How to cope with a mountain of psychiatric diagnoses and unemployment?
July 6, 2020 2:06 PM   Subscribe

As a kid I was diagnosed with OCD and Asperger's (no longer a valid diagnosis; now folded into Autism Spectrum Disorder). Last year I was evaluated against my will for a personality disorder, under false pretenses and in my second language after which I was given a diagnosis of "mixed personality disorder with borderline and closet narcissistic features". Quarantine terminally interrupted both my work and the public service therapy I was being given. During the hiatus, I was dropped by the public service because they were uninterested in treating me in my first language. What do I do?

I don't have a lot of social relations, especially ones close enough to discuss any of this with. Essentially, I am alone in life. Can ASD, OCD, BPD and NPD all co-occur? How can I be so riddled with psychological problems? I read some academic literature on closet narcissism, and it pretty closely describes a lot of whatever is wrong with me that doesn't already fall under ASD/OCD. That said, I'm not sure if I lack empathy entirely, I don't believe I'm abusive, and I certainly don't want to be abusive. I'm very confused as to how to make sense of all this. The professionals who evaluated me gave me no further guidance, other than this useless diagnosis I didn't ask for, scrawled on a piece of paper in my second language. I was blind-sided, because the institution did not tell me they were testing me for a personality disorder, did not provide the hundreds of questions across several panels in my only fluent language, and placed such pressure on me to fill them over a short period that I had a meltdown in the parking lot.

Outside of academic literature, NPD seems to be universally seen as roughly synonymous with evil. There's this sad irony to the fact that I originally went in, asking for help because my OCD obsessions have gotten to the point where I feel suicidal, only to be provided an even better (and objectively valid, given that I'd be doing my part to erase dangerous genetic traits from the gene pool) reason for suicide. I already furiously and obsessively hate myself for being stupid, ugly; inferior, etc. Though, in an apparent expression of NPD, I regularly resent and envy others for being objectively better than me, I do not fault them for that, because it is my inherent failure from birth (seeing as so much of one's value and potential are the product of genetic bounty). I have fewer friends each proceeding year (almost none where I live; those that remain live elsewhere and the correspondence is sparing). I struggle to find and maintain interpersonal relationships ("find" being the hardest part, since it is difficult for me to approach people with confidence, and put on an appealing presentation) of any kind (especially sexual or romantic).

Can any of this ever change? Can this overwhelming clusterfuck of psychiatric maladies be managed? The literature I've seen says that treating NPD is ineffective. All the layman's material says much of the same, in harsher terms. CBT, in my past experience, didn't really help much with OCD. Medication just dampened my sexual appetite and increased suicidal thinking, without so much as putting a dent in the compulsions, even at 200mg of Sertraline (the recommended ceiling, I believe). Previous conversations with the professionals who I was in contact with established that I can only receive one treatment regime (DBT, CBT, etc.) through the public system at a time. In the absence of employment and given that I've been dropped(more specifically, perma-waitlisted after being transferred to an overcrowded hospital significantly further away), where am I supposed to find hope?
posted by constantinescharity to Health & Fitness (11 answers total) 3 users marked this as a favorite
Well, yes, theoretically they can co-occur. Some people with ASD, NPD, or BPD experience a sense of separateness from other people and society. This might be a trauma and attachment thing. BPD is almost always a trauma and attachment thing. The jury's out on what causes ASD, but there's a good amount of overlap in some of the symptoms (especially the ones related to social functioning, executive functioning, and emotional regulation) with personality disorders. You may not have a bunch of separate "diseases," but a cluster of traits that make you uniquely you.

The thing about mental health is that we have arbitrarily decided that all of these things are unique illnesses with unique borders around them and we have given them names, but they don't really refer to anything specific or observable going on in your body. Having four mental health diagnoses is not the same as having four viruses which are floating around separately in your body at once. It means you might not fit neatly into an [arbitrary] diagnostic category. Because you're a complex, unique person. Not because you're bad or irretrievable. Please try to remember that what you experience as symptoms today have also been coping strategies for you throughout your life. If your coping strategies come from lots of categories, it might mean you have tried a diversity of tactics to survive.

