Marriage may be the most challenging relationship in one’s life. Loving feelings are precious, and can be fragile and difficult to sustain. Many times when a couple enters the office in a crisis, the issues and problems they bring up in therapy have developed over a period of years, and have become compounded by a recurring cycle of disappointment, feeling wounded, and being ignored or taken for granted. Often times the drive, energy and focus devoted to one’s career and children are exhausted, and little is left over to nurture the marriage. As a result of this neglect, a valuable life together built upon the foundation of marriage begins to crumble. Every divorce is tragic, even when justified.

Marriage counseling is designed to surface and explore the root causes of marital conflict and distress; reconstructing how, when and where the relationship went off-track; hopefully bringing understanding to the inevitable misunderstandings that have been created and amplified over time; and learning how to implement new tools, for more effective emotional connection and problem resolution. Understanding one another can help to reduce the feelings of anger and hurt, and break the negative cycle that threatens to destroy the marriage. How are feelings of love restored in a battered marriage? The most important ingredient is listening, truly listening to one another. Exactly what does that mean in practice?

Listening has an enormously powerful effect when a loving relationship has been damaged. The most effective type of listening is best characterized as empathic and compassionate. Listen from your heart. Pay attention without interrupting. Take note of what is being said, and really try to understand what you are being told, even if you don’t agree with it. Put yourself in your partner’s place and work hard to understand what he or she has experienced. Listen with a spirit of cooperation, of jointly embarking on a journey of discovery, even when it is painful. Convey your understanding without hostility, and whenever possible, and where it is true, take responsibility for what you are being told about your own destructive or neglectful behavior.

Empathic, thoughtful listening creates a feeling of safety in the relationship. A readiness to blame your partner is the surest way to reinforce feelings of vulnerability and rejection, and discourage the honest sharing that is needed. How often in our lives do we feel listened to and understood by those we care about? The healing power of empathic and compassionate listening should never be underestimated. Injecting a needed dose of hope into the relationship, it enables one’s partner to feel special, and loved. It helps to restore a caring emotional connection and positive momentum.

Mignon McLaughlin once said, “A successful marriage means falling in love many times, always with the same person.”Falling in love once again with your spouse protects and enhances the life you have built together, and is energizing and rejuvenating. It can bring newfound satisfaction and joy to the other areas of your life as well.

A stable, positive feeling about oneself is to be cherished. For many people it is hard to come by, at least for extended periods of time. Some patients report that they may feel good about themselves from time-to-time, yet they can be plunged into the depths of despair and emotional vulnerability seemingly without cause and with no warning. These episodes may be mild and short-lived, lasting a few hours to a day or two; or they may be more severe and incapacitating, and last for several weeks to a number of months. Others report that as far back as they can remember they have lacked positive self-esteem, and have been unable to experience joy. Still others report that their feelings about themselves are quite unstable, ranging from times where they feel inadequate, helpless, hopeless and have difficulty getting out of bed and functioning; to other times where they are filled with great energy, sleep very little, are immensely productive, and may come across as abrasive or aggressive to loved ones and colleagues.

Self esteem regulation is a central problem for all patients with mood disorders, and difficulties with self-esteem can have neurobiological, psychological, social, and existential origins. Let’s explore each of these potential causes under the BioPsychoSocial Model of emotional illness.

Beginning with the biology of mood disorders, normally the DNA in a brain cell codes messenger RNA that then codes what are called “neuroprotective proteins,” that protect the normal structure and function of the brain cells from the negative effects of stress. While there is no “mood disorder gene,” we now know that certain types of repetitive stress such as learned helplessness, defeat stress, substance abuse, and oxidative stress; when experienced by individuals who have a genetic susceptibility to a mood disorder; may cause serious problems in maintaining a stable feeling of self worth. Learned helplessness (“No matter what I do it doesn’t make a difference – I have little or no power in the relationship – I feel helpless and powerless”) and defeat stress (“In the relationship I frequently feel emotionally abused or neglected”) interact with the DNA in the nucleus of the brain cells to cause fundamental changes in the type of messenger RNA and proteins that are coded, such that the neuroprotective protein levels decline, the structure and the function of the brain cells are adversely affected, and self-esteem regulation may be severely impacted. Here is a picture that summarizes how this works:

At the top right of the next picture, the unprotected brain cells are shown to have shrinkage of their branching portions, called dendrites, and a decline in the number of chemical transmitters available to make the multiple interacting circuits work. With effective treatments such as medication and psychotherapy, these changes are reversed and normal function is restored as demonstrated at the bottom right of the picture. The treatments restore positive feelings of self-esteem and self worth, or in some instances enable the patient to experience healthy self-regard for the first time in their entire life.

With respect to the psychology of mood disorders, what life events predispose a person to developing low self-esteem as a child, which is then carried over into adulthood? There are many unconscious psychological influences on self esteem that have their origins in childhood, ranging from sibling rivalry, to being raised by a critical or unempathic parent, to suffering from ADHD or other disability, to parental divorce or death, to physical or sexual abuse.

A sibling who is perceived as favored, or more talented and capable, can cause one to feel demoralized and stir up feelings of competitive envy and jealousy, which can undermine the development of self-confidence. The child may feel that no matter how hard they try they simply can’t compete, which creates for them the experience of learned helplessness.

