And another seizure…

As the title suggests, I had another one. Last night, around 10 pm. Even though, logically, I know the body goes into protection mode when it has a seizure, my brain started telling me that I would have another seizure and stop breathing in my sleep. It scared the living daylights out of me, to the point where I forced myself to stay awake all night. I couldn’t stop obsessing over the thought that I would stop breathing. I couldn’t make my brain stop or move to a different thought.

It’s almost 6 am, and I haven’t slept. Energy drinks and coffee will be my friend today… I’m actually working on my 4th cup of coffee at the moment. Just sitting on the front porch, enjoying the breeze. I spent most of the night writing. In my journal and also free writing, a poem of sorts. I’ll post it here once I get it typed up. Possibly later today or tomorrow. It ended up being 4 pages long in my composition book… I usually don’t write that much when I write poetry, I just kept going. The words just kept coming. It was strange.

The depression is still ever present. And it’s still very much debilitating. All I want is to leave this world at times. The fantasy of how I would achieve that end enters my mind and sometimes refuses to leave. I can’t force the image of where and how to go away even though I try my damnedest. When I say it is all I want, it is. But I do have reasons to stay. I have my friends. I have goals. I have ambitions.

And I believe, in my heart and soul, that even if I were to try, if it’s not my time to go, I will not go. There may be consequences for that attempt, and I may not be able to live with those consequences.

I fully believe that there is a reason I have survived my previous attempts. I am supposed to do something or meet someone or help someone with something. I don’t know what kind of impact my life can have on those around me and I don’t know what kind of impact my death would have on those left behind either. I would not be able to bear the burden of knowing that one of my friends hurt themselves because of something I did. When someone knows a person who dies by suicide, they have a higher chance of attempting suicide themselves. It’s a statistical fact.

I already hate seeing the looks on the faces of my friends when they see marks from self harm on my arms. The pain in their eyes is torture to me. I saw it yesterday in my friend Ray’s eyes… He tried to brush it off with a joke; “Do you always stitch yourself up?” But I could see the torment that he felt when he saw the cut with the sutures. That hurt. I wish I could hide it from them. Living in Texas during the summer months makes that impossible. It’s either wear short sleeves and have the marks be visible for the world to see or wear a sweater in July and have them not see but know anyway.theres no other reason that I would be wearing a sweater in July.

The only solution is to stop altogether. I know that is what you are thinking… It’s not that easy. I have tried and am trying. I haven’t cut since the early morning hours of the 11th. Which for me is amazing, actually. I have had some nervous picking at scabs that haven’t healed (because I keep picking at them) and a little punching and head banging. But I haven’t done anything that has left permanent damage to my body since the 11th. That is major progress for me.

In PHP, we set goals on Mondays. My physical goal for this week is no cutting or burning. At all. We use the SMART goal model. Specific, measurable, attainable, realistic, and timely. So for specific, I specified cutting and burning. Measurable, I said none for the week. Attainable, it will be difficult but it is possible. Realistic, it is something I have done before. And timely means if there a timeframe for the goal. I specified an end day of Friday. I only have to maintain the no cutting and burning through Friday for the goal. One thing about not self harming for me, I like seeing my arm without injuries. I like seeing a clean arm. It gives me hope for the future, in a way, hope that I can keep away from the self harm.

Well, it’s 6:30 am. I usually leave around this time to go to an AA meeting before PHP. I’m gonna go get ready to go.

Life and Death Questions

Why do I constantly feel this way?

Why does it never end?

Why do I always have to pay?

Why does my life feel like pretend?

When will I finally be happy?

When will the pain take flight?

When will the world finally see?

When will I not want to die?

What is the point of life anyhow?

What can the purpose be?

What is the point of fighting now?

What can be done to save me?

Where is the solace in this pain?

Where is my rescuer hiding?

Where can I escape the rain?

Where can I hide from the lightning?

Who has listened close enough to see?

Who has even heard my song?

Who will try to find me?

Who will miss me when I’m gone?

