It is considered unethical and unprofessional for psychiatrists to hand out opinions about public personalities from afar. This rule was broken recently, with regards to, of course, Donald Trump.
Letter to the editor
A letter to the editor in The New York times, signed by Lance Dodes, an addiction psychiatrist, former Harvard assistant professor (and 34 other professionals) on the 13th Feb 2017 stated:
“Silence from the country’s mental health organizations has been due to a self-imposed dictum about evaluating public figures (the American Psychiatric Association’s 1973 Goldwater Rule). But this silence has resulted in a failure to lend our expertise to worried journalists and members of Congress at this critical time. We fear that too much is at stake to be silent any longer.”
“Mr. Trump’s speech and actions demonstrate an inability to tolerate views different from his own, leading to rage reactions. His words and behavior suggest a profound inability to empathize. Individuals with these traits distort reality to suit their psychological state, attacking facts and those who convey them (journalists, scientists).”
“In a powerful leader, these attacks are likely to increase, as his personal myth of greatness appears to be confirmed. We believe that the grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president.”
A strongly-worded response to the letter
A pretty badass response came in the next day, 14th Feb 2017: a follow-up letter to the editor from Allen Francis, who wrote much of the DSM IV, including the diagnostic criteria for Narcissistic Personality Disorder. Much as the DSM IV has its flaws, this guy is really on point, in my more than humble opinion:
“Most amateur diagnosticians have mislabeled President Trump with the diagnosis of narcissistic personality disorder. I wrote the criteria that define this disorder, and Mr. Trump doesn’t meet them. He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder.”
“It is a stigmatizing insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr. Trump (who is neither).”
“Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely. Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy. He can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers.”
“His psychological motivations are too obvious to be interesting, and analyzing them will not halt his headlong power grab. The antidote to a dystopic Trumpean dark age is political, not psychological.”
Should psychiatrists stay silent?
Looking down from her moral high ground on the 2 lads in a newspaper fight is the president of the American Psychiatric Association, Maria A Oquendo, who pointed out that while she could understand the desire to “get inside the mind” of a presidential candidate, having psychiatrists comment publicly about people they have not examined threatens to erode the public’s confidence in the profession.
“Simply put, breaking the Goldwater rule is irresponsible, potentially stigmatizing, and definitely unethical,” she wrote.
As for me, I believe that, psychiatrists shouldn’t be analysing living political figures – as psychiatrists. As people with opinions, however, I feel they should be heard – just like anyone else. They also happen to be very good at analysing people’s behaviour. It is up to the reader to understand that this is not an excerpt from Trump’s personal medical files, instead it is just another opinion made legitimate by our commitment to free speech.
What is this psychiatric condition they are debating about?
Narcissistic personality disorder is a mental disorder in which people have an inflated sense of their own importance, a deep need for admiration and a lack of empathy for others. But behind this mask of ultraconfidence lies a fragile self-esteem that’s vulnerable to the slightest criticism. For those of you not familiar with the DSM, it is a (the?) diagnostic guide for psychiatrists. We are currently of the 5th edition. Here are the criteria for NPD:
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.
b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others‟ experiences and predominance of a need for personal gain
B. Pathological personality traits in the following domain:
1. Antagonism, characterized by:
a. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.
b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
Man cannot endure his own littleness unless he can translate it into meaningfulness on the largest possible level
Ernest Becker
Fear of the passage of time
I recently came across the term chronophobia in the context of people doing exams: knowing that exam day is ever closer makes people anxious. Chronophobia was defined as an experience of unease and anxiety about time, a feeling that events are moving too fast and are thus hard to make sense of, in “Chronophobia: On Time in the Art of the 1960s” by Pamela Lee.
Chronophobia isn’t a formal diagnosis, neither does it feature in scientific literature. In other words, it’s not really a phobia. It is more of an unpleasant feeling – one that is often expressed in art.
It is common in prison inmates, students in long academic programs and the elderly. When one is anxious, it is not only possible to be anxious about the event, but also its inescapable approach. Chronophobia is less about the doom and more about it being impending.
Salvador Dali: The Persistence of Memory, 1931. The melting clock describes the feeling of chronophobia rather well
Chronophobia appears to be connected with heightened awareness of the passage of time that is inherent in distant deadlines for significant events.