A parent who is excessively critical and demanding, and who lacks compassion and empathy can also predispose the child to feel “not good enough,” even unlovable. This can of course create an emotional environment of defeat stress for the child.

A disability such as ADHD may undermine the feeling of positive self worth. Chronic feelings of frustration and humiliation develop as a result of the struggle to absorb, retain, and effectively work with information presented in class or through reading and homework assignments. Increased conflicts at home may occur due to what is perceived as “not listening” to parents; along with messiness and procrastination. Because fellow students seem to “get it” faster and better, and the child with ADHD frequently misses important social cues, feelings of low self regard can intensify all the more. The pervasive effects of ADHD in a child’s life can create both learned helplessness and defeat stress.

Parental divorce or death, and various forms of abuse, can destroy the “protective envelope” of childhood. These events constitute losses of one form or another, which breach a child’s sense of stability and security, disrupt and disturb feelings of trust, may lead to feelings of guilt and self-blame, and serve to undermine or erode the development of positive self regard. Since the child is helpless to prevent these losses or abuses, learned helplessness stress can bring about the alterations of brain cell activity depicted above.

A number of childhood psychological stressors can predispose the child, adolescent or adult to developing a major mood disorder. What determines whether this becomes a Major Depressive Disorder or Bipolar Disorder? Here is where the genetic contributions play a key role. Most people with major depression do not have close relatives with bipolar disorder, but the relatives of people with bipolar disorder are at increased risk of both major depression and bipolar disorder. With this in mind, what childhood experiences conclusively interact with a genetic predisposition to increase the likelihood of developing a major mood disorder? The answer to this question has the potential to help us prevent the development of a major depressive or bipolar disorder in childhood or later in life.

The interaction of psychological factors with specific family genetics certainly play a role in the development of Major Depressive Disorder. The heritability of major depression is probably 40-50%, and may be higher for severe depression. This means that around 50% of the cause is genetic, and around 50% is unrelated to genes (with contributions by psychological or physical factors).What we don’t know is whether this means that in some cases of depression the tendency to become depressed is almost completely genetic, and in other cases it is not really genetic at all. We do know that severe childhood physical or sexual abuse, childhood emotional and physical neglect, and severe life stress are probably all risk factors. Losing a parent early in life probably also increases risk to some extent.

Psychological factors interacting with family genetics also plays a role in the development of Bipolar Disorder. Studies show a 10 times greater risk of developing bipolar disorder if a first degree relative, such as a parent or sibling, has the disorder, for an overall 8.7% chance. How do we know whether this is from a genetic susceptibility or results from how the child is raised? The answer lies in the fact that there is a much greater chance (around 65%) that identical twins will share the disorder, vs. around a 5% to 20% chance for fraternal twins. Since the figure for identical twins is 65% and not 100% science has determined that certain environmental factors also predispose to the development of Bipolar Disorder; such as sexual abuse, highly critical parents, and low levels of maternal warmth. Substance abuse can also “kindle” abnormal activity in the temporal lobes of the brain, the so-called “seat of emotions,” resulting in a higher likelihood of developing Bipolar Disorder.

Social factors in the immediate or extended family also play a role. Divorce, death of a child or spouse, severe setbacks in ones career, economic reversals, or a child with a physical or mental illness can all contribute to feelings of despair and hopelessness, and engender both defeat and learned helplessness forms of stress. A major mood disorder including severely disrupted self esteem can then ensue. Once again the common theme is the experience of specific types of stress that involve loss, and real or perceived powerlessness to effect a different outcome, that interact with a genetic susceptibility to Major Depression or Bipolar Disorder.

Finally, existential factors can contribute to a diminution of self-esteem. At significant transition points in an individual’s life, one may experience an “existential crisis.” A useful framework for understanding the developmental challenges at each life stage, and the corresponding opportunities for emotional growth, is provided by psychologist Erik Erickson’s Stages of Psychosocial Development. In Erickson’s description of eight life stages, an “identity” or “existential” crisis may develop in stages five through eight, if the developmental challenges of one or more of these stages is not successfully confronted, negotiated and mastered. This may be manifested as an identity crisis in the adolescent or young adult, failure at achieving intimacy and commitment in early adulthood, a career that lacks a sense of accomplishment and social value in middle adulthood, or despair in late life when reminiscence brings regret and a sense of failure.

In “The Psychiatrist as Psychotherapist” I wrote about the psychiatrist’s capacity to integrate a knowledge base comprising neurobiology, general medicine, the unconscious, behavioral science, family systems, workplace/environmental stressors, and nutrition, to design and implement holistic treatment plans. To create positive feelings of self worth for the very first time in a patient’s life, or to restore confidence following the onset of a major depression, or to stabilize wide swings in self esteem in someone suffering from bipolar disorder, necessitates drawing from all of these knowledge bases, and is both a science and an art. Influence is brought to bear at the level of gene expression, brain cell circuit function, the unconscious, family interaction, and existential meaning and purpose.