I'm curious if you were diagnosed in a hospital setting. When I've worked in adult psychiatry inpatient units, pretty much anyone with suicide/self-harm history, repeated mental health admissions for anything that's not pure psychosis/mania, disrupted relationships, or who doesn't agree and comply with their plan of care gets BPD traits written on their chart. It's basically code for staff thinking that a person is kind of difficult. It's not right, but it's how it is. It's probably not like this everywhere, but in some places it is. As a therapist, I take these in-hospital diagnoses with a grain of salt. Everyone is crazy in a crazy-making environment, and they are often added to a chart without out much thought or a proper differential diagnosis process.

I wonder if you might have success with DBT? If you've had major trauma or disrupted attachment in your life, a workbook or a psycho-educational group might not be the interventions most suited to you, because they can feel impersonal and mechanical. Healing trauma and attachment stuff is best done with an individual therapist with whom you have good rapport, and with whom you can develop a trusting, healing relationship. That therapist might recommend a workbook or a DBT skills group as well, which are nice to have, but the therapist themselves is really key. I'm not making treatment recommendations to you - this is just what DBT research says and how DBT was designed to work.

I have OCD too, and I can tell you that my OCD gets really out of hand when I get emotionally dysregulated, especially by trauma/attachment stuff. DBT skills help me stay regulated so I can take care of my OCD. So does a low-dose SSRI. I'm not making treatment recommendations to you (IANYT), but those are the things that worked for me.

It's super hard to maintain relationships with untreated mental health. The fact that it's untreated isn't your fault if your options all suck. Focus on trying not to beat yourself up right now. Diagnosis grief is real. Care for yourself like a grieving person because you are one right now.
posted by unstrungharp at 2:29 PM on July 6, 2020 [15 favorites]

Psychological and psychiatric assessment isn't likely to be valid unless it's done in a language you speak fluently. If your native language isn't English, there's a good chance that these diagnoses haven't been validated on people from your home culture at all. "Closet narcissistic features" isn't a standard psychiatric diagnosis, and there's very little research on personality disorders that don't meet formal diagnostic criteria, certainly nothing that would tell you a definite prognosis for this person's opinion. All this to say: I wouldn't take that diagnosis as the word of God about you. I would encourage you to seek out care in the language you know best if at all possible and to ask for a professional interpreter to be provided if they don't have a provider on staff who speaks that language. Recognize that your providers' lack of cultural competence puts you at risk for misdiagnosis-- this is not your fault. If you're in the U.S., you might want to see if you can get help for your OCD from the OCD Institute, too. I am sorry you are having such a hard time.
posted by shadygrove at 2:43 PM on July 6, 2020 [5 favorites]

Psychiatric diagnoses are highly unreliable. Scientifically, they are almost worthless as tools to identify discrete mental health disorders, and even worse in prescribing effective treatment on an individual basis.

I encourage you to focus on what you think would be most helpful to you in achieving your goals for yourself, and put your energy into that. You might find some comfort and validation in a book like What's Right With You.
posted by dancing leaves at 2:53 PM on July 6, 2020 [4 favorites]

Walk away from those acronyms. They do not define you. Going back to a cliche, these diagnoses are like the blindfolded people describing an elephant. One person describes the tail as a rope. One person describes the trunk as a snake. One person describes the leg as the trunk of a tree.

None of these things capture the essence of the elephant. They are one manifestation of an aspect of the elephant, using a metaphor within the range of understanding of the psychiatrist.

Psychologists & psychiatrists are limited in their understanding of human nature. They have a diagnostic rubric, and they match behavior or speech against those structures.

I call bullshit on those diagnoses.

You don't sound like a narcissistic, because I hear empathy and longing for communion with others. Narcissists are entirely self contained and transactional in relationships.

