Category Archives: Therapy

May 25

Malingering: Faked Psychiatric Conditions

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Malingering involves the intentional production or display of false or grossly exaggerated physical or psychological symptoms, with the goal of receiving a specific benefit or reward such as money, an insurance settlement, disability status, evasion of legal consequences or release from incarceration, or avoidance of work, jury duty, the military, or other types of service. Psychologytoday.com

Some cases of malingering are relatively easy to detect, but some can be especially tricky for mental health professionals (and/or physicians) to identify. Such cases of malingering can lead to abuse of the system, with unnecessary tests and interviews being performed and time taken away from other clients and patients.

Malingering is a condition not listed in the DSM-5. However, “It is similar to, but distinct from, factitious disorder, in which an individual fakes symptoms of physical or mental illness but without a concrete motive or expectation of reward. Malingering is also distinct from somatic symptom disorder, in which someone experiences actual psychological distress due to imagined or exaggerated symptoms” (psychologytoday.com).

It may go without saying that individuals who do have ulterior motives for showing up at your therapy door don’t really want or need your help of the therapy kind; what they want is to manipulate you so that they get something else—something they presumably feel they can’t get otherwise.

A couple examples from pop culture: 1) Corporal Max Klinger (actor Jamie Farr) on the old TV show M*A*S*H (1972-83). His plan for getting out of the Army involved trying to prove that he was psychologically unfit. He couldn’t achieve his goal, though, and eventually gave up.

2) Liz Lemon, played by Tina Fey on the more recent TV sitcom 30 Rock. Her goal was to escape jury duty. See below:

A malingerer presenting at a mental health setting could also be driven by such motives as getting out of work, obtaining disability insurance, and seeking drugs.

Reportedly, research has shown, though, that a person who fakes symptoms of mental illness can actually start to believe the illness is real (Scientific American). Put into action, this means Klinger would start to really believe, for example, that he can fly (in his pink bathrobe and slippers), while Liz Lemon would settle into the delusion that she’s a Star Wars character.

On a more positive note, psychologist Elizabeth Loftus is quoted in the above-cited article as envisioning “therapeutic potential in the new study”…

…musing on a hypothetical strategy she calls ‘feigning good,’ which could motivate patients by helping them believe in improved cognitive skills and diminished symptoms of illness. ‘Should clinicians be prescribing a form of feigning? You wouldn’t want patients to feign anxiety, but maybe they could feign the opposite. Maybe they could feign crystal clear concentration.’

May 04

“Can’t Just Stop” All Kinds of Compulsions

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While extreme compulsions often appear odd, irrational, pitiable and self-destructive, our emerging understanding of compulsions implies something quite different: Even the craziest-looking compulsions are adaptive, even pragmatic, and all too human. A compulsion is at once psychological balm and curse, surface madness (or at least eccentricity) and profound relief. Sharon Begley, author of Can’t Just Stop (Wall Street Journal)

Behaviors such as OCD, hoarding, exercise, shopping, video-gaming, hyper-conscientiousness, and even hyper-do-gooding—which can all be responses to anxiety—are examined in Can’t Just Stop: An Investigation of Compulsions by science journalist Sharon Begley (1956-2021).

Compulsions “are repetitive behaviors that we engage in repeatedly to alleviate the angst brought on by the possibility of harmful consequences,” states Begley. Examples of compulsions of varying levels of severity are offered (Wall Street Journal):

There’s the woman who hit the treadmill so compulsively that she could do little else—and all because, every moment that she wasn’t exercising, the thought of fat cells proliferating in her body drove her nearly mad with anxiety. There’s the actor who was so certain he suffered from a dire illness that he compulsively pressed his doctors to give him CT scans, over and over, to assuage his angst. And there are the millions of us who feel compelled to check our phones before we get out of bed in the morning and constantly throughout the day, because FOMO—the fear of missing out—fills us with so much anxiety that it feels like fire ants swarming every neuron in our brain.

Publishers Weekly notes that Begley’s research and writing “demystifies compulsive behavior, exploring its history and manifestations and the many difficulties its sufferers face in finding appropriate diagnoses and treatment.”

Selected Quotes from Can’t Just Stop

The saddest thing I came to understand in researching and reporting this book is that so many of our behaviors draw us into them not because they bring joy but because they promise to quiet anxiety. But the most heartening thing was the realization that the ability of compulsive behaviors to quiet anxieties great and small is one of the greatest gifts our brains can give us.

For compulsions, according to a growing body of scientific evidence, are a response to anxiety. Suffused and overwhelmed by anxiety, we grab hold of any behavior that offers relief by providing even an illusion of control.

We cling to compulsions as if to a lifeline, for it is only by engaging in compulsions that we can drain enough of our anxiety to function.

Selected Reviews of Can’t Just Stop

Joel Gold, MD: “At once fascinating and compassionate, funny and informative, this volume should be on the bookshelf of every psychiatrist, and on the nightstand of anyone who enjoys absorbing and incisive writing.”