This morning during my 10 minutes of mindfulness, something interesting bubbled up. I randomly remembered myself on an airplane travelling back to Moscow to visit family about 2 years ago. I felt a strong urge to be that person again, a bit like when I’m on vacation and towards the end, with a sigh, I think back to how liberating the first day off felt. Or when I reach the last bite of some dopamine-explosive dessert, I think back to how happy I felt when it was just put in front of me. We all love vacation and desert. However, my wish to be 2 years younger makes little sense. I was in the throes of a challenging 70-80 hours per week medical rota. It took much ingenuity to carve out enough time to travel. Is it regret? It wouldn’t be fair to say that the last 2 years were somehow a waste of time in any regard. Why do I feel so drawn to the thought of going back in time?
Salvador Dali: The Disintegration of the Persistence of Memory, 1954. Dali saw the fish as a symbol of life
Fear of opportunity cost
Aged 27, I frequently contemplate what it would go back to a previous point in time. I think it’s the understanding of the limited nature of time. I also worry about opportunity cost. In economics, there is the term opportunity (alternative) cost is the value of the option that we don’t choose when making a decision. [If I have 1 euro and buy a 1 euro can of Coke, I would have to forego the 1 euro Mars bar in order to have it. I would thus potentially worry about what it would have been like if they got a Mars bar instead.] The feeling is different to decision-anxiety. It’s not even about second guessing one’s choice, but more about imagining alternative paths.
The word decision literally means the cutting off – of other options. Thinking of the alternatives always reminds us of the unyielding nature of choice and how we really can’t literally “have it all”.
Robert Frost’s famous (infamous?) “The Road Not Taken” is a brilliant and often misinterpreted examination of the nature of choice. It is important to recognise the speaker’s deliberation: he says the roads are much the same: “just as fair”, “really about the same”, “equally lay”.
“The Road Not Taken”, a frequent feature of post-card philosophy, is often oversimplified to say that the speaker chose the less travelled road – and, woohoo, that’s amazing. It’s more complex than that.
The speaker admits that he left the first road “for another day”. While he knew he would never go back, the torment of admitting the final nature of choice is just too much.
One can get very detailed when describing their particular fear. I certainly don’t support the idea of including “fear of opportunity cost”, “fear of the passage of time” or even “fear of choice” as phobias into the DSM. Indeed, this is perfect ground for thinking by induction. Is there a common thread here?
Hans Holbein the Younger: The Ambassadors, 1533. Note the anamorphic skull in the foreground. It surely is a reminder of death
Boiling down fears to a common denominator: could it be death?
Why does chronophobia affect students? Time forces them to deal with events that will affect serious aspects of their lives such as their future careers – and thus even more permanent things like social class, the kind of people they will be likely to marry and so on. Exam results’ effects are by no means definitive, but probabilistically they are significant.
It has become popular to say that there are only 2 human emotions: fear and love.
Everything negative is a form of fear. It kind of makes sense: anger is a way of defending one’s point of view, property or whatever other boundary. Being sad is a fear that one will never be as happy as they were before as a result of an event (not talking about depression here). Disgust is a fear that something will negatively impact one’s existence. You get the gist.
The other popular thought is that all fear is a form of the ultimate fear – of death.
Going back to chronophobia again, why does it affect the elderly? Time threatens the existence of the elderly. It threatens all of our’s existence, but the elderly are more aware of it – mostly for social and cultural reasons. Now, none of us are deluded enough to actually think we’re not going to die. However, as Ernest Becker points out:
we have 2 ideas of the self: the physical and the symbolic.
In my opinion, our rationality only extends as far as the physical self. We are preoccupied with ways to immortalise our symbolic self. As per the “Mahabharata”:
“The most wondrous thing in the world is that although every day innumerable creatures go to the abode of death, still man thinks that he is immortal”.
Salvador Dali: Metamorphosis of Narcissus, 1937. Dali had an interest in psychiatry
The recent debate that followed my discussion of the role of validation in our self-esteem sparked some follow on thoughts. In short, it showed that people with narcissistic tendencies experience much emptiness or even self-hatred – and validation is used to take the edge off. However, as all creatures who make choices, people with narcissistic tendencies are subject to avoiding pain and seeking pleasure (thank you, Dr. Freud). Clearly, they find narcissism more tolerable that the alternative. How could this be?