A Lot Going On

My life has been hectic as of late… I’ve had three trips to the psychiatric hospital since Spring, the last one being in June. I was released on the 30th. I am currently in a partial hospitalization program at a local hospital. I’m still struggling with depression, suicidal thought, and psychosis. I’m also having a lot of dissociative symptoms and “spacing out” daily. Sleep has been an issue, as well. The night of July 4th, I didn’t sleep at all because the psychotic symptoms kept me awake all night, and Sunday night I didn’t sleep as well. I took a nap yesterday for 5 hours, and woke up at 9 pm, which meant I couldn’t sleep last night either. As I’m typing this, I’ve been awake since that nap.

I also had another pseudoseizure last night around 2 am. I was sitting at my computer desk watching television, and then I was on the floor, unable to move, and still shaking. They are terrifying when they happen. I’ve only had three seizures in my life and would prefer to never have another. Pseudoseizures are like regular seizures but don’t show up in the brain like epilepsy. The brain waves are normal, to my understanding. That is how they diagnose them as “pseudo” rather than regular seizures. They are typically caused by increased stress or psychological symptoms, and usually coincide with PTSD, schizophrenia, depression, and/or anxiety. All of which I am diagnosed with…

I am not looking forward to going to PHP today. I’m worried that they will want to send me to the ER because of the seizure, and I really don’t think I need to go. I’m going to call my neurologist first thing in the morning and leave a message for her. I have an appointment with her in September already, although she may want to see me earlier now. I also see my primary care physician next week, so that may appease the PHP therapist and nurse. Hopefully, at least.

As far as my psychological symptoms are concerned… I’m having increased depression that is leading to suicidal thoughts and auditory and visual hallucinations of demons. The demons are telling me to do things that are not healthy or good for me to do. They want me to self harm and every now and then will tell me I need to die. They aren’t telling me to kill myself, just that I would be better off dead. Does that make sense? I hope so…

My narcissistic mother has actually been pretty decent lately. She hasn’t been as demanding as she normally is. I think she is compensating and adjusting her behavior because of my hospitalizations. I’m not complaining in the slightest. It’s nice to get a break from being treated like a slave 24 hours a day.

I think that all I have for this update. I hope y’all are well and enjoying your day! Take care!

Just Another Day

the sun sets on the day

just another day really

nothing special happened

nothing out of the ordinary

a day like any other day

except it wasn’t

to her

it was a horrendous day

couldn’t have been worse

nothing could have

made this day

any more

horrid

than it was already

even though nothing happened

nothing special

nothing different

nothing extraordinary

just another day

but on this day

she wanted to die

she wanted to die so terribly

that she could feel it in her bones

she could feel it in each strand of hair

from the top of her head

to the tips of her toes

the desire to die

was so strong

it was consuming her every waking moment

the thoughts of how and when

and who would find her

how they would react

who she wants to have her things

who to apologize to beforehand

and who to say sorry to in her note

who would cry when they found out

and who would just be angry

these thoughts keep bouncing

in and out

‘round and ‘round

all over the place

all the time

she worries about her friends

and the people she’ll be

leaving behind

but they aren’t enough

to keep her soul firmly planted

within her body and her brain

she worries that they will hate her

for what she has done

and never forgive her

but it’s something that must be done

she is past the point of no return

she is too miserable to keep going

too tired to keep fighting

too worn to keep trying

the fight is over

this day will be her end

 

~Emily Love

and it continues… but so do I!

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It has been awhile.

And it has been up and down… mostly down. There have been a couple more hospital stays. One to get me on an injectible mood stabilizer and antipsychotic, after some noncompliance with meds due to psychosis, and another due to the third suicide attempt this year.

I went into a PHP (partial hospitalization program) again after the last hospital stay, but had to discharge early to have back surgery. Pain is a massive trigger for me, and I can say the last month has been really hard. I have been increasingly suicidal and the self injury has been getting worse over that time as well. Finally, after about 3 weeks, I was able to go back for an assessment and start the PHP again. I’ve been back in it since Wednesday, now.

I have wanted to give up many times over the last month. More times than I can count, honestly. It seems like anything that can go wrong has or will, even though that is not necessarily true. It is how it seems when my brain is spiraling down the rabbit hole. The only way to keep my brain from going all the way down seems to be cutting or other forms of self injury.

I know, logically, that is not true. I know, logically, that using coping skills “should” work to calm the storm in my head. It’s that “should” that gets me. The coping skills I typically use are distracting or postponing (video games, 5-minute rule, youTube), processing (journaling), or talking to a friend or another support person or even texting or calling a crisis line (text 741-741 or call 1-800-273-8255).  However, when I do attempt to use one or more of these, they only tend to work, if they work at all, for the time that I am doing them. As soon as I stop, the urge, whether it is for self injury of suicide, comes right back.

