Ritual and Blood, Honor and Death

Today I decided to add a theme to my Firefox browser, and I choose one based on Japanese tattoos. I then decided to put “Japanese tattoos” into Google, which led me to reading the Wikipedia article on the Yakuza and then reading about the presence of women in Western mafias on a Canadian website. I noticed two things: one, my Internet habits are a reflection of my thought patterns and two, organized crime groups require members to adhere to various traditions and rituals that apply to more than criminal behavior.

I also remembered a brief article I read on anorexia mirabilis (full text here), which led me to think further on how rituals are things humans seem to do regardless of who they are, what they believe, and where they live. Ritual is a framework and brings comfort, it can make things otherwise nonsensical legitimate. Once learned it is difficult and rattling and possible to unlearn. Ritual can be bedded into sense of self, or be viewed as a hassle, or viewed as menacing, or all of the above.

Ritualistic does not morality make. Mob codes of conduct do not negate murder. Extreme food restriction isn’t about spirituality. Structure does not make things moral. Intention matters in the case of morality – if one’s intention is entirely self-serving, there is a chance it isn’t entirely moral.





Do Your Best, Just Don’t Hurt Yourself

On a semi-regular…er, once a week or so… basis, one of many clients will refer to me as a hypocrite. Sometimes directly, sometimes indirectly. I’ve had weeks when I’ve worked six days straight. I have been known to drink too much coffee in order to offset lack of sleep. And I can be very focused on removing those little fringes from torn sheets of notebook paper.

Here’s the thing. I am a happy person, I have self-esteem, I love my family, I love my little spot in suburbia, and I love my job. People who end up in my office have some combination of unhappy, worthless core beliefs, self-injury, have difficulty forming valued relationships, feel disconnected, hate others, cling to others, restrict their eating, are anxious, and yes I could continue.

Perfectionism is almost like a cute beauty mark with a biopsy indicating it’s a malignant tumor in need of treatment. Fine on the surface while it festers, but eventually it’s going to become blatantly obvious to everyone it’s a problem. The plus to perfectionism is that treatment is more about hanging on to what works – such as achievement – and learning to let go of what doesn’t work – harsh self-appraisal, self-punishment, etc.

So when is perfectionism helpful?

When it’s adaptive perfectionism (some researchers refer to it as conscientiousness). Adaptive perfectionism is all of that great perfectionism you know and love – grades, promotions, goals, beauty, “doing the right thing,” competitive spirit, sense of accomplishment, and more – without all of the self-loathing, insecurity, and at times life-threatening behavior. We call that stuff maladaptive perfectionism.

How does you know when you’re engaging in adaptive vs maladaptive perfectionism?

One being able to accept disappointment if things do not go as planned, and not viewing these events as some sort of confirmation of inferiority. Maybe the Easter ham was overcooked. Maybe you failed an exam. Maybe you bought the wrong socks for your partner. It happens.

Another is something I’ve seen in my practice is how perfectionists motivate themselves. It often has a moral tone to it. Recurrent themes include a sense of responsibility to others (and objects in those with Hoarding Disorder) and being worthwhile to friends, family, or peers. People may criticize themselves or ritualistically engage in self-injury in order to punish themselves when they do not meet their very high standards. Those engaging in adaptive perfectionism do not do this or are at least in the process of challenging these thoughts and behaviors when they occur. They use more positive reinforcement with themselves, such as tangible rewards for a job well done or use of cheerleading statements.

Ultimately, adaptive perfectionism meets the goals of perfectionism: being the best possible and feeling good about it. Perfectionism can be broken down into subcategories, which is for another blog post.

I’m sold on the idea of adaptive perfectionism, but I’m skeptical about my ability to change.

Which is normal. The plus is that Cognitive Behavior Therapy, CBT for short (That therapy the dusting, straightening yours truly uses), is helpful for maladaptive perfectionism. CBT teaches perfectionists to challenge their thinking, practice self-kindness, and improve efficiency.

