Explore these 9 factors so you can make an informed decision. Lucy and Larry are the best of friends, and both are in long, unhappy marriages. Lucy complains that her husband is remote and withdrawn, and Larry complains that he and his husband are constantly quarreling. Lucy feels lonely in her relationship, while Larry is often triggered and upset by the tension and arguing. For months they debate whether to divorce or stay in their unhappy relationships. The decision to stay or go depends on finding clarity, but finding clarity depends on these factors. Think about the dynamics of your relationship. What are the patterns of interaction? Is there mutual respect, admiration, and emotional support? Do you still share common goals, values, and interests? Are you able to support each other's personal growth and development? Think about your needs, your wants, and your goals. If you stay in your relationship can you fulfill your long-term goals? Do you believe divorce would realistically offer greater opportunities for personal fulfillment and growth? How will staying together or divorcing affect your overall quality of life, including your emotional well-being, financial stability, and mental health? Often there are unexpected losses during divorce. Making well-informed decisions is crucial. Do you have children ? How will divorce or staying together impact your children? Try to make decisions that prioritize their stability and happiness. With few exceptions, divorce negatively impacts children, especially when parents are in conflict. Educate yourself about how to divorce in a way that reduces the negative effects on your children. For example, will you work with your spouse to co-parent your children should you decide to divorce? Do you believe that your spouse will co-parent well with you? Have you sought help? Seeking guidance from a qualified therapist or marriage counselor can help improve communication, identify underlying issues, and provide strategies for resolving conflicts. Lucy and Larry both spend months in marriage counseling with their spouses and feel it helps them to consider whether they’re facing temporary challenges or deeper fundamental incompatibilities. Look for specially trained discernment counseling in your area. If you have children, try to explore avenues for reconciliation through couples therapy, individual self-improvement efforts, and open communication. Perhaps, with effort, motivation, and commitment to change, you and your partner can find new ways to strengthen your bond. Be realistic: divorce can have significant financial and health implications. Most divorcing partners experience a serious drop in their standard of living and lifestyle. You’ll be dividing assets, and debts, and paying or receiving child support or spousal support. Non-working parents are often expected by the courts to contribute to their own support. If you haven’t worked for a while, you may need retraining or vocational counseling. Some of the hardest things about divorce are unpredictable. The stress of divorce can affect your physical and mental health unless you learn to minimize it. Consult with a qualified family law attorney to obtain personalized legal advice and guidance. Laws relating to divorce vary in different jurisdictions, so you’ll need to understand the costs, requirements, procedures, and potential outcomes if you decide to divorce. Consider mediation or a collaborative divorce instead of a court-involved process. Consider a trial separation: In some cases, a trial separation can provide respite, clarity, and perspective. During this time apart, both partners can reassess their feelings, priorities, and the feasibility of reconciliation. Counseling during a trial separation can help you decide whether or not to reconcile. Ultimately, you’ll need to listen to your intuition and inner wisdom. Your feelings and instincts about the relationship are important data. While it's important to think through the factors above and seek advice, in the end, you are the best judge of what is right for you and your family. Whether you choose to stay together or pursue divorce, strive for a resolution that promotes mutual respect, dignity, and emotional health for all involved parties. After thorough consideration and exploration of options, Lucy and Larry want to make decisions that match their values, priorities, and mental health. Ultimately, Lucy falls in love with a co-worker and leaves her marriage. She is now happily remarried and is no longer lonely in her marriage. Larry is afraid to be alone, and so he stays in a volatile relationship. However, over the years, he and his husband have learned to defuse arguments more easily, and have found new pleasure as grandparents. When Lucy and Larry reflect on their decisions many years later, they talk about the “road not taken,” but neither has regrets about their decision. Ann Gold Buscho, Ph.D., - Website -

Part 3: Identifying and understanding major depression subtypes Anxious distress is not the same as having an anxiety disorder along with major depressive disorder. Physical tension, feeling something bad will happen or you'll lose control, are signs of anxious distress in a major depressive episode. Anxious distress within depression is believed to elevate suicidal thinking and activity. It's no secret that anxiety conditions and depression co-occur. In fact, most researchers agree they co-occur at least 60 percent of the time. They're so interrelated that most antidepressants are also often effective for anxiety; both conditions are highly associated with decreased serotonin. With these facts in mind, it's no surprise that some people, when they experience a Major Depressive Disorder (MDD) episode, there is an onset of some specific anxiety that is congruent to the depression. The presentation: MDD patients with Anxious Distress are down and out. They're tormented by inner restlessness and anticipating worst-case scenarios that compound the negative thinking already present from the depression. Unfortunately, it seems like anxious distress is more common than meets the eye. Researchers like Zimmerman et al. (2018) have noted that, in a sample of 260 people with MDD, 75 percent met the criteria for the specifier; this was after controlling for co-occurring anxiety disorders. Imagine the compounded misery of patients, like Liz: The case of Liz: Liz, a 26-year-old part-time college student, was no stranger to anxiety. She struggled with Social Anxiety Disorder (SAD) throughout her teens and 20's. It was tough for her to get through college, but she was gaining on it. Nonetheless, like many suffering from SAD, Liz was prone to MDD. For Liz, the episodes would come on when she began dwelling on how stalled her life was from SAD. Many peers were already in careers and had a family, and she wondered if she'd ever make it. Liz made an appointment with Dr. H, her long-term psychologist, because the depression felt different this time. In her voicemail to Dr. H, she said, "Doc, I've dealt with being depressed, I've dealt with getting through socially anxious situations, but I'm not handling well whatever is happening to me this time." At her appointment, Dr. H noticed Liz not only going to that dark place again, but she also appeared to have a tense jaw and was prone to hand wringing; she looked very uneasy on top of being depressed. Liz confessed that the past couple of weeks she was increasingly dreading that she will never get out from under this psychological roller coaster. "I'm so stuck!" she lamented, noting she worries about the depression never ending and being alone forever. "It seems so futile, I may as well give up," Liz mumbled through tears. Courtesy of page 184 in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the criteria for With Anxious Distress (which must be present more days than not during the current Major Depressive episode) are: Poor concentration due to worry Feeling tense Restlessness The feeling something bad will happen The feeling of losing control. Critical thinking about what qualifies as an Anxious Distress specifier: Though Liz experienced an anxiety disorder at baseline, Social Anxiety, it does not make the fact she experienced an anxiety disorder and a depressive episode together as "with anxious distress." These would be considered independent, co-occurring diagnoses. The anxiety symptoms that arose with the MDD episode were a direct consequence of her mood; "owned by the depression," if you will, and therefore meet the criteria for With Anxious Distress specifier. Interested readers are directed to Yang et al. (2014) who explores this in detail. You may be asking yourself, "What about if the person develops panic attacks from being so overwhelmed by the depression?" Panic is "special" in that any condition can have a "with panic" specifier. Just