A psychiatrist is privileged when he or she is able to work with a determined and earnest patient, as they embark upon a journey toward that cherished place – the achievement of stable, positive feelings of self-regard. This cherished place includes an abundance of newly discovered riches: such as the ability to enter into a committed relationship and feel safe; looking at yourself in the mirror and liking what you see; hopeful feelings about the future; an end to comparing yourself to others, and coming up short; no longer being your own harshest critic; and leaving behind those self-sabotaging behaviors that preclude a more joyful experience of self and others. As their work together creates both social value and a great sense of accomplishment, the journey provides one additional benefit – it is exceptionally good for the middle-aged psychiatrist’s own self esteem!

In the United States, an estimated 4.4 percent of adults ages 18-44, 4 percent of children ages 4-8, and 9.7 percent of children ages 9-17 experience symptoms and some disability from ADHD. As such, ADHD is one of the most common of all psychiatric disorders. It is also among the most treatable.

Research has established that ADHD is a neurobiological condition with a likely genetic component, wherein critical circuits in the frontal cortex of the brain responsible for sustained attention, organization, planning, and various other executive functions are not functioning properly. The speed and efficiency of information processing is inconsistent, and compromised. These circuits mainly rely upon two neurotransmitters to function (dopamine and nor-epinephrine), and most medications used to treat ADHD increase the availability of one or more of these two transmitters. Additional treatments typically include education, cognitive/behavioral techniques, and cardiovascular fitness exercise. Exercise activates the frontal cortex in all age groups, and increases levels of both dopamine and nor-epinephrine.

If you are a patient suffering from ADHD, or a family member living with someone with ADHD , what is the impact on your life?

For the patient with ADHD, living in reality feels like a “discontinuous experience.” Because they are frequently distracted by wandering thoughts, excessive daydreaming, and external motion and sounds in the environment when trying to focus on a task, they miss out on a number of important environmental cues, and struggle harder to learn new information. This has nothing to do with their level of intelligence, as I have treated many outstanding students, executives, and professionals with ADHD. These highly capable individuals have become overwhelmed and emotionally depleted from the challenge of processing increased volumes of information. Certain information from the environment therefore never “gets inside” their brain, and therefore is unavailable to be processed, particularly when their “supply” of information processing is exceeded by the “demand” to process information while at school or in the workplace.

A useful analogy to assist in explaining this experience is to imagine for a moment that your computer suffers from ADHD. As a result, an average of one out of every ten keystrokes that you type on the keyboard never register in the computer – that portion of the data never gets entered. In addition, the keystroke data that is “dropped” on the way in is random and unpredictable. The computer then inconsistently processes the information that has been entered – at times with the latest Intel Core 2 Duo Processor, and at other times with an Intel 386 microprocessor designed 20 years ago. The end result is that this computer could run Windows 95 just fine, but what about Windows Vista? For simpler processing tasks it would function just fine, but as processing complexity increased, it would begin to function poorly, if at all. How well would the computer function with its varying processors that are commanded to process incomplete information? What would the work product (for example the text or financial information you have created), look like when displayed or printed out?

While our brains may function in certain respects like a computer, a machine lacks a heart. Having ADHD is not just cognitively challenging, it is emotionally painful, as learning becomes more of a struggle, social cues are missed, distractibility is interpreted as a “lack of interest” or “rudeness” by others, and self-esteem is diminished over time. Anxiety and depression may set in. Patients with ADHD are twice as likely to develop a major depressive disorder, significant anxiety disorder, or substance abuse problem as the general population. Social development is slower and more challenging due to missed social cues and delayed brain maturation. Symptoms may be masked by high intelligence and a strong work ethic, which provide for a temporary “work around” the ADHD processing deficits. But as the complexity of life increases at certain transition points (for example moving from middle school to high school; taking standardized tests such as the SAT, LSAT, medical boards or bar examination; or receiving a significant promotion at work) the attentional system may become overwhelmed, emotional symptoms become more pronounced, and psychiatric care becomes necessary.

Living with a loved one suffering from ADHD is also emotionally painful. Life with someone who frequently misplaces or loses belongings, forgets to accomplish chores or duties that were seemingly explained and understood, procrastinates, is disorganized leading to messy bedrooms and assignments, acts impulsively due to a lack of planning, and is distractible in a way that seems like “they just don’t listen,” can lead to feelings of anger, frustration and exasperation. There is also the experience of sadness in watching a loved one struggle with some of the routine demands of everyday life.

The good news is that ADHD is highly treatable, and that medication, education, exercise, and cognitive/behavioral therapy can be “game changing.” Not uncommonly a stimulant medication can improve symptoms 80% to 90% by improving the speed, efficiency and consistency of information processing. Typically the most stubborn symptoms to treat are procrastination and disorganization, which often respond to higher doses of the stimulant (which mainly boosts dopamine levels), or require the addition of Strattera (which boosts nor-epinephrine). Simple organizing techniques such as the use of a PDA, a spiral notebook (not Post-its), and habitually returning personal belongings back to the same location, can be helpful. Specialized neuropsychological evaluations, psychotherapy and educational services, providing tangible techniques to improve study skills and workplace performance, can also bring about increased feelings of mastery and success, and result in improved self-esteem. Effective treatment of ADHD not only enriches the life of the person suffering from the condition, it also enhances those important relationships at work and at home.