Another promising treatment is Radically Open Dialectical Behavior Therapy, or RO-DBT for short. It isn’t widespread, though that will likely change when more clinicians are trained.

Alright, I will give it a shot.

Contact Cortney Modelewski at 269-389-0402 or cortney@cortneymodelewski.com

Autism, Empathy, and Something About Accountants

I finally watched The Accountant. To summarize, it’s a thriller movie with a bunch of the usual thriller tropes, except the anti-hero is an attempt at portraying diversity but instead ends up an amalgamation of clichés about people on the spectrum. Pro Tip: If you’re making a film with an autistic character, consider spending more time consulting with autistic people than time with neurotypical people.

Anyway, the film got me thinking about empathy. Especially the way in which people who do not appear to have much empathy are filed in with abusive spouses, serial killers, and those who maim kittens. While abusive spouses, serial killers, and those who maim kittens are often low on empathy, it does not mean that all who are low on empathy are any of those things nor does it mean that abusing, killing, and maiming requires low empathy. Empathy is not the same thing as compassion or sympathy or pity or loving-kindness or being moral or whatever other nice-sounding quality you think is associated with empathy.

Empathy is, per Merriam-Webster, “the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also :  the capacity for this”

Empathy can be broken down into cognitive (being able to take the perspective of real and fictional people), affective (being able to respond to someone else’s emotional state), and somatic (having a physical reaction). Deficits in these types of empathy are found in yes, autism, as well as anorexia, all personality disorders, psychotic disorders, OCD and a few of the related disorders – a significant number of people, the majority caring and welcome in society.

Deficits in empathy makes violence and cruelty easier, no doubt. What often happens, though, is that people with a lower ability to be empathic feel disconnected from others, lonely, and depressed. It is harder to communicate effectively with empathy is lower. People are punished for being being different, and those punished withdraw from others.




Today is the last day of OCD Awareness Week. I have been putting up links to informative websites on my Facebook page to, well, bring some awareness. I have also spent some time reflecting on how U.S. views OCD, which is pretty warped.

OCD is a neuropsychiatric disorder, which means the cause is attributed to abnormal brain function. It is not caused by weak will, lack of exercise/nutrition, or difficulties with mothers. It is likely caused by a mix of genetic and environmental factors, with an emphasis on the genetic part. It is treatable with therapy and medication.

Misconceptions about OCD are abound. I don’t expect people in general to understand everything about the disorder, but it would be nice if people could at least tone down the judgments to be on par with epilepsy or cancer. OCD isn’t anyones fault, even if individuals with OCD (and sometimes their families) have to solve those problems anyway (DBT reference). And of the things I’ve learned in my personal and professional life, the inclination to psych problems would be higher if fear of being judged weren’t an issue. Instead, people may wait to get treatment until it’s unbearable, or worse commit suicide.

Yes, OCD can cause people to be miserable to the point of killing themselves.

It’s not a personality quirk.

It’s mental torture.

Stigma continues to decrease as people continue to speak out. OCD Awareness Week is one way to do that. Having OCD does not mean someone is defective. It just is what it is.





“It Doesn’t Have to be Perfect…

…it just has to be good enough.”

My supervisor chuckled at that one.

Perfectionism is one of those things that, to some, sounds less pathological than what is the case. People have their quirks, and we all know at least one person who spends a lengthy amount of time scrubbing their kitchen floor to quasi-sterility but seems to otherwise behave normally. Some people use the statement “I’m a perfectionist” to describe how they want things to be a specific way but actually are able to accept when they aren’t to their liking. These traits can be useful. Perfectionism of the useful sort is closer to what some clinicians call conscientiousness, which is marked by being detail-oriented, hardworking, and self-disciplined.