because someone experiences a panic attack or occasional attacks, also doesn't mean they have panic disorder. There must also be significant fear of future attacks and or maladaptive behaviors to try to keep future attacks at bay, like avoiding exercise and sex because the exertion can lead to feelings that are reminiscent of panic symptoms and there is fear it may evolve into an attack. Of course, someone may have MDD and Panic Disorder if full criteria for the latter are also met. Readers are directed to page 214 of the DSM-5 for more information on this nuance. Though uncomfortable, panic is often sporadic and fleeting, while the symptoms of With Anxious Distress must be specifically noted because they are chronic and gnawing, adding torment to the person's condition. Imagine suffering the low feeling of serious depression, coupled with a feeling that you can't gain control, feeling physically tense, and worrying it will never end. This is quite a problem in that, as seen with Liz, the depression encourages the anxiety, and that added anxiety encourages intensifying depression. Treatment implications: This additional insult of anxiety on the MDD episode can induce so much havoc that Barlow and Durand (2015) note, "The presence of anxiety [in depressive episodes] makes a more severe condition, makes suicidal thoughts and completed suicide more likely, and predicts a poorer outcome." Research is not clear if Anxious Distress tends to be a trend in every episode for people prone to it, or if it may vary. Regardless, given the gravity of the matter, clinicians must be vigilant to the possibility of arising Anxious Distress amid their patients' MDD episodes, and evaluate accordingly. Patients may not be as forthcoming and obvious as Liz. Perhaps it is more of an inner tension they are experiencing, and the patient assumes worrying their life will never get on track is just part of being depressed. Directly asking depressed patients if they've begun to develop muscle tension, worry, and feeling they're losing control takes mere minutes and can have big clinical payoffs. Assuaging the anxiety will help in managing the MDD. Clinical considerations if Anxious Distress is suspected: Suicide prevention: Suicide attempts may be more prevalent with anxious distress, evaluating for risk is even more important. Be sure to consult with the person's prescriber if you are concerned about Anxious Distress. They should be aware because some medications could exacerbate the anxiety, and there is always the possibility the anxiety will not get reported or noticed in the prescriber's office. Evaluate if the person's lifestyle may be exacerbating the anxious distress. Namely, are they caffeine consumers, eat a lot of junk food or sugar, and get no exercise? It's no surprise that caffeine and sugar can make things worse. Exercising, if they are capable, can help "burn off" some anxiety; it can also provide further structure and occupation rather than being 100 percent stuck inside their mind. The old saying is particularly true for sufferers of depression and anxiety: "idle mind = devil's playground." The positive effects of exercise on anxiety and depression are well-documented. If the person does not already exercise, of course suggest they consult their doctor before initiating a regimen. Once beginning to stabilize, the job of a therapist is to not only help the episode to continue to remit but continue to evaluate for any return of the Anxious Distress. In the long run, prevention is the best option. If we know a patient is prone to Anxious Distress, it is of utmost importance to have a plan in place to immediately return to treatment if they or friends and loved ones recognize the onset of a depressive episode. Keeping the MDD at bay likely will help keep the Anxious Distress away. Stay tuned for the next post on Monday, October 11, for a tour of Melancholic Features , perhaps the "darkest flavor" of Major Depressive Disorder. Anthony Smith, LMHC, References Barlow, D.H. and Durand, V.M. (2015). Abnormal psychology: an integrative approach. Cengage. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013. Yang, M.J., Kim, B.N., Lee, E.H., Lee, D., Yu, B.H., Jeon, H.J., & Kim, J.H. (2014). Diagnostic utility of worry and rumination: a comparison between generalized anxiety disorder and major depressive disorder. Psychiatry and Clinical Neurosciences (68), 712–720 doi:10.1111/pcn.12193 Zimmerman, M., Martin, J., McGonigal, P., Harris, L., Kerr, S., Balling, C., Keifer, R., Stanton, K., & Dalrymple, K. (2018). Validity of the dsm-5 anxious distress specifier for major depressive disorder. Depression and Anxiety (36) 1, 31-38.

Why caregivers fail to support kids who disclose abuse. Up to a third of children abused in the home may not receive a supportive response when they disclose. Poor parental attachment , patriarchal beliefs, and emotional and economic dependence may cause non-support. Lack of support or disbelief has been linked to poorer, more severe long-term outcomes post-disclosure. Andrea Robin Skinner, the daughter of late Canadian author and Nobel Laureate Alice Munro, wrote an essay in the Toronto Star in which she described how she was sexually abused by her stepfather in 1976. Her story of intrafamilial child sexual abuse is unfortunately not uncommon, but what has shocked many was that Skinner wrote that when she told her mother in 1992, Munro acted “as if she had learned of an infidelity," returning to her husband, whom she stayed with until his death, causing an irreparable rift between mother and daughter. Many are struggling to understand how a lauded and respected author who wrote about trauma failed to support her own daughter. Why would a non-abusing parent disbelieve or fail to adequately support their child post-disclosure of CSA? This is a complex question, and answers can vary based on the individual. Little recent research has examined this question, and many existing studies have small samples, with most focusing on the role of mothers, as it is often the stepfather or biological father who the perpetrator is. In cases of intrafamilial CSA, it is estimated that between 15 and 35 percent of non-abusing parents disbelieve some aspects of their child’s report. One study of 10 mothers found that those mothers who were rated as “unsupportive” of their children post-disclosure adhered more strongly to patriarchal cultural or religious beliefs and values, causing them to remain in contact with the abusing partner. Several studies have found that mothers were more likely to believe their children when the perpetrator was a biological father or extended family member than when it was a boyfriend or stepfather. Economic and/or emotional dependence on the abusing parent was also found to be related to disbelief or unsupportive responses. The findings regarding the age and gender of the child are inconclusive, but some studies have found that mothers are more likely to believe younger children and male children than adolescent, female children. Other studies have found that poor attachment between mother and child can result in disbelief or non-support. It is also speculated that perpetrators engage in familial grooming, such that the perpetrator not only engages in the sexual grooming of the child but also of the non-offending family members, thus increasing the likelihood that the abuse will not be detected or believed. What happens when children are disbelieved or not adequately supported when they disclose CSA? There are many negative long-term consequences of CSA, however, research suggests that they are exacerbated when a survivor comes forth and is not supported. Parental support post-disclosure has consistently been associated with the adjustment of sexually abused children, such that children who are believed and supported have better long-term outcomes. A recent meta-analysis found that this relationship was not as strong as previously believed, but perhaps that was because of the way support was conceptualized. That is, perhaps the long-term outcomes were less about whether the child was believed or disbelieved than about the quality of the parental attachment to the child and the child’s perception of the parent-child relationship. However, the worst outcomes result when a child discloses the abuse, nothing is done, and they remain in the abusive situation. Thus, it is imperative for children who have disclosed abuse to be supported by caregivers, and the quality of this support should be a focus of the healing process. Elizabeth Jeglic, Ph.D., - Website - References Jeglic, E.J., & Calkins, C.A. (2018). Protecting you child from sexual abuse: What you need to know to keep your kids safe. New York: Skyhorse Publishing. Winters, G.M., & Jeglic, E.L. (2022). Sexual Grooming: Integrating Research, Practice, Prevention, and Policy. Springer.