I think your mind works differently. It could be that your brain has fractal patterns, or keeps processing ad infinitum. When this crosses into intrusive thinking or causes you distress, we can call it OCD. DBT can be helpful against intrusive thoughts, and SSRIs are usually successful with OCD.


Do you make any kind of art? Have you ever engaged in an activity that brought you peace of mind, or joy? Are you happier in the city or the country? Are you happy near the water? Animals? Children? Working with wood? Programming computers? Music? Giving massages? Building rock walls?

Actively seek out new experiences and activities, and evaluate your response to them. Your differences are a strength when you are doing the right thing.

posted by ohshenandoah at 3:47 PM on July 6, 2020 [4 favorites]

Insurance companies, as well as medicaid and medicare, require diagnoses for reimbursement purposes. I work as a therapist in community mental health, and trust me- diagnoses are basically a mental health professionals best guess based on a list of symptoms (at least in the early stages of treatment)

Where I work, a diagnosis must be made during intake (and I think that might be true of all Medicaid-funded mental health). The diagnosis can be changed. On top of that, there is disagreement in the mental health field about the validity of diagnosis, period. Some (non-insurance-accepting) therapists don't diagnose.

I'm not saying diagnoses are useless, but there are huge grains of salt to be taken with them.
posted by bearette at 4:09 PM on July 6, 2020

" pretty much anyone with suicide/self-harm history, repeated mental health admissions for anything that's not pure psychosis/mania, disrupted relationships, or who doesn't agree and comply with their plan of care gets BPD traits written on their chart"

Quoted because this was my experience. The shrink at a private inpatient place labeled me as borderline because I wouldn't do the MMPI and some other testing. I thought they were BS based on undergrad/grad psych courses. She gave me some book to read (I Hate You, Don't Leave Me" I think) telling me that I would see myself in it. Spoiler alert. I didn't. The therapist back in the city I came from was pissed. He told me not to listen to that shrink. That dx followed me from the private hospital to a state hospital where it followed me to a private private practice shrink.

I dropped out of the psych system for a while and when I went back in, I never mentioned that BPD dx again.

Hope that helps some. I don't speak your first language, but if you want to chat in English, feel free to MeMail me.
posted by kathrynm at 4:12 PM on July 6, 2020

Can ASD, OCD, BPD and NPD all co-occur?

All sorts of things can co-occur and often do, but this does not mean that you have four-plus different things wrong with you! It likely means you potentially have some one over-arching issue or difficulty that does not map neatly onto a single DSM entry. Most people with issues are the same way. Usually you, or the person diagnosing you, pick the one that seems the closest, and if there are standard treatments for it, you try a few and see what happens.

Some will argue that psychiatry isn't that sloppy and haphazard, but quite often, it really is. Some of these diagnoses have measurable neurological differences associated with them, but nobody does a brain scan on you before giving you a label; they go by observation, experience, and instinct. Sometimes they go by detailed psychological testing; that provides more real data but is still ultimately someone's opinion. Personality disorder diagnoses are particularly influenced by doctors' biases and subjectivity. If you look at how they have historically been classified and reclassified, you may be reassured by how changeable it all is. Again--this is someone's impression of you. Unless you are being involuntarily held somewhere, the only purpose of a diagnosis is to help you. If a given diagnosis seems wildly different from your self-perception, or if the thought of it frightens or depresses you, it is unlikely to be helpful.

This is all to say: you may or may not have a couple of real, official Disorders. Textbook treatment for those named disorders may or may not be helpful or even necessary; that's for you to say. If you are not troubled by the things the DSM says you should be troubled by, the diagnoses are very likely wrong. and it is very normal for these things to be imprecise.

You have described your problems pretty clearly, and I am not a professional so I'm not qualified to say that they all sound very common and treatable, though severe. but they do sound that way. Bear in mind also that all some people mean by "narcissism" is that you're primarily focused on yourself and your own miseries, and by that definition, just about everyone who suffers greatly is "narcissistic" for the duration of their suffering. It does not mean you are a bad person.
posted by queenofbithynia at 5:59 PM on July 6, 2020 [4 favorites]

First of all, yes, this can change and it can definitely get better. You are already showing a large amount of self awareness about how your brain works, how that's causing you pain, and how you want to improve. That is very important and means you are a good candidate for mental health treatment in general.

