Sex on the Brain

FIX THE BRAIN ISSUES THAT GET IN THE WAY OF SEX

PMS, Depression, ADD, Substance Abuse, Denial, and Being a Jerk

Get away, get away, get away, get away
Get away cause I’m pms-ing

—“PMS,” MARY J. BLIGE

Celia and Greg fell madly in love for five weeks. They met on Match.com shortly after Labor Day. On the surface they seemed like a perfect couple. They were both well educated, caring, hardworking, and had similar lifestyle habits. The attraction was amazing, even between their families. Greg loved Celia’s little girl, and Greg’s teenage girls got along very well with Celia. With new love comes hope. They were together most days and on the phone for several hours a day when they were apart. Five weeks into the passionate relationship things started to abruptly change. Celia started to back up. She became distant, irritable, and short tempered. Nothing Greg did seemed right. Even though she was fully involved with moving the relationship forward, she felt the need to backtrack. Greg felt disoriented. What happened?, he wondered. Initially, he felt anxious at the change. He had met few women as wonderful as Celia, few women that took his breath away. But he did as Celia wanted. That still didn’t seem good enough and Celia broke off the relationship. Greg felt very sad. Then Celia started her menstrual period. She was horrified by her behavior and for losing Greg. When she called him, he was happy to hear from her, but hurting from what happened. He was gun shy. Premenstrual tension syndrome (PMS) is real and causes real problems in the brain and in relationships.

It is not just PMS that can ruin relationships. Other brain problems, such as depression, ADD, substance abuse, anxiety disorders, obsessive-compulsive disorder, and personality disorders also interfere with love. Understanding and treating these problems is critical to healthy relationships and healthy sex. In this chapter, I will explore the most common brain ailments interfering with love and sex that we see in our clinics and give you a way to think about how to get the best help for them. Some people will need psychotherapy; some will need medication; others will need more directed guidance with supplements or other alternative treatments. I will also help you decide if and when you need to seek professional help. In lecturing around the world, I am frequently asked the following questions: When is it time to see a professional about my brain? What should I do when a loved one is in denial about needing help? How do I go about finding a competent professional?

A Quick View of Common Brain Problems Affecting Love and Sex

PMS

When I saw patients with PMS after I started my brain-imaging work in 1991, I just had to look. Now I know more about PMS than I want to. I have five sisters and two daughters. Plus, I have an ex-lover (I’ll call her Laura) who suffered from severe PMS. She loved me passionately for the first seven days of her menstrual cycle, was very neutral on me for the next fourteen days, and just seemed to hate me for the last seven days or so of her cycle. Laura’s behavior the first seven days of her cycle kept me hooked into the relationship. Our relationship was being intermittently reinforced, a psychological term about learning behavior; when someone is reinforced occasionally or intermittently, it causes them to want to stay in a relationship, hoping for more.

Over the past years we have scanned many women with PMS just before the onset of their period, during the worst time of their cycle, and then again a week after the onset of their period, during the best time. Even though brain-SPECT scans are very consistent from day to day in most people, they can radically change in women with PMS. I knew from my own experience with Laura that likely the PMS brain changed over the month. When PMS is present, we see dramatic differences between the scans. When a woman feels good, her deep limbic system (emotional brain) is calm and cool and she has good activity in her temporal lobes (mood stability and memory) and prefrontal cortex (judgment). Right before her period, when she feels the worst, her deep limbic system and anterior cingulate gyrus (worry center) is often overactive and she has poor activity in her temporal lobes and prefrontal cortex!

I have seen two PMS patterns, clinically, and on SPECT, that respond to different treatments. One pattern is increased deep limbic activity often accompanied by poor activity in the temporal lobes, which correlates with cyclic mood changes and anger. This finding often responds best to anticonvulsant medications, such as Depakote, Neurontin, Lamictal, or Tegretol. These medications tend to even out moods, calm inner tension, decrease irritability, and help people feel more comfortable in their own skin.

