ask dr-robert

Dear Dr. Robert,

To begin with, I should probably explain myself, even though this is about a friend. I am in high school. I am, according to others, smart. My grades are mostly B's simply because I am too lazy to do anything other than show up and complete the tests. I was recently diagnosed with depression and put on medication by a psychiatrist. I try to be very open-minded. I don't have a problem with anyone's opinions, and I allow their opinions to influence me, but not much. I make my own decisions and come up with my own ideas based on what I know. I suppose this is one of those situations where I don't know much.

I have this friend. I would say she is very smart. However, unlike me, she works to get the best grades in the class. There has always been something about her that annoyed me. We could never really get along just right. After not talking to her for awhile, I decided I was ready to try and be rational about the whole thing again. So I emailed her. We have this weird thing going on. All our emails are like mini-novels. Each one fills my inbox up about one percent. They're all about what we believe in, and our friendship, and our "problems".

My friend thinks she has a mental disorder. The first time this came up was when she told me she heard voices. It was right after her sister came home from college because she was anorexic. She told me they were getting worse, and that they made her do stuff. She gave them names. She told me mostly about the evil one. She told me it wanted her to stop eating like her sister. She told me she was scared that she'd listen to the voice again. Then randomly throughout the night, she'd just tell me not to let her go anywhere, because the voices were telling her to do evil things.

At first she said she thought she had multiple personality disorder (this is now called dissociative identity disorder? maybe?). She said that she looked it up and it said it was caused by extreme trauma as a child, and that this trauma may not be remembered. She then decided she must have experienced some traumatic event and forgot about it.

Later, she found out about me cutting. A day later, she kept making a big deal out of the voices now telling her to cut. It's not like I put the idea in her mind. She has plenty of friends who cut. I'm just the only one who knows about the "voices".

Then, she kind of left the voices alone for awhile. We started talking about how I had depression according to all my counselors and people like that. Then, a couple days later, she was scared that she was depressed. She kept talking about how her dad has some form of depression (I don't know what it's called. She doesn't either. I think it may be something that starts with a D. It's like major depressive disorder or whatever it's called, but it doesn't count as an episode), and how she was scared that she was developing it too. She told me about how her dad is "sometimes depressed", as in he takes the medication every so often whenever he feels depressed, but doesn't have a major depressive episode. So then she was talking about how she said she felt like she was getting it too. Like how you can sometimes tell when you're going to get a cold because of the stuffed up nose the day before. I didn't really understand that, but I'm not her. I know I didn't think I was going to get depressed. I didn't even realize I was until people told me I was, and there wasn't really any warning or even a situation I can think of that triggered it. Apparently some grandparent or great-grandparent had depression, so they think I may have just randomly had it in my genes. And my mom has pmdd or something like that. (Sorry if this is getting kind of long).

Well, I told my friend I wasn't sure if she had depression, and I couldn't be anyway because I didn't go to school and study it. So she asked me to tell her the symptoms. And she asked what medication I was on. I told her the medication and she went to the website for it. There, she found an "Are You Depressed" test. She took it. She got very severe depression for her results. She told me to take it. I got severe. I was actually honest on this one. When I was first kind of wondering if I really did have depression I took a similar test, and tried to convince myself that nothing was wrong with me, and lied on a few of the questions. I still got moderate depression even with my lying, so I gave up on that. But all the questions were about symptoms of depression. The next email I received from her was all this stuff that she'd never told me about how she wakes up at abnormal times and can't fall asleep after that, and how she sometime! es isn't hungry, and is tired all the time. Basically all the physical symptoms of depression in the test.

Somehow, she then decided she wasn't sure what mental disorder she might have. So I went to this site that describes the symptoms of mood disorders, personality disorders, etc. I took a few symptoms from each disorder and asked her if she was ever like that. She said yes to things like having an excessive and irrational fear of something, or feeling a need to have someone with her, or having nightmares. She answered no, or gave an unclear answer on questions that asked if she ever used people fro her own benefit, or if she thought she was special, or if she did violent things to people. I went back and looked after she answered (I didn't tell her why I was asking; I wanted her answers to not be based on her looking at a site, choosing a disorder she liked, and then answering accordingly) and she had enough symptoms to have pretty much every major disorder except schizophrenia (although if she does indeed have depression as she says she may, it could be schizoaffective), avoidant, and antisocial.