Both NPD and BPD are often diagnosed as a sort of last-resort where there isn't some other explanation for what's going on, and the symptoms you describe can definitely be explained by a combination of OCD and ASD, so in my semi-professional opinion the doctors were incorrect in giving you that diagnosis. Others have covered the general idea here, but I want to talk more specifically about your symptoms and distress:

I believe I have a combination of Anxiety, Depression, and ASD so my symptoms are similar to yours but not identical. One of the major symptoms of ASD is an inability to understand and process emotions at an intuitive, natural level, which can show up as a lack of "felt" empathy. But, this does not make you in any way evil or narcissistic! You already clearly understand that other people have important emotions and what is good/evil at a rational/thought level so you already know how to help or hurt someone else. It really doesn't matter if you have the "right" emotions, what matters is your actions and your actions sound totally fine to me.

But it does sound like your thoughts are very disturbing to you, and I have felt similar things. I found CBT therapy to be vaguely helpful, but it has never been effective at changing my deeply held beliefs about things like my own self worth. DBT is likely to be more effective, and it sounds like there are many different prescriptions you have not yet tried, it took me multiple attempts to find something to deal with my suicidal thoughts. I also benefited from learning some mindfulness meditation skills, and channeling my very negative thoughts into something creative. Specifically I spent a month writing a work of interactive fiction specifically dealing with my obsessive negative thoughts and used that flush out a lot them so they don't really bother me anymore. That was just for me, everyone has different ways of processing thoughts they wish they didn't have.

I still have issues (mostly about not really enjoying positive things), but my negative thoughts have gone way down over the last 5 years and yours can too. If I were you I would look for whatever treatment seems like it could help give it a try, maybe DBT combined with a new affordable anti-depressant. Good luck!
posted by JZig at 7:19 PM on July 6, 2020

> Can ASD, OCD, BPD and NPD all co-occur?

I learned that the traits and behaviours encapsulated by these categories fall on a spectrum. Everyone has some traits that are BPD-like, NPD-like, etc. It becomes a problem for people when these traits block functioning in life (at work, in relationships). Personality disorders differ from other mental health concerns in that they’re thought to be a sort of entrenched way of coping (which doesn’t mean “unfixable”, it’s just that they came about developmentally, as instinctive coping strategies.)

Both BPD and NPD are “cluster B” disorders. There are some overlapping traits. It sounds like the people assessing you felt like you had some traits from BPD, and some from NPD. They didn’t say you had both full disorders.

(Leaving the question of validity to one side... there are definitely fads and controversies in psychology, but I do believe there are, like, real ways of being that are fairly described by some of these labels. But they’re still abstractions. Again it’s all on a spectrum, and people are complex and can have bits from one or another category.)

I know a bit about BPD because I’ve had to learn it, as I’m close to someone who has BPD traits. (Sharing as someone who doesn’t have it, so it’s more sort of what I’ve learned & read/from a close observer of one person’s POV.)

There are nine criteria for BPD. You could have just a few of them, and it could be said that you have traits. (To have the full PD, you’d need five.)

With BPD, the criteria fall along two key themes - emotional instability (ie both sensitivity and reactivity, and dysregulation), and identity issues. Many people with BPD have histories of trauma, as well.

Moods shift *rapidly*, over the course of hours, vs longer periods. Moods are intense, as well - thought to be related initially to a super sensitive CNS, to start with. (I could see an early Aspergers diagnosis perhaps capturing this part). So there’s a baby who’s born super sensitive. To all kinds of stimuli, sensory and otherwise.