The key, for me at least, is to keep trying. Keep moving. Keep pushing forward. Don’t stop. Don’t give in and don’t give up.  As much as I may want to, even feel like I need to at times, giving up is permanent. In this circumstance, giving up cannot be undone. As long as I make it through the day, alive, and go to bed, alive, there is the chance that tomorrow may be better.  Maybe. Possibly. I have enough hope left in me to want to see what tomorrow will bring. That idea that 12 step programs live on… one day at a time… I live by it with my mental health as well. Instead of making it through just one day sober or clean, and worrying about tomorrow when tomorrow comes, I live my life as I only have to live today. The possibility of suicide is there… tomorrow. Not today. It works for me, at least. I’m not giving up. I am stubborn. It may be out of spite, it may be out of some deep-seated need for survival, but I am still alive, so something is working.


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Found Here

And I was right…

I ended up back in the hospital.

On April 4th, I got admitted again.

Technically, I should have gone in much sooner than that, but I wanted to wait until payday so that I could bring cigarettes with me and get some sketching paper and pencils that I would be allowed to have as well. No metal and no hardback books makes things difficult. I pushed myself pretty hard, just to make it the few extra days, and I did make it, but the self injury got worse over that time.

Being in the hospital wasn’t awful, but finding the right medications seemed to take awhile. I hope what they have me on will work longterm. However, I am already getting more depressed. I’ve been isolating, not hanging out with friends, just staying in the house and sleeping a lot.

The day I got home from the hospital, though, I had a moment of wanting to throw away my razors. I did. I don’t have any razors at this point. I’ve been known to self harm in other ways, but cutting has always been my preferred method. Oddly, I’m only having fleeting urges to self harm and am able to easily brush them off.

I have an assessment for an intensive outpatient DBT on Tuesday. Hopefully, things will work out and I won’t need to go back to the hospital.

Here’s hoping…

Depression, Suicidal Ideation, Psychosis, and the Psych Ward…

Found here


There has been a lot that has happened over the last couple of months… so much, I don’t really know where to start. I guess the beginning is always a good place.

Back in October or November, I started getting more depressed. I couldn’t really place why, exactly. My mood just started crashing. My psychiatrist was getting concerned and started having me come in more often than I had been. Eight weeks apart went down to four weeks apart. My baseline is usually passive suicidal ideation, and I always have a plan of how I would do it if I got to the point of attempting suicide again. In December, the ideation got stronger and harder to fight, but I managed. During this time, the self-injury was getting a lot worse. At times, I was having to go for sutures 3 or more times a week and was having difficulty keeping things clean. A couple of them got infected.

In January, my psychiatrist finally convinced me to go for an assessment to do intensive outpatient Dialectical Behavioral Therapy, which is considered the only treatment for Borderline Personality Disorder. Usually, if a person has any history of self-injury, they get thrown into DBT, whether they want to or not. I have done the IOP probably 7 times already which was why I didn’t want to do it. I know everything they teach and I know that I don’t like DBT. I use the parts that work for me, but it’s hard to remember the healthy coping skills when I am triggered or in crisis. I made the appointment for the assessment and showed up. They decided afterward that my situation was too much for IOP and referred me to a partial hospitalization program, so that was another assessment I had to go through because the IOP location doesn’t do PHP as well. The partial programs are 6 hours a day instead of 3, and 5 days a week instead of 4, so it’s more intensive, and I would see a doctor once a week and there is a nurse on site every day.

I made an appointment at a local, private hospital for the assessment for the partial program. I chose that particular hospital because if I ended up getting admitted, it is the only one in my city that allows smoking while inpatient. I smoke 2 packs a day and have a history of getting so stressed from not smoking that I lie my way out of the hospital, just to be able to smoke. The assessment was stressful because it is the same as the assessment for inpatient. They take your shoes and jewelry and anything you can use to hurt yourself with, as well as your phone… so basically I was really bored while I was sitting and waiting during the whole process. The assessment took about 2 hours total, but only involved maybe 30 minutes of actual questions. I was approved for the partial hospitalization program, however.