In a prior blog posting entitled “The Psychiatrist as Psychotherapist” there was a reference to the privilege of being trained during “The Golden Age of Psychiatry.”As the following story illustrates, This Golden Age had a somewhat turbulent beginning…

When I completed my medical school education at Georgetown in 1975, and prior to beginning residency training at the psychoanalytically-oriented program at Tufts New England Medical Center in Boston, I traveled to London to learn about the emerging and exciting field of psychopharmacology. This was a conscious decision to round out my education and become exposed to new ideas that I would not receive in Boston, as the Tufts program focused on providing some of the top psychoanalysts in the country teaching residents how to perform intensive psychotherapy of hospitalized patients as well as outpatients. As the Tufts program lacked a psychopharmacologic curriculum, I felt that I needed to go to London.

Upon arriving I was surprised to learn that there was a severe dichotomy between the teachings of the psychopharmacologists, and those of the psychoanalysts. In short, not only did they vehemently disagree as to the origin and treatment of serious emotional problems, there appeared to be a lack of respect for or synthesis of differing points of view.
Nonetheless, I was there to learn about how medications could assist in restoring the brain’s emotional functioning, and I excitedly engaged with my professors at England’s Maudsley Hospital and Institute of Psychiatry, who were pioneers in the research and clinical use of medications to treat emotional disorders. It was a wonderful experience that I treasure to this day.

Now flash forward several months to the beginning of my residency training at Tufts. I was in my first month of the program, and I was on weekend emergency call at the New England Medical Center emergency room. A nineteen year old young man came in who was in a highly agitated manic state. Armed with my newfound European knowledge about the use of Lithium to treat Manic Depressive Psychosis (later renamed Bipolar Disorder), I admitted him to our inpatient unit and confidently placed him on Lithium. I was really proud of myself. That feeling of pride would turn out to be very short-lived.

On Monday I received an urgent call from the Director of Residency Training at Tufts, who insisted upon seeing me immediately. Nervously entering his office (he was a world famous psychoanalyst), he sat me down and proceeded to rake me over the coals for placing my patient on this “unknown” and “dangerous” substance, Lithium, which I had no right to do, particularly since I hadn’t discussed it with my supervisor (who as a social worker could not advise me on prescribing any medication, so I didn’t see much sense in that requirement).
I was crushed, and when he dismissed me from his office I was convinced that he would terminate me from the program. Shaken by the experience, and looking for an immediate reality check and some support, I went to see one of my supervisors (also a world famous psychoanalyst, with a kindly demeanor) and asked him whether I would be terminated, and what I needed to do to restore my good graces with the Director. My supervisor patiently listened as I described my experiences in London, and what I had learned that I simply tried to apply to my poor manic patient to alleviate his suffering. The supervisor told me that he would intervene with the Director on my behalf, and asked if I could provide him some articles on “that Lithium medication” as he was curious about it. (Interestingly, Lithium was first used to treat patients in Australia by John Cade in 1949 , and this was 1975, one year after the FDA had approved it for use in the United States, so it was not as if I was some wild-eyed radical psychiatrist).

Relieved, I left his office and was not bounced out of the program. I provided him two articles on the use of Lithium, and we discussed how the Lithium, combined with my seeing my manic patient five times per week in intensive therapy, worked together to help him. Two years later Tufts brought in a new Department Chairman- trained as both a psychoanalyst and a psychopharmacologist. I went from being the radical first year resident to being selected as Chief Resident in my third year, and a member of the medical school faculty the following year.

The Golden Age was underway.

Of course what was interpreted as a reckless and a bold move by me at that moment in history is now routine practice, and today treating a manic patient with psychotherapy alone would be considered malpractice. The Biopsychosocial Model of psychiatry is in full bloom – integrating a number of knowledge bases and databases to optimize the care of our patients.

It was my great privilege to go to London to learn psychopharmacology, and an even greater privilege to train in psychotherapy under the tutelage of top psychoanalysts in Boston. I feel grateful for these experiences every day, and remember with fondness and humor my turbulent initiation into The Golden Age of Psychiatry.

Many psychiatrists are expert at prescribing medications to treat the variety of symptoms that accompany the cognitive, emotional and behavioral problems that afflict their clients. Why do fewer psychiatrists engage in psychotherapy as well? One reason is that newer generations of psychiatrists were trained in residency programs that were heavily influenced by the “Psychopharmacologic Revolution.”

For much of the twentieth century psychiatry had few medications to offer, and those that were available had significant side effects, and poorly targeted the underlying symptoms of anxiety, depression, ADHD, psychosis, and substance abuse that bring about emotional pain. Prior to the “Revolution,” psychiatry was considered the “black sheep” of medicine – looked down upon as “voodoo science” by our medical colleagues – and occupying the bottom rung of respectability among medical specialties. Some doctors even questioned why psychiatrists needed to graduate from medical school, as their practices were almost exclusively oriented toward psychotherapy.

All of that changed with the Psychopharmacologic Revolution, as first generation medications were introduced and found to be effective, and second generation medications were equally or more efficacious with far fewer side effects. Psychiatry rapidly and dramatically began to achieve documented positive outcomes that rivaled or exceeded most of the other fields of medicine, exerting a profound effect on psychiatric training programs, as this newfound “respectability” dramatically transformed these programs into a biologically-oriented curriculum focused almost exclusively on medication management. At the same time, managed care companies were providing negative financial incentives for psychiatrists to perform psychotherapy. The net effect is that newer generations of psychiatrists are not as solidly grounded in the fields of psychotherapy as their predecessors.

Those psychiatrists trained in “The Golden Age of Psychiatry” received intensive training in various modalities of psychotherapy, such as psychodynamic, cognitive-behavioral, and family systems; as well as learning the science of psychopharmacology. These fortunate physicians are able to evaluate and treat the whole person, including the ability to address biological, psychological, social/environmental, and existential issues throughout the course of therapy with their clients, according to the Biopsychosocial Model.

There are many fine non-medical therapists who work closely with psychiatrists to support the medical aspects of treating their clients. What is unique about the psychiatrist as psychotherapist is his or her capacity to integrate a knowledge base comprising neurobiology, general medicine, the unconscious, behavioral science, family systems, workplace/environmental stressors, and nutrition, to design and implement holistic treatment plans. These doctors utilize the latest psychopharmacologic science combined with an eclectic use of psychotherapy, to help provide symptom relief and put an end to the self-sabotaging behaviors that serve to undermine personal growth and diminish the quality-of-life of their clients. As physicians, psychiatrists have received broad training in the science and art of general medicine, surgery, neurology, and other medical specialties in addition to their psychiatric training – including decisions that involve life and death responsibility – which adds another dimension to the psychotherapy that they provide. It is truly a gift for those of us psychiatrists who were trained during “The Golden Age,” to have the privilege of being able to care for the whole person.

Marriage is one of the most challenging of all human relationships. It can also be one of the most rewarding. True intimacy, including friendship, compassion, empathy, sharing and realizing dreams, advising, comforting and supporting each other through life, sexual satisfaction, and deep love and affection, are all possible – yet at times can be elusive and even feel like an impossibility. Most marriages are characterized by highs and lows – times of joy and times of despair – tender intimate moments and periods fraught with conflict and emotional distance. What makes a marital relationship so complicated?

To begin with, marriage is the most intimate of all human relationships. Emotional and sexual intimacy stirs up deeply felt and largely unconscious conflicts, feelings and fantasies. Dependence and independence, loyalty and betrayal, need satisfaction and disappointment, commitment and fears of abandonment, trust and mistrust, narcissistic love and mature love, freedom and self-sacrifice are just some of the contrasting and conflicting conscious and unconscious emotions that characterize any intimate relationship, and are most intensely experienced in a marriage.

Our relational experiences with our mothers and fathers, stemming from early childhood, become significant determinants in how these unconscious emotional issues are played out in a marriage. How our parents behaved in their own marriage are also influential factors. Later disappointments in the love affairs of adolescence and young adulthood also shape ones feelings and expectations in adult relationships, as can a prior divorce. In addition, biological, social/environmental, and existential issues can come into play. If one’s spouse has ADHD, depression, anxiety, or a substance abuse problem, additional burdens are placed on what is already a complex relationship.

Not uncommonly, when a couple presents for marital therapy, there is a true feeling of crisis in the marriage, and fears that the marriage is over. What happened? Not uncommonly, the marriage went off track and the couple did not become aware of this until much later. The pressures of careers, raising children, and finances often result in the marital relationship being relegated to second, third or fourth place in the hierarchy of what is attended to, cared for, and nurtured. This neglect, along with one or more unrecognized and unspoken major disappointments and emotional wounds, derails what had once been a stable and mutually satisfying marriage. Gradually the marriage deteriorates and may be characterized by hostility, indifference and escalating conflicts.

At the outset, the goal of marital therapy is neither to “save” nor to “civilly end” the marriage – there is no preconceived agenda – it is to create a safe and open environment to begin to explore what happened to a previously satisfying relationship, and determine where it went off track, and the circumstances surrounding those events. Not uncommonly, there was a deep misunderstanding that developed, and mutual hurtful actions served to usher in a period characterized by a downward spiral in emotional relations. Once the initial causes are identified, talked through, and understood, forgiveness and empathy can begin to develop. Neurobiological factors such as ADHD, depression, anxiety, substance abuse or bipolar disorder can be addressed by medication management and individual therapy. Earlier passions, whether they are physical or experiential, can be rediscovered as a result of initial healing, which in turn can transform a downward spiral into a more hopeful situation for the future, enabling the development of new positive experiences together and upward momentum in the marriage.

Mignon McLaughlin once said that “A successful marriage requires falling in love many times, always with the same person.” If a couple has the courage to face up to and work through their feelings of disappointment, hurt, and anger, they can rediscover their loving feelings and begin to delight once again in each other’s company.

There has been increasing interest in adults with attention deficit problems in both the popular press as well as the psychiatric literature. Some of this results from a greater awareness that the attentional deficits of childhood often persist into adulthood; while other aspects relate to a pervasive anxiety over the need to perform at ever higher levels in the workplace, given the Great Recession and its attendant job loss and painfully slow recovery.