The second PMS pattern that I have noted is increased deep limbic activity in conjunction with increased anterior cingulate gyrus activity. The anterior cingulate, as we have seen, is the part of the brain associated with shifting attention. Women with this pattern often complain of increased sadness, worrying, repetitive negative thoughts and verbalizations (nagging), and cognitive inflexibility. This pattern usually responds much better to medications that enhance serotonin availability in the brain, such as Lexapro, Zoloft, and Prozac. Here are two examples.

Brittany. Brittany was a thirty-eight-year-old married female referred for evaluation of suicidal thoughts, depression, and temper flares. She also experienced problems with anxiety, excessive tension, and overeating. These problems occurred primarily during the last ten days of her menstrual cycle and abated two to three days after the onset of menses. On several occasions she separated from her husband within the seven days prior to the onset of her period; on one occasion, she lashed out at him physically. The patient and her husband confirmed the cyclic changes to her symptoms. Both Brittany and her husband kept a symptom log over the next month. On Day 27 (of a twenty-nine-day cycle) Brittany called the clinic saying that she was having problems with suicidal thoughts and depression. She was scanned the same day. Her SPECT study revealed significant increased activity in the anterior cingulate gyrus and marked decreased activity in the left temporal lobe and prefrontal cortex bilaterally. She was then scanned on Day 8 of the next menstrual cycle when she was symptom free. Her follow-up scan revealed improved temporal lobe and prefrontal cortex function but persistent cingulate hyperactivity. Due to the clear temporal lobe problems, Brittany was placed on the anticonvulsant Depakote, which stabilized her temper outbursts and suicidal thoughts. The serotonergic antidepressant Zoloft was then added a month later due to persistent premenstrual sadness. Three years later she remains symptom free.

Anne. Anne was a thirty-three-year-old married female referred for evaluation of suicidal thoughts, depression, anxiety, and irritability. These problems occurred predominantly during the last week of her menstrual cycle and significantly let up several days after the onset of menses. She had experienced a postpartum depression after the birth of one child but not after the birth of her other two children. Anne and her husband confirmed the cyclic changes to her symptoms. Both she and her husband kept a symptom log over the next month. On Day 25 (of a twenty-eight-day cycle) Anne called the clinic complaining of severe agitation and moodiness. She was scanned the same day. Her SPECT study revealed significant increased activity in the anterior cingulate gyrus and deep limbic regions. She was then scanned on Day 10 of the next menstrual cycle when she was symptom free. Her follow-up scan revealed excess activity in the anterior cingulate gyrus and deep limbic system. Lexapro was very effective in calming her symptoms. Two years later she remains symptom free during the premenstrual period.

Mood Disorders

Mood disorders severely affect libido and relationships. Depression is often associated with low libido, negativity, and a higher divorce rate. The “up” or manic phase of bipolar disorder can be associated with impulsivity, hypersexuality, and hyperreligiosity.

Depression

Burl, a fifty-two-year-old contractor, husband and father of two boys, was referred to me because he was tired all the time. His family physician ruled out the physical causes of fatigue and thought he was stressed. Additionally, he had trouble focusing at work and had trouble sleeping. His caffeine use went way up, but it didn’t help his energy, just made him edgy. His sex drive was gone, his appetite was poor, and he had no interest in doing things with his family. Burl would cry for no apparent reason and he even began to entertain suicidal thoughts. Burl had a serious depressive illness.

Depression is a very common brain illness. Studies reveal that at any point in time, 3 to 6 percent of the population have a significant depression. Only 20 to 25 percent of these people ever seek help. This is unfortunate because depression is a very treatable problem.

The following is a list of symptoms commonly associated with depression:

• sad, blue, or gloomy mood

• low energy, frequent fatigue

• lack of ability to feel pleasure in usually pleasurable activities

• irritability

• poor concentration, distractibility, poor memory

• suicidal thoughts, feelings of meaninglessness

• feelings of hopelessness, helplessness, guilt, and worthlessness

• changes in sleep, either poor sleep with frequent awakenings or increased sleep

• changes in appetite, either markedly decreased or increased

• social withdrawal

• low self-esteem.