Now how is that different than the perfectionism to which I am referring? Well, perfectionism lends itself to be more compulsive to the point of failing to complete tasks because they’re not “good enough” (OCPD), poor body image (Anorexia), low self-esteem, and treatment-resistant depression. The journey to “good enough” doesn’t mean a whole lot if you are miserable and especially if you are dead (such as medical complications from Anorexia or suicide from psychiatric issues in general). Perfectionism is a personality trait seen in people with overcontrol disorders, and it typically does not go away when a disorder is treated unless it is also targeted during treatment. For example, you can treat the hoarding behaviors in Hoarding Disorder, but that doesn’t mean the individual with that diagnosis will no longer have perfectionism once the hoarding is under control. Same with OCD, eating disorders, etc.

Perfectionism isn’t positive. It’s a crippling plague of distorted thinking, insecurity, anger, fear, and sadness under the guise of striving for achievement. But a plague that can be tempered to actions leading to feeling a genuine sense of accomplishment. Finding value in “good enough.” This involves some introspection, allowing imperfection, and ignoring those who punish “good enough.”

Which is not easy.

Musical Obsessions a.k.a. Earworms

I had a song stuck in my head the other evening. A couple snippets of circa 1992 Swedish pop that had bore into a space meant for a therapy manual I was trying to read. I tried to ignore it. I tried to mindfully observe it. I tried to purge it by listening to it. I tried to listen to a different pop song. Finally, I picked out something from a different genre and was able to get some work done.

Earworms are the common name for the “I have a song stuck in my head” phenomenon. They’re also known as intrusive musical imagery (IMI). Most people experience it and don’t find it particularly bothersome. A small number of people find them aversive and some these people may have obsessive-compulsive traits, frequently related to OCD.

IMI are not listed in the DSM-5’s section on Obsessive-Compulsive and Related Disorders. I’ve heard people with OCD comment on the presence of IMI and there is a question about it on the YBOCS (Young-Brown Obsessive Compulsive Scale, which is used to diagnose OCD, determine severity, for research purposes, etc). I’m not entirely sure why it didn’t make it into the DSM-5, but then again the DSM-5 is an example of what can happen when books are written by committee.

This is a fantastic review article on IMI:

Musical obsessions: A comprehensive review of neglected clinical phenomena

IMI Article Takeaways:

  1. It can be an obsession, and some sort of avoidance behavior (compulsion) may be accompanying it.
  2. It tends to co-occur with other obsessions, such as familiar ones like contamination or harm.
  3. It sometimes gets misdiagnosed as part of a psychotic disorder or just plain ignored by clinicians.
  4. Unlike other types of obsessions, use of distraction can be helpful – here is an opportunity to indulge in distraction, folks (I kid).





Minocycline for OCD

If you have ever had bad acne, MRSA, and/or gonorrhea, you may be familiar with minocycline. Minocycline is a broad-spectrum antibiotic that kills all sorts of nasty pathogens. It also affects glutamate, the most abundant neurotransmitter in the brain which serves multiple functions. Glutamate is the current target for innovation in psychiatric medication, because the whole dopamine and serotonin business hasn’t panned out as well as the mental health community would like. Minocycline is a convenient drug to study given that it has been in use for a long time and is relatively safe to use in both adults and children.

Apparently, it helps some people with Obsessive-Compulsive Disorder (OCD) be less obsessive and compulsive. A Google search will produce multiple articles on the topic. For something that isn’t super jargony, check out the third article in the series titled Brain Hacking in the Washington Post.

People with OCD are stereotyped as orderly, perfectionist, and rigid. The OCD stereotype is inaccurate. The disorder is not characterized by personality traits, though people with OCD can struggle with them (perfectionism particularly). When I read about a medication for Leprosy that also treats OCD, I do wonder if the personalities of these folks changes somewhat – to what extent does personality reinforce OCD behaviors, and vice versa.

Frankly, I hope researchers find a magic pill for some of these things. As much as I love my job, I’d probably be content as a librarian or something. In the meantime…