It’s thought that when there’s something that’s perceived by this sensitive child as traumatic - could be abuse, or, merely a poor fit with their parent/s, or having struggling and therefore inconsistently responsible/unavailable parents - the child grows a sense of insecurity in their outer world (so they have to be vigilant) and in themselves. The strong feelings that result don’t get consistent reactions from parents - so the child either pulls in or acts out (or both), in an attempt to get desired responses and so feel soothed. If there’s a lot of instability/insecurity, and very strong, shifting emotions, it can be difficult to establish a stable container of feelings and sense of self. It is about feeling *invalidated*, from this period of life on.

Friendships and other relationships suffer in part because a person w BPD - who again is super sensitive to stimuli, especially emotional stimuli, especially when that stimuli seems to suggest rejection or criticism - anticipates invalidation (or rejection or criticism). And then because the emotions are so strong, the person reacts, sometimes in a big way. Either by acting out emotions in an attempt to get much-needed validation, or by withdrawing and never giving others a chance to reject or criticize them.

(That last coping style, withdrawal, isn’t the one most people think of with BPD, which is usually about “acting out”. But it can be. I don’t know much about covert narcissism but from what I’ve read the withdrawal might be similar. Or maybe the same... So maybe that aspect is what was connected with NPD over BPD?)

Also, a common thing is conceptually “splitting” people into good, and then bad (when high hopes are Also, a common thing is conceptually “splitting” people into good, and then bad (when they inevitably disappoint), and then devaluing the “bad” inevitably disappointed), and then devaluing the “bad” person, and reacting to that (with strong actions, withdrawal or not.)

With all these big and confusing emotions, and interpersonal instability (because *consistent* feedback from other people also helps shape a sense of self), identity can be a big question mark.

Self-harm often happens with BPD because pwBPD are trying to regulate their emotions by distraction (from worse emotional pain) or sometimes it’s a form of self-punishment - there is often a sense of worthlessness and especially guilt, after a strong reaction, as well (this I think is what distinguishes BPD from NPD, the guilt, and a sense of shame. I think with NPD it’s not as present.) and I suppose it is a way of finding validation too, whether or not it’s a conscious motivation. But someone might not self harm, they might get angry, if they’re externalizing emotions and more sensitive to criticism than rejection. And a (hyper) sensitivity to perceived criticism is a narcissistic thing as well.

So, I talked about BPD but tried to explain how there’s some common ground there with NPD, and potentially with Aspergers.

For sure, people can have other conditions along with one of those (I think OCD and other anxiety disorders are common in people with BPD).

So in terms of how to cope... As mentioned, DBT does help people with BPD, as I imagine it actually would help pretty much most people, it’s about learning to cope with strong emotions. To the point that people no longer meet diagnostic criteria.
Therapy with a focus on interpersonal relationships could also help, if you do get that opportunity (and I am so sorry it’s not available to you right now). Self help would be worth considering in the interim - see which well-reviewed books on DBT might work for you on Amazon.
posted by cotton dress sock at 11:14 PM on July 6, 2020 [1 favorite]

This is sort of an oblique answer to your question, but I just got a feeling that this might be helpful to you, at least as a jumping off point:

I was recently reading about a type of therapy called Radically Open DBT (RO-DBT). The people who came up with this therapy did so because they had patients they saw as being poorly served by existing therapy styles. They introduce a "transdiagnostic" distinction I thought was really interesting, between disorders of undercontrol and disorders of overcontrol.

They define overcontrol as something like excessive self-control. It is associated with disorders like anorexia, OCD, anxiety, long-term depression, and OCPD, and is also seen in some clients with autism spectrum disorders. In broad strokes, overcontrolled people tend to be more inhibited, and to have rigid, rule-based criteria for action.

Undercontrol, in contrast, is associated with disorders like borderline personality disorder, where behavior is more impulsive, less inhibited, and exhibits big changes depending on mood. (Overcontrol and undercontrol are thought to be continuous traits and are not necessarily pathological in and of themseves; the point as I understand it is that they can help understand some overarching problems people have that aren't neatly captured by existing diagnostic categories.)