Gary Greenberg, therapist and author: “Sharon Begley has done us all a service, writing about compulsion without writing about disease and offering a new perspective on a phenomenon that is common if not universal. People troubled by their own compulsive behavior will appreciate her nuanced and balanced approach and perhaps come away with a new understanding of themselves.”

Publishers Weekly: “Begley’s final chapter on brain function in the compulsive mind contains fresh insight that could fundamentally alter how we think of, and treat, mental illness going forward.”

Mar 30

Introversion: A Summary of Helpful Resources

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Although Susan Cain‘s Quiet (2012) may be the best known of the introversion resources/books, the following are some additional suggestions.

I. Books on Introversion

The Myers-Briggs Type Indicator (MBTI) can only be administered by certified practitioners, but a book by David Keirsey, Please Understand Me II: Temperament, Character, Intelligence (1998), offers a quick test, the Keirsey Temperament Sorter, that gives results similar to the MBTI. Keirsey gives detailed descriptions of each of the 16 types. Introversion is one of the key traits analyzed.

Additional books:

II. Article on Introversion

Possibly my favorite resource is an article by Jonathan Rauch entitled “Caring For Your Introvert: The Habits and Needs of a Little-Understood Group” (The Atlantic), March 2003.

Although tongue-in-cheek, the many good points in this piece have resonated with tons of people since its publication. Some excerpts:

  • Introverts are not necessarily shy…Introverts are also not misanthropic, though some of us do go along with Sartre as far as to say ‘Hell is other people at breakfast.’ Rather, introverts are people who find other people tiring.
  • For introverts, to be alone with our thoughts is as restorative as sleeping, as nourishing as eating. Our motto: ‘I’m okay, you’re okay–in small doses.’
  • Extroverts have little or no grasp of introversion. They assume that company, especially their own, is always welcome.
  • The only thing a true introvert dislikes more than talking about himself is repeating himself.
  • We tend to think before talking, whereas extroverts tend to think by talking…
  • The worst of it is that extroverts have no idea of the torment they put us through. Sometimes, as we gasp for air amid the fog of their 98-percent-content-free talk, we wonder if extroverts even bother to listen to themselves.

Rauch’s concluding remarks offer a (naturally) cheeky response to the following question: How can I let the introvert in my life know that I support him and respect his choice?

First, recognize that it’s not a choice. It’s not a lifestyle. It’s an orientation.

Second, when you see an introvert lost in thought, don’t say, ‘What’s the matter?’ or ‘Are you all right?’

Third, don’t say anything else, either.

III. A Test to Measure Introversion and a Chart

Scott Barry Kaufman in Scientific American introduces a test that purports to measure four different aspects of introversion based on previous academic findings of Jennifer Odessa Grimes. Go to the above-linked article and scroll down to “What Kind of Introvert Are You?” to take the test.

When you score your results you’ll have a number for each type. It’s not about the highest score being your type—rather, each score indicates how much of that type is part of your introversion.

For a quick read, go to this popular Huffington Post article by Lindsay Holmes, who provides an illustrated chart, “Dr. Carmella’s Guide to Understanding the Introverted,” by artist Roman Jones.

Mar 23

“What My Bones Know”: Complex-PTSD Memoir

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The widely acclaimed new book by Stephanie Foo, What My Bones Know: A Memoir of Healing from Complex Trauma, is bound to educate many about a type of PTSD we don’t often hear about—C-PTSD (complex PTSD). It can occur when trauma is repeated and prolonged.

Sarah McCammon, NPR, introduces Foo:

Stephanie Foo grew up in California, the only child of immigrants who abused her for years and then abandoned her as a teenager. As an adult, Foo seemed to thrive. She graduated from college, landed a job at ‘This American Life,’ became an award-winning radio producer, was dating a lovely man, but she was also struggling. Years of trauma and violent abuse as a child had left her with a diagnosis – complex PTSD, a little-studied condition that Foo was determined to understand.

C-PTSD, however, is not to be found in the DSM (Diagnostic and Statistical Manual of Mental Disorders). This, despite its widespread recognition among trauma experts since psychiatrist Judith Herman coined the term back in 1988.

And unfortunately, many of Foo’s initial treatment experiences weren’t too helpful. And her efforts were wide-ranging; they included EMDR, microdosing and megadosing (acid, psilocybin), a support group, meditation, yoga, and acupuncture.

Foo then heard a podcast that featured a therapist who compared complex PTSD to the Incredible Hulk (NPR interview): “Because the Incredible Hulk was actually abused as a kid. His father was an alcoholic, and now he had a hard time controlling his emotions when he was angry. He would sort of literally not be able to speak well, and he would just focus on surviving. And that is exactly what having complex PTSD is like. But the Hulk is not a villain. The Hulk is a hero.”

