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Blog

Can time structuring be used for differential diagnosis?

Posted on November 26, 2012 at 11:03 AM Comments comments (214)
A fellow TA trainee asked this interesting question: 

When putting together a differential diagnosis of personality disorder in therapy, has anyone used time structuring to choose one diagnosis over another? She said that her instinct was that someone with a narcissistic personality structure would spend more time in games while someone with obsessive compulsive personality structure more time in rituals.

I think this is an extremely interesting question but we need to be careful about how we use terms such as "ritual" or "withdrawal" which have different meaning in DSMIV from that in which we use them in transactional analysis. 

"Ritual" as a concept in TA to my mind is not the same as the sense in which it is used in the DSM IV. Rituals play a major part in Obsessive Compulsive Disorder (OCD), but these are not social rituals in the sense that we understand them in TA. They are repetitive compulsive behaviours. Rituals also play some part in Obsessive Compulsive Personality Disorder (OCPD) but to a lesser degree. Also, OCPD should not be confused with OCD. OCPD clients are concerned with rules, order, hoarding and overworking. OCD clients may not in fact have a personality disorder but an anxiety and compulsion disorder. OCD is on Axis I. OCPD is on Axis II.

A client with obsessive compulsive structure will feel entitled to a game of Uproar if someone else interferes with their order or rules (and perhaps in their thinking is playing Schlemiel -messing things up). They may constantly play this game with their partner.

I think Berne's concept of time structure is useful diagnostically. Enquiring about how a client structures their time in a social sense, alerts the therapist and the client to whether the client is mixing in all the ingredients that make her feel she's doing the things she wants to do in life and relationships. 

However, I would be cautious though about linking this with the personality diagnosis as I don't think the correlation is straightforward to make and one could end up with generalisations that don't fit all clients with the same diagnosis. Perhaps it's better to keep time structure as a useful diagnostic tool, but not insist on an over-arching theory that links it with personality disorders. 

The truth is we all need and do a combination of withdrawal, rituals, pastiming, games and intimacy and this is very much guided by our temperament (introverts will shy away from too much stimulation from other people) and culture (some cultures value separateness more than others). 

This is the first time I've ever considered what an extreme preference for one form of time structuring would look like, but here it is: 

Generally others will not allow us to persist with one form of social structure beyond what the unspoken norms dictate. Therefore, I do think that that someone whose entire time is structured around one activity only may be extremely mentally disturbed. 

Withdrawal
For instance, a client with catatonic schizophrenia will be in complete withdrawal and not acknowledge another in any way. Deeply traumatised clients, clients suffering with PTSD or clients on the autistic spectrum may also show extreme withdrawal. Again - caution - this isn't the withdrawal we talk about in TA terms. Social withdrawal at a gathering may simply mean that you're burying your head in a book and not that you've literally left your body as happens in dissociation.

Rituals and pastimes
Can one be a pathological ritualizer or pastimer (in the social sense not the OCD or eating disordered sense)? I remember talking with someone suffering from dementia, who spent most of the hour re-setting our conversation at the stage of ritual. She kept saying "Hello" and "What is your name?" as she couldn't remember that we'd already covered this. 

Games
Clients addicted to the thrills of violent of three degree games may well have an antisocial personality disorder or borderline personality disorder or be addicted to mind-altering substances. 

How about when clients are incapable of playing games? I think they do exist. Such clients may suffer from a form of learning difficulty (perhaps retardation as lying requires intelligence) or be on the autistic spectrum (not adept at picking ulterior transactions or transacting at an ulterior level because they are limited in making sense of subtle non-verbal communication such as facial expressions.) 

Intimacy

Can an excessive preference for intimacy be indicative of something gone wrong? Someone who is prematurely intimate in the sense of being uninhibited in disclosing the entire content of their mind from the word "go" without any concern about censorship. This could again be a patient with Schizophrenia (but again you also have to watch out for cultural differences). 

Zero degrees of empathy

Posted on November 7, 2012 at 8:03 AM Comments comments (99)
Empathy. It is considered an essential skill and a core condition (Rogers) in psychotherapy and counselling. It is the ability to put oneself in another person's shoes, to experience the world as they are experiencing it. In essence when we are being empathic we are recreating in our own mind and body a map of another person's mind, we are resonating with their pain and experiencing it as our own. 