Early detection and treatment is important to a full and complete recovery. My imaging work has revealed that there are multiple types of depression and treatment needs to be specifically tailored to the type. See my book Healing Anxiety and Depression (written with Lisa Routh).

Bipolar Disorder

Patricia is a twenty-eight-year-old married mother of two children. She had a period of depression six months earlier and had been prescribed an antidepressant by her OB/GYN. Initially she felt much better. Then she started slowly having trouble sleeping. Her thoughts raced, she became more irritable and much more sexual. She was used to having sex several times a week with her husband, but now wanted it every day. She propositioned three of her male coworkers, which was out of character. Two of her coworkers took her up on her offer and she ended up contracting herpes, which she gave to her husband. On the verge of divorce, they came to see me. Patricia had bipolar disorder triggered by the antidepressant, which is not an uncommon scenario. It is sad to think that an improperly treated psychiatric illness can tear apart families. With the right treatment, which included a mood stabilizer and fish oil, Patricia and her husband did much better.

Bipolar disorder is a mood illness where people cycle between two poles of emotion. There may be periods of depression that alternate with periods of high, manic, irritable, or elated moods. Mania is categorized as a state distinct from one’s normal self, where there is greater energy, racing thoughts, impulsivity, a decreased need for sleep, and a sense of grandiosity. It is often associated with periods of hypersexuality, hyperreligiosity, or spending sprees. Sometimes it is also associated with hallucinations or delusions. In treating the depressive part of the cycle, both pharmaceutical and supplemental antidepressants have been known to stimulate manic episodes. It is important to vigorously treat this disorder, as it has been associated with marital problems, substance abuse, and suicide.

Here is a list of symptoms often associated with bipolar disorder:

1. Periods of abnormally elevated, depressed, or anxious mood

2. Periods of decreased need for sleep, feeling energetic on dramatically less sleep than usual

3. Periods of grandiose notions, ideas, or plans

4. Periods of increased talking or pressured speech

5. Periods of too many thoughts racing through the mind

6. Periods of markedly increased energy

7. Periods of poor judgment leading to risk-taking behavior (separate from usual behavior)

8. Periods of inappropriate social behavior

9. Periods of irritability or aggression

10. Periods of delusional or psychotic thinking.

Bipolar I, which used to be called manic depressive illness, is thought to be the more classic form of this disorder. In recent years, a milder form of the disorder, called Bipolar II, has been described; it is associated with depressive episodes and milder “hypomanic” issues.

The treatment for bipolar disorder, both I and II, is usually medication, such as lithium or anticonvulsants such as Depakote. Recent literature suggests that high doses of omega-3 fatty acids, found in fish or flaxseed oil, can also be helpful.

Antidepressants and Romantic Love

Depression inhibits romantic love. People who are depressed tend to be negative, socially isolated, and often have little interest in sex. They might also have suicidal feelings, which are usually a turnoff to potential partners. Treating depression is essential for people to have healthy relationships. Yet, the specific type of treatment can either enhance or hurt attraction in romantic love. In my imaging work I have discovered that depression is not one illness and that the treatment needs to be tailored individually. In general, however, bupropion (Wellbutrin) is prosexual and enhances sexual feelings and function. It enhances dopamine availability in the brain and increases attention and focus. It is useful to treat depressions associated with low energy. SSRIs, useful in treating depression associated with obsessive thinking, can jeopardize romantic love. Low serotonin levels help explain the obsessive thinking common in early romantic love. In a study by Helen Fisher, subjects reported that they thought about their loved one 95 percent of the day and couldn’t stop thinking about them. This kind of obsessive thinking is comparable to obsessive-compulsive disorder, also characterized by low serotonin levels. Serotonin-enhancing antidepressants blunt the emotions, including the elation of romance, and suppress obsessive thinking, a critical component of romance. “When you inhibit this brain system,” Dr. Fisher warns, “you can inhibit your patient’s well-being and possibly their genetic future.” These antidepressants also inhibit orgasm, clitoral stimulation, penile erection, and seminal fluid. From an anthropological perspective, Dr. Fisher concludes, “a woman who can’t get an orgasm may fail to distinguish Mr. Right from Mr. Wrong.” As one woman on an SSRI told me, “I thought I no longer was attracted to my husband.” In a study, women on SSRIs rated male faces as more unattractive, a process called courtship blunting. Seminal fluid contains dopamine and norepinephrine, oxytocin and vasopressin, testosterone and estrogen. Without an orgasm, men may lose the ability to send courtship signals. These warnings should encourage us to look for alternative treatments in depression.