What if those who crave validation to feel good about themselves chose to be this way because the alternative – knowing that one is inherently valuable, without any validation – makes the thought of inevitable death absolutely intolerable? If one feels that they’re not that valuable, dying isn’t quite as scary or tragic.
Realising that a person is valuable, getting attached and then letting go is much harder than never getting attached – in this case to your self, as is the case with death. This devaluation allows people to cope with the fear of death. At the same time, the person with narcissistic tendencies maintains the upside of being able to work on “their immortality projects”, like winning medals and getting promotions. This is just a hypothesis of mine. I understand that I have no idea what Steve Jobs was really like. A lot of people say that he was an obnoxious narcissist. He said this, which happens to be congruent with my hypothesis:
Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart.
There are other psychologically sneaky ways that we deal with the fear of death that have stood the test of time (well, since 1974 or so when “Denial of Death” was published):
Becker argues that everything we do: writing books, starting businesses, having children are all ways to transcend – and not have to deal with – death.
It makes sense too: the thought that everything one ever does will disappear into oblivion is so hard to accept that in order to keep going we find ways to defy death’s erasure of our existence by leaving a legacy.
One’s own death is hard to imagine. It is as if we believe we will still be alive on some level after we die, but unable to act on our dreams and stuck reminiscing of the time we were alive and lamenting we didn’t do more.
If leaving a legacy isn’t an option, then one can choose to believe in the afterlife to help themselves cope with the concept death.
Paradoxically, dying may be a way to transcend death. Physical death could be a route to symbolic immortality. Just think of war heroes.
...what dreams may come, when we have shuffled off this mortal coil…
Constant reminders of death were common all throughout the last millennium: having a skull on one’s desk was kind of like having sticky notes or an extra mouse. An experiment where people were asked to write about death before they were asked about their country’s war efforts showed that thinking of death made people more enthusiastic about war -as it adds meaning, purpose, a sense of belonging, a feeling of impact…
The purpose of my reflection isn’t to say we shouldn’t fear death, and it will all be fine. It is more of an inquiry into what behaviours of ours are motivated by the fundamental, underlying fear, which so far appears to be that of death. However,…
It’s not death we fear, it is not having an impact
Is it really death we fear? I think a better way of putting it is that we fear that we’re inconsequential, insignificant, that we made no difference through our existence.
For those who insist that it is a fear of death: it’s that of the symbolic self. For those who insist that our biggest fear is to not be loved: to have someone love one is probably the biggest impact one can have on another human being. Perhaps, it is the ultimate, or the one that really count. I am not sure. However, my point remains: it is about impact.
It could just be a millennial’s take on it. With a lesser role of traditional religion in today’s society, millennials have the unfulfilled need for meaning – and have a habit of finding it in the most peculiar places.
My recent discussion of meaning according to Nietzsche prompted many to comment that the fact that we die and that the universe will ultimately end (something to do with the Sun and physics) implies that there could be no meaning in our lives. I don’t follow this argument. To me, it is like saying there’s no point in eating because you’ll get hungry again. Clearly though,
for a lot of people death is the ultimate enemy in a game rigged against them.
I used the word impact above for a reason. I could have said consequence or meaning, but something stopped me. Both of those words are overused and call to mind all kinds of associations. Furthermore, I thought of animals. They are driven largely by the same evolutionary forces as we are, and I think we overestimate the extent to which animals are different. They may not have insight, but they are a reflection at least of how nature intended things. To illustrate, I will use an example I recall from watching a BBC documentary on giraffes. Two massive male giraffes were fighting for a female. How on earth do giraffes fight, I hear you ask. Well, they violently swing their entire necks to strike. The force of the swing is enough to shatter their skulls. The battle went on to the point of near death… for the sake of a female. The giraffes decided/were driven by nature to go that far just to reproduce – so death is less important than an opportunity to have impact, which, for giraffes I think is reasonable to assume, is to have progeny.
I don’t think that the fear of not having an impact is the same as the fear of failure. One can fail, but still achieve a lot and have an impact. Failure is defined in terms of a percentage of the way to realising a dream. Impact, or lack thereof, is much more real.