How self-views evolve over the lifespan. Some types of narcissism are more interpersonally harmful. Many people age out of narcissism over their lifetime. In contrast to narcissism , self-esteem often includes prosocial orientation. Most people know a narcissist—at least in the practical, although not necessarily clinical sense. Usually, this is someone who holds themselves in high esteem and puts themselves first, both personally and professionally, at the expense of others if necessary. Yet, as we age, beauty fades, physical prowess diminishes, and mental acuity declines. Perhaps healthy self-concepts adjust accordingly. Narcissism impacts not only the individual but also the lives of those around him or her. Although many narcissists are extraverted, flashy, and fun, they also experience relational difficulties, often stemming from some of the same traits that make them popular. If you love a narcissist as a family member, friend, or potential future paramour, research has some positive news for you. More Than a Number: The Impact of Age Ulrich Orth et al. (2024) examined the development of narcissism across the lifespan and studied changes over time.1 They describe three models of narcissism. Agentic narcissism is characterized by assertiveness and leadership but also the need for admiration, as well as feelings of grandiosity and superiority. As we might imagine, they note that agentic narcissism results in fewer interpersonal problems as compared to the other two models. Antagonistic narcissism embodies the disagreeable and antisocial facets of narcissism including qualities such as deceitfulness, callousness, arrogance, exploitative Ness, a sense of entitlement, and a low level of empathy. Neurotic narcissism is characterized by hypersensitivity, emotional dysregulation, and propensity to experience shame. Among other things, Orth et al. note that the three-factor model helps to comprehend the relation between the characteristics of different types of narcissism and self-esteem, described as including subjective evaluation of personal worth. They also note that self-esteem and narcissism are distinguished conceptually because high self-esteem is often linked with prosocial attitudes and does not necessarily indicate personal feelings of superiority. Examining data from 51 samples, including 37,247 participants, Orth et al. found that narcissism usually decreases from age 8 to 77 years, with small differences due to the type of narcissism experienced. They also discuss the concept of rank-order stability, which encompasses the stability of interindividual differences in a construct across time. They note that the rank-order stability of narcissism is high, even across long time periods, suggesting that narcissism should be considered a personality trait. Is Generation “Me” a Myth? In terms of popular ideas about whether narcissism is tied to generational differences, Orth et al. found that birth cohort was not a moderator of mean-level change for narcissism factors. The mean year of birth in their samples ranged from 1923 to 2002, and the narcissism trajectory has not changed over the generations, meaning their results fail to support the popular idea that “Generation Me” (people born in the 1970s to 1990s) express more narcissism than previous decades. Orth et al. note, however, that as with some of their other findings, more research would be beneficial here as well. The bottom line is that narcissism, even viewed as a personality trait, can change—for the better. With age comes wisdom, acceptance of less-than-perfect traits, and enhanced appreciation of others. With acceptance, love, support, and respect, narcissistic individuals can turn over a new leaf, slowly but surely. Wendy L. Patrick, J.D., Ph.D., References 1. Orth, Ulrich, Samantha Krauss, and Mitja D. Back. 2024. “Development of Narcissism across the Life Span: A Meta-Analytic Review of Longitudinal Studies.” Psychological Bulletin 150 (6): 643–665. doi:10.1037/bul0000436.

Better be more friendly and less boastful to win friends. Being liked by others is important for our survival and well-being. Research has explored which behaviors predict liking in social situations. Communal behaviors predict both general popularity and being liked in one-on-one situations. Agentic behaviors may help your popularity but may hinder you in one-on-one situations. When meeting other people for the first time, how should one behave to be liked? When given a choice, most of us would prefer being liked by—and popular with—members of our social group. Human beings spend much energy on becoming socially accepted, and for good reasons. Those who like and esteem us are more likely to offer protection, encouragement, and support when times are bad. And times will get bad at some point. Social standing is an evolutionary insurance policy, shielding one from all kinds of risks. No wonder psychologists have long been interested in the dynamics of interpersonal liking and group popularity. A useful framework for studying social relations was developed by David Kenny of the University of Connecticut. In his Social Relations Model , one person’s view of another is broken into three components: perceiver, target, and relationship. “The perceiver effect reflects how the person tends to see others; the target effect reflects how a person is seen in general by others; and the relationship effect reflects how a perceiver uniquely sees the target,” he writes. By way of analogy, if we wish to analyze the relation between Mary and her little lamb, “the perceiver effect would represent how much Mary, on average, likes little lambs; the target effect reflects how much the little lamb is liked by others; and the relationship effect is how much Mary likes her little lamb.” Thus, in the model, liking can be examined in two ways. On a more general level, we can study how certain behavioral choices and tendencies make one popular within a group (target effect). On a more personal level, we can study how certain behaviors make one uniquely liked by their immediate dyadic partner (relationship effect). Both are socially advantageous, yet they are not one and the same, and the forces that shape them may differ. Psychological research has long shown that when judging others, people tend to base their evaluations on two main categories: agency and communion (also known as warmth and competence). We look at how competent or powerful a person is, and how friendly and trustworthy they are. As I’ve written before, both qualities are important to judge early and accurately. From an evolutionary perspective, separating friend from foe and competent from incompetent is crucial for survival. You want to surround yourself with people who not only want to but also can help you. A recent (2023) study by German psychologists Michael Dufner and Sascha Krause set out to explore whether specific behaviors associated with agency and communion predict popularity and/or unique liking. They designed a round-robin pre-post study in which 139 young adults were assigned to same-sex groups of four to six members, all previously unacquainted. In each group, members first provided liking ratings of each other based on pictures and a brief group introduction. Then, every member of the group had a five-minute one-on-one conversation with every other member, after which they completed similar liking ratings again. Additionally, the conversations were recorded on video and the individuals in each interaction were rated by trained observers on four agentic behaviors (leading, dominant, confident, boastful) and four communal behaviors (polite, benevolent, warm, friendly). The authors ran a series of analyses to explore how various behaviors affected popularity within groups and unique liking within dyads. Results showed that all agentic and communion behaviors significantly predicted popularity, although, taken together, the communion behaviors were a stronger predictor than agentic behaviors. When it came to unique liking, however, two specific communion behaviors (benevolent and friendly behavior) and the composite score of communion behavior were significantly and positively correlated with higher ratings. Further analysis found that “when communal behavior is held constant, behaving in a uniquely agentic fashion toward specific others might even reduce one’s unique liking.” Regarding general popularity, the authors conclude: “The current findings indicate that actors who generally