Anxiety Disorders

There are five common types of anxiety disorders that can affect people’s relationships, moods, and sexuality in a negative way: panic disorders, agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, and performance anxiety. I’ll briefly discuss each of these and their treatments.

Panic Disorder

Healthy sexuality is usually enhanced by a sense of safety and peacefulness. But what if all of a sudden your heart starts to pound. You get this feeling of incredible dread. Your breathing rate goes faster. You start to sweat. Your muscles get tight, and your hands feel like ice. Your mind starts to race about every terrible thing that could possibly happen and you feel as though you’re going to lose your mind if you don’t get out of the current situation. You’ve just had a panic attack. Panic attacks are one of the most common brain disorders. It is estimated that 6 to 7 percent of adults will at some point in their lives suffer from recurrent panic attacks. They often begin in late adolescence or early adulthood but may spontaneously occur later in life. If a person has three attacks within a three-week period, doctors make a diagnosis of a panic disorder.

In a typical panic attack, a person has at least four of the following twelve symptoms: shortness of breath, heart pounding, chest pain, choking or smothering feelings, dizziness, tingling of hands or feet, feeling unreal, hot or cold flashes, sweating, faintness, trembling or shaking, and a fear of dying or going crazy. When the panic attacks first start, many people end up in the emergency room because they think they’re having a heart attack. Some people even end up being admitted to the hospital.

Anticipation anxiety is one of the most difficult symptoms for a person who has a panic disorder. These people are often extremely skilled at predicting the worst in situations. In fact, it is often the anticipation of a bad event that brings on a panic attack. For example, you are in the grocery store and worry that you’re going to have an anxiety attack and pass out on the floor. Then, you predict, everyone in the store will look at you and laugh. Pretty quickly the symptoms begin. Sometimes a panic disorder can become so severe that a person begins to avoid almost any situation outside of home—a condition called agoraphobia.

Panic attacks can occur for a variety of different reasons. Sometimes they are caused by medical illnesses, such as hyper-thyroidism, which is why it’s always important to have a physical examination and screening blood work. Sometimes panic attacks can be brought on by excessive caffeine intake or alcohol withdrawal. Hormonal changes also seem to play a role. Panic attacks in women are seen more frequently at the end of their menstrual cycle, after having a baby, or during menopause. Traumatic events from the past that somehow get unconsciously triggered can also precipitate a series of attacks. Commonly, there is a family history of panic attacks, alcohol abuse, or other mental illnesses.

On SPECT scans we often see hyperactivity in the basal ganglia, or sometimes temporal lobe problems. Psychotherapy is my preferred treatment for this disorder and in some studies has been shown to calm basal ganglia activity. Sometimes supplements or medications can also be helpful. Unfortunately the most helpful medications are also addictive, so care is needed.

Agoraphobia

The name agoraphobia comes from a Greek word that means “fear of the marketplace.” In behavioral terms it means the fear of being alone in public places. The underlying worry is that the person will lose control or become incapacitated and no one will be there to help. People afflicted with this phobia begin to avoid being in crowds, in stores, or on busy streets. They’re often afraid of being in tunnels, on bridges, in elevators, or on public transportation. They usually insist that a family member or a friend accompany them when they leave home. If the fear establishes a foothold in the person, it may affect his or her whole life. Normal activities become increasingly restricted as the fears or avoidance behaviors dominate their life.

Agoraphobic symptoms often begin in the late teen years or early twenties, but I’ve seen them start when a person is in their fifties or sixties. Often, without knowing what is wrong, people will try to medicate themselves with excessive amounts of alcohol or drugs. This illness occurs more frequently in women and many who have it experienced significant separation anxiety as children. Additionally, there may be a history of excessive anxiety, panic attacks, depression, or alcohol abuse in relatives.