A while ago I read a book by Simon Baron-Cohen "Zero degrees of empathy". Baron-Cohen asked the question "why does evil exist?" and wanted to find a scientific answer rather than a religious one. Baron-Cohen is an expert in autism, a condition which is characterised by a person's reduced ability to pick up and interpret another person's facial and bodily expressions in order to understand what they are feeling. This causes a considerable amount of strain socially. People are unable to gauge whether what they are doing is appropriate to the situation at hand. For instance, they might tell you a story about a subject that they are passionate about and fail to notice that you are drifting off, getting bored and would like them to stop. People with autism feel lost in social situation. They find it difficult and confusing - a minefield. They notice that people frequently get irritated and fed-up and this is scary because they don't understand what they've done wrong. 

People with high-functioning autism (Asperger's) can be helped to manage social situations by being taught about non-verbal communication and the significance of social cues. It's a little bit like learning to colour by numbers. 

There is another category of individuals tthat display zero-empathy. Baron-Cohen suggests that in this category are people on the high-end of spectrum of personality disorders such as borderline personality disorder (BDP), narcissistic personality disorder and antisocial personality disorder. 

Amongst other traits, patients diagnosed with BDP show an inability to connect with the pain caused to others through their self-harming acts and suicidal threats. They do not understand or experience the turmoil and the extreme fear that the other person is overwhelmed with. 

Clients with narcissistic structures are unaware of the other having any needs. They fill up the space with their discourse and tend to put others down. 

Antisocial personality disorder (psychopathy) is a condition rarely encountered in the therapy room. Psychopaths who are also violent and break the law tend to end up in prison. Those who don't break the law may be highly successful professionals. Cambridge trained psychology researcher dr. Kevin Dutton is fascinated by psychopaths. He has interviewed many of these individuals. 

Dutton has a certain admiration for psychopaths. He has found that some psychopathic traits (charm, ruthlessness, low empathy, focus, low stress response under pressure), if  coupled in an individual with high intelligence and low predisposition to violence may be highly useful in certain professions such as surgery, law and the arm and facilitate a high degree of achievement in these areas. (Psychopath in your family is a short film uploaded on his website www.wisdomofpsychopaths.com. I also found this documentary: I am fishead that proposes the thesis that corporate leaders are psychopaths)

The psychopath can accurately create a map of another's mind. He (because it tends to be a man) is extremely good at gauging what the other may be experiencing or thinking. However, the psychopath fails to experience another person's pain and are themselves emotionally under-aroused. Functioning MRI brain scans show that in psychopaths the amygdala (the structure of the brain that gets activated when we experience negative emotion and fear) is under-activated. 

In other words psychopaths cannot display the kind of "hot" empathy that translates into compassion and moral restrain. They are very good at thinking on their feet, focused, driven and because they brain/body rarely triggers the stress response, their verbal and manual performance remains highly accurate even in the most daunting situations. 

Why is that? Stress response translates partly into the release of a steroid hormone - cortisol. This hormone triggers bodily reactions that are biased towards facilitating a motor reaction such as running really fast. Prolonged exposure to glucocorticoids however has negative effects on the hippocampus (the part of the brain involved in the retrieval of autobiographical memory). We have all experienced stressful situations in which we feel tongue tied and cannot remember facts that we do know. Cortisol is to blame. In fact, cortisol not only interferes with the functioning of the hippocampus but can also contribute to premature cell death at this site. Prof. Dr. Robert Sapolsky from Stanford University has proved that stress has a negative effect on memory and the hippocampus. (The audio of his talk Stress and memory Forget it! is uploaded on youtube. Ignore the picture of the cat.)

Psychopaths have no such concerns. They are able to withstand extremely stressful situations without their nervous system being overwhelmed and without their body swimming with adrenaline or cortisol. 

Unsurprisingly, it turns out that what all people with zero-degree of empathy have in common is that they are not so good at relationships. The inability to hold someone else's mind in your mind, to respond with compassion is not conducive to being able to form a strong bond with another human being. 

The good news is that we are getting better and better at identifying low-empathy in children and that there are ways to train people in empathy. 

And to end, I found this brilliant short animated history of empathy by Jeremy Rifkin. It is called "The empathic civilisation". Rifkin argues traces the evolution of the empathic brain and argues that our ability to extend empathy to others with whom we don't share the same culture and religion, as well as to other species is essential to our survival on this planet.