behaved in a communal fashion toward others were generally popular,” yet “popularity was also incrementally predicted by agentic behavior, which means that…people who generally show agentic behavior might also be generally liked.” As for unique liking, the authors conclude: “The results indicate that uniquely behaving in a communal fashion toward a specific other evokes unique liking... By contrast, uniquely behaving in an agentic fashion toward a specific other does not appear to evoke unique liking by that other. Quite the contrary, when communal behavior was controlled for, showing higher than usual levels of agentic behavior toward a particular other was even linked to being uniquely disliked by that other.” The study is not without limitations. The authors note that the sample of young, Western adults may not represent the population at large well. The effects may differ by age or culture. Moreover, people’s reactions may differ in different social contexts, and it may depend heavily on the goal. Interaction partners may approve of agentic behavior if it serves their own goals and disapprove of it if they feel undermined. Likewise, the interactions in this study were few and short, without future expectations. People’s reactions may follow a different pattern if they expect further encounters down the road. Moreover, aspects of the interaction not studied here (e.g., nervousness) may significantly impact early impression formation. Finally, the study focused on same-sex pairs. The dynamics may shift with opposite-sex interactions. Still, the study provides useful data to suggest that when looking to become more socially accepted and liked, communion behaviors—warmth and friendliness—are across-the-board winners. Agentic behaviors (boastfulness, domination), however, are a mixed bag. While they may advance your general popularity within a group, they may also hinder your ability to make new friends. Noam Shpancer, Ph.D.,

Research on normative male alexithymia. So many adult men find it difficult to know what they're feeling. There's a term for this: normative male alexithymia. Boys are born with similar emotional capacity as girls; emotional fluency is discouraged as they grow older. Men can re-learn and reclaim their feelings through self-confrontation and a trusted partner. As is the case with many men, it’s always been hard for me to know what I’m feeling. I would observe my behavior and from there try to deduct what’s going on inside me. I believe this difficulty might have played a role in my choice to be a therapist. Clinical training has taught me firsthand how to better recognize, own, and verbalize my feelings. Over the last 12 years as a couples therapist, I’ve met hundreds of men struggling to feel. I’ve also met hundreds of their partners, feeling alone and frustrated by their emotionally unavailable mates. Covert Male Depression An important source of understanding this phenomenon is Cambridge, Mass. psychotherapist Terry Real. His seminal book, I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male Depression , describes how boys endure the “loss of the relational”—being forced to separate from their feelings and their mothers on the way to becoming “men.” They learn to turn away from their fathers and their own pain toward work, money, success, sex, drugs, and other distractions. They covertly experience depression , which manifests mostly as numbness, boredom, apathy, limited emotional range, and cynicism. Their partners see them as emotionally handicapped, stoic, cold-hearted—and more. When I begin talking to such men about covert depression, they initially display surprise at the idea of depression but then quickly feel validated and understood. Their partner’s eyes light up as a new empathic discourse starts to emerge. Normalizing the emotional struggle of men helps the partners join forces to heal the hidden depression. Permission to Feel Accompanying the covert depression is another crucial phenomenon—what’s officially labeled normative male alexithymia. The American Psychological Association defines it as ”a subclinical form of alexithymia found in boys and men reared to conform to traditional masculine norms that emphasize toughness, teamwork, stoicism, and competition and that discourage the expression of vulnerable emotions.” The inability to feel or describe emotions—considered normative among men—was what these men (and I) have been suffering from all these years. The fact that it’s normative doesn’t mean that it's natural or good. In fact, boys are born just as sensitive as girls. But through the socialization process, boys lose permission to feel and become disconnected from their core. When a man suffers from covert depression and normative male alexithymia, he essentially is surviving and not living. He is not experiencing the whole emotional range and therefore experiences the world as hard, dull, and boring. Over time, his partner forms the impression that he is stoic, boring, and uninterested. Feeling unloved and alone, the partners often become bitter and look elsewhere for emotional companionship. Reconnecting men to their feelings, expanding their emotional range, and subsequently their emotional eloquence, I began to witness changes in such couples. Hope and newfound animation began to spread through my clinic. So You Want to Feel? Feeling is natural. We’re born feeling. But disconnection from feelings is often imposed on boys. Here are some useful suggestions for those wanting to overcome the imposed emotional handicap. Choose to see that feelings are what make us human. The unique human essence is emotional. Therefore, if you want to enjoy life to its fullest, you must dare to feel the good, the bad, and the ugly. Expand your emotional range. The wider your emotional range, the livelier you’ll be. Choose to believe that the key to your joy is in your pain, so open yourself to the darker shades of emotions as well as the lighter ones. Understand that joy is a verb, and therefore must be consciously practiced in order to rewire your brain and inscribe it in your life. If you do all this, you’ll feel free in your relationships, because after all, love is to feel free. As I apply these processes with men, they begin to open up and share their fears, vulnerabilities, and difficulties with their partners. They bravely stop running away and confront their past, their pain, and their wants. The men are returning to their full self, and their relationships began to flourish. As for me, the word “feel” is now emblazoned on my arm. How will you remember to feel? Assael Romanelli, Ph.D., - Website -

The real culprit of OCD may not be what you originally thought. It is not uncommon to hear an OCD sufferer make a comment such as “OCD thoughts are ruining my life,” or “I have to get rid of these thoughts!” This refrain is echoed by many of my clients who lament their unwanted, intrusive thoughts and the seemingly endless struggle to suppress, neutralize, and explain away their thoughts. The common belief, whether explicit or implicit, is that the presence and content of the thoughts are the problem, and getting rid of them will restore hope, confidence, and happiness. But OCD is not a thought problem — it's a feeling problem. In other words, if the thought did not have the accompanying painful feeling, you would ignore the thought, call it “weird,” and simply move on without compulsions or a second thought. Allow me to unpack this as it may seem like what I’m saying is controversial or missing some important point about OCD. Obsessive Compulsive Disorder is a condition marked by a pattern of unwanted, intrusive thoughts, feelings, images, sensations, or urges that take the form of a Feared Story. This story tells the sufferer of a potential, and as of yet fictional, outcome or truth about their actions, intentions, character, or future. This story, being completely unwanted, makes the sufferer feel an overwhelming sense of anxiety . To deal with this anxiety and to get back to a sense of normalcy, confidence, and comfort, the OCD sufferer will then engage in overt or covert compulsive behaviors as an anxiety management strategy. Compulsions can include avoidance, reassurance seeking, mental review, rituals, and other repetitive acts. Once done, the sufferer gets a false sense of security that unfortunately reinforces the anxiety cycle. OCD’s deception is that you have to struggle with and resolve the content of the thought. You have to