I feel that a human being on their death bed is likely to think of what impact they have had, not where they ranked compared to their dream.
Salvador Dali: The Elephants, 1948. Not quite giraffes, but close enough
On the bright side…
There is a “cure” for fear of choice
Going back to my own ENTP-torment of being more interested in talking about choices rather than actually making them, I am looking for some kind of resolution. N. N. Taleb, a favourite writer of mine, is popularising the concept of optionality. He argues that having options is a great thing:
Optionality is the property of asymmetric upside (preferably unlimited) with correspondingly limited downside (preferably tiny).
It’s not really a way to get out of making choices. Instead, it is a way to do what you were going to do anyway, but leaving cheap enough nets here and there to see if one day something nice washes up in one of them such that covers the cost of having had the nets n times over.
He argues against specialisation (i.e. going down too far in the decision tree of choices or going down to the end of just one branch). We are all familiar with specialisation success stories. The Nobel Prize goes to the person who studied a particular enzyme for 30 years. The startup that solves a specific problem in one particular niche is the one that does well. Kim Kardashian has one thing going for her, and she’s taken over the world…
Taleb reminds us that there are cemeteries of specialised ventures and people. Just because the successes that make into the media are specialised, doesn’t mean all of them are. Specialisation comes from the propensity to make choices. It is not the only way to achieve something. Hence, it is possible that the act of making choices is overvalued.
Richard Branson has over 400 companies. Is it because he is greedy – or perhaps because he understands that specialisation is a dangerous game to play? Venture capitalists and angel investors back things in a non-specialised way. All financial investors do. It may look like it is specialised on the surface, but it really isn’t. Biotech, or robotics, isn’t a specialisation. These are incredibly broad fields. It’s like saying blogging is a specialisation. Investors take directional bets once is a while, i.e. ones that really require a choice, but they do so in a way that for every 1 euro they invest, they stand to gain 10, and only invest a tiny fraction of their euros into these schemes. This is exactly congruent with Taleb’s definition of optionality.
I have fabulously rationalised away the pressure to make choices here. However, the real work is in putting oneself into situations where optionality can be exercised.
The older I get, the more I realise that there’s quite a lot of engineering involved in all of this. It’s not so much about going after specific visions, but creating situations where visions can flourish – and ultimately have an impact.
Maybe, the millennial/Gen Y variety of man (and woman) are a bit different…
I’ll drop my glove, to prove his love; great glory will be mine.
Leigh Hunt
Vanity and fair are simple words. However, it was only recently that I understood what these words mean together. In more contemporary English, it means an exchange of validation between two people. What got me thinking about it is the book I recently read by Robert Cialdini called Influence. It describes the mechanics of how easily people’s need for validation can be used to play them in a Machiavellian way.
Validation is always a treat. We must be wired for it. Given that humans are social animals, it makes sense to yearn for validation as it increases one’s chances of survival. If one is part of a tribe (i.e. accepted/validated by the tribe), he/she is less likely to get eaten by a sabre-toothed tiger. However, it seems that this pathway gets hijacked an awful lot.
I think the best way to explain this is by looking at an extreme example: narcissism, because the logic is the same no matter where someone is on the spectrum. I grew up with and subsequently encountered some florid narcissists – though I didn’t always know it at the time. While the full blown narcissistic personality disorder is relatively uncommon, traits thereof appear quite ubiquitous. I will loosely use the word narcissistic here to signify anyone with traits of the disorder. During my late teens I loved high-achieving people and hated arrogance. It made no sense to me why somebody would act so unpleasantly. I thought that arrogant people believe they are better and that I am not worth their time. It turns out that’s only half-true.*
I subsequently figured out – through a mix of psychiatry training and reading (Daniel Goleman’s Emotional Intelligence is brilliant for this) – that arrogance is a form of insecurity. However, the exact same insecurity can be revealed through being super friendly (hence, not all narcissistic people are arrogant**).
Much of it boils down to the source of one’s self-esteem. I hypothesise that a self-esteem based on external circumstances is one of the factors that contributes to much unhappiness and perhaps even the poorly understood personality disorders – such as narcissistic, histrionic and emotionally unstable.