I started the PHP on the 7th of February. I enjoyed it but was still struggling. I was still cutting quite a bit and needing sutures. I was letting the therapist and nurse of the program know when it happened as well as the doctor when I saw him. I was also having a lot of anxiety and kept having to leave the room and step outside for some fresh air and nicotine. I was having a hard time regulating. The suicidal ideation was getting worse every day, and I was reporting that to them, as well. Everyone was getting concerned, including me. On February 22nd, the doctor brought up inpatient again. He was starting me on an antidepressant and starting a cross-titration of antipsychotics. He also said that if the next day didn’t go any better didn’t go any better than that day was going, he would want me to be admitted. The 22nd was a Thursday, and he was seriously concerned about my ability to make it through the weekend alive. I wasn’t willing to tell them, but I was as well.

Friday started out better, less anxiety and less having to leave the group, but one of the other patients had a moment and threw a pillow across the room and my PTSD kicked in and I freaked out. I couldn’t regulate after that. The nurse called the doctor, and he said to walk me over to admissions. I tried to sweet talk my way out of being walked over. I tried everything… I had a lot that needed to get done over that weekend and the following week. I told them I was fine, that there was absolutely no reason I needed to be admitted, that I wasn’t going to kill myself and I would be back Monday morning. I was suicidal, but I was telling them there wasn’t any intent and that having a busy weekend would help me stay out of my head. They had to follow what the doctor wanted, though, so there wasn’t another option except to walk over.

So, there I was, back in the admissions area for another assessment. The doctor for admissions sided with the doctor from the PHP immediately, but I did not want to stay. I kept thinking of everything I had to get done. I was thinking of everyone else and not myself. I was more concerned about everyone and everything else and not myself. I fought the admission so much that I ended up on a 72-hour police hold. I was committed to the psych hospital, for the first time in my life. I have been in and out of the hospital for 15 years and had never been committed, until the 23rd of February. Once the hold ended on the following Monday, I was given a choice… sign in voluntarily or go to court. I wouldn’t be able to go to court until Thursday. I decided to sign the papers and stay on my own. The doctor released me on the following Friday, March 2nd, so I was inpatient for an entire week. For me, it was a reminder that there are things that I cannot control and I need to just accept that I am not in control and do what I need to do at the moment to keep moving forward.

I started the PHP again on March 6th, but I only lasted a week in the outside world. The antipsychotic that I had started back on the 22nd of February didn’t work, at all, for me. I had had a moment of hallucinations toward the end of the first hospital stay, but I thought it was a one-off because of stress. Apparently not… Over that week out, the psychosis kept getting worse and my depression was getting worse, as well, because my physical pain was unbearable.

On March 13th, I had a consultation with a rheumatologist because of some lab work I had drawn. The answer I got left me hopeless. I was basically told to do things that I was either already doing that didn’t work well enough or had been doing that stopped working. My brain went into “if I have to live with this much pain for the rest of my life, then the rest of my life won’t be very long.” That night was rough. I was severely depressed, seriously contemplating suicide. I knew if I didn’t go back to the hospital that I was going to commit suicide. I had PHP in the morning, though, and knew if I could just get to the group and tell the truth, they would not let me leave. It was the only hope I had to stay alive. It was all I could hold on to, the only spark I had left in the darkness. I packed up a few clothes and my CPAP and some meds that the hospital isn’t able to provide so I would be more comfortable while I was there.

The next morning, I got up early, because my car had been at the mechanic and I had a rental that needed to be returned. I dropped the rental and picked up my car and headed toward the hospital. The drive felt like it was taking forever. I got on the highway and was driving my normal route when I was the exit for a particular highway. My plan for suicide involves jumping from a certain cliff, off of that highway. I’m not sure why, really, but I exited there and started driving toward the cliff. When I got there, I pulled off the road and just sat in my car, looking up at the top. I didn’t get out of the car, just sat there staring at the cliff for about 15 minutes, debating my choices. Did I want to continue driving to the hospital or did I want to hike up to the top?

I finally started driving again and got to the hospital safe and sound.

At the beginning of PHP, we would always fill out a form that gave the therapist an idea of where we were at with suicidal ideation and actions. I answered every question with a yes, which is a bad sign. The look on her face showed concern when she glanced at it as I handed it to her. At check-in, she mentioned that there were more yesses than normal; I just nodded. Later in the day, I was starting to completely shut down. She asked what I was thinking about and I just shrugged. She asked if she was right to be concerned for my safety and I answered maybe.