She eventually chose him as her own shrink. Although this has certainly been helpful, her course of treatment is about management, not cure—as is the case with most chronic conditions. As Foo told NPR:

…I don’t think that you ever totally heal from complex PTSD. It’s sort of something that you carry with you all the time. But I feel like if the burden, the weight of complex PTSD, is like a pack on my back, then the process of healing has made me stronger. Does that mean, of course, that sometimes the pack gets really, really heavy and I need to sit down and take a break and cry a little bit and figure some new stuff out? Of course. Of course. That’s what life is. But now I feel like I can hold the sadness and the anger and the joy all together.

Selected Reviews of What My Bones Know

Publishers Weekly: “What takes this brilliant work from a personal story to a cultural touch point is the way Foo situates her experiences into a larger conversation about intergenerational trauma, immigration, and the mind-body connection…This is a work of immense beauty.”

Kirkus Reviews: “As Foo sheds necessary light on the little-discussed topic of C-PTSD, she holds out the hope that while ‘healing is never final…along with the losses are the triumphs’ that can positively transform a traumatized life.”

Kathleen Hanna: “This book is a major step forward in the study of trauma. It’s also a huge artistic genre-busting achievement. Stephanie Foo’s brilliant storytelling and strong, funny, relatable voice makes complex PTSD enjoyable to read about.”

Nov 17

“The Shrink Next Door”: Wrong Therapist

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When it comes to finding the wrong therapist, there’s “wrong” as in not the best match, and then there’s “wrong” as in unethical and/or criminal behavior on the part of the shrink. It’s the latter that is the theme of the new fact-based Apple TV+ mini-series The Shrink Next Door starring Paul Rudd as Dr. Isaac (Ike) Herschkopf and Will Ferrell as Marty Markowitz, the client who had the misfortune in real life of choosing this psychiatrist. Despite the comedic talents of these stars, this is not really a comedy but a tragicomedy.

Another key character is Marty’s sister Phyllis (Kathryn Hahn), who’s apparently responsible for encouraging Marty to seek therapy but who then becomes estranged from Marty because of Dr. Ike’s control.

The Truth Behind The Shrink Next Door

Herschkopf, per Dave Itzkoff, New York Times, was ultimately “ordered in April to surrender his license to practice in New York after a committee convened by the State Health Department found him guilty of multiple professional violations” against not only Markowitz but others too.

How bad was it from Markowitz’s point of view? Kai Green, Parade, reports that he told the New York Post a couple years ago that he’d felt like he was in a cult. “He took over my life very quickly…It was one ethical violation after another.”

Markowitz had no reason to suspect Dr. Ike would be like this; he was well-known on the Upper West Side of Manhattan, counting Gwyneth Paltrow and Courtney Love as two of his clients. Paltrow even attended a party at Markowitz’s home, reportedly. The story came to light when Bloomberg columnist Joe Nocera moved to the Hamptons and was invited to a barbecue at the house next door by someone who he thought was the gardener. Meeting the host, ‘Dr. Ike,’ Nocera was invited back for another get-together, where the good doctor insisted on having a picture of Nocera to add to his pictures of celebrities like Brooke Shields and OJ Simpson. However, Nocera ultimately discovered that the man he thought was the gardener, Martin Markowitz, was the actual homeowner—even though Dr. Ike acted like he owned the place. And that’s just the beginning of the shocking truths Nocera ultimately came to learn about the ‘shrink next door.’

Nocera went on to do a podcast about this true story. Additional information about Markowitz’s case has been reported by Debra Nussbaum Cohen, Forward.com:

New York State’s Department of Health, in its decision, found 16 specifications of professional misconduct – from fraudulence to gross negligence and gross incompetence as well as exercising undue influence and moral unfitness. The decision was based on records and testimony from three of Herschkopf’s patients. Markowitz is ‘Patient A…’

Markowitz says that he is ‘much happier now’ than when he was under Herschkopf’s care. ‘It’s my 40-year ordeal. It was 29 years under his power and 11 years seeking justice. I finally got it.’ What matters most is that ‘I got justice. That’s what I wanted.’

The TV Series

Kristen Baldwin, ew.com, describes the essence of Dr. Ike’s destructive actions:

Using manipulation, mind games, and precision-guided guilt, Dr. Ike inveigles his way into his patient’s business affairs, and even his grand summer home in the Hamptons…At first, therapy seems to do Marty some good, as Dr. Ike encourages him to ‘grab the reins’ to his life and stop living in fear of conflict. But it’s all in service of a larger plan: Herschkopf operates like a one-man cult, slowly alienating Marty from Phyllis, his loyal employees, and anyone else who suggests that the shrink’s methods are suspect.

Dave Nemetz, tvline.com: “It’s almost like What About Bob? in reverse, with the therapist becoming attached to his patient like a parasite.” (See my previous posts about What About Bob? here and here.)

Watch the trailer below:

A second trailer reveals more about Marty and his sister’s rift: