.) It is a bad sign in everyday conversation, also.  A close relative once posted on Facebook about some political cause that is largely a pose for him "This issue is very, very important to me."  I want to say "I'm sure you mean that it is very, very, very important to you."  But I didn't. As with the truth discussion below, too many intensifiers is a bad sign.

“…died in my arms.” = Antisocial Personality Disorder.   It’s amazing how often this is claimed, and how seldom it is true. Of political note: Jesse Jackson claims that MLK died in his arms.   He didn’t. So now we know Jesse’s diagnosis.

The wife or mother of the violent sociopath who says “I just want him to get help” is going to take him back (See “I need therapy,” next.)

“I need (undefined) therapy.” Means I feel bad and think I will feel better if other people listen to me endlessly. Our other offerings, including group therapy, DBT, skill-building, IMR, etc won’t be considered real therapy.  Real therapy might mean no homework and a person of the opposite sex to say “there, there.”    But even short of that, it means other people will just listen. Variations include “I haven’t gotten any therapy here.”

Identifying “low self-esteem” as your problem means you want someone else to fix it. Self-esteem (in the popular sense, not the older, precise sense) is entirely subjective.  Self-respect is based on actions. Seeking self-esteem is seeking to feel better without doing anything, and does you no good.   But no matter how far down you go, you can always do something to increase your self-respect. I think of that when public figures have screwed up. One can usually tell pretty quickly quickly whether they are protecting self-esteem or self-respect.

If you take an antisocial male on a ride near his home community he will keep claiming to see people that he knows, or their trucks or motorcycles. (“That’s Tiny’s Harley!”)

Not original to me:  Tattooing L-O-V-E on one fist and H-A-T-E on the other is a type of intimidation that Antisocial Personality Disorders are fond of.  It's your fault if they have to hit you, y'see, because they are basically peace-loving people who aren't looking for a fight.

When a patient claims that the hospital doesn’t know him, and therefore has no right or foundation for evaluating him, he means that the objective evidence should be ignored in favor of his rationalizations.  "That doctor only spent five minutes with me."  Dude, I had 90% made up my mind just reading the first page of your chart.


 Related:  To a person with Borderline Personality Disorder “No one is listening to me,” means “no one is agreeing with me.” This has been remarkably durable over my career.  The idea seems to be "If you were really listening to me you couldn't possibly disagree."  Countering with the statement "I hear what you are saying, but I don't agree with it" can actually provoke assaultive rage.  It must come near the core of problem.

 Pts. referring to length of time they have been in hospital as an argument for privileges or discharge means they still don’t get it. Similarly, arguing "But it's my daughter's birthday party this Saturday" or "I'm supposed to be at work today.  I could lose my job," mean much less after a suicide attempt.  What was your daughter going to do if you were dead? These are, sickeningly, often followed by "My children are everything to me."  Your actions say the opposite is true. But if that ever sinks in, you probably will commit suicide, so I don't say it out loud.

Gazing intently slightly upward -- choosing among several things to say (Lots of people do this.)

 The further up the gaze, the more possible responses - usually not a healthy sign.
Gazing at ceiling: = Choosing among a multitude of things to say, i.e. lying.

Turning back to interviewer, spinning in chair:   =  Antisocial PD

Commenting that there are a lot of people in the interview room.   = Borderline PD.
(Thinking it or acknowledging it doesn’t count. Anyone might do that.) I don't know why.  There may be something around the insecurity of managing so many emotional dyads.

Shaking hands with more than one person = manic.   More handshakes, more mania. Today I had someone who wanted to high-5 everyone in the room.

Substance Rehab excuses:

Meatloaf version: I would do anything for rehab (said Monday), but I won’t do that (said Tuesday.)

Goldilocks version: That Rehab is too far. That Rehab is too near. No rehab is just right.
 Wearing clothing with beer logos to your rehab interview suggests you aren’t serious.

Chronic pain really can make you look like a Borderline or Dependent Personality.  It’s harder than it looks.  Mania can also make you look like an antisocial.  Be slow on the blaming attitude with these.

Paranoids have an uncanny ability to make their worst fears come true.   Eventually, everyone is watching them.

Borderlines seeking cool alternative diagnoses have an uncanny ability to locate the only private therapists who can’t help them.

Manipulating staff or lying is a high-level skill indicating significant organization and readiness for discharge. Sicker patients try to manipulate staff but do it poorly. To the complaint “but she’s just telling you what you want to hear,” my response is “I’ve got a caseload full of people who would love to tell me what I want to hear, but can’t.”

Some staff consider that a patient enjoying anything is a bad sign. “She likes it here,” is synonymous with “she’s not sick, she’s malingering.”

People who have a “problem with women,” or “problem with men,” reveal behaviorally in about 24 hours that they don’t do well with the other sex either.   Ditto for “problems with authority:” those folks tend to also show “difficulty working independently” and “difficulty sharing responsibility.” What’s left?