That is when the admissions process started all over again, but I didn’t fight it this time. I went into the hospital voluntarily and stayed for 11 days.  Over the time between the two stays in the hospital, the psychosis had been getting worse. The medicine that I had been put on during the first stay didn’t work at all, and I had a complete psychotic break while sitting in admissions. While I was inpatient the second time, the hallucinations were commanding me to do things like banging my head or burning myself with cigarettes and even using the cord of my CPAP to hang myself. I submitted to the first two, but the last one, the cord of my CPAP, I was able to express to staff before acting on the command.

At the end of the stay, because of the amount of banging I had done, there was some concern I had done damage to my brain. I called my neurologist and made an appointment for the next day, Tuesday, to get checked out. Lo and behold, I had given myself a concussion. I went today for a CT scan of the brain, just to be sure there isn’t anything more serious going on.

Part of my discharge plan was to go to a Dialectical Behavioral Therapy intensive outpatient program, but they couldn’t even get me in for an assessment until Friday of this week, which is too long to wait, in my opinion. I’m having a difficult time, at the moment. The new antipsychotic, that replaced the one that didn’t work, seems to also not work. I feel like I am running out of options and I am stuck. I don’t want to have to live the rest of my life with hallucinations every waking hour of the day. I want to find something that works to make them go away, that makes these creatures that are literally screaming at me go away. I never get a break. I never get peace and quiet. They are always screaming into my ears, calling me names and telling me to hurt myself in a number of ways or to go ahead and just kill myself. I am doing everything I can to be strong, but honestly, I foresee another hospital stay in my future.

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Found Here


 

I have a difficult time expressing when I am struggling. Doesn’t everybody, really? I have this deep-seated belief that asking for help, in any form, shows weakness. As someone with mental illness and addiction, the culture, norm, and expectations around getting better involve “asking for help,” either from doctors or therapists, sponsors or friends.

I think for me, part of that belief that I am showing weakness simply by asking for help comes from my childhood. The parts I remember (which are few and far between, honestly) remind me that I was raised and taught to take care of myself at a young age.

I was a latch-key kid, I rode the bus home from school and let myself in. I was the first one home, and depending on the day, my sister and my mother would get home later, usually at different times. So, out of hunger and necessity, I usually prepared my own snack or small meal when I got home. I had a lot of TV dinners or microwaveable things, and also sandwiches. Then when my mom got home, she would make herself something, and the same when my sister got home. So in turn, we hardly ever ate as a family, at the table.

I don’t really remember my mother being involved in my life much at all once I became a teenager. I was pretty self sufficient at that point, did my homework without having to be told, went to bed at an appropriate time and never even had to be given a curfew. I got a driver’s license at 15 years old, a hardship license, because of my mother’s mobility problems. I started running all of the errands without her, the grocery shopping, putting gas in her car for her, driving myself to school, and so on.

As I entered high school, I really had no friends, but I was okay with that. I had never been social, and my mother had never really pushed me to try to be social. My sister always had friends, she was going to friends’ houses, staying at school for extracurricular activities, etc. I never really did. In classes, when I would finish the assigned work, I would take my “fun” book out of my bag, and start reading, while the other students in the class would usually start chitchatting when they finished. The teachers loved me, because I never caused problems. Throughout high school, people knew me, don’t get me wrong, but usually in the way of “hey, what was the book about?” on the day of the English quiz. Explaining Macbeth in 10 minutes is not really that possible, by the way. It is highly likely that there were times that half the football team would have failed English and “no pass, no play” without my assistance, hence the people knew me.


Basically, the entire time I was growing up and coming into my own, I had the mindset and understanding that I could do it on my own. I never really had to ask for help. When I started to struggle, started to get depressed, started to self harm with cutting and addictive substances, I still believed that I could take care of myself. I still believed that I didn’t need help. I first attempted suicide when I was 20 years old, after one of the most important women in my life passed away suddenly.

That was 14 years ago, and even though I now have my therapist and psychiatrist, I still cringe at that thought of asking for help.  I want to be able to do it myself, which in turn lands me in the emergency room needing sutures, or back at NA getting a white keytag yet again. When I do end go to the ER for sutures, they usually offer for me to speak with the social worker, and most of the time I answer that it’s not worth it and it won’t change anything.