Agoraphobia often evolves out of panic attacks that seem to occur “out of the blue,” for no apparent reason. These attacks are so frightening that the person begins to avoid any situation that may be in any way associated with the fear. I think these initial panic attacks are often triggered by unconscious events or anxieties from the past. For example, I once treated a patient who had been raped as a teenager in a park late at night. When she was twenty-eight, she had her first panic attack while walking late at night in a park with her husband. It was the park setting late at night that she associated with the fear of being raped and which triggered the panic attack. Agoraphobia is a very frightening illness to the patient and his or her family. With effective, early intervention, however, there is significant hope for recovery. The scan findings and treatment are similar to those for people with panic disorder. The one difference is that people with agoraphobia often have increased anterior cingulate gyrus activity and get stuck in their fear of having more panic attacks. Getting stuck in the fear often prevents them from leaving home. Using medications, such as Prozac and Lexapro, or supplements, such as 5-HTP and St. John’s wort, to increase serotonin and calm this part of the brain is often helpful.

Obsessive-Compulsive Disorder (see Lesson Eight)

Posttraumatic Stress Disorder

Joanne, a thirty-four-year-old travel agent, was held up in her office at gunpoint by two men. Four or five times during the robbery, one of the men held a gun to her head and said he was going to kill her. She graphically imagined her brain being splattered with blood against the wall. Near the end of this fifteen-minute ordeal, they made her take off all her clothes. She pictured herself being brutally raped by them. They left without touching her, but locked her in a closet.

Since that time her life had been thrown into turmoil. She felt tense, and was plagued with flashbacks and nightmares of the robbery. Her stomach was in knots and she had a constant headache. Whenever she went out, she felt panicky. She was frustrated that she could not calm her body: her heart raced, she was short of breath, and her hands were constantly cold and sweaty. She hated how she felt and she was angry about how her nice life had turned into a nightmare. What was most upsetting to her were the ways that the robbery affected her marriage and her child. Her baby picked up the tension and was very fussy. Every time she tried to make love with her husband, she began to cry and get images of the men raping her. Joanne had posttraumatic stress disorder (PTSD), a brain reaction to severe traumatic events such as a robbery, rape, car accident, earthquake, tornado, or even a volcanic eruption. Her symptoms are classic for PTSD, especially the flashbacks and nightmares of the event.

The worst symptoms came from the horrible thoughts about what never happened, such as seeing her brain splattered against the wall and being raped. These thoughts were registered in her subconscious as fact, and until she entered treatment she was not able to recognize how much damage they had been doing. For example, when she imagined that she was being raped, a part of her began to believe that she actually was raped. The first time she had her period after the robbery, she began to cry with relief that she was not impregnated by the robbers, even though they never touched her. A part of her even believed she was dead because she had so vividly pictured her own death. A significant portion of her treatment was geared to counteract these erroneous subconscious conclusions.

Without treatment, PTSD can literally ruin a person’s life. The most effective treatment is usually psychotherapy. One type of psychotherapy that I think works especially well for PTSD is called eye movement desensitization and reprocessing (EMDR). You can learn more about this technique in my book Healing Anxiety and Depression or visiting www.emdria.org. Depending on the severity of PTSD, certain types of medications and supplements can also be helpful.

Performance Anxiety

Feeling anxious or nervous before speaking or performing in front of a group is one of the most common fears of human beings. Many people hate feeling judged, scrutinized, or “on the spot.” As anxiety levels go up in the brain, thoughtfulness usually goes down. This is particularly true with sexual performance. It is very common for lovers, especially new lovers, to want to please their partners. They feel anxious and their nerves tend to get in the way of sexual play and enjoyment. Often this type of anxiety is associated with what I call Fortune Telling ANTs. ANT stands for automatic negative thoughts. These are the thoughts that go through your head automatically and ruin your day. Fortune-telling ANTs are the thoughts that predict a bad turnout, even though there is no evidence for the idea. Examples include, “He will not like my body.” “She will think I have a small penis.” “I will come too quickly.” “I have to fake an orgasm, or he will not be happy with me.” The problem with fortune-telling ANTs is that your brain makes happen what it sees. If you predict failure, you are more likely to fail. For example, when you see yourself not pleasing your partner, the subsequent anxiety will interfere with your feeling relaxed and present, in the moment; then you will not read his or her body language and end up missing important clues to making it a special sexual time. Learning how to calm performance anxiety, through correcting negative thoughts, deep breathing, and meditation, is essential for great sex.