Within this framework, RO-DBT treats disorders of overcontrol (OC), whereas regular DBT targets undercontrol (UC). So even though they share an acronym, these types of therapy in some ways have opposite purposes. This means that you would not necessarily expect someone with overcontrol to improve in regular DBT therapy, where a main goal is to be able to act regardless of emotions. The goal of RO-DBT, in contrast, has a lot more to do with improving things like social connectedness.

The thing that really grabbed me about this work is that according to their research, between three and four out of ten people they saw who were diagnosed with something like BPD were actually mis-diagnosed and were subsequently identified as having problems relating to overcontrol, not undercontrol. In another study, many people who reported as many as eight or nine symptoms of BPD were actually assessed by independent raters as being over-, and not undercontrolled.

This seems impossible, but a big part of this actually seems to be because suicidal behavior and self-injury, despite their stereotypical association with BPD, are also associated with overcontrol disorders! One of the major differences they identify is that in OC individuals, these behaviors tend to be planned, private, and rule-based, as opposed to impulsive, public, and mood-based as in UC individuals. You mentioned having "objective" reasons for self-harm and self-hate in your post, which to me seems right in line with this schema. (People with OC may also have angry outbursts or meltdowns, like people with UC disorders -- but these tend to happen in private, in anonymous public settings, or around "safe" people like family members, and tend to follow a long period of exerting self-control. Your experience in the parking lot sounds like this to me.)

Here's an interesting summary quote from a review [PDF] about OC disorders: "Five OC social signaling themes are posited to be uniquely influential in the development and maintenance of maladaptive OC, including (1) inhibited or disingenuous emotional expression, (2) extreme caution and excessive focus on details, (3) rigid, rule-governed behavior, (4) an aloof, distant style of relating to others, and (5) frequent use of social comparisons along with frequent feelings of envy or bitterness." Your statement about being resentful and envious of others whom you think are "objectively better" than you on some axis really reminded me strongly of that fifth point in particular.

Another parallel I saw was your statements about having difficulty with intimate relationships. One of the main difficulties OC people have according to this framework, and importantly, one of the main things RO-DBT is designed to address, is connecting with other people, the absence of which causes isolation and loneliness.

I do have to say, I am not a therapist or a specialist of any sort and I of course wouldn't be able to diagnose you even if I were. I also don't know where in the world you live and what resources would be easiest for you to access. I brought it up because this type of therapy 1. is not yet nearly as widely known as CBT or regular DBT, and 2. might be uniquely valuable to you in a way that other forms of therapy would miss. Also, if any part of this does actually resonate with you, even just reading more about it could be a helpful step since it might make you feel like someone gets what you're going through and that there is a more explicit, documented path to change.

Regardless of whether this does end up applying to you, I also just want to second that mental health diagnoses are messy, imprecise, human constructs. They do not in any way determine whether or not you are a good person.
posted by en forme de poire at 12:10 PM on July 8, 2020 [3 favorites]

Okay, one other sidebar and then I'll shut up! I'm not sure exactly what type of CBT you were referring to when you mentioned you got treated for OCD, but I felt like I should mention that the "plain vanilla" type of CBT that most therapists practice actually has limited efficacy for OCD. If at any point you were told to manage your thoughts by challenging their factual accuracy or finding evidence for or against their veracity, you weren't getting the correct type of treatment. There are effective therapies for OCD, but the standard of care uses a really specific approach called exposure and response prevention (ERP), sometimes in conjunction with other approaches like ACT.

OCD in particular is one of those conditions where seeing a specialist is really, really useful, since approaches that work for more garden-variety anxiety and depression can actually do more harm than good for a person with OCD. Even ERP as a treatment can be somewhat tricky to do correctly, so if you tried it and found it didn't work for you, a different or more specialized therapist might be better able to troubleshoot what was going on.

Anyway, sorry if this is obvious or not useful, but since "CBT" can mean a lot of different things, and since people with OCD often have trouble getting the most effective, evidence-based care, I figured I would mention it just in case.
posted by en forme de poire at 12:23 PM on July 8, 2020 [2 favorites]

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