Too Much Self Esteem

• Manic Traits: An EP/SB Description by James Brody, 4/5/97
  
  

The following essay has a "let's pretend" quality, that risperidone has one or two known actions and that it's useful to put rejection sensitivity and grandiosity on the same continuum. The former is certainly not true and is an old problem in psychopharmacology. The latter rings true for the moment but certainly may not be accurate or helpful. Nonetheless, the material below seems more real than real for the moment. Comments are welcome.

Peter Kramer (1993) wrote that once you are aware of rejection sensitivity, you see it everywhere. The same is true of its inverse, the other end of the continuum, whether you call it grandiosity or rejection insensitivity. Rejection sensitivity, perhaps originally defined by Don Klein, can be summarized by a sense that you don't fit in, that you are somehow inferior, or left out of social events. You see yourself as the bottom of the hierarchy and consequently, tend to be inhibited or easily embarrassed. RS is thought to respond specifically and powerfully to manipulations that increase availability of serotonin at CNS receptors.

The common, unspoken assumption is that the SSRIs (that increase serotonin availability) act to restore a deficiency to a normal condition. There is little thought of a overload situation and the behavioral consequences of it. Some of this practice may be due to the CNS adjusting (perhaps through down regulation of receptor sites, too much serotonin eventually leads to there being fewer receptors for it) to the richer supply so that any behavior changes are transient and less destructive.

Perhaps because of genetic variability and correlated neurochemical differences between people, some of us show a more enduring shift, become less sensitive than normal to reactions from others in our lives. Thus, we seem less guilty, less inhibited, more manipulative, and more grandiose, acting as if consequences and sanctions are suspended for our benefit. Grandiosity can be associated with spending beyond our means, insisting on our wishes while ignoring those of other people, and becoming angry, manipulative, or forceful when our demands are slighted. It likely underpins the thoughts and actions of old guys who, pursuing young females, feel themselves exempt from Symons-Buss guidelines and expect to be loved rather than assayed.

Clinical focus on mania typically is on heightened activity level, impulsiveness, and perhaps mood shifts. While mania is often characterized by a more rapid motor and speech pattern, impulsive actions, reduced need for sleep, and hypersexuality, grandiosity is a core feature. John Pearce once commented to me that "Risperidone is a pretty good antimanic." Much of these effects are likely due to its presumed actions on dopamine (Gosh, I love causal chains with "maybe" at each of 12 steps!). The serotonin blocking action, however, is far more interesting in regard to grandiosity. Just as Prozac made it possible to change rejection sensitivity in a manner apart from other aspects of depression, risperidone has opened the door to our watching grandiosity. (1,2)

However, grandiosity is not the same as high activity although the two may often be positively correlated. Scanning for grandiosity is similar to rotating a polarized lens, new features become prominent, others blur. Some of the next examples are echoes from the African Savannah (or Danakil Isle) as a young rhesus prepares to move up a rung. (3) See my related posting, "Someone to watch over me" for examples of similar issues in preschoolers.

Mike, 9 yo, has a mix of ADHD and bipolar disorder. Although not suicidal, he ordered his parents about, displayed up to 3 hours of rage if mom (a nurturant Suomi type) delayed one of his requests for 10 minutes, insulted his teachers and other children, and locked his mind on moving from private to public school where he will have less supervision. Mom sometimes retaliated with threats of military school. Mike confidently retorted, "You would never do that to me." He was given TO on the outside deck (warm day); he climbed to the roof and back into his room through a window. He looked at his mother and announced, "I won." Like many such children, he was managed during the days with a substantial dose of Ritalin but became a despot in the evening when home with his parents. He also had difficulty getting to sleep, getting up, and was thin for his age.

A quarter mg. of risperidone twice a day cut his fidgeting (dopamine again!) and stopped his aggressive outbursts even on the first day. (4) He also ate a reasonable breakfast and lunch and went to bed on time and slept. On the second day, he got himself up on a Sunday morning and let his parents sleep while he made himself breakfast. He had promised over a week earlier to serve Mass for the priest; Mike walked the half mile to church and kept his promise. All of these things were "firsts" for him.

My explanation to Mike was that he did not take risperidone in order to make him behave or sit still, although he thought those goals were reasonable. Instead I spoke of his being a team player instead of telling his parents what to do and getting angry to make them comply. I also mentioned our need to count on his following directions and the hope that he would sample this new kind of teamwork while he took the medicine for 3-6 months. We would next reduce it to see if his new social relationships eliminated the need for medicine. He had no arguments; he seemed to understand. He will gain some pounds and his Ritalin can likely be reduced significantly in the oncoming weeks.