Symptoms such as trouble sustaining attention, being easily distracted by internal or external stimuli, trouble staying on task, jumping from one task to another without completion, procrastination, problems with organization, difficulty focusing and executing on tasks particularly when they are boring, fidgeting, frequently being in motion, and interrupting others while they are speaking, are among the hallmarks of classic adult attention deficit disorder.

However. a note of caution is in order, given the risk that “Adult ADD” may become over-diagnosed, and stimulants may become over-prescribed, much in the same fashion as childhood ADD. It is important to recognize that there are many causes of disrupted attention in adults that bring about symptoms similar to adult ADD, but have differing origins and treatments. A careful diagnostic assessment is in order.

Attentional problems can result from a number of conditions including: anxiety disorders, ranging from OCD to recurring panic attacks; certain prescription and non-prescription medications; vitamins, supplements and nutriceuticals; concussion and/or whiplash injuries; alcohol abuse; use of marijuana, and other illicit drugs; sleep apnea syndrome; thyroid disorders and other hormonal or metabolic disorders; lead, or other heavy metal intoxication; overexposure to pesticides; vitamin deficiencies; mood disorders; petit mal or partial complex seizures; or other conditions.

The optimum approach to determine a correct diagnosis and treatment plan is called the BioPsychoSocial Model. Only through a careful history of potential biological, psychological, and social/environmental factors can the various contributors to attentional problems in adults be delineated and addressed. Sometimes it is helpful to bring in a spouse or significant other to corroborate symptoms, or to detect the subtle gazing spells that characterize petit mal or partial complex seizures.

Ultimately, the correct diagnosis and initiation of successful treatment can bring to a close years of frustration, demoralization, despair, and anxiety over these attentional problems and their destructive effects on self esteem, important outside relationships; and one’s relationship with oneself. A new chapter may begin, characterized by greater personal fulfillment, and a richer awareness of a life that was previously overlooked.

A number of highly talented young adults are living through what might be termed an “existential crisis.” Typically these are young men and women in their late teens or early-to-mid twenties, with a track record of tremendous academic and extracurricular success, who seem to “hit a wall” while in high school, college or graduate school. Dramatically and seemingly without warning, they become depressed, angry, and “lost.” Their life as they and their parents have come to know it grinds to a halt. They rebel against and at times abandon their prior styles of driven accomplishment, energetic involvement in multiple pursuits, and pride of achievement. Their traditional values of a strong work ethic, academic excellence, predictability, pleasing the adults in their life, future orientation, and linear goal-seeking is abandoned, and they and their parents struggle to make sense of it all. It is a time of high anxiety and great uncertainty for those who love them, and the young adults and their parents endure significant emotional pain and despair.

Prior to this crisis, there are a number of common characteristics that are shared by this group. Many tended toward perfectionism, and were very high achievers. They took enormous pride in being at the top of their class academically while managing multiple extracurricular activities. As “stars” they received many awards – distinguishing themselves at a young age – while seemingly basking in the glow of their parents’, teachers’, and personal pride.

What themes emerge as they engage in psychotherapy? To begin with, as they develop trust in their therapist, a history of hidden but intense fears and anxieties over the failure to perform at the very highest level began years before. Their fears would devolve into panic attacks at times – particularly when they would not turn in a top performance – and they would become severely self-critical and filled with self-loathing. In some respects they became their own “tough act to follow” through a history of near-flawless performances. They would fear being given poor grades (sometimes describing failure as achieving a “B”) and losing their “star status.” Other fears include disappointing their parents, worrying about whether they would continue to be loved or be severely criticized if they let up on their perfectionistic strivings, or did not gain admission into one of the most prestigious colleges or graduate schools. A history of emotional sensitivity, and delayed social maturity characterized by challenges in dating and finding a boyfriend or girlfriend, feeling unpopular, being identified as “nerds” or “kiss ups,” favoring adults over peers, and an unusual degree of empathy and compassion are common characteristics. At times there is a history of attention deficit disorder, inattentive type, which was masked until later in their lives because of high intelligence and a strong work ethic.

The existential crisis may be precipitated by extreme disappointment in one or more love relationships; the death of a loved one such as a friend, parent or grandparent; the transition from high school to college, college to graduate school, or university into the real world; or may have no apparent precipitant at all. Commonly, in one form or another, there is a “loss of an ideal,” and what previously provided meaning, guidance and purpose is actively repudiated.

Treatment involves initially establishing an open and non-judgmental rapport, helping the young adult understand what has happened to them, and assisting them in making sense of the dramatic turn of events in their relationship with themselves. A judicious use of medication to help them with overwhelming symptoms of anxiety and depression is not uncommon. As the therapy unfolds they begin to differentiate between values that they were taught, and values that truly represent their core personality. They distinguish between the passions they previously shared with their parents, and newfound passions that feel rock solid, and are theirs alone. Rejecting a more traditional and secure path into self-sufficient adulthood, they experiment and explore, they wander. They make mistakes. Their parents must learn to tolerate and accept ambiguity and uncertainty, feelings of great helplessness, and recognize that they have no control of their child’s life and must let go while continuing to provide love and support. While there may be many sleepless nights (at times including their therapist!), there are newly forged understandings that feel right and true, as opposed to the “falsehoods” they have been living out in the past. It is helpful to bring their parents in for sessions along this journey, to assist them in understanding, bring comfort and support, allay anxieties and fears, and develop a shared knowledge of what was and what is to become, as their child fashions a new identity.

Meaning, purpose, satisfaction, and happiness are newly discovered through self-knowledge and a greater understanding of their place and potential in the world. These overly-perfectionistic young adults learn how to play, and to love aspects of themselves unrelated to performance and stardom. Their ride, and for those that ride along with them, is filled with potholes, and unexpected twists and turns. With patient and persistent hard work they eventually launch themselves – this time with an aim that is true.

“Once upon a time there was a man named Narcissus who came across a deep pool in a forest from which he took a drink. As he did, he saw his reflection for the first time in his life, and fell in love with the beautiful boy who was staring back at him. Realizing that he could not kiss or hold his own image, (only the water), he pines, withers away, and dies.” (From Greek Mythology)

Much has been written about the Narcissistic Personality in the last 30 years in the psychoanalytic literature and in popular psychology. There are important lessons that can be gleaned from this research in how to identify the Narcissist in love and at work…such that you can avoid unnecessary pain in relationships with Narcissists… as they inevitably result in breached commitments, dishonored contracts, and broken hearts.

What are some of the hallmarks of the Narcissistic personality? First and foremost is excessive self absorption. The Narcissist is rarely, if ever, truly interested in others. He or she may go on at length about themselves, but rarely demonstrate a meaningful interest in you.

Second, Narcissists are incapable of true empathy. They may be able to feign empathy because they are intelligent enough to have learned the concept of empathy, and may use it as a technique to manipulate others and win people over. But true empathy requires compassion and understanding – capacities that the Narcissist sorely lacks. When he or she attempts empathy, it has a shallow quality that will not resonate within you emotionally, and will lack a feeling of emotional connection. Genuine empathy is felt as a deep emotional resonance within your heart that comes along with a caring emotional connection with another human being.

Third, the Narcissist is only interested in his or her own happiness, and you exist only to make them happy. A Narcissist attends to your happiness only when it can bring them something they desire or covet – whether it is showing you off to others, getting you into bed, or manipulating some favor. It is all about boosting their self esteem and sense of self by fulfilling their needs. In contrast, someone capable of mature love is concerned about his or her own happiness, but is also genuinely committed to helping you find happiness in your own life.

The Narcissist may be extremely attractive, charming, interesting, fun and exciting for quite some time in the early phase of a relationship. They may sweet talk you – saying how important you are to them and how much they need you in their life. However, the Narcissist can “talk-the-talk” but cannot “walk-the -walk.” Count on the Narcissist to bolt when reality, ambivalence, or conflict that isn’t resolved in their favor start to enter the relationship. “Bolting” may take place at an emotional level where they withdraw from you into self-absorbtion, or it may involve their ending the relationship to move onto the next object of their Narcissistic pleasure. When the inevitable conflicts arise in a real relationship, count on the Narcissist to focus on your flaws and the various ways you don’t satisfy them, as opposed to working toward an understanding your point of view, as well as expressing their own, to enable a win-win resolution of conflicts.

The Narcissist can outwardly radiate a great aura of confidence and competence that may be beguiling. At times this personality trait may be expressed as arrogance. This posturing often masks deep feelings of insecurity, inadequacy, and unmet dependency needs that are threatening and frightening to them at an unconscious level. The Narcissist may jealously and possessively attempt to control you, or alternatively remain at an emotional distance, as a result of his or her unresolved dependency needs, which threaten the development of true intimacy. Thus a relationship with a Narcissist can feel like a very lonely place, even while being physically together and participating in an active social life.

Not all narcissism is bad. “Healthy Narcissism” is a positive trait that brings along with it positive self-regard and self-esteem; an appreciation of one’s strengths and capabilities; the confidence to explore the world, adult relationships, and one’s own inner life; the ability to ensure that one’s own needs are met in a relationship, along with a keen interest in meeting the needs of one’s partner, and a willingness to compromise to achieve mutual happiness; and a rock-solid set of principles and virtues that are not shaken or influenced by external pressures. If one has healthy narcissism and finds themselves becoming involved with a Narcissist, they typically have the inner strength to break away and move on, even if it means bearing the feelings of loneliness, and living alone.

Many adults repeatedly become engaged with Narcissistic Personalities. Due to unconscious forces, lack of self esteem, a repetition of earlier formative relationships, and a compulsion to repeat self-sabotaging behaviors, they seek out love relationships (and enter business relationships) that from the beginning are destined to bring heartache and failure.

“Knowing Yourself is the Beginning of All Wisdom.” Many clients first come in for psychotherapy in the midst of a crisis, or when they have recognized a pattern in their lives where they have been involved in a series of relationships that don’t work out, and where they feel chronically unhappy. We come to learn in the course of therapy that they repeatedly choose Narcissists as lovers and companions. We also uncover the sources of their low self-esteem that serve to perpetuate this pattern. Through psychotherapy, the unconscious determinants and propagators of this pattern can be identified and resolved, and healthy narcissism can be nurtured and strengthened. Through the process of therapy one makes healthier choices – seeking out and finding true partners who provide mature love, an emotional connection, empathy, support, and a durable love. Successful therapy helps to ensure that future relationships do not wither away and die, but remain alive and vibrant.