Attention Deficit Disorder

In my lectures I often ask, “How many people are married? Raise your hands.” Usually, a good portion of the audience raises their hands. “Is it helpful,” I ask next, “to say everything you think in your marriage?” Everyone laughs. “Of course not,” I continue, “relationships require tact, they require thoughtfulness. Saying everything you think is usually a disaster in relationships.” Unfortunately, you need healthy PFC activity to suppress the sneaky thoughts that just creep through your brain. Attention-deficit/hyperactivity disorder (ADHD) is usually associated with low PFC activity and people are more likely to blurt out, without forethought.

Do you often feel restless? Have trouble concentrating? Have trouble with impulsiveness, either doing or saying things you wish you hadn’t? Do you fail to finish many projects you start? Are you easily bored or quick to anger? If the answer to most of these questions is yes, you might have attention deficit disorder (ADD).

ADD is the most common brain problem in children and adults, affecting 8 to 10 percent of the United States population. The main symptoms of ADD are a short attention span, distractibility, disorganization, procrastination, and poor internal supervision. It is often, but not always, associated with impulsive behavior and hyperactivity or restlessness. Until recently, most people thought that children outgrew this disorder during their teenage years. For many, this is false. While it is true that the hyperactivity lessens over time, the other symptoms of impulsivity, distractibility, and a short attention span remain for most sufferers into adulthood. Current research shows that 60 to 80 percent of ADD children never fully outgrow this disorder.

Common symptoms of the adult form of ADD include poor organization and planning, procrastination, trouble listening carefully to directions, distractibility, short attention span, relationship problems, and excessive traffic violations. Additionally, people with adult ADD are often late for appointments, frequently misplace things, may be quick to anger, and have poor follow-through. There may also be frequent impulsive job or relationship changes and poor financial management. Substance abuse, especially alcohol or amphetamines and cocaine, and low self-esteem are also common.

Many people do not recognize the seriousness of this disorder and just pass off these kids and adults as lazy, defiant, or willful. Yet, ADD is a serious disorder. Left untreated, it affects a person’s self-esteem, social relationships, and ability to learn and work. Several studies have shown that ADD children use twice as many medical services as non-ADD kids, up to 35 percent of untreated ADD teens never finish high school, 52 percent of untreated adults abuse substances, teens and adults with ADD have more traffic accidents, and adults with ADD move four times more than others.

Many adults tell me that when they were children, they were in trouble all the time and had a real sense that there was something very different about them. Even though many of the adults I treat with ADD are very bright, they are frequently frustrated by not living up to their potential.

From our research with SPECT scans, it is clear that ADD is a brain disorder, but not one simple disorder. I have described six different types of ADD. The most common feature of ADD is decreased activity in the prefrontal cortex with a concentration task. This means that the harder a person tries, the less brain activity they have to work with. Many people with ADD self-medicate with stimulants, such as caffeine, nicotine, cocaine, or methamphetamine, to increase activity in the PFC. They also tend to self-medicate with conflict-seeking behavior. If they can get someone upset, it helps to stimulate their brain. Of course, they have no idea they do this behavior. I call it unconscious, brain-driven behavior. But, if you are around ADD people long enough, you will see and feel the conflict-seeking behavior.

The best treatment for ADD depends on the type of ADD a person has. See my book Healing ADD for a complete description of types and treatments. In general, intense exercise helps, as does a higher protein, lower carbohydrate diet. Sometimes medications or supplements are helpful, but sometimes they can make things worse if they are not right. When correctly targeted, ADD is a highly treatable disorder.