Aaron in his late teens was a graffiti specialist, sharing his art on local walls despite his being on probation and in dread of another residential confinement (grandiose people hate confinement). He also drove 110 MPH in his mom's car, with 4 friends, to various concerts and to clubs in Manhattan without parental knowledge. His older brother met full criteria for bipolar disorder. Aaron was stopped cold by 1.5 mg of risperidone. No more racing, no more graffiti and relatively more honest with his parents about his activity. He ran several stop signs but is paying his fines.

Sometimes tricky things happen. Aaron became obsessed with a former girl and increased his risperidone dose by a mg per day. Massive tears and guilt followed in regard to his past treatment of her as well as his treatment of his family. He expressed a need to settle down and to be part of a family, both feelings absolutely novel to him. He even insisted on a 2nd appointment that week with me just in case he needed it (which he didn't) There was no criticism of his fat sister (ordinarily a target for scorn).

He next stopped his risperidone cold and within a week was back to graffiti, scheming for money in order to get a fast car, going to clubs in several cities, and applying to several colleges despite his poor grades. He mocked fat women again and refused to walk to work for a "lousy $5.80 per hour." One segment of his mind saw the need for medication; another disliked it. He needed some more "therapeutic walls" to convince him that he is not immune from natural consequences. (Skipping medicine appears a common trait with mania; they sometimes interpret medicine as evidence of impairment. Life is also less fun if you're less impulsive.)

Charley was in his 60s. He was noted for dropping trash on the ground and not caring despite the presence of his wife and an audience of strangers. He had been in trouble with her for decades because of his arrogance and hostility as well as his similarity to her father. She had once evicted him from the house for a year but let him back home after he had major surgery. Their contract was that he would be respectful or be evicted again; Charley managed to stay just within the boundary while keeping her upset. He averaged 2 nights per month in a motel, booted from home because of rudeness and oppositional behavior.

He was confronted often for not caring and for inconsiderate behavior , for acting as if relationships did not count. He was known to be poor with partnerships. His rebuttal was that he had an automatic defense mechanism to avoid being hurt, thus, pretended to not care even though he did. She didn't particularly believe him, neither did I. (There will be long debates about whether when denial exists and when certain adaptations simply fail to work.)

He had two incidents of tantrums the week before starting risperidone; none afterwards.(5) After starting risperidone he seemed to stay with our conversations in therapy, even when his wife was critical. He didn't act baffled as in the past. His wife reported a series of small miracles. She went with him to a home center and shopped for building materials. His tolerance was usually 15 minutes; he lasted an hour. Further, he had a plan for making the cabinet and put the materials in their cart. However, he accepted her suggestion to check the Ready Built Department and bought one of the store models. She could not recall his ever doing this before. Charley typically made up his mind and ignored her opinion even if his way did not work. She felt "it was a pleasure" to shop with him that evening. She wanted a partner, not a puppy and not a defiant child.

Installation was another surprise. He measured the placement and asked her to check his measurements (totally novel!). She found a 1/2 inch mistake; he made the correction. His past routine was to ignore her contribution, stick to his measurements, discover his mistake after driving more than a few nails and screws, and abandon the project in disgust, leaving her with scraps, incomplete pieces, and sawdust.

On another evening, he fixed dinner, she complimented it. He remarked "of course it was good," and she retorted, "I taught you." He quietly agreed, "That's right" instead of arguing with her.

There are costs with risperidone, costs such as possible dystonias or parkinsonian reactions. Still, they are said to be smaller than with other neuroleptics and males, especially adolescent males, are thought to be more resistant to extrapyramidal effects than is true for older females. Two of these guys were on the verge of not having a place to live, the third was close to living someplace he did not want to be and the courts did not want to put him. The two younger ones may do well on depakote eventually or lithium. For the moment all of them and their families had a break from chronic manipulations, lying, and temper displays. While it was too early to assess the contrast in their conduct for stability, I still felt as if someone had given me (and their families) a bouquet.