clarify, rectify, and examine the thoughts to determine whether they are true or false. For example, the contamination OCD sufferer believes he must be sure that his hands are fully clean, or at least clean enough, before they can interact with anyone. In the brief overview of the OCD cycle above, you likely noticed that I mentioned thoughts and feelings. Wouldn’t this suggest that OCD is both a thought and a feeling issue? Yes, but in practice not really. People with OCD often get wrapped up in three potential issues: the trigger, the feared story, and the feeling. Ultimately, freedom from OCD requires you to face down the feeling, because OCD is a feeling problem. The Trigger OCD can be triggered by almost anything, including things we see, random thoughts we have, sensations we experience, and objects we encounter. Everything that you and I will ever encounter, think, feel, or experience is neutral until we place some value upon it. Meaning it is neither good nor bad, right nor wrong. Is a knife good or bad? It can be used to open to letter, but it can also be used to open a person. How about therapy? It is both good and bad. It can bring about profound positive life transformation, but it can also be emotionally draining, time-consuming, and costly. Likewise, triggers to one’s fears are also neutral. Yet those with OCD and anxiety disorders exaggerate the meaning and importance of triggering thoughts or images as they relate to the Feared Story. Each fear has any number of neutral associations. Remember the knife example? It doesn’t have just one meaning or significance. A knife can conjure thoughts of cooking shows. It can cause someone to think of their dad’s fishing knife or Julius Caesar. The thought of a knife can also spark thoughts of suicide, harm, or crime. If you blame the trigger (i.e. the feared thought or object) and label it as the problem, you are being misdirected. OCD, and the history of repeated compulsions, exaggerate the importance of a select number of mental associations. Over time, the other neutral or positive associations are downplayed or ignored leaving the feared associations as seemingly the only associations for these thoughts or experiences. When you scapegoat the trigger as the problem, you believe minimizing your contact with it will make the obsession about it go away. Unfortunately, avoiding the trigger leads to isolation and reinforces the false notion that the trigger is the problem, resulting in greater fear of the trigger and the feared story it spawns. The Feared Story Our brain tells us stories all day. Some we like. Some we don’t. OCD tells us stories too, and they are catastrophic, threatening, and at odds with who we are. These Feared Stories are a combination of distorted thoughts and mental images about the result of actions, one’s character, or an inevitable future that concludes in something terrible. Some people blame the Feared Story as the problem within OCD. They think that if they were to simply get rid of the thoughts, think the opposite of the thought, prove that the thought is wrong, or simply “just think right” that their OCD would evaporate. They believe OCD is a thought problem. To their point, treatment for OCD and anxiety disorders commonly begins by challenging the feared story using rational thought to develop a broader, reality-based view of the fear. This exercise helps the sufferer develop confidence that their intrusive thoughts are likely irrational, overvalued, and not deserving of excessive and exhausting compulsive responses. When I challenge the Feared Story in session, my clients are quick to point out how their Feared Story is wrong. They usually say, “I know this doesn’t make sense,” then proceed to point out all the reasons why it doesn’t make sense, and they are right! For example, a client with Pedophile OCD (POCD) might say, “I’m not a pedophile because I’ve never been attracted to a child in the past. I’ve never wanted to do anything sexual with a child. Whenever I have the thought about molesting a child, I always get anxious and have never felt feelings consistent with my typical feelings of attraction when I think about adults.” Generally speaking, people with OCD are capable of combating their feared thoughts with rational alternatives. However, compulsions exist because a feared thought comes with, or takes the form of, an uncomfortable and unwanted feeling that overwhelms the sufferer. Despite developing a list of rational observations and objections to the Feared Story, it does nothing long term because the issue has never been a matter of “right thinking,” but of an intolerance of the feeling brought on by the Feared Story. The Feeling Here is the actual problem of OCD. The feeling. More specifically, it is the feeling that makes you engage in compulsive behavior, which subsequently reinforces the OCD cycle. Chasing down and embracing that feeling with a welcoming and accepting posture desensitizes you to the feeling over time. Conversely, if you are unwilling to feel the feeling, but instead rely on compulsions and avoidances, desensitization cannot happen. Remember, we are able to acknowledge that the trigger is neutral and has a number of alternative associations. Additionally, we are very capable of telling ourselves why the Feared Story is irrational and wrong. However, we are unable to convince ourselves to not feel something because feelings are largely out of our control. While not bad or wrong, feeling anxiety in an OCD moment is unwanted. Typically speaking, we say anxiety feels bad, but it by itself is not “bad.” It is an unwanted feeling state at the moment you’re feeling it. When we ride a roller coaster or see a horror movie, we expect to feel butterflies in our stomach, feel our heart racing, and feel jumpy. You know, anxiety feelings. But in this context, we paid good money for the experience! So, the feeling itself is not bad, just unwanted at that moment and inconsistent with the level of actual risk. Similarly, when it comes to OCD, sometimes the feeling isn’t just anxiety, but sadness, loneliness, anger , apathy, or emptiness. The goal of Exposure and Response Prevention treatment is to intentionally feel this feeling, acknowledge this inconsistent emotional response, and let it remain without compulsive behaviors until it passes. Remember, it will always pass. Counterintuitively, your job in Exposure and Response Prevention is to engage the feeling. It’s the enemy and the problem. The solution is to show that you’re stronger than it by calling its bluff that the feeling is heralding in something terrible and that you are not strong enough to shoulder the uncomfortable experience. You are strong enough, and the terrible outcome probably is not coming. Stand firm and let the storm pass. Feel the Pain, See the Results If you are not ready to do this, you are going to have a hard time overcoming your anxiety. But you can start small, and progressively work up. If you are consistent and keep pushing yourself, you will eventually find more mental and emotional strength and freedom. Kevin Foss - Website -

Here’s why and what we can do about it. Less than half of people talk about having suicidal thoughts or behaviors. Talking about suicidal thoughts is the best way to help, and to get help. Suicidal thoughts are common, you're not alone. Many people at risk of suicide are going undetected and unsupported in our community, our research suggests. Our recently published study found under half of the people tell anyone they’re thinking of suicide, making plans, or have attempted suicide. Here are some reasons why people don’t often talk about this and what you can do to help a friend or loved one get the support they need. We’re Getting No Better at Predicting Worldwide, more than 700,000 people take their life each year. Globally, suicide is the fourth leading cause of death among 15–29-year-olds. But our ability to predict who might have suicidal thoughts and behaviors or end their life has not really improved over 50 years of research. Because suicide is relatively infrequent (as a percentage of the population), it is difficult to identify robust risk factors for suicide we can generalize across the population. We need to know who’s at risk. One of the most crucial steps in understanding and managing the risk of suicide is for individuals to disclose their suicidal thoughts and behaviors to other people. It also gives us a chance to mobilise support. However, when colleagues and I looked at the evidence, we found less than 50 percent of people tell anyone else about their suicidal thoughts or behaviors. Even if they had these thoughts or behaviors over the past month, only an estimated 38 percent of people told anyone. Most people don’t ever disclose any suicidal thoughts or behaviors, however long ago these occurred. Most people don’t ever disclose suicidal thoughts or behaviors, however long ago these occurred. Our study was a meta-analysis, which combined information from almost 100 studies to estimate how commonly people disclosed. Women were slightly more likely to disclose than men, and disclosure was more likely when associated with a psychiatric disorder. Notably, among studies of people who had died by suicide, close to 60 percent of people had no documented evidence of telling someone they had thoughts or plans of ending their life. Put simply; the findings suggest a large number of people at risk of suicide are undetected and unsupported. Why don’t people say anything? Reasons people don’t disclose thoughts of suicide include stigma and shame about having the thoughts, fear of rejection or unsupportive reactions from others, concerns about burdening other people, and believing nothing can be done. Worrying about the consequences of telling other people, such as being hospitalised or receiving unwanted treatment, might be particularly important when people have had negative experiences with disclosure. A lack of confidence in expressing oneself is another significant barrier. Some people avoid thinking or talking about it as their main coping method. Having more social support can increase the likelihood of disclosing suicidal thoughts. This is important, given most disclosures are made to family or friends. Increased understanding and knowledge about suicide are also linked with a higher likelihood of disclosure. How do we start conversations? Public campaigns to increase mental health literacy and normalize discussions about suicide have likely helped facilitate disclosures. Most times, this means talking about it. Asking someone about suicide risk indirectly can be more comfortable, such as checking in on how they are feeling or doing. But the question might be misunderstood or answered in a “socially desirable” way. A conversation might go, “How are you doing?” with a response, “Yeah, not bad.” General questions like "Are you OK?" might not work. Asking more direct questions might. But research shows asking more direct questions does not increase their distress and does not cause someone to have more suicide-related thoughts or behaviours. So, clear questions – such as “Are you having thoughts of ending your life?” or “Are you thinking about hurting yourself?” – may help draw an answer. Asking about how safe they feel now can also be useful: “Do you feel safe at the moment?” Offering the choice of not responding might lead to opportunities to ask about it later. You can say, “It’s OK if you don’t want to answer that right now.” Talking about suicide can be difficult. But it is important to know we don’t need to be perfect at it, and we’re not tasked with trying to solve all of a person’s problems. You Can Really Help For some people, thoughts of suicide reflect a negative or hopeless mental state but not an intent to harm themselves. Most people who have thoughts of suicide do not end their lives. But what you can do for someone is significant. First, the emotional support and acceptance you show by simply asking and listening are immensely important to help people feel understood and cared for. This can help normalize and de-stigmatize their experience. Depending on your relationship, you may want to know more about what drives those thoughts and being curious and non-judgmental can help. Second, you can give simple, practical support by asking someone what they might need. You could try, “Is there anything you need right now? How can I help?”. You could encourage them to tell loved ones and support them in finding professional help. This might be their general practitioner or mental health professional to call a helpline or 000 if the person seems very unsafe. If this has caused any distress from reading, please get in touch with a health professional, and talk to a loved one. If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist, visit the Psychology Today Therapy Directory. David Hallford, Ph.D., - Website -

Higher scores on social media addiction were related to higher infidelity. Higher scores on social media addiction were related to higher scores on social media-related infidelity. Younger participants scored higher on social network site addiction and social network infidelity. Men scored higher on the social media infidelity compared to women. Social media can be used to facilitate contact with friends, former friends, or even former romantic partners, through messaging or via interactions and comments on social media posts. Sometimes, although more rarely, we may even begin to perceive social media friends as possible romantic alternatives to our current partners. In addition to this, we know that social media interaction and online interaction are characterized generally by lower levels of inhibition, whereby people are bolder and more candid in what they say. What is the level of social media interaction that is acceptable between us and those outside of our romantic relationships ? Furthermore, is there a connection between social media interaction and possible infidelity? This was investigated by Irum Saeed Abbasi from San Jose State University, California. Abbasi employed 365 participants ranging in age from 18 to 73. About one-third of participants reported being married, half reported casually dating, and the remainder said they were in a committed relationship . In order to assess infidelity related behavior on social media, participants in the study completed the Social Media Infidelity-Related Behavior Scale. An example item: “'I sometimes like to chat or message old romantic partners online or on social networking sites." Participants responded from strongly agree to strongly disagree. Participants also completed the Modified Facebook Intrusion Questionnaire that measured behavioral addiction. An example item from the scale: “'I feel connected to others when I use social media.” Responses were again ‘strongly agree’ to ‘strongly disagree.’ Initially, Abbasi found a simple relationship in that social networking site addiction was found to be positively related to social networking site infidelity. Participants who scored higher on social media addiction also scored higher on social media-related infidelity behavior. However, this relationship was to an extent affected by age. Younger participants scored higher on social network site addiction and also social network infidelity in comparison to those who were older. More specifically as age increased, the association became weaker. This age difference is explained by the researcher as being a consequence of younger individuals perhaps taking more risks compared with older individuals, and therefore also more likely than older individuals to take more risks while online. Furthermore, Facebook use is generally higher in younger people, mainly driven by a wish to use new technologies. This explains why younger individuals are more likely to develop an internet addiction. Older individuals use social media less, generally because the need to compare and connect with friends, reduces with age. In terms of gender, Abbasi found no difference between males and females, although men did score higher on the SNS infidelity measure compared with women. Numerous previous findings have linked Facebook use with higher levels of jealousy between romantic partners, driving them to engage in social media surveillance behavior, eventually leading to lower levels of relationship trust. Social media interactions can become compulsive, which may ultimately lead to flirting and perhaps unfaithful behavior. The study described here adds to our understanding of infidelity driven by social media use in finding that younger individuals are more likely to engage in social media infidelity because they are likely to take more risks online. Martin Graff, Ph.D., - Website - References Abbasi, I., S. (2019). Social media addiction in romantic relationships: Does user's age influence vulnerability to social media infidelity? Personality and Individual Differences. 139, 277-280.

Body dysmorphia can lead to unrealistic expectations about cosmetic procedures. Body dysmorphia is often revealed through behaviors like frequent mirror checking and excessive grooming. This history can be traced back to the term imagined ugliness syndrome. Cosmetic interventions may exacerbate psychological distress in some cases. Body dysmorphic disorder, BDD, a psychiatric condition marked by excessive concern over imagined or minor defects in appearance, is intricately linked to the prevailing cultural ideals of beauty. Research suggests these standards of attractiveness, heavily influenced by societal norms, play a significant role in the development of BDD, contributing to a distorted self-image and body dissatisfaction. Origins and Evolution of BDD BDD’s history can be traced back to when it was termed imagined ugliness syndrome. Recognized formally in psychiatric literature with the advent of the DSM-III, BDD has since evolved in its diagnostic criteria. The DSM-V categorizes BDD under obsessive-compulsive and related disorders, emphasizing its compulsive nature and the significant distress or impairment it causes in one’s life. Identifying BDD BDD is often revealed through behaviors like frequent mirror checking, excessive grooming, or seeking reassurance about one’s looks. The relentless belief that one is unattractive or repulsive dominates the patient’s thoughts, overshadowing any reassurance they might receive. This disorder can lead individuals to pursue unnecessary dermatological treatments or cosmetic surgeries, often with the unrealistic expectation that these procedures will fix their perceived flaws and, by extension, their life problems. Demographics and Prevalence BDD typically emerges in adolescence, with a significant number of cases reported before the age of 18, although it can also appear later in life. Estimates suggest that up to 1 percent of the U.S. population may suffer from BDD, with higher prevalence noted in aesthetic medical settings, such as dermatology and plastic surgery practices. Etiology of BDD The causes of BDD are multifaceted, involving psychological and physiological factors. Experiences such as childhood teasing, bullying, and abuse can contribute to the condition, as can complex psychological processes like the displacement of emotions. The proliferation of social media has introduced another layer, providing a platform for comparison and cyberbullying that can aggravate BDD symptoms. Cosmetic Procedures: A Growing Trend There has been a notable rise in individuals seeking cosmetic procedures, with millions undergoing surgeries worldwide. This increase has led to more frequent encounters between medical professionals and patients with BDD. Historically, BDD has been considered a contraindication to cosmetic surgery. Patients with BDD often harbor unrealistic expectations and are typically dissatisfied with surgical outcomes, which do not align with their distorted self-perception. This dissatisfaction can lead to severe repercussions for both the patient and the surgeon, including legal actions and, in extreme cases, acts of violence. For instance, one study found that 2 percent of plastic surgeons had been physically threatened by a patient with BDD. Assessment and Treatment: A Multi-Dimensional Approach A more nuanced approach to understanding BDD suggests differentiating between mild and severe cases. Patients with less severe symptoms who do not exhibit significant life impairment may benefit from cosmetic procedures if their expectations are managed appropriately. Treating patients with mild BDD symptoms requires careful screening and collaboration with mental health professionals to ensure the best outcome. Screening for body dysmorphic disorder is an essential step in the diagnostic process, particularly for professionals in the fields of dermatology, cosmetic surgery, and mental health care. Using validated screening tools can help clinicians determine the presence and severity of BDD symptoms and make informed decisions about the appropriateness of cosmetic interventions. There are two widely used questionnaires for BDD screening. The BDD Questionnaire-Dermatology Version (BDDQ-DV) The BDDQ-DV is a specific form of the Body Dysmorphic Disorder Questionnaire, adapted for use in dermatology settings. It’s designed to be a self-administered screening tool. Patients can fill it out while waiting for their consultation, which can then inform the clinician’s assessment and subsequent discussions about treatment options. The BDDQ-DV consists of questions that gauge the patient’s preoccupation with their appearance, the extent of their concern, behaviors they may engage in because of their appearance concerns, such as checking mirrors or seeking reassurance, and the impact of these concerns on their daily life. If the responses indicate a possible case of BDD, the clinician can pursue further evaluation, possibly involving a mental health professional. The Dysmorphic Concern Questionnaire (DCQ) The Dysmorphic Concern Questionnaire is another screening tool for BDD, though it is more complex and comprehensive. It includes questions that are not exclusively about BDD symptoms, which can help to identify broader concerns that may require attention, including other mental health issues. For instance, the DCQ asks about worries over body odor, sweating, and general appearance and assigns points to responses. A cumulative score can indicate the likelihood of BDD, with a higher score suggesting greater concern and possible BDD diagnosis. This tool is beneficial for identifying individuals who may be at risk for BDD but may not be aware that their concerns are disproportionate or indicative of a deeper psychological issue. Both the BDDQ-DV and the DCQ have been validated, meaning they have been tested for their effectiveness in accurately identifying BDD in patients. Validation gives clinicians confidence in using these tools as part of their practice. Moreover, these tools can facilitate communication between the patient and the clinician, providing a structured way to discuss concerns that might otherwise be difficult to articulate. When BDD is identified, treatment can focus on psychological interventions, which are the first line of treatment for BDD, rather than cosmetic procedures, which may not address the underlying disorder. In summary, screening tools for BDD should be an integral part of the assessment process for individuals considering cosmetic procedures. These tools provide a standardized way to identify symptoms of BDD, ensure that patients receive appropriate care, and prevent procedures that may not be beneficial. Clinicians are encouraged to incorporate these validated questionnaires into their practice to support the well-being of their patients. Concluding Thoughts As cosmetic procedures become increasingly common, both cosmetic professionals and mental health practitioners must recognize and understand the implications of BDD. Using a multidisciplinary approach, including careful patient screening, can aid in distinguishing those who might benefit from cosmetic procedures from those for whom such interventions may exacerbate their psychological distress. Further research is needed to refine treatment strategies for BDD, aiming to enhance the psychological well-being of those struggling with this often-debilitating disorder. Tara Well, Ph.D., - Book - References Dufresne RG, Phillips KA, Vittorio CC, et al. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001; 27: 457-62. Higgins S, Wysong A. Cosmetic Surgery and Body Dysmorphic Disorder - An Update. Int J Womens Dermatol. 2017 Nov 20;4(1):43-48. doi: 10.1016/j.ijwd.2017.09.007. PMID: 29872676; PMCID: PMC5986110. Mancuso SG, Knoesen NP, Castle DJ. The Dysmorphic Concern Questionnaire: A screening measure for body dysmorphic disorder. Aust N Z J Psychiatry. 2010 Jun;44(6):535-42. doi: 10.3109/00048671003596055. PMID: 20397781.

A constant need to please others is not the same as natural generosity. People-pleasing behavior can be the result of childhood emotional injury and trauma. Parents with symptoms of certain personality disorders demand that the children put the parents' needs first. People-pleasing behavior is driven by fear and is different from generosity driven by self-expression. Children raised by unhealthy parents are often trained to please their parents above pursuing their own interests and proclivities. Significantly impaired parents, such as those suffering from symptoms of borderline personality disorder (BPD) , narcissistic personality disorder (NPD) , and other serious mental illnesses, often traumatize their children if they do not do what they want. This often occurs through parents lashing out at their children when they are not pleased. These children grow up to be adults who consistently put the well-being of others ahead of their own. They do not do this out of generosity. Instead, they do this to feel safe. Allowing generous people to be generous to you can create a healthy bond, but allowing people-pleasers to please you can create a trauma bond and retraumatize those who are trying to please you. Healthy individuals whose personality predisposes them to be generous with others enjoy the experience of sharing with others. They offer their time and other resources to others and feel closer to others when their generosity is accepted and reciprocated. They are not significantly impacted when others decline their generosity. In many cases, they give anonymously, which makes them feel closer to humanity. Donations to special groups such as the homeless, veterans , cancer survivors, etc., are common examples. The giver generally does not meet the recipient. People who volunteer their