Rescuing women often accept the reasoning from the violent men in their lives that those just need to “get their anger out" somehow.  Actually, these guys get their anger out just fine. It’s keeping it in we want them to work on. This seems terribly unhealthy to both the violent male and his rescuing female, who are puzzled that mental health professionals do not understand this very obvious psychological need to get anger out.   This particular bit of faulty reasoning is often paired with needing “therapy,” as above. No one understands them, it seems. (I hear this less now than I did early in my career.)

What I call Oppositional Treatment Design is remarkably accurate.  If you want to sleep, we want you to get up.  If you want to be up, we want you to sleep.  If you want meds, you probably shouldn’t have them, but if you don’t want them they are likely to be exactly what you need.  If you want to leave, we make you stay.  If you want to stay, we make you leave.  If you’re blaming yourself, you should stop that.  If you’re blaming others, you should start blaming yourself.  It’s not as stupid or mean as it sounds.  People usually come to the hospital because of a particular point of contention with the usual flow of life.  That inability or refusal to change is usually the central difficulty getting along in the world.  The patient will usually hand you the opening, though it’s wiser to use a Colombo indirect approach than a direct confrontation. “People say I’m getting manic, but they just don’t understand that I have a lot of energy.”  That may sometimes be true for folks getting along in life, going to work, paying bills.  Involuntary arrival at a psychiatric hospital is usually an indication that something has gone wrong, however.

The content of paranoia is often a function of what is floating about in the air at the time of the first breaks.  In the early 70’s it was the CIA.  During the era of the Godfather movies it was the mafia. Radio waves were big for a while.  Now it’s computers or satellites, and implanted chips are going to have a strong run this decade. Plus, there's always the old reliable "drug dealers are after me because I told the cops that Bennett and Preston are using drugs."  Dude, the cops know all about Bennett and Preston, it's proving it that's the problem.  People of religious leanings might have demonic or angelic interpretations to their voices.    Movies may figure prominently.   Trying to tease out other meanings provides lots of exercise for ego-analytic psychologists, but no objective help to the patient.

If one staff member moves to rescue a patient with Borderline Personality Disorder, someone else will lean toward punishment to an equal degree. “You’re giving her everything that she wants!”  In large groups the mathematics of balance is more complicated but the principle is the same: the group will balance its negative feelings.  Moving to the extremes just increases splitting: shift wars, team vs. line staff, community vs. hospital.  The longer the staff discussion is going on, the more likely it is that this patient has Cluster B traits.  Everyone wants the last word on those.

The Rorschach protocol measures the psychologist’s ability to consider alternative diagnoses.

The closer you are to the situation, the more you are convinced the other person is being bad on purpose.  The more distance you have, the more you are convinced that non-elective forces are driving the behavior.  Both are inaccurate. Choices are always mixed, driven by both will and external factors. This is not patient-nature, this is human-nature.

If it’s Friday afternoon and it’s a crisis, there’s a personality disorder behind it.  But 50-50 it’s a staff member who’s got the Cluster B traits that is sucking the fluoride out of your teeth.

You can’t reach much of anyone on a Friday afternoon, but those you do reach are usually pretty competent. The others left them in charge and snuck out the back way.

Punching the wall is not something to be congratulated for just because you wanted to hit a person instead. You are still rehearsing violence. In fact, you are ably demonstrating how unconcerned you are with your own pain, so long as you get to show how angry you are.  It’s an intimidation tactic.

Multiple personalities usually add up to less than one.

New social workers want to intervene in everything at once: couples counseling, substance rehab, going on disability, finding a self-help group, etc. This is the human services equivalent of invading not only Afghanistan and Iraq, but North Korea, China, France, Mexico, and the Maldive Islands, all at once. Addendum: If you suggest this to social workers, they won’t understand the analogy, noting irrelevantly that they were against going into Iraq.   Note:  This is changing.  I am noticing a trend of social work interns wanting to change the agency, and its institutional racism and sexism.


Psychiatrist: Can you tell me something about what brought you to the hospital?

Patient: I wrote it down last night and want to read it to you. ( It's three pages long. And this goes triply if it's a poem.)

Diagnosis: Borderline Personality Disorder. (Though Narcissistic might be a go.)

Naming your daughter after an alcoholic beverage is a bad sign (Brandy, Margarita, Champagne, Martini).   Exception for Margarita if you are from a culture where the name is historically common.