In television, movies, and books, consumers are frequently presented with an image of love that is passionate, blissful, and all-encompassing. Characters such as Wesley and Buttercup in the movie The Princess Bride, and Edward and Bella in the movie Twilight, exhibit undying devotion and affection which sustains them through every hardship they encounter. These movies, and others in this genre in which we have been immersed since childhood, present an idealized view of a love relationship, which may cause us to develop unrealistic expectations for the love relationships in our own lives. To have a successful romantic relationship, one must first understand the components of a REAL love life, as opposed to a fantasy.

A romantic relationship may evolve through three phases – the first phase is what we might call the “romanticized phase,” or “phase of idealization.” This is where you feel enraptured and incredibly excited about the other person. You think about them almost all of the time, there are frequent calls and/or text messages, and you feel that they are the greatest thing that has ever happened to you. Feeling as if you are on Cloud 9 can last as little as a night or two, or as much as several months. However, it is important to note that this romanticized phase will always end. (This does not necessarily mean the end of romance in the relationship, which is different).

The second phase is what we might call the beginning of the “reality phase.” This phase begins when you are still having fun together and are attracted to each other, yet you begin to notice the flaws in the other person, or they comment upon flaws in you. You begin to feel disappointed in a variety of ways. They may let you down or make you angry…or you may feel neglected or poorly treated. Some of this may be normal disillusionment and expectable in a real relationship. At other times it may be that the person is too self-absorbed and narcissistic to be able to truly satisfy your basic needs. (Look for a subsequent blog on “The Narcissist”).The beginning of the reality phase of a romantic relationship can be a difficult phase to negotiate, and for this reason many romantic relationships end here.

However, there is hope for conquering this phase. It is important that you talk with your romantic interest about some of your feelings and concerns, and listen to theirs. Do you try to resolve conflicts together? Are you willing to compromise? It is important to get good at talking, listening, and finding a middle ground, with a willingness to make some changes. Intimacy and commitment can feel scary, and make you or your partner want to run away from the relationship, but those feelings can be talked through as opposed to acted upon. Past deep disappointments in love, significant unresolved losses of a loved one, parental divorce, or growing up in a family where the relationships were characterized by emotional distance, can all result in fears of a close and lasting commitment. If you have persisting fears of intimacy that interfere with your love life, or you repeatedly end promising relationships before they can mature, then these issues can be addressed and resolved in psychotherapy . The therapeutic process can assist you in moving on into a healthier and more satisfying relationship.

At this point you may be thinking, “This sounds too complicated. Is there anything I can do to prevent this phase and continue the romanticized phase?” Unfortunately, there is no way to prevent the reality phase from emerging. However, take comfort in the fact that YOU get to decide whether your partner’s traits are satisfying enough to continue on. It is important to recognize that without self- reflection on the part of your partner, independently or through psychotherapy, their negative traits will persist over time. If they frequently disappoint or make you feel inadequate – such that you never develop a comfortable contentment – you may choose to end the relationship.

In the alternative, if you feel that you can fully accept your partner’s flaws, and that the good attributes outweigh the bad, then you may feel willing to continue. Ultimately, if you can each accept each other for who you are, within the context of working on the relationship to bring greater satisfaction, then the bond can develop into a real and durable one.

Sometimes your romantic interest decides to end the relationship. This may elicit feelings of self-doubt, or fears that you are flawed and not good enough. You may question whether you should have behaved differently. Feelings of confusion may arise if you and your partner had seemingly enjoyed your time together both emotionally and physically. There are no simple answers to these questions. Perhaps you chose someone with significant narcissistic problems, who is incapable of mature love. Alternatively, perhaps your own fears of intimacy, excessive emotional dependency, rushing the relationship, or holding back emotionally or physically may have contributed to the demise of the relationship. Sometimes these patterns of thinking, feeling and behaving are unconscious and result from earlier dysfunctional love relationships in your life, and can be addressed and resolved in psychotherapy.

The third phase of a romantic relationship is what we might call the “durable real” phase. Here, you have a wide range of feelings toward that other person. At times you feel love, affection, and sexual excitement. You really enjoy being with them and can’t wait to see them. At other times you may feel furious, and want out. You may feel relatively neutral at times, and just experience your partner as a companion. At other times you may feel ambivalent, as your partner can meet some of your needs, but not others. These conflicting feelings and impulses are the hallmark of a REAL relationship. If you work hard to keep the relationship alive, and motivate yourself to understand your partner; prioritize their happiness in addition to your own, and genuinely try to please them; then it’s possible to build a life together of passion, trust, and devotion. To develop and maintain an adult love relationship, it is essential to align your thoughts and expectations toward what is possible and real (as opposed to fantasized).

At times even a satisfying, mature love relationship can fall into crisis, manifested by stagnation or intense and persistent conflict. Prior repressed emotional traumas, upsetting life events , and aging and health concerns can all serve to undermine what had been very satisfying. Here again individual and/or couple’s therapy can make a significant difference in bringing about understanding that will “unstick” the relationship, provide a tangible pathway toward improvement, and restore the prior feelings of satisfaction and an intimate bond.