time at soup kitchens, fundraisers, or fighting fires are other common examples. These individuals offer their resources to anyone who might need them. They don’t seek recognition because the satisfaction comes from self-validation. They are expressing the best part of themselves, and it makes them feel good to do so. People-pleasers have a different motivation and a different method. Most people-pleasers are motivated by fear. Many of them grew up in families where if they didn't, please others they were either punished, rejected, or ignored. This often occurs when children are raised by a parent or parents with symptoms of personality disorders. For example, parents with symptoms of BPD tend to lash out at their children when their child fails to please them. Parents with symptoms of NPD tend to ignore their children when they don’t, please them. These children often grow up to be people-pleasers as adults. They generally approach others feeling they need to please them to be safe or accepted. When others are not pleased, they become fearful that they will be punished or abandoned. They need to know that others are pleased by them, so anonymous giving does not satisfy them. They need to be recognized or celebrated when they give to others. There are many ways that people give to others out of fear. They present gifts to individuals in person, or they leave cards or notes with their signature. They expect that for others to like (love) them, they must consistently put the feelings and needs of others above their own. They do this because they have been raised to believe that they will only be loved for what they give and not for who they are. Almost all people-pleasers have low self-esteem. People with high self-esteem please themselves first most of the time. Allowing generous people to give to you is healthy. If you fall and a random stranger offers you a hand, take it. If you are hungry, go to a food kitchen and let them feed you. This gives healthy people a chance to do something that makes them feel good. They will not ask anything of you in return. Allowing people-pleasers to please you is unhealthy. Allowing others to give you gifts, services, or other resources without reciprocity confirms to them that they are only worth what they can offer to others. It repeats the patterns of behavior that resulted in the development of people-pleasing, and therefore it is enabling. It may also be retraumatizing to the person if their childhood experience was traumatic. Refusing to allow a people-pleaser to please you is giving them a gift. It gives them the chance to experience someone accepting them and wanting to be with them for who they are, not for what they can give. The sample conversation that follows models how you can turn an unhealthy enabling experience into a healing and growth opportunity. Jeff and Ray went to high school together. They hadn’t seen each other since graduation, and they reunited at their 10th high school reunion. Jeff was very happy to see Ray, but he quickly remembered that he was uncomfortable being around Ray because of his constant efforts to please. In the past, he just let Ray keep paying for things and yielding to all his choices and whims because it was easier than arguing, but this time he decided to handle it differently. Ray: Great to see you again, Jeff. How about you and your wife come to dinner? I will cook you the best dinner you ever had. Jeff: How about we go to a restaurant? Ray: Sounds great. You pick the place, and I will treat. Jeff: I am sure you know some wonderful places. Ray: OK. What do you like to eat? Jeff: It is not about what we eat. I just want to catch up with an old friend. Ray: Nobody has ever spoken to me that way before. Jeff: You deserve to be treated this way. If you are a people-pleaser, you will do well to take a chance and let others like you for who you are without pleasing them first. It is the only way that you can experience healthy relationships. It is possible that some people might lose interest when you stop giving. You should focus on cultivating relationships with those who don’t. Relationships with individuals who punish you if you don’t, please them are unhealthy and possibly abusive and should not be tolerated. Daniel S. Lobel, Ph.D.,

The neurological and psychological differences between hoarding disorder and OCD. Hoarding disorder (HD) has been considered a type of obsessive-compulsive disorder (OCD). David F. Tolin, Ph.D., and colleagues have examined the organic basis of the categorization in several ways. Research has led to a recategorization of hoarding disorder in the DSM-5. Hoarding disorder (HD) has been considered a type of obsessive-compulsive disorder (OCD) . Now, there is mounting evidence against this notion. One of the most compelling is a research examination performed by Tolin et al. (2012). David F. Tolin, Ph.D., is from the Institute of Living in Hartford, Connecticut. The other authors are from various institutions. Research 2012: The Neural Mechanism In this study, the researchers examined three groups: patients with HD and OCD, comparing them to healthy controls (HC). In all, there were 107 subjects, 43 of whom had been diagnosed with HD, 31 with OCD, and 33 who were HC. Each group was asked to bring a piece of junk mail from home to the laboratory. This mail, as well as junk mail furnished by the lab, was photographed. Then, the subjects’ brain activation in deciding whether a piece of mail should be retained or discarded was measured using functional magnetic resonance imaging (fMRI). Patients with hoarding disorder displayed minimal activation levels in the insula and anterior cingulate cortex (ACC) while they assessed what to do with the experimenter’s mail. These are brain areas involved in decision-making and emotional regulation. On the other hand, when the HD group was deciding what to do with their own mail, these same brain regions burned brightly. Consistent with this, the patients with HD opted to remove fewer pieces of personal junk mail compared to the other groups. This observation and others like it gave the organizers of the Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) important information. From that time on, they designated hoarding disorder differently than previously. Originally, it had been considered a form of OCD. Now, it is a distinct condition included under "OCD and related disorders." Clinical Differences Between HD and OCD Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value. There is a perceived need to save them, and personal distress is associated with discarding them. This leads to significant clutter that disrupts the hoarder's ability to use living spaces as intended. A hoarder might say, “If I were to throw away any of my stuff, it would cause me too much pain and anxiety to bear.” Obsessive-compulsive disorder, on the other hand, involves intrusive, unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) performed to reduce the distress associated with obsessions. Such an afflicted person might say, “I am compelled to wash my hands repeatedly so I don’t have germs on them that could cause disease.” Treatment Differences Between HD and OCD Selective serotonin reuptake inhibitors (SSRIs), commonly used to treat OCD, are often less effective in treating HD. This suggests different underlying neurochemical pathways. Cognitive-behavioral therapy (CBT) tailored for HD focuses on decision-making, organizational skills, and cognitive restructuring related to attachment to possessions. It is less effective for OCD, again suggesting different pathways for the two. A new therapy for HD advertised by the Mood Center in Annapolis, Maryland, combines ketamine and transcranial magnetic stimulation (TMS). To my knowledge, it has not been rigorously tested for this purpose, so any benefit would be anecdotal. Research 2023: Trial of CBT for HD In one of several follow-up examinations to that 2012 study, Tolin and colleagues used group CBT (2023) for 16 weeks for 64 treatment-seeking patients with HD. They were compared to those on a waiting list. Again, as in the 2012 study, functional magnetic resonance imaging was used to examine neural activity during simulated decisions about whether to acquire and discard objects. The aim of the study was to determine whether the therapeutic benefits of CBT follow improvements in the ACC dysfunction noted in the 2012 examination or abnormalities previously identified in other brain regions. During both acquiring and discarding decisions, activity decreased in several regions. In this study, however, the ACC activity did not show any dramatic change. As the researchers concluded, “Therapeutic benefits of CBT for HD do not appear to be mediated by changes in ACC activation.” By implication, it is my understanding that the insula was also not affected. Summary HD and OCD, despite some superficial similarities, are fundamentally different in terms of their neurological underpinnings, clinical manifestations, and responses to treatment. Future research should continue to explore these distinctions, particularly through longitudinal studies and larger sample sizes. Shirley M. Mueller, M.D., - Website - Book - References Tolin, D. F., Stevens, M. C., Villavicencio, A. L., et al. (2012). Neural Mechanisms of Decision Making in Hoarding Disorder. Archives of General Psychiatry, 69(8), 832-841. Tolin DF, Levy HC, Hallion LS, Wootton BM, Jaccard J, Diefenbach GJ, Stevens MC. Changes in neural activity following a randomized trial of cognitive behavioral therapy for hoarding disorder. J Consult Clin Psychol. 2023 Apr;91(4):242-250. doi: 10.1037/ccp0000804. Epub 2023 Mar 6. PMID: 36877480; PMCID: PMC10175200. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.