I'm a paranoid person. I don't trust anyone. However, even if I don't trust them, I like to try to give the benefit of the doubt. If she says she is lonely all the time, I will listen. So I tried to help her and figure out what disorder could potentially be the cause of her "problems". But even though I help, I don't know if I really and truly entirely believe what she is saying. I don't want to say that she's making it up. It's just that, with our new honesty policy, she tells me there is nothing more she loves than attention. (I'm kind of the opposite. I hate attention. I have way too much of it.). And she always comes into class with the exact same look of pain on her face. It is probably just me, but it always seemed to me like it was only real half the time. Like she was trying to get our sympathy or something. I don't know. I'm probably wrong. But she always complains of headaches, or being too cold, or "not feeling good". If one friend comes in upset because! e she broke up with her boyfriend, this friend always gets annoyed. Like someone is stealing her sympathy or something. It's kind of annoying. If I'm unhappy, even a little, and I let any of it show on my face, she immediately gets all pouty and does that thing where she stares downwards while talking. This is kind of hard for me, because I am depressed, and sometimes I'm unhappy because of that. So I have to be careful not to let it show.

I don't know. I don't want to think that she's faking any of this. I'd like to believe her and try to get her help for her "disorder" (whatever it may be), but I don't think I entirely believe her. It just seems like a bit much of a coincidence how her level of happiness corresponds with other people's. Like her randomly getting "anorexic" for a day or two when her sister came back. She did admit to being a little jealous of her sister for getting attention for it, but said she'd never try to get attention in such a negative way, because she is better than that. But she's better than everything. Or at least it seems that way. She's always been considered by friends to be almost perfect.

She always writes about how her parents make her feel terrible and depressed. I told her they're supposed to do that. We're teenagers, and they're parents. She gets all upset and sad when her parents say she should improve her grades because she had a B on her report card. She said ! she was more upset about her bad grade than anyone else was about their bad grades. I mean, they're parents. Aren't they supposed to do that? My mom is loud and seems angry all the time, and the sound of her voice makes me shiver, but isn't she supposed to be like that? She's a parent. She has a right to try and control my life. She did create me, after all. Her only mistake was letting me take over some of it.

But now that I have sufficiently wasted a large portion of your time (assuming anyone would even bother to read this far), the main point. Am I justified in thinking she may be faking some of this? Or am I just being my usual excessively paranoid self? Does she need help? If I told someone about her symptoms she says she has, and that she thinks she's depressed, would this help her? She thinks she would benefit from being on some sort of medication, but claims she doesn't want to be on them because she wants to be independent. (I kind of want to know how that fits in with her answer to a question saying that she is very dependent). Is there something wrong with my thinking, or hers, or am totally wasting my time writing this all down? I don't want to deny that she has a disorder, but I'm not totally believing it, and I guess I just need someone else's opinion before I go and do the obvious thing and tell the guidance counselor about her and the voices and feeling depressed and stuff.

From,

A person who despises signing anything with her own name



dr-robert

Thank you for writing. Your letter, which purports to be about helping your friend, really seems to me to be much more about finding the help know you need, and apparently are not getting. Your very first words, "To begin with, I should probably explain myself," suggest this quite clearly. In fact, I read your letter as a cry for help to which I will attempt, given the obvious limitations of this email protocol (we have not met, and there is much about you I do not know), to respond. But first, a word about your friend.

I cannot, without a personal interview, diagnose your friend, but everything you have written about her is suggestive of serious disorder, including, perhaps, the onset of schizophrenia, which requires, as you know, immediate evaluation. Hearing "voices" is a major red-flag which simply must not be ignored. Yes, your friend may be malingering or feigning illness as an attempt to attract attention or sympathy, but that kind of behavior calls out for treatment anyway, so in any case your friend needs help. As a practical matter, I cannot say at a distance if reporting her condition to a school official is the best way to go or not. Perhaps it would be better to begin by speaking seriously with her--not from a diagnostic point of view, but simply by telling her that you are concerned about her and that you believe she should speak with an expert about her inner life. This is something you will have to determine for yourself, but your friend seems to be in a dangerous condition, and, as her friend, you are correct in your feeling that you ought to try to help her. You seem bright enough and aware enough of mental health issues to puzzle this out somehow. If you cannot come up with anything which seems better, then by all means speak to the school counselor, since anything would be better than simply ignoring your friend's distress.

Now, to your situation. You say that you have been diagnosed with depression and prescribed medication by a psychiatrist. But is that the extent of your treatment? If so, your psychiatrist is, in my opinion, guilty of malpractice, since, given what you have written to me, you are in urgent need of much more than simply a prescription for some pills. I suggest, and in fact urge you to seek the best psychotherapist you can find, and get into treatment immediately.