What does that actually mean? What is it like to be narcissistic (or a person with some narcissistic traits)? Most people think they are deluded with their own glory. This can be true – if the narcissistic person doesn’t have insight into just how hooked they are on validation. Sadly, having insight doesn’t instantly cure it. If the person with narcissistic traits does have insight, it’s a never ending cycle of feeling high from validation, feeling pathetic for being like that and seeking more validation to take the edge of. New Insights Into Narcissistic Personality Disorder highlights their fragility, internal vulnerability and external self-enhancement, their attempts to regulate insecurity by numbing emotion, especially in interpersonal contexts and their preoccupation with blame, and criticism.
For some, it is “I think therefore, I am”. For people with narcissistic tendencies, it is “I produce a good reflection, therefore I am worth existing.”
Interestingly, patients with narcissistic personality disorder have intact cognitive empathic ability and can identify with thoughts, feelings, and intentions of others. However, their capacity for emotional empathy is compromised, especially their ability to care about and share feelings of others.
Having one’s self esteem decided by external factors is hugely painful. It’s like waking up every morning and feeling awful about oneself – and yearning to encounter something or someone in the world that will prove that one’s actually worth something. No amount of proof will ever stop this feeling of emptiness for very long.
This proof could be likes on a social media post, getting any sort of good news, a reassuring friend, attention from a member of their desired sex – anything that reminds them that they aren’t near worthless (which is the default setting). This is also why so many narcissistic people are high achievers. Actually “being the best” is sometimes the only way to get rid of the pain.
If one’s self-esteem is only lifted from the depth of despair by accomplishments (validation), then he/she will do anything to accomplish – and ease the pain.
If one’s self-esteem is set externally, validation is like an addictive drug. If it’s set internally, validation is like an occasional glass of wine. These two types of self-esteem are also knows as contingent and non-contingent.
However, what does that even mean, “set internally”? Having an interest in mindfulness, I often come across things like loving-acceptance, unconditional positive regard, etc. Maybe the reader understands them better, but more often than not, they make me feel like there’s something fake there. To me, an internally-controlled self-esteem means answering the question: is a person proud of his/her actions.
It’s impossible to hold oneself fully responsible for one’s circumstances. Yes, over time, patterns emerge that reflect the small decisions made everyday. However, there is so much beyond our control that one needs to be cautious making conclusions about themselves based on results. As all of these kind of musings, this is specific to the person in question. Some people are perhaps too laid back about how much they control and others – too intensely determined to control everything. (See this post on how to find good tailored advice.)
I think that one has to always learn from their results, but it isn’t always true that their results are a reflection of their actions. Even learning from results is tough because it is so hard to attribute results to causes.
So to bring one’s self-esteem back to being internal, one can only judge whether he/she is happy with their actions and decisions given the information they had at the time.
…I have a single definition of success: you look in the mirror every evening, and wonder if you disappoint the person you were at 18, right before the age when people start getting corrupted by life. Let him or her be the only judge; not your reputation, not your wealth, not your standing in the community, not the decorations on your lapel.
Taleb says that by his definition, he’s not successful. Fair enough. However, he doesn’t strike me as the kind of person who lacks in self-esteem. This goes back to how different people use the same words to mean different things. Obviously, to Taleb being successful is a kind of a luxury, not a must-have. Otherwise, if one looked in the mirror and resented themselves everyday, that’s a shortcut to despair.
I wonder what it’s like for other people. For me, my 18 year old self had no clue about how the world works, so I can’t adopt this definition of success – it’s pretty useless to me. Maybe though, that’s Taleb’s point – that one should think back to their idealistic self and see what they would think. I probably shouldn’t say what my 18 year old self would think of me now, but I do wonder what Taleb got up to so that he doesn’t approve of.
I think that’s it though – reconnecting with one’s internal self-esteem is an uncanny exercise of separating oneself into two people and getting one to judge the other’s decision and actions – not their results.
* Whether a narcissistic person believes they are better depends on their insight into the need for validation and their actual achievements. However, narcissists do prefer to associate with people they see as being worthy of surrounding them.
** Some narcissistic people are sweet and charming. Different people use different strategies to feel special and seem worthwhile to others.
A millennial's musings 