Being a Jerk or a Bitch

I know “being a jerk” or “being a bitch” are not medical diagnostic terms. They are negative, name-calling phrases about someone’s behavior. Yet, in my experience, it is possible that these behaviors are the result of poor brain function and not completely under conscious will. Sometimes, a head injury, toxic exposure, sleep deprivation, and personality disorders (see below) can interfere with someone’s effectiveness in social and sexual situations.

Our character can be defined in part by the way we interact with others. When the way in which we interact with others doesn’t work, when we notice a pattern of multiple relationships and multiple disconnections, it may be that a personality disorder is at the root of the problem. The term personality disorder implies inflexible and long-standing patterns of experience and behavior (Diagnostic and Statistical Manual of Mental Disorders IV, or DSM-IV) that impair healthy functioning. They can be the source of great personal pain for the person suffering and those he or she loves. A personality disorder can sabotage relationships, prevent the realization of desired goals, and impede our moral development and our spiritual and sexual health. When we are preoccupied, for example, with intrusive thoughts, deep fears of abandonment, or feelings of paranoia or superiority, it’s hard to reach beyond the self to the expansive concerns of spirit and morality. It’s hard to be our best selves. A person with a personality disorder may feel inexplicably apart from a sense of well-being, of closeness to others, and to God. It may be hard for someone with a personality disorder to feel empathy and thus to feel part of a reciprocally loving community. Feelings of isolation and disconnectedness can lead to the sense of life being meaningless and to devaluing one’s own individual contributions. This sense of aloneness and lack of purpose can place people with personality disorders at higher risk for suicide. Personality is what we present to the outside world. It is not the true self, which is broader and deeper than the outward-appearance self. When we think of working on aspects of the personality, we think not of correcting flaws but of opening doors to greater joy and connectedness.

Personality disorders have been traditionally resistant to psychotherapy. Traditional psychiatric thought has focused on developmental causes of these disorders rather than brain abnormalities. It has been my experience that many people labeled as personality disordered are really brain disordered. The implications for treatment are immense—do we talk someone through their difficult behaviors or try to change their brain? Probably we need both.

Antisocial Personality Disorder

Antisocial personality disorder is characterized by a long-standing pattern of disregard for the rights of others and may be an extension of conduct disorder seen in adolescence. The likelihood of developing antisocial personality disorder seems increased in young children with conduct disorder and ADD. People with antisocial personality disorder frequently break rules, inhabit prisons, and have constant relationship and work problems. They often get into fights. With little or no empathy, they may steal, destroy property, manipulate or deceive others for their ends. They tend to be impulsive and lacking in forethought. Traditionally, these people are thought of as evil, bad, and sinful. The work of psychologist Adrienne Raine of the University of Southern California has seriously challenged this notion. Dr. Raine found that compared to a group of healthy men, the MRI scans of the men with antisocial personality disorder showed decreased PFC volume. They are likely dealing with less access to the brain part that controls conscience, free will, right and wrong, and good and evil. A fascinating additional finding of Dr. Raine’s work was that people with antisocial personality disorder also had slower heart rates than the control group and decreased sweat gland activity. Lower heart rates and sweat gland activity are often associated with low anxiety states (your hands sweat and your heart races when you are anxious). Could this mean that people with this type of difficult temperament do not have enough internal anxiety? Could the PFC be involved with appropriate anxiety? Intriguing questions. For example, most people feel anxious before they do something bad or risky. If I needed money, and got the thought in my head to rob the local grocery store, my next thoughts would be filled with anxiety:

“I don’t want to get caught.”

“I don’t like institutional food.”

“I don’t want to be thought of as a criminal.”

“I could lose my medical license.”

The anxiety would prevent me from acting out on the bad thoughts. But, what if, as Dr. Raine’s study suggests, I do not have enough anxiety and I get an evil thought in my head like, “Go rob the store”? With poor PFC activity (a lousy internal supervisor with little to no anxiety), I am likely to rob the store without considering all of the consequences to my behavior. There is an interesting treatment implication from this work. Typically, psychiatrists try to help lessen a person’s anxiety. Maybe we have it backward for people with antisocial personality disorder; for them we should try to increase their anxiety.