I have written elsewhere, but will repeat here, that medication alone is not a sufficient approach to treating depression. Medication, if it is indicated, must always be accompanied by competent psychotherapy of some kind or other, and the first step in treating depression is not handing the patient a prescription, but rather the establishment of a positive therapeutic relationship between therapist and patient in the context of which the patient can reveal safely the kinds of things your letter touches upon. In years past, psychiatrists routinely established that kind of relationship with their patients, but now that antidepressant medications have become relatively safe, effective, and available, many psychiatrists have been converted into little more than pill pushing machines who do not treat people, but only symptoms. This is profitable for the psychiatrists, since it allows them to see and charge several patients per hour instead of only one, and also it relieves them of the "burden" of having to share in detail the suffering of another human being, which is something that many of these cold fishes are not willing to do. Of course, not all psychiatrists have fallen into this sad state--in fact, there are some wise and kind people still practicing that profession in the more holistic manner--but in my experience, many psychiatrists in the twenty-first century are people who either have succumbed to greed, or else simply are not capable of offering any help beyond symptomatic relief via drugs. I hope your psychiatrist is not one of these, but I suspect that he or she may be, since, as I said, you clearly have not been receiving the kind of help you most urgently require.

Without meeting and getting to know you personally, I will not discuss in full detail why I feel so strongly that you are in trouble and require expert help, but I will touch on two points, and leave it to your obvious intelligence to understand and do something about your situation. In the first place, your reference to "cutting," is extremely worrisome, particularly since you state it in a tone which seems intended almost to normalize that behavior. Self-injurious behaviors, such as taking a razor blade to your own body may serve many purposes in the psychic economy--expressing anger which one is afraid to manifest openly; escaping from emptiness, depression, or feelings of numbness or unreality; preventing suicide; expressing or repressing sexuality; continuing abusive patterns from earlier childhood; attempting to remind oneself of physical reality as a way of dealing with feelings of depersonalization and dissociation; establishing a feeling of uniqueness or of being somehow special; etc.--but in your case, again without really knowing you, I suspect that self-injury is a way of being "in control", in other words, an attempt to deal with an internal sense of powerlessness, helplessness and anger. I make this assumption, which is admittedly a bit of a leap, based on what you wrote about your mother:

"My mom is loud and seems angry all the time, and the sound of her voice makes me shiver, but isn't she supposed to be like that? She's a parent. She has a right to try and control my life. She did create me, after all." 

You seem to be saying here that parents have a obligation to frighten and dominate their children. Do you really believe that? If so, I can understand why you would find relief in self-injury, which would allow you to convert your psychological pain into physical pain that might seem more understandable and controllable. Perhaps you also use cutting as a form of self-medication since physical injury promotes the release of endorphin hormones which can counteract anxiety and depression. Further, you may feel that by "taking control" of your own body in this way, you are thereby establishing a boundary between your self--both contained in and symbolized by your physical body which you, and only you, are permitted to harm--and your mother, who may be able to "cut" you with words, but may not cut you physically, since only you have that right.

If you were my patient, we would take time to explore these feelings and particularly the profound philosophical misunderstanding which seems to underlie them--all the time you would need, in fact, to come to your own awareness of that misunderstanding--but here I do not have that luxury, so I will simply state it:

Your mother did not "create" you. Your mother had sex with someone, one of the eggs in her uterus (which egg she also did not create) was fertilized, a fetus developed, and later, sometime after the birth of that fetus, awareness came to feel that that particular body was "you." Your mother did nothing to create "you" except to do what most people do--act out their sexuality for their own purposes, motives, and satisfactions.

Personally, I do not imagine that any of us was "created," but rather that each of us simply arose in the world, or, it might be better to say arose out of the world, in the same natural way that all the other aspects of this world arise: fish from the sea, roses from a rose bush, etc. Who was the rose's creator, after all?

To me, it feels important that you understand this point. If you imagine that your mother created you, in the way a painter creates a canvas or a potter a pot, you are ascribing to her far too much control, and even ownership, over your life. It is getting to be time for you to grow up and take control of your own situation. I recommend that you begin to reduce your emotional enmeshment with your mother--I say "enmeshment" because your mother's voice is not just unpleasant to you, but can make you shiver, as you wrote--by getting the therapeutic assistance you need to establish proper boundaries between you and her. Then, I think you will not need to "cut."

A second point which suggests to me that you need therapeutic help is your obvious fascination with mental illness. Apparently you have familiarized yourself with the names and diagnostic criteria for various ailments, and your approach, not just to yourself but also to your friend, is frankly diagnostic, almost as if you were her psychiatrist. (By the way, since you like this stuff, the word you were looking for in regard to her father is "dysthymia").

As an intellectual exercise, there is nothing wrong with learning and wanting to understand some of these matters, but the tone of your letter suggests to me that your interest is not at all intellectual, but rather an attempt at self-diagnosis and self-understanding. Both the tone and the content of your letter which you chose to send to me, a depth psychotherapist, suggest that you suspect your problems involve more than just depression, and that you are searching for a proper diagnosis as a way of trying to deal with your problems. It would be wrong of me to offer a diagnosis based only on your letter, and I will not do so, but I will say that getting a real diagnosis, which I believe will involve more than just depression, and finding real and effective treatment, which will certainly require more than just medication, is a good idea, and most definitely not a do-it-yourself project.

I hope this helps, and I wish you well.

Be well.