It appears likely that we can separate grandiosity from other aspects of bipolar disorder. We can probably find it in some cases of conduct disorder and I suspect someone even now is studying the effects of risperidone on antisocial behavior. It seems paradoxical to seek a medication that may lower self-esteem and increase anxiety or guilt, even for the purpose of inducing social compliance, compliance for the goal of working effectively with other people. Mike, however, had no complaints about his medication (a sharp contrast to his opinions about Ritalin); likewise for Aaron and Charley. The three of them enjoyed feeling a part of their respective groups instead of their prior sense of alienation. If risperidone is a useful lead with respect to serotonin blockage at particular sites (it is not a general blocker but only affects a portion of the serotonin targets in the brain), then similar blockers might be effective but with less dopamine effect and perhaps less risk of extrapyramidal changes. We may be able to give more people the choice of being active but modest to complement our now hidden cadres of the quietly arrogant. (6,7)

NOTES & REFERENCES:

1) Possibly 1 mg of risperidone bid would have kept Kennedy (several of them), Bono, or Mary Jo alive.

2) Risperidone may be another tool that allows us to dissect existing diagnostic categories and reorganize them by chemical or by adaptive mechanisms (grandiosity, activity level, sexual interest, territoriality, aggression) rather than statistical commonalty.

3) The dominant rhesus in a group commonly raises his tail straight up like a battalion flag. I recall a photo of a rhesus monkey running with a pack of baboons, each 3-4 times his size. The rhesus had his tail up!

4) My suggestion to physicians is to start medication changes on Saturdays so that parents can observe their child rather than send him to school with a new medicine and with uncertain outcomes. I saw Mike for a few minutes on the first two days to check for dystonias and to train his mom in watching for them.

5) Older clients are often on many medications and supplements. It's can be difficult, for example, to separate his temper issues from Ritalin effects, from sugar changes associated with his diabetes, testosterone shifts from his patches, or fluctuations in his blood pressure medication. His wife also had him on a high protein diet for weight control. They agreed, however, that his temper and stubbornness were family traditions, seen in other members as well as existing in Charley well before he started various medical regimens. He began on a minimal dose of risperidone; the pharmacist do a computer check for negative interactions between risperidone and his other medications. Charley responded immediately and felt no side effects.

6) These examples all involve disruptive behavior. Beck has described "love" as comparable to mania and reflection suggests many grandiose feelings associated with infatuation. Infatuation (along with a heightened sense of perceived similarity) seems to be elicited or reinforced by intercourse. Manics seek it more than many of us, forming instant alliances whether in bed or on the Internet. We are as one flesh (and one mind). No more being alone.

There is often substantial grandiosity, denial, selective perception, lessened worry of failure with infatuations. Substances with actions similar to risperidone might be effective in moderating infatuations. "I don't want to give up the affair" is a common reaction from teens or from wives. I cannot imagine someone actually treating inconvenient attractions with risperidone, still, it's a possibility if the afflicted person has children and a decently behaving if boring, formerly attractive spouse. The affective shifts, the change in perception that occurs, the extra tingling that go with every look and word can be difficult to combat. Likewise for the bias that an existing mate seems awkward, boring, selfish, & clumsy while the new partner is sensitive, understanding, and "just like me."

There is also the inverse problem, that of being in love but dumped. The rejection model suggests that SSRIs would be the effective treatment but many only respond partially to them. The partial responders may have some manic features in their background; a manic without hope is not only depressed but may still have a grandiosity problem, perceiving the universe as betraying special them. (Indeed, it's possible that dysthymia, also said to be sometimes difficult to treat, also reflects manic traits but with no chances of success, of winning whether a partner or a contest) Treat the grandiose expectations with the right serotonin blocker and cure the depression?

7) I recall a stubborn 30 yo, physically solid but with a gut hanging over his belt. I shared some findings about male body fat distribution and cardiac risk. He felt that he still had some time, despite Type A behavior, poor cardiac history in his family, holding several jobs, and having unpredictable, sudden physical demands in his work. Is this grandiosity or detachment in the face of delayed consequences. Denial? Probably grandiosity. He had recently visited Alabama and remarked to me that "Some of those southern guys are really big boys." Can size function as a supernormal stimulus for some people, inflating self esteem because of being large even if fat? I am currently treating one chunky, combative male with a low dose or risperidone. Risperidone commonly increases eating. I'm curious to see if he eats less because he's perhaps no longer competing for a larger size.

Beck, A. (1989) Love Is Never Enough. NY: Harper & Row.

Kramer, P. (1993) Listening to Prozac. NY: Viking.

• Published: Too Much Self Esteem by James Brody, 4/10/98