Categories
Mental Health

Honoring LGBTQIA+ Pride Month 2021 With Rainbows, Glitter Galore & Reflection

June is LGBTQIA+ Pride Month every year, honor of the 1969 Stonewall riots, a milestone in the gay liberation movement, and LGBTQIA+ rights in the United States. Yet despite advances in LGBTQIA+ rights, LGBTQIA+ youth and adults continue to face harassment and discrimination for their gender identity and sexuality. In fact, the statistics for hate crimes against trans individuals have actually gone up significantly in recent years. Despite the legalization of same-sex marriages and acknowledging the gay community in establishment politics, the anti-LGBTQIA+ bias persists in the job market, medicine, schools, and society.

Part of the impact of widespread victimization towards LGBTQIA+ teens includes an increased risk for mental health issues and a greater risk for substance use. LGBTQIA+ youth – trans youth in particular – have higher suicide rates than the general population and lack access to adequate mental health resources. This year, we need to find ways to do better – and empower our children to become the adults they want to be while ensuring that the world around them begins to treat them just as well as any heterosexual and cisgender adult.

LGBTQIA+ and the Importance of Mental Health Advocacy

Mental health resources are more critical than ever, particularly to older teens, who are most at risk of developing mental health issues due to the isolation caused by the COVID-19 pandemic. Researchers have identified that because older teens are less reliant on their parents than younger children and lack the established and lifelong social bonds that older adults have had before the start of the pandemic, the impact of long-term loneliness and a lack of human contact during the coronavirus pandemic is often much more severe for them. A strained healthcare system also means fewer Americans have had access to the mental healthcare resources they need.

Research from the Trevor Project has also brought to light that LGBTQIA+ youth continue to have a harder time getting access to the resources they need. Of the 35,000 teens and young adults aged 13 to 24 that the organization surveyed, a dire 42 percent reported contemplating suicide in December 2020. The number was higher among trans and nonbinary teens, at 52 percent. By recognizing the need for better and easier access to mental healthcare, as well by addressing discrimination in the healthcare industry, we can ensure that our teens and future generations can benefit from advances in psychiatric medicine and treatment and get the help they need to enjoy a better quality of life, even when faced with severe mood disorders or substance use disorder.

Participating in Pride Month 2021

While the world is still far from having recovered from the pandemic, there are organized Pride events in the US this year. There are many ways to safely attend these events, either virtually or by attending small gatherings and staying socially distant. You can find a Pride event near you online and inform yourself of the requirements and restrictions around the event nearest to you. Or you can join in virtually.

Helping LGBTQIA+ Youth Find Local Resources

This Pride Month, take the time to find and share local and national resources for the mental healthcare of at-risk LGBTQIA+ youth through the following links, as well as state resources.

Take Time for Yourself

This year should also be a time for reflection. Many of us have raced from week to week to survive, make ends meet, or figure out our next steps. Let’s take this Pride Month to consider the impact of the last year and reevaluate our own needs – whether as teens and students, as young working adults, or as parents. Each of us has had to make compromises due to COVID-19, and we have all felt the effects of the pandemic in one way or another – whether through the death of a loved one, the strain on society, the economy, or through healthcare. Statistics show that mental health issues are slated to grow across the board due to the pandemic and that the effects of the ensuing “mental health epidemic” will be felt for years to come. Take the time to address or figure out your needs – and take preventative steps or talk with a professional.

More Than Homophobia

Most people would agree that there is nothing fundamentally wrong with this statement: heterosexuality is the norm in society. However, the impact of assigning a “norm” to gender and sexuality can be harmful to some, especially young teens, who are in the middle of trying to fit into the world and are quickly learning that their existence is “not normal” and is considered uncomfortable to some people. One of the elements of Pride is attempting to help those who feel self-conscious about their identity learn to embrace it, accept it, and feel proud despite some people’s reactions. We need to be conscious of how young people whose identities are seen as uncomfortable or “not normal” can harm them.

Because we live in a heteronormative world, much of society is structured around differentiating between heterosexuality and everything else. Until recently, non-heterosexual representation was tough to come by, and to this day, there is serious stress associated with coming out and making one’s relationships public. Being non-heterosexual and non-cisgender often singles one out. There’s nothing wrong or problematic with acknowledging that heterosexuality is more common than other sexual identities. But that shouldn’t stop heterosexual and cisgender parents and friends from considering how the world might feel exclusionary to their loved ones and how they might need to be empowered to rise above that fact.

Looking for Help?

If you are looking for ways to help someone with signs of depression or anxiety, it may be a good idea to speak to them about getting in touch with a professional. Sometimes, teens don’t get the help they need because they aren’t sure who or how to ask for it.

Categories
Mental Health

Key Takeaways From New Research on Teen Social Isolation

The coronavirus has had an enduring and horrific impact on the world, claiming the lives of over three million people as of May 2021 while ushering in an unprecedented global economic crisis. Experts agree that the long-term impact of the virus is immeasurable and sure to be felt for years to come – and in more ways than one.

Included in the long-term damage is the untold mental impact of coronavirus on teen social isolation that we have had to impose to curb its spread. Since the beginning of the pandemic, countries worldwide have instated different lockdown measures to reduce infection rates, including curfews and guarded checkpoints, enforced social distancing, mandated mask-wearing, and the closing of schools, restaurants, and bars.

The full impact of quarantine, social isolation, and the pandemic on youth mental health remains to be seen. However, the preliminary research and anecdotal observations suggest a coming tidal wave of behavioral health needs among youth, especially late teens and young adults. While social distancing measures and lockdowns may have helped combat the virus, it may have triggered a so-called loneliness pandemic.

Impact of Teen Social Isolation and Loneliness in the Wake of COVID-19

Feelings of loneliness and isolation have gone up drastically following the beginning of the pandemic, with up to 61 percent of Americans aged 18 to 25 reporting high levels, even more than among the elderly. This paints a very troubling picture when combined with the information from the CDC claiming that 63 percent of young people in the US were reporting signs of anxiety and depression as early as June 2020.

Some researchers stipulate that the reason older teens, in particular, are struck by the social isolation imposed due to the coronavirus is that many of them were in the process of transitioning from their family lives into new and different environments and are thus missing the established relationships and close contacts that both younger and older people have access to throughout the pandemic.