I know I need help, and even when help is offered to me without having to ask, I cringe. My insides ball up and I have this insane urge to run as fast as I can. When my therapist show care and concern, it is painful. I wasn’t raised being told that I matter, so hearing it now is painful. Asking someone to sponsor me is anxiety inducing and I am almost more comfortable being miserable and continuing to harm myself in various ways than I am asking for help.


The hand I was dealt, the emotional neglect as a child, being taught to take care of myself, is just that, the hand I was dealt. That is my story, up until this point. The author of the story can always end one chapter and begin another at any point in the story.

I need to realize that I am the author.  My story up until this point has already been written, and I need to own the fact that the past cannot be changed. I cannot change the way my mother was growing up. I cannot change the ways I learned to manage my emotions. I cannot change the way I learned to never ask for help. I can change, however, what I do from now on, and how I treat myself in that process.


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Found Here

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As I began to come into my own, started to develop the concept that I am a person in my own right, I started to realize that my friends’ parents were not like mine. Namely, my mother. It took years, and I do mean years, to realize that the woman who was supposed to raise me to be independent, to take care of myself, and eventually move out on my own and have my own family… that woman had programmed my brain, in a sense, to the point where I became her slave.

I was (am?) terrified to say no to her, even though she has never gotten physical with me… the emotional and mental abuse and neglect sometimes seem worse than if she had just beat me. At least if she had beat me, I could show someone, and they would understand the severity of the situation…

Instead, I got labeled as “the crazy one”, “the addict”, “the cutter”, etc… I could keep going forever, it seems. Breaking away from those labels once they are in place is nearly impossible. Anything I say, especially about her, gets twisted because I’m “crazy,” so I must not be understanding the situation, or I’m “an addict,” so I must be lying for some personal gain.

The hardest part of having a narcissistic mother, for me at least, is that no one really believes me. She is extremely skilled at putting on her “normal person” face, when in public or with her friends and family. However, the instant we are back in the house, just the two of us, she reverts back to her natural, evil self. The tone, the orders, the yelling, the expectations… everything has to be done on her time, and to her standards. God forbid I forget to do something, or be in too much pain (I was in a serious car accident, recently) to do what she is demanding… With the pain, she doesn’t care, she doesn’t want to hear it, she is in pain too, don’t you know, but my pain, my depression, my exhaustion, etc, doesn’t matter at all… the only thing that matters is what she wants and when she wants it…

Recently, I realized that growing up, and now, I cannot remember a single time that she has said “I love you.” I can only remember one time that she has shown any affection at all. She never says “please” when she asks for something, and very rarely says “thank you” when I do something without her having to ask. I am expected to be able to read her mind and act before she tells me to do something, and then if I don’t, but she thinks it is something that is obvious, I get berated for not just knowing that she wanted it done. This can be putting gas in her car, which I barely ever drive, or watering the plants, which i never look at, since I don’t care about them.

I still live with her, because as a result of the trauma I went through from her, I have been declared disabled since I was 21 years old, and even though I have attempted to work, mostly part-time jobs, I cannot hold a job long enough or work enough hours to support myself. Financially, I am dependent on her, and there are no real options to get out and away quickly. I am working on applying for low-income housing or housing for the disabled, at the moment, but my disability makes the process of doing this extremely overwhelming and terrifying in itself.

I feel like an outsider, an intruder, in her house all the time. She does nothing to make me feel welcome here. Then, she wonders why I leave the house before she wakes up and stay away until nearly time for me to go to bed. I have been in therapy for years, and in that time, have started to see all of this for what it really is, and have finally gotten to the point where I just cannot take it anymore.

My hope, for this blog, is to chronicle my relationship with her and progress that is made, either between us or in getting away from her for good.


 

The DSM-5 Criteria for Narcissistic Personality Disorder (revised June 2011) is below.

(Criteria pulled from Here)

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met:

A. Significant impairments in personality functioning manifest by:

1. Impairments in self functioning (a or b):

a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.

b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.

AND

2. Impairments in interpersonal functioning (a or b):

a. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.

b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain

B. Pathological personality traits in the following domain:

1. Antagonism, characterized by:

a. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.

b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).