In every generation there seem to be given names of children associated with a much higher proportion of pathology.   No recent DCYF worker will be naming her own daughter Crystal, for example. (Crystal is now passe.)  The mechanism for this is opaque to me.  Most Justins and Jasons are just regular people of course, but somehow an enormous number of pathological mothers decided that those were the best names for their sons.  This annoys the hell out of the regular Crystals, Justins, and Jasons, who usually sense that they share their name with a lot of delinquents pretty early.  Just ask them.  The delinquents themselves never pick up on it – it’s always a surprise. “Krystl, that is like so amazing!  My boyfriend last summer was like Justin, too, and he had to go to rehab too!” Amber, Brandon, and Sean were problem names earlier. (Update: Sean not so much now.)   Cheyenne and Dakota may be on the rise. (Update: I was right.) Raven. Cody.

People who work at developmental agencies are concrete and fearful of change, like their clients.  We don’t know who gets it from whom.

Seeking guardianship is a measure of staff frustration.

If an experienced social worker has arranged a placement with only a small window of availability, the patient automatically becomes clinically ready to go, and you’d damn well better agree.
Otherwise, the SW will bite your head off the next time you ask about discharging someone.

When line staff says, “He needs to be discharged,” they mean “I’m sick of him.”

When psychiatrists are finished with med changes, they conclude the patient is at baseline, independent of any data.

When anything changes, the psychologist will find a way to interpret it as progress.

The difficulty with being a MHW (psych tech) is the social and emotional battering they receive from both patients and ungrateful staff. Stress reduction classes make this worse. Encouragement might work, but no one’s ever tried it.

Intense borderlines tend to live near the hospital and interact with each other. When any one of them dies, or especially if one commits suicide, several others will have short memorial admissions to the hospital. I no longer think this is a bad thing. 

When a patient challenges your credentials, no credentials will be good enough. There will always be something you lack. “Oh, so you’re not a psychonutritionist.” I have come to understand that this applies to everyone, not just psychiatric patients and their families.  When someone challenges or asks for your credentials, their only intent is to tear them down. This may be strongest in the social sciences, where credentials can be kinda fuzzy and science not well-regarded to begin with.   I have found that this is true of everyone, not just psychiatric patients and the       

When a patient – and some providers – claims a “right to be angry,” there will be a sudden shift in the meaning of ordinary words. That one is entitled to ones own feelings and opinions will be made to equal “I am justified yelling at people. Or worse”

Bonus international political comment. France is a glamorous borderline personality disorder – the cause?  An abusive incestuous relationship with Germany.  Much of European politics suddenly becomes clear if you keep this in mind.  The rescuing Americans are the bad parent who didn’t rescue enough, and so get blamed more than the perpetrator, who she has now gone back to live with.

Russia tends to paranoid personality disorder, and about half of the Arab nations are narcissistic personality disorders. Societies which oppress women tend to raise entire generations of narcissistic males. It is not a healthy thing for a boy to pass his mother in cultural status, for nothing that he has earned, when he is still a complete twerp.


11/22/16 Bethany thinks it should be a whole book.  But really, I don't think I've got much more material.  However I have things to add today, and maybe I should just keep adding that into the larger post.

When someone says anything about honesty -
Can I be honest?
Not gonna lie
I'm just being honest
I truly think
I'm not sh---- you here
I really, really want
 - they usually mean something else.  Sometimes they mean candor, or bluntness.  Sometimes it's a feeling that they have no supporting evidence for. Sometimes they are saying true things, but leaving out other information that is important.  Sometimes it's just lying.  People who are speaking the truth generally don't reference "hey, did I mention that this is the truth?" They certainly don't make repeated references to how truthful and honest they are being.  In a side note, any political or religious organisation that uses the word "truth" in its name should be watched with the closest scrutiny.

This may be connected to the Biblical admonition of "Let your yea be yea and your nay be nay." (James)

Perhaps relatedly, many statements in mental health bureaucracies don't mean what their content would suggest, and I suspect there are parallels in your industry as well.  "I just want what's best for the patient," or "Look, we all want what's best for the patient here" usually means "Let's do what's best for my agency," or even, horribly, "we don't want to put in much effort to fix this and you're stuck with him, so we don't much mind if the patient is not being served."

Oh, oh, that reminds me.  When the hospital is discharging a patient over the objections of the family*- and this is often a risky proposition that we are wincing at and crossing our fingers over - I breathe a sigh of relief when someone shouts into my phone "If you discharge him today, I guarantee you he will be dead before midnight."  Whew.  So this is just a family that postures in overdramatic fashion, and the patient is cut from the same cloth, so their cat-and-mouse about suicide is mere drama. Good to know. The few actual suicides usually take us more by surprise.

And speaking of suicide, remember that there is a suicide rate for people leaving banks, people leaving schools, people leaving work, and people leaving hotels. The suicide rate for people leaving psychiatric hospitals over the next 30 days is only marginally higher.  It's just that ours make the newspapers and people think we should have done...something.

*this happens all the time and often really does suck for the family, who are up against it and have legitimate gripes, and a hospital is at least a safe and treatment-oriented environment for their brother, daughter, whatever. It's brutal to have a mental illness, and sometimes it's brutal to even be close to it.