In other words, teens caught in the middle of their transition into adulthood are effectively “floating” between their given and chosen social groups. This further hints at the importance of established contacts and relationships as guardrails against the impact of teen social isolation in a viral pandemic. Furthermore, young people are also at a critical juncture in their lives regarding both their personal life and their professional future.

The uncertainty painted by a pandemic throws any planning out of the window, which translates to an enormous amount of stress. In addition, as with many other mental health issues, teen social isolation and feelings of loneliness tend to exist in the form of downward spirals. This means that the thoughts and feelings introduced by increased isolation and loneliness during the pandemic can quickly devolve into self-defeating and self-loathing emotions and the onset of anxious and depressive symptoms including (but not limited to):

    • Low mood
    • Low energy
    • Feeling hopeless
    • Lack of motivation
    • Struggling to function
    • Struggling to seek out social interaction

Teens and young adults without an existing robust social infrastructure are most at risk. This includes those living alone, those between schools, those without a source of employment, those living away from friends and family/those who had recently moved to a new area.

Teens Are at a Higher Risk of Developing PTSD

A review of the impact of the COVID-19 policies shows that teens experiencing social isolation after lockdown are at a higher risk of developing post-traumatic stress disorder and other severe anxiety issues. This data is supported by previous studies examining the effects of teen social isolation following a natural disaster, with research compiled over the course of two decades.

Even more worrying is the finding that teens whose social lives have been completely halted by the virus are at greater risk of turning to other things as a way of coping with the pain and anxiety – including drugs. As a result, some experts are warning of a nationwide spike in addiction.

This is not an isolated phenomenon – the same issue was seen in the areas left devastated by Hurricane Katrina, where survivors were much more likely to face substance use issues with cigarettes and alcohol. In addition, some studies show that even after the emotional and behavioral problems following a natural disaster begin to fade, the alcohol use issues remain.

Access to Mental Health Resources Is Limited

Despite expanding telehealth services throughout the country, few teens are getting the help they need for their mental health. The World Health Organization estimated that over 90 percent of countries experienced stopgaps and interruptions in the availability of critical mental health services following the beginning of the pandemic. Moreover, even before the pandemic, the average investment in mental health resources per country was less than two percent of the national health budget.

Aside from social isolation, the pandemic weighs heavily on our minds in the form of loss and grief, job loss, broken families and businesses, exacerbated chronic or pre-existing health conditions, massive financial casualties, increased drug use, and more. In addition, the coronavirus has highlighted how unprepared we are for something of its caliber – not just in the way of physical healthcare but mental health as well.

The Long-Term Effects of COVID-19 on Mental Health

One of the most frightening aspects of how the pandemic impacts today’s youth is that we aren’t sure how these months will shape this generation’s future. However, we know that loneliness and social isolation in adolescent years can contribute to the onset of major depressive disorder and other mood disorders up to nine years later. Substance use issues can stick around for even longer.

A Generation at Risk

Teens today are turning to tech as a means to communicate with one another and stay connected. However, this is often coming at the cost of less sleep and less exercise. For example, a report on the use of social media among adolescents during the pandemic shows that nearly two-thirds of teens report little to no physical activity and continue to use their phones past bedtime.

We need to continue to support our teens and help them develop healthier coping mechanisms to combat the effects of prolonged social isolation and a lack of face-to-face contact during the pandemic. Shaming them for behavior is counterproductive – but so is doing nothing. If you’re worried about your child, speak with a teen mental health professional today. It takes time, support, and a structured approach to combat mental health issues – whether in the early days or long after their onset.

Categories
Mental Health

Genetic Factors in Teenage Mental Health

Teenage mental health issues arise from a combination of internal and external conditions, defined as risk factors. These risk factors help explain why someone’s child might have developed symptoms of a mood disorder, a substance use disorder, or a psychotic disorder. In addition, they can help explain the roles that both a person’s circumstances and their own physiological quirks played in the onset of disordered behavior and thinking, the kind that lowers the quality of life, disrupts relationships, and much more.

One of the most significant factors behind the development and onset of a diagnosed mental health condition is a teen’s genes. Many of the neurological characteristics that might enable or lead to disordered thinking can be, and are, inherited. Mental health issues begin in the brain, and some people’s brains are more likely to combat disordered or unhealthy thoughts throughout their lifetime. This can mean that, depending on the condition, one in two, five, or ten direct relatives to someone with a mental health issue may one day be diagnosed with that same condition.

But it’s not quite as simple as just saying that we all have the potential to inherit the same conditions as our parents, siblings, or cousins. There are many other risk factors at play and protective factors, unexpected triggers, and ranges in severity. And above all else, a diagnosis is far from a final judgment. Nevertheless, everyone diagnosed with a mental health issue can, with enough care and support, enjoy a normal and fulfilling life, manage the symptoms of their condition, and find the right treatment plan to help them cope.

Teenage Mental Health and Genetics

We are beginning to unravel how our own inherited physiology can affect mental health through abnormal gene expression and the presence of specific genetic markers. In addition, some conditions seem more susceptible to hereditability than others in the sense that teens may be more likely to struggle with certain conditions later in life if their close relatives were diagnosed with them.

But genetics is still only one piece of the puzzle, albeit a large one. So it is important not to get fixated and lose the forest for the trees. While genes may affect how our brains work and may act as an immutable risk factor in the long term, we need to understand that the use in knowing this is to preempt certain conditions through protective factors.

Knowing that our children may be more likely to struggle with certain health issues than the general population can help us ensure that their environment prepares them through positive relationships, the availability of mental health resources at school and within the community, a strong support network, healthy self-esteem, early social skills building, the development of good coping mechanisms, and more.

The Hereditability of Depression and Anxiety

Depression and anxiety are two of the most diagnosed mental disorders in the world. It is important to understand and distinguish between emotion and disorder – while feeling sad and worried is normal and healthy under most circumstances, teens struggling with depression or anxiety are experiencing unhealthy and disordered thoughts that can influence behavior, causing self-isolation, self-harm, suicidal ideation, irritability, conflict at home and in school, and more.

We know that there are genetic influences on the development of depression in teens and that genes and gene expression play a role in the severity of a teen’s mood disorder. The same can be said for anxiety symptoms. But many other factors contribute to the development of these conditions. Likewise, certain factors can help prevent or reduce the severity of symptoms – or help improve treatment success.

Predisposition and Chance

There are always ways to beat the odds. In this case, statistics can help us recognize patterns – and preempt problems. When you understand that family history plays a role in your teen’s mental health, you can take measures to help ensure that your teen has access to everything they need to inform themselves about what their thoughts and feelings might mean. It’s important not to misinterpret a slight predisposition as some predetermination – and wait for the day your teen will wake up with a mental disorder.

It’s a much more complex process, and onset can be slow or subtle. Some teens go through hell and manage to cope – and there are teens from loving homes who eventually struggle with panic attacks and severe anxiety. The human mind is a complicated thing – and sometimes the best we can do as caregivers, parents, and therapists, is to hope for the best and do our best.

Risk Factors and Protective Factors

We have covered that genetics and family history play a role in developing different teenage mental health issues, down to specific genes often associated with one or more conditions (including common comorbidities). But there are other risk factors – and more importantly, many protective factors – worth discussing. Common risk factors include:

    • Brain damage
    • Stressful life events
    • Traumatic experiences
    • Victimization (bullying)
    • Unhealthy relationships
    • Another mental health issue
    • A physical chronic health condition
    • Social isolation (few or no relationships)
    • Frequent substance use (including alcohol)

Protective factors help improve mental wellbeing and reduce the risk of a mental health condition. They can also help reduce the severity of symptoms and improve the efficacy of treatment. Some protective factors include:

    • Physical activity
    • High self-esteem
    • Positive parental bonds
    • Social capital within the community
    • Connectedness and belonging at school
    • Social support (from friends and family)
    • Playing a role in the community (sense of belonging)
    • Living environment (housing quality, air quality, local crime rate)

Seeking Teenage Mental Health Help

At the end of the day, we may all need help in one form or another. Teens who struggle with mental health issues need specific kinds of help. This can range from taking an anti-depressant to visiting a therapist once a week or considering an inpatient/residential program. Mental health conditions always require a holistic approach – meaning different teens and different conditions need different treatments, ones that also consider co-occurring health issues (both mental and physical), family and social life, school problems, bullying, and drug use.

Categories
Mental Health

Managing Mental Health in College

For most teens, the transition from high school to college is an immensely stressful one. There are many new freedoms, opportunities, and exciting futures to explore – but they come with greater responsibilities and expectations, new environments, and plenty of unfamiliar faces. College days can be fun, but they can be punctuated by overwhelming course loads, frustrating schedules, and sleepless nights. Throughout all of this, it’s important to learn how to manage your mental health in college. A few simple habits and a couple of rules can go a long way.

You Don’t Need to Drink

A few myths surround the typical college lifestyle – but the ubiquity of alcohol isn’t one of them. The pandemic aside, statistics on college drinking show that most students consume alcohol regularly, with as many as a third engaging in binge drinking at least once a month. But you don’t need to drink with the others to fit in. There’s nothing wrong with learning your limits.

Still, if you have a history of alcohol use, a family history of alcoholism, or are currently struggling with the stresses of college life, it would be best for both your mental and physical health to stay sober. Not only does frequent binge drinking do major damage to your organs, but it also affects brain development and cognition. In addition, it can lead to co-occurring substance use issues in teens struggling with a diagnosed mental health issue, such as depression, anxiety, or untreated ADHD.

Watch Your Coping Styles

College can be stressful, and teens need to find their own ways to cope with that. Late nights, tough deadlines, expectant professors, and the social stress of a new and strange environment means finding outlets for all that pressure. Some coping mechanisms are healthier than others. Some are downright harmful.

Consider how your coping mechanisms are affecting you in the long term, as well as those around you. The habits you build in college can end up shaping a better part of your life, including the way you deal with stress. If you’re at a loss for positive coping mechanisms, consider giving the following a try:

    • Setting a weekly budget.
    • Cleaning an area of your room.
    • Owning and caring for a little plant.
    • Watching some standup or comedies.
    • Picking up a new skill during downtime.
    • Setting a simple sleep ritual to fall asleep quickly.
    • Making time for your hobbies and personal pursuits.
    • Setting consistent mealtimes and avoiding snacking.

Keep Track of How You’re Feeling

Journaling can be a helpful way for you to keep track of how you’re feeling over a period and bring along a written log of your ups and downs, should you need a record for a professional diagnosis. But the act of writing alone can help provide a great deal of catharsis for many teens struggling to verbalize otherwise or process their emotions.

It’s also a way to monitor your symptoms and discuss them with a therapist. You can use journaling not just to take note when you’ve had a terrible day but to work through exactly what it is that made it so bad. For example, oftentimes, you might realize that you didn’t have as much reason to be upset as you were – or you might feel a little better that you had some way to express your frustrations and vent a little without involving someone else.

Seek Out Local Mental Health Resources

While college is an important time to work on independence and self-reliance, we aren’t meant to go through life without help and support along the way. Take the time to familiarize yourself with the mental health resources available to you, from counseling to referred therapists. Learn about your school’s policies for disabilities due to mental health, medical leave, accommodations for students with certain difficulties, and the level of confidentiality guaranteed to students.

Get an Exercising Buddy

Physical health is important for mental health, and there are distinct therapeutic benefits to regular exercise. But it can be especially hard for someone with mental health issues to stay consistent with their physical health. One way to overcome this problem is by finding someone to work out with, either in person or virtually.

You can push one another to take the time to get moving a few times a week and keep track of one another. Unfortunately, it can get too much to try and motivate yourself to stay committed to an exercise plan while struggling with the stress. Still, you’ll find that even just half an hour a day spent getting active can help you study and retain information, avoid procrastination, and cope better.

Keep Your Days Structured

Downtime can be especially difficult, as can a loose schedule. Sometimes, just having a reason to get up in the morning can make the difference between an awful day and a decent start. Create a schedule around your course load and interests, make room for rest and recreation, and structure your daily obligations.

Utilize Your Privileges

Depending on the severity of your symptoms, you may be entitled to certain accommodations and special education services under your school’s mental health program, especially for community colleges managing mandated Individuals with Disabilities Education Act (IDEA) programs.

If you have made use of such programs during high school, you can bring any relevant paperwork over during the transition period to discuss your options in college with the administrators responsible for your accommodations. But, again, try to identify your core needs, gather the reports and doctor’s notes you might need to explain your condition, as well as how you’ve managed it in the past, and how it can affect your studies.

Consider a Medical Leave

If necessary, you might want to consider temporarily requesting a leave of absence during your semester to seek medical help for managing mental health in college, particularly if things have gotten worse during college or if you have developed different symptoms during your time on campus. Different schools have different policies and protocols for medical leave due to mental health issues and different levels of financial aid (i.e., refunded fees, grace periods, etc.).

Be sure to discuss these with your school and therapist. Many students are currently completing their courses from home while the pandemic is ongoing. College life these days has its own completely different set of challenges and problems, especially with the social isolation and deaths caused by COVID. It’s important to prioritize your mental health in college and seek help. Consider teletherapy counseling or an appropriate outpatient program.

Categories
Mental Health

Understanding and Identifying Teen Dissociative Disorders

Dissociative disorders have a relatively high prevalence yet are also easily one of the most misunderstood psychiatric conditions in the general public’s eyes. Dissociative disorders are characterized by a disconnection from reality following a traumatic experience. Dissociation in a clinical sense can take on many different forms – but it is best described as a state of mind that allows a person to break away from the past and present and become separated from their pain.

Unfortunately, the overwhelming majority of people with a dissociative disorder have an additional psychiatric diagnosis, from depression or anxiety to substance abuse. According to data pulled from several countries, dissociative disorders are estimated to affect about 1 to 5 percent of the general population. One study on teens seeking help at an outpatient psychiatric facility estimated that as many as 45 percent were struggling with a dissociative disorder of some form.

What Is a Dissociative Disorder?

Dissociative disorders are a class of conditions defined as problems with the following:

    • Memory
    • Identity
    • Emotion
    • Perception
    • Behavior
    • Sense of self

In a sense, mild dissociation is a common occurrence, one most people experience. For example, many of us may have daydreamed at some point, gotten lost in our thoughts, or experienced a form of “highway hypnosis.” However, dissociative disorders describe behavior and symptoms that are much more severe.

Dissociative disorders are pervasive across settings and disrupt nearly every aspect of life. Teens struggling with a dissociative disorder aren’t just aloof. Still, they may appear completely changed after a traumatic event, to the point that they seem like a different person, either due to the coping behaviors they’ve adopted or due to lapses and holes in their memory.

Types of Teen Dissociative Disorders

Dissociative disorders are split into three different diagnoses:

Dissociative Identity Disorder (DID)

In cases of dissociative identity disorder (DID), previously known as multiple personality disorder (MPD), a teen will switch between two or more enduring personalities. These are not just different behaviors but give the impression of being several distinct people. However, in DID cases, a teen is not actually inhabited by multiple persons or “alters” but has instead constructed different personalities to cope with their past.

Sometimes, these personalities are not necessarily human. Instead, they may each have their own set of memories. The overwhelming majority of people diagnosed with DID have experienced overpowering and often recurring trauma, usually before age 6. While dissociative disorders may be more common than we suspect, rates for DID remain around 1 percent. Another major symptom is gaps in memory, far more than regular forgetfulness.

Dissociative Amnesia (DA)

Dissociative amnesia (DA) is a more common form of dissociation and may involve blocking out information that would otherwise be consciously available after a traumatic event. However, such information would often still be subconsciously affecting one’s behavior and decision-making. For example, someone who was victimized in a closet may have an intense aversion towards opening closets or being inside them without remembering why.

Dissociative amnesia is usually diagnosed after trauma, in cases where gaps in memory or amnesia cannot be explained by another potential cause (such as brain trauma, intoxication, or the intake of certain memory-affecting substances (including surgical anesthetics). Dissociative amnesia is often either localized (not being able to recall an entire event or period), selective (not being able to recall certain portions of an event or period) or generalized (not being able to remember anything about themselves and their history).

Depersonalization/Derealization Disorder (DPDR)

Teens diagnosed with depersonalization/derealization disorder (DPDR) are either experiencing symptoms of feeling like they’re living life in the third person, from someone else’s perspective (depersonalization), or they might seem intensely aloof, isolated, and disconnected from the world around them (derealization).

As with other dissociative disorders, DPDR is often the result of trauma but can occur alongside neurological problems such as seizure disorders or neurological damage after prolonged drug use (particularly hallucinogens, marijuana, or ketamine). Most DPDR symptoms are experienced episodically rather than consistently. They are recurring over the years, however, and onset is usually around age 16.

Other conditions may feature depersonalization or dissociation as part of their list of symptoms (schizophrenia and other psychotic disorders) and others closely related to dissociative disorders (acute and post-traumatic stress disorder).

Recognizing Teen Dissociative Disorders

Your teen may be experiencing a dissociative disorder if they often display severe gaps in memory, seem to be mentally somewhere else, have suddenly become emotionless at times, seem disconnected from reality, appear to be switching between distinct personalities, or are behaving very strangely, moving around almost automatically, and describing themselves as having no control.

Dissociative disorders can be difficult to treat, and a professional diagnosis is always needed before a treatment plan can be formulated. In addition, most teens with a dissociative disorder are also struggling with a co-occurring mental health condition, including depression, anxiety, stress disorders, or drug use. These co-occurring disorders can make treatment more difficult – but a holistic plan can help address them as well through a combination of talk therapy, pharmacology, and long-term care.

Teen Dissociative Disorders and Substance Abuse

Substance use disorder (SUD) is one of the most common co-occurring disorders among teens with dissociative disorders, in part because certain drugs can help teens better cope with their experiences. A case of SUD coupled with another mental health issue is often called a dual diagnosis. However, drugs are poor coping mechanisms and carry with them a slew of physical and mental downsides ranging from long-term organ damage to cognitive impairment, further memory problems, anxiety, and exacerbated dissociation.

How Are Teen Dissociative Disorders Treated?

Dissociative disorders are treated through a combination of trauma therapies, talk therapies, and medication in cases where co-occurring disorders require them. Unfortunately, there are no medications that effectively treat symptoms of dissociation. In some cases, a doctor may prescribe an antipsychotic drug, but most drugs prescribed to patients with dissociative disorders are antidepressants.

The bulk of treatment plans relies on cognitive-behavioral therapy (CBT) based therapies and modalities. It can take several months for therapists to successfully help their teen patients reintegrate into their lives, reclaim different elements of their identity, and lead a more fulfilling life. Finding ways to cope healthily with the past is vital to the process and success of long-lasting recovery. Family and friends play a critical role herein and provide the fundamental backbone for long-term treatment as the teen’s support system.

Categories
Mental Health Self-Care

Commemorating National Teen Self-Esteem Month in 2021 and Beyond

May is National Teen Self-Esteem Month! While we should take the time to commemorate the importance of building self-esteem in our children and our peers, building self-esteem is a matter of long-term consistency. So let us commit to lifting each other in 2021 and beyond.

Bridging the Gap Between Teen Self-Esteem and Mental Health

Adolescent self-esteem is a critical protective factor for good mental health – and crucially, low self-esteem is a common risk factor for symptoms of depression and anxiety. Self-esteem also plays a protective factor against attention problems (ADHD), although to a lesser degree. The effects of self-esteem on behavioral issues, however, are inconclusive.

Having a healthy and robust sense of self can help teens feel more secure in the face of certain stressors and be less prone to self-deprecating thoughts. However, just as self-esteem can help improve a teen’s mental health, it bears mentioning that teens who have a proclivity towards anxiety issues or depression (due to family history or environmental factors such as early trauma) will generally struggle with poorer self-image.

The two are intertwined, and addressing one can help address the other. But building up a person’s self-esteem is no easy task, regardless of whether the initiative comes from the inside (self-motivation) or the outside (a concerned friend or loved one). So, this May, we are encouraging teens, as well as friends, families, and communities, to take part in uplifting one another.

This year’s effort is significant, as teens face a mental health crisis unlike any we have seen in decades. Worse yet, we have no idea how this period of their lives will affect them in the years to come. Your contribution could be as simple as refraining from hypercritical comments or considering your words more carefully before you speak, or making helping a close friend develop in a way that might give them a personal boost to their self-esteem.

Teen Self-Esteem, Depression, and Anxiety

Mood disorders and anxiety disorders constitute most mental health diagnoses among teens. The most common ones include major depressive disorder and general anxiety disorder, including low self-esteem as a major risk factor. While there are other factors behind the development and cause of these conditions, the link between self-image and mental health is undeniable, and it is often a two-way street.

Boosting teen self-esteem – or more practically, helping them boost their own self-esteem, may go a long way towards reducing or even preventing the development of a disorder, or at least majorly improving quality of life and helping prevent suicidal ideation.

It Starts With You

Our sense of self is a complicated thing, developed over the years through observation, social interaction, as well as our own inner headspace. A person’s voice can be naturally self-critical or conditioned that way over the years, and they may have a harder time registering or even accepting praise as genuine.

Others have a harder time recognizing their own flaws – or, in an ironic twist, possess such a fragile sense of self that they brutally lash out at even constructive criticisms. Learning to recognize and differentiate between healthy and problematic voices in our own head, at least with regards to how we treat ourselves and comment on our own thoughts and behavior, can help address self-esteem issues.

It might sound silly to start with the voice in your head, but just learning to identify the downward spiral before it goes completely out of control can be a good first step. It is healthy to be humble and reflective, but it is not healthy to constantly refer to yourself with harsh words or think in such negative extremes like “I’ll never amount to anything,” and “of course I couldn’t do it, I could never do something that great.”

Instead, consider rephrasing such sentiments. For example, “I’m just starting, and there’s a long and tough road ahead” is a much healthier response to an early stumble or initial failure. No one who has ever done anything great in their lives has gotten to where they got without many moments of self-doubt and failure. Similarly, “I didn’t get it this time, but I’ll keep trying” or “and that’s okay” are important sentiments, too.

Your Friends Matter

Unsurprisingly, who you surround yourself with can have an impact on how you feel, both about yourself and in general. We are all human and rely at least in part on each other to better understand how to think of ourselves – and if your “friends” or family include bullies and scolders, then you will find yourself becoming overly critical of not only your actions but your personality, your temperament, and immutable characteristics. This can lead to self-hate and depression. On the other hand, when those around us are patient with us and accepting, it teaches us to accept ourselves. Bullying does not make someone stronger – it breaks them down.

Learn to Set Better Goals and Expectations

Failure hurts, and a life well-lived will see many failures before any successes roll in. But that does not mean we should only ever set our sights on the stars. Instead, it is important to learn to set healthy and realistic goals and expectations and benefit from meeting them.

You do not have to look and move like an athlete, be a valedictorian, speak three languages, and play an instrument all at the same time. Instead, start with daily goals that you can consistently work towards, prioritize in a direction that interests you, work with your strengths and recognize (and accept) your weaknesses, and focus on being grateful for the things in life that go well for you.

Embrace the Power of Giving

Studies have shown that giving is a much more satisfying feeling than receiving – and it can go a long way towards helping you improve your self-esteem. We are not just talking about charity or good intentions. Making an effort to give your time to someone else, for free, whether by volunteering at a local organization or making a nice meal for your friends as a show of appreciation, generally makes us happier than receiving the same kindnesses from others.

Are you or a loved one struggling with self-esteem issues? Working on developing a healthier sense of self and being kinder towards yourself can go a long way, but some people struggle with thoughts and emotions that cannot be dealt with alone. It’s okay if you need help; we all do eventually! Thus, if you feel discouraged about asking for help, know that you are not alone! Get in touch with a mental health professional today.

Categories
Mental Health

Honoring Mental Health Awareness Month 2021: “You Are Not Alone”

This May, the National Alliance on Mental Illness emphasizes an important message for Mental Health Awareness Month 2021: You Are Not Alone.

As of 2019, one in five American adults experienced mental disorders, and one in 20 American adults struggled with a serious mental health episode. Half of all lifetime mental disorders begin at age 14, highlighting the importance of supporting our teens as well. In addition, researchers believe that the long-term mental health effects of the pandemic are just beginning to unfold, meaning we may be on the horizon of a serious upward curve in our mental health crisis.

2020 had us all struggle with the isolation and sorrow wrought by a devastating pandemic. Besides the direct impact of COVID-19, many Americans continue to struggle with the measures used to combat the pandemic, from mandated lockdowns to strained healthcare resources. In 2020, NAMI launched the Tools 2 Thrive campaign, emphasizing the importance of safeguarding one’s mental health during the pandemic and building the toolkit to attend to one’s own mental needs.

2021 is about pulling together to reiterate the importance and power of community and family in treating and managing mental health issues and remind one another that we are not alone.

What Is Mental Health Awareness Month?

Mental Health Awareness Month, or the Mental Health Month, has been observed in the United States every May for the last 50 years. It has always been a time for mental health institutions in the country (and other parts of the world) to remind readers to care for one another, spread awareness of the ongoing struggles of people with mental health issues (particularly marginalized communities and minorities), and share resources that are effective in combatting mental health issues at home and throughout the community.

Mental Health Awareness Month 2021 takes place all month and will be honored through encouraged community-wide posts, shared personal stories and experiences, video and photo content, regular blog content from NAMI’s blog, and featured resources, featured warmlines, and featured organizations that help address ongoing mental health crises throughout the country.

NAMI’s Message: You Are Not Alone

After a year highlighted by isolation, NAMI’s message is specifically meant to guide people to the help they need by highlighting available support organizations and resources, driving home the importance of providing support to loved ones and fellow community members, and raising awareness on just how common certain mental health issues have become, including depression, anxiety, and a dual diagnosis of a mental disorder and substance use disorder.

Showing Your Support This Year

If you are interested in impacting mental health this year, consider getting involved directly through a donation of your time or money. Organizations that advocate for those struggling with mental health disorders include:

As well as state-specific mental health charities and local shelters, you can also volunteer your time and find local volunteering opportunities through your state or county’s respective Department of Health or Mental Health.

Share Your Story

This year, part of the event is sharing personal stories about facing and overcoming mental health struggles, whether through COVID or any other time, to help others understand that they are not alone.

Through the hashtags #MentalHealthAwarenessMonth, #MentalHealthMonth, #MentalHealthMatters, and #NotAlone, people all over the country are encouraged to talk about the difficulties their diagnosis has caused them, the stigma and trials they’ve faced as a result of their condition, and the ways they’ve found help and support over the years.

NAMI will be featuring specific stories throughout the month, hoping that sharing these experiences will help readers feel a kinship with others who have had to walk a similar path and have found hope and help. COVID-19 has left many feeling isolated and alone, struggling to find a sense of community around them, particularly if they belong to a vulnerable group due to a different health condition.

These stories can also help readers find virtual communities to connect with while helping them find resources and toolkits online to gain access to telehealth solutions, find safe outpatient clinics near them, and help implement activities and exercises at home to reduce mental health symptoms.

Engage With the Community

Having a community to engage with is a critical boon in the fight for better mental health and awareness. Unfortunately, the pandemic has made this a difficult task. Still, organizations like NAMI are trying to help people leverage online resources to find opportunities to connect with others and establish lasting, meaningful relationships online – through telehealth services, online support groups, and social media.

Teens have been struck by the interpersonal and social impact of the pandemic, and are struggling with a level of isolation that can have a long-lasting effect on their ability to socialize and seek out meaningful connections. While a virtual call doesn’t supersede a face-to-face interaction, virtual friendships can be meaningful and provide huge benefits for teens isolated in their homes by anxiety and local restrictions.

Download the Event Guide

NAMI has produced its own online event guide for interested readers and parties to follow as they continue to present Mental Health Awareness Month 2021. The event guide provides and names multiple resources and organizations, helps provide context for MHAM via updated statistics and infographics, shares the importance of providing support both to individuals and the community, and highlights how mental health impacts individuals and communities, respectively.

It also provides text and graphic examples for you to share with others to raise awareness for mental health issues this month, as well as more specific brand information for organizations and companies interested in following NAMI’s brand guidelines when scheduling or organizing a mental health awareness event this month.

Categories
Personality Disorder

Treatment Options for Teens With Paranoid Personality Disorder (PPD)

Paranoid personality disorder (PPD) is one of ten personality disorders currently recognized by the DSM-V. The characteristics of PPD center around mistrust and paranoia permeating one’s thoughts and behaviors. Teens struggling with PPD are extremely suspicious of others, often lash out, struggle to interact with others in a healthy way, and misinterpret random or innocent events, words, and gestures as somehow malicious and personal.

How do you treat someone who is fearful of everything around them, constantly worries about being manipulated, and suspects that there is a plot against them hiding behind every corner? Very carefully. Most of the treatment options for teens with paranoid personality disorder center around psychotherapy and rely on the quality of the relationship between the teen patient and their psychotherapist.

Experience with the condition and how best to treat it is an important premium in these cases, as therapists must gain their patient’s trust for any therapy to be effective. Insisting that each therapeutic session is a collaborative effort is a good first step. PPD patients are very unlikely to cooperate if they somehow perceive that therapy is something being done to them, rather than with them. It can take multiple attempts to find the right therapeutic fit for a patient, and establish the kind of long-term relationship needed when treating PPD.

Cognitive Behavioral Therapy for Paranoid Personality Disorder

Cognitive behavioral therapy (CBT) is often the first choice of talk therapy in the treatment of different disorders, ranging from major depression to general anxiety, alcohol abuse, eating disorders, and personality disorders. As a concept, cognitive behavioral therapy espouses the idea that we can learn to recognize disordered thinking, and address both our thoughts and behavior through a structured therapeutic process. This concept has even proven to be as effective or more effective than pharmacological means in the treatment of some mental health issues.

On a practical level, CBT is a heavily researched and studied therapeutic method that can be adapted to help patients form protocols and alternative coping methods to deal with unhelpful ways of thinking and behaving. A therapist takes time to work through these patterns with the patient to try and better understand why they occur, where they come from, how they are triggered, and what steps the patient might take to address them. This can include learning to re-evaluate negative thinking patterns in the light of reality, better understanding one’s own motivations, and developing problem solving skills to work through stressful situations without returning to a maladaptive method.

Cognitive behavioral therapy can play a central role in the treatment of paranoid personality disorder by helping a teen reflect on their thoughts and behaviors considering inalienable facts, understand and gain insight into the context behind how their actions have affected others, and learn to better control their own impulses and mood changes. CBT often also involves using breathing exercises to calm down when faced with anxious feelings or stressful situations. These therapeutic methods are meant to arm teens with the means to become their own therapists, in due time. A lot of CBT exercises are also treated as homework, to be repeated often outside of the therapy room.

Dialectical Behavior Therapy for Paranoid Personality Disorder

Dialectical behavior therapy (DBT) can be considered an offshoot of CBT but is more often considered its own type of talk therapy. It has its origins in the treatment of personality disorders, particularly borderline personality disorder, which some doctors felt was not adequately treated via the guidelines and concepts of CBT. It centers on self-destructive behavior. DBT incorporates a new idea into CBT based on dialectics. Dialectics are a philosophical concept that originates from truth-seeking discourse (dialogue, dialektikḗ in Greek) between individuals with different points of view.

The main characteristic behind DBT is a focus on the conciliation of opposite views, and the acceptance of these conflicts. Imagine, for example, loving someone very dearly, and being proud of them for working hard, but feeling resentment towards them for not being able to spend more time with you and your family. This is a conflicting situation where both thoughts are true and valid, and conciliating the two is a dialectical exercise. What we end up with is not just two separate thoughts, but an interpretation of the truth that takes both sides into account.

In this instance, DBT for paranoid personality disorder would try to tackle the contradictions created by wanting to develop a stronger sense of self-esteem and understanding that one’s thoughts can be deceiving or dangerous. This is especially important for paranoid personality disorder because the thought of changing can be frightening to many teen patients struggling with paranoia. Learning to both validate oneself and understand that there is room for improvement can lead to a more constructive treatment path.

Psychodynamic Therapy for Paranoid Personality Disorder

Psychodynamic therapy is centered on the traditional concepts of psychoanalysis, truncated to be simpler and more effective. It involves working with a patient to gain insight to their daily lives and how their thought patterns affect the decisions they make, considering factors such as belief systems and early life experiences. By sharing this process with the patient, the therapist helps them learn to evaluate and analyze themselves, understand how early-life experiences and beliefs shape their actions, and develop healthier responses.

Why Group Therapy Might Not Be the Best Option

One therapeutic treatment option that is rarely suggested for teens with paranoid personality disorder is group therapy. The one-on-one relationship between the patient and their therapist is central to the treatment of PPD, because of the innate importance of trust. Patients with PPD will be much less likely to open and agree to therapeutic suggestions while in a group with other teens.

What About Medication?

There are no medications specifically targeting PPD. However, some medications are used in the treatment of concurrent mental health issues, particularly anxiety disorders and depression. Antidepressants, for example, may help reduce the severity of symptoms that might be exacerbating a teen’s paranoia. It would not address the root issue but could act as an important supplemental tool along with therapy. Paranoid personality disorder is a complicated and difficult condition to treat. It takes time, commitment, and the right treatment plant.

Categories
ADHD Substance Abuse

ADHD and Substance Abuse: What Parents Need to Know

Attention-deficit hyperactivity disorder (ADHD) is diagnosed in about one in ten adolescents (and fewer young children), yet many cases go unnoticed for years and remain undiagnosed and untreated. It is those cases that are at the most risk of developing substance abuse issues later in life. In many cases, teens with ADHD who began using drugs were not looking to get high – instead, they sought drugs to combat the symptoms of an untreated disorder.

While the treatments for ADHD rely on controlled and addictive substances (amphetamine and methylphenidate), research also shows that teens with ADHD who are treated early and routinely take prescribed ADHD medication are much less likely to struggle with drug use later in life.

For reasons not yet completely understood, there is a strong link between ADHD and drug abuse, with potential factors including genetic proclivity, unrecognized ADHD symptoms, how they respond to self-medication, and the link between drug-seeking behavior and risk-taking novelty-seeking behavior linked to ADHD diagnoses. Either way, ADHD often co-occurs with addiction, and concurrent treatment through a holistic, multimodal approach is often necessary.

The Link Between ADHD and Substance Abuse

Adult alcoholics are five to ten times more likely to have undiagnosed ADHD than the general public. Among adults being treated for addiction, about a quarter have been diagnosed with ADHD. Among teens, some studies note that as many as 40 percent of teens with ADHD start drinking at an early age, versus 22 percent of teens without ADHD. Among young adults, the likelihood of using alcohol evened out – but those with ADHD were more likely to use alcohol excessively.

The two major factors researchers take into consideration are behavior and genetics. Both alcoholism and ADHD can be hereditary, and there is an increased rate of addiction in close relatives of people with an ADHD diagnosis. The impulsive, novelty-seeking behavior associated with ADHD may make some teens more likely to try or overindulge drugs than others. While ADHD medication itself is addictive in large doses, most cases of ADHD-related addiction are not because of the medication.

Instead, teens diagnosed and treated with ADHD meds early were less likely to struggle with drug use later. However, that does not mean these drugs are not dangerous for teens without ADHD symptoms. It seems amphetamines and methylphenidate work differently in the brains of teens with ADHD and those without. In other words, addiction to alcohol and other drugs is linked to ADHD, not to ADHD medication.

Recognizing ADHD in Teens

ADHD is a condition with multiple subtypes, and a correct diagnosis can only be achieved through mental healthcare professional. But knowing what to look for in yourself or a loved one can help you make the important decision of seeking a professional diagnosis. Common signs of ADHD in teens include:

    • Trouble finishing tasks.
    • Mood swings and emotionality.
    • Difficulties with executive functions.
    • Lack of focus, chronic distractibility.
    • Poor decision making, impulsiveness.
    • Hyperactivity, often presented through fidgeting movements.
    • May have one or more hobbies where they excel – everything else feels impossible to concentrate on.

ADHD is not just easily excitable, somewhat hyperactive, or scatterbrained. Children and teens with ADHD are often all over the place, cannot sit still, are easily consumed by boredom (even when everyone else is engaged), and are incredibly prone to risk-taking and dangerous, self-destructive behavior. Their executive dysfunction has often advanced to the point that it leads to chaos in their daily lives, including:

    • At school
    • At home
    • With friends
    • In relationships
    • And more

Teens with ADHD develop slower than their peers when it comes to time management and metacognition, and many undiagnosed cases of ADHD are unfairly labeled as lazy or just plain difficult.

Treating ADHD and Substance Abuse in Teens

Drug addiction with a concurrent mental health issue is often known as a dual diagnosis. Treating the dual diagnosis of ADHD and substance abuse requires a holistic approach because the two conditions are heavily entwined. There are neurological and psychological considerations during both heavy use and total withdrawal and their effect on the efficacy of a targeted treatment plan. Comprehensive dual diagnosis treatment often takes on the form of an inpatient or outpatient program with:

    • Multiple talk therapy methods to address and modify destructive thoughts and habits.
    • Skill-building to help identify and improve upon alternative coping mechanisms.
    • A consistent medication plan.
    • Group therapy to help patients become part of a larger support network and benefit from shared experiences.
    • The incorporation of friends and family as crucial elements in on-going, long-term treatment, long after the end of the initial treatment period.

ADHD is a condition that requires a combination of behavior-modifying therapy and medication. Teens with ADHD often cannot just learn to overcome their nature – they are inherently struggling with an atypical brain structure. Their addiction is often the result of numerous attempts to cope with these abnormalities and the problems they bring to the table during day-to-day activities. Addressing both concurrently means providing ample treatment for ADHD while arming the patient with the means to recognize, address, and avoid signs of recurring drug abuse.

Long-Term Treatment and Consistent Support

In some cases, the most important skill is knowing when to call for help and recognizing – and embracing – the importance of support networks when self-motivation is not enough. Coping with ADHD itself can be difficult – coping with addiction on top of that is even harder. The journey towards a fully functional and healthy life is a long one for many teens, and it cannot be walked alone.

The role of a friend or family member is not the same as that of a therapist or doctor, but it remains crucial, especially in the long-term. These conditions are not treated over the course of several weeks but instead require consistent effort over the years and a commitment towards alternative coping mechanisms and the lessons of therapy. It is also a loved one’s job to recognize when family support is not enough and when it is important to seek professional help once again.

Categories
Personality Disorder

How to Deal With a Narcissistic Teenager

Self-obsession is a natural trait in children. Toddlers are in a stage of personal development where they must learn to attend to (and defend) their own needs and identify sources of danger to their own well-being. As preteens and teens go through adolescence, they begin to develop independence, taking the time to define their sense of self.

While empathic traits are also a normal part of being human – regardless of age – it is still normal for kids to generally put themselves first, feel jealous of others, and even seem egotistical. Narcissism becomes a dangerous trait in teens when they are self-centered and wholly incapable of showing interest or compassion for others.

The Roots of a Narcissistic Teenager

Narcissistic personality disorder, or narcissism as a psychiatric diagnosis, is not typically diagnosed in children under 18. This crucially includes most teens, as some signs of natural behavior may be misinterpreted as narcissistic behavior. There are still a few key differences between being self-centered and true diagnosed narcissism, or NPD.

A psychiatrist or doctor may refuse to diagnose your child unless they exhibit clear signs of disordered behavior, such as severe problems with interpersonal relationships, clear lack of empathy, signs of grandiosity across situations and settings, and explosive (dangerous) jealousy. In general, teens start to develop out of their self-centered mindset around ages 15 and 16.

Personal development is highly individual, so it is difficult to put an exact number on it. As your teen approaches the final stages of teenage life, they will likely change in behavior to show that they are beginning to grasp that the world does not revolve around them, that they have certain responsibilities to others. There is more to life than impressing others. But that does not mean these things happen overnight.

Parenting styles, experiences, and even advertising play a role in how your teen thinks of themselves, and the world. Your teen might not be a diagnosed narcissist, but their self-centered thinking may still be an undesirable or grating character trait that could be addressed through less drastic measures than full-on therapy. Consider speaking with a professional about how your parenting philosophy might influence a child to develop narcissistic tendencies, such as:

    • Exclusively tying consequences and punishments to possessions (causing your child to place too much value in material wealth).
    • Your teen’s media consumption or attitude towards advertising (advertisers and social network companies collaborate to instill superficial positivity into their customers, incentivize online engagement, and sell more).
    • Your family’s attitude towards the importance of charity, volunteering, and empathic community endeavors.

Narcissism vs. Narcissist Personality Disorder

After the Greek myth of the young man who accidentally drowned himself, narcissism is defined by self-obsession, enamored with his reflection in the water. Yet, a crucial and defining part of that myth (and definition) is the inability of the narcissist to love or care for anyone else.

Teens who put themselves first may be entitled or self-centered, but not necessarily narcissistic. A narcissistic teenager struggles to function as a partner, is impacted by their negative behavior at work or school, and is disruptive. About 6 percent of people above the age of 18 are diagnosed with a narcissistic personality disorder.

Signs of Narcissistic Personality Disorder (NPD)

Signs of narcissistic personality disorder include:

    • Inflated sense of superiority.
    • Exaggerating achievements and accomplishments.
    • Remorselessly manipulative behavior.
    • Lack of ability to empathize with others/cannot understand the needs of others.
    • Arrogant and haughty behavior.
    • Chases after status symbols.
    • Typically leans towards valuing cerebral superiority (believing themselves as omnipotent, incomparably brilliant) or somatic superiority (focused on looks and status, allure, sex appeal, and body).
    • Depression and anxiety issues.

Some risk factors associated with developing narcissistic personality disorder later in adulthood can include:

    • Learning how to manipulate others.
    • Sudden loss during childhood.
    • Severe emotional abuse.
    • An excessively critical or over-indulging environment.
    • Lack of consistent parenting/caregiving (had to fend for themselves part of the time or most of the time).

Building Empathy With Your Teen

Self-absorbed teens may be helped through a targeted parenting approach. By working to address each of the behavioral flaws your teen is exhibiting, you might be able to help them achieve a different outlook and tap into their inner sense of empathy and compassion.

Do not expect a child to mature into an adult over the course of a few weeks but know that being needlessly and constantly self-absorbed is not necessarily healthy or normal behavior either. You could try building empathy with your teen by bringing the topic up whenever it becomes relevant.

When your teen is angry that something did not work out in their favor, such as a friend canceling dinner plans due to a sudden family emergency, ask them to consider what their friend might be going through at that moment and the fear and sorrow they might be feeling. Encourage your teen to consider acting on their emotions by consoling their friend.

When something tragic happens in the news, ask your teen what they think it would be like to be in such a horrible situation. Or when they act in their self-interest while going against their word with a friend or betraying someone’s trust, compel them to take a moment to reflect on their actions and consider whether they feel guilty.

These exercises aren’t about teaching a teen to share or apologize in an earnest tone – they’re about getting them to take other people into account, take a look at the bigger picture, and grow.

Helping Your Narcissistic Teenager

A narcissistic teenager is a little more difficult to treat. A psychologist will interview and review your teen’s symptoms and behavior, run tests to rule out other potential causes, and prescribe a treatment plan. In general, true narcissists will not accept treatment and would not volunteer to be labeled as needing help. You cannot convince them that something is wrong.

However, they may be convinced to consider talk therapy and change their behavior to better fit in with others and reduce the challenges of interpersonal relationships. This can help a professional slowly get to the root of the patient’s behavioral issues and thought patterns, often ironically centered around insecurity and low self-esteem, and deep-seated self-resentment.

Teens diagnosed with NPD need friends and family to help support them by highlighting their therapy goals and reminding them that it is a long-term step-by-step journey. It takes time to learn to develop one’s empathy in cases of NPD and separate oneself from the problematic thought patterns that feed narcissism.