Narcissistic Personality Disorder

People with narcissistic personality disorder believe that they are special and more unique or gifted than other people. They require constant admiration and recognition for their achievements. A sense of entitlement derived from a bolstered sense of superiority may lead people with narcissistic personality disorder to place great demands on others, expecting their needs to be met immediately, regardless of the inconvenience. Although they may appear confident, they may in fact have very low self-esteem, which they attempt to boost by association with others they imagine being as gifted as they. They may seek connections exclusively with those whom they perceive to be as special and form alliances solely to advance their careers or other endeavors. While lacking empathy and ability to listen patiently to others’ concerns, a person with narcissistic personality disorder may spend an inordinate amount of time thinking about what others think of her or him. People with narcissistic personality disorder may belittle or be envious of others’ achievements and be unwilling to acknowledge contributions others make to their own successes. A person with narcissistic personality disorder may appear to be rude, condescending, and arrogant, criticizing others while being unable to tolerate criticism him- or herself. A person with NPD often seesaws between a depressed mood because of feelings of shame or humiliation and grandiosity. As with other personality disorders, a person with narcissistic personality disorder may suffer from additional problems such as anorexia, substance abuse, anxiety, and depression. People with narcissistic personality disorders may have overactive cingulate systems, disallowing them to see outside themselves and to take a broader perspective. Poor prefrontal lobe activity may cause the lack of empathy so pronounced in this disorder.

A feeling of social connectedness is the basis of a healthy soul and character. Clinging to the notion that you might be better than others, somehow more privileged or entitled, erects barriers between you and the people to whom you want to get close and makes it impossible to empathize with others’ needs. Protecting yourself with distancing tactics such as criticism, disinterest in others’ problems, belittling others, or refusing to acknowledge their accomplishments makes it tough to develop a sense of security and companionship, of being loved. It’s very hard to make moral decisions from this place, from the position of “What I need is most important.” Persistent focus on yourself, your appearance, how others see you, and the neediness that accompanies these anxiety-provoking concerns takes you away from your true self, the self that can focus on what you really care about and what you want your life to be about. Because people with narcissistic personalities disorder may sometimes accomplish external goals, it can be hard to discern the reasons for a lack of connectedness and a hollow spiritual life. Identifying with others; being able to be humble, grateful, and kind; to listen; and to truly appreciate others’ caring and contributions to your life readies you to receive spiritual learning.

Borderline Personality Disorder

Instability in relationships, impulsivity, and low self-esteem characterize borderline personality disorder. People with borderline personality disorder may quickly switch attitudes toward others, identifications, values, and goals. For example, someone with borderline personality disorder may worship a new friend or lover and then drop him or her quickly, complaining that their new friend wasn’t caring enough. Professional goals and interests may change suddenly, as may moods. Highly reactive and impulsive, they may experience periods of extreme irritability, anger, or anxiety. They may engage in self-destructive behaviors such as drinking heavily, driving fast, overspending, bingeing on food, or having unsafe sex. People with borderline personality disorder may feel periods of great emptiness and engage in suicidal or self-mutilating behaviors. Boredom may be intolerable to someone with this disorder, and consequently, he or she may perpetually seek stimulation. Childhood abuse or neglect or the early loss of a parent may be found in family histories of people with this disorder.

The biological underpinnings of borderline personality disorder are complex. People with borderline personalities may have a combination of prefrontal lobe problems, which accounts for impulsivity, conflict, and stimulation-seeking behaviors, and the tendency to intensely value or devalue individuals. Anterior cingulate problems may also exist, evidenced by the obsessive thinking, cognitive inflexibility, and a very strong tendency to hold onto grudges and past hurts. As well, there may be temporal lobe abnormalities. The left temporal lobe is involved with aggressive behaviors toward the self and others.

Consistency and control over impulsivity are necessary to developing and sticking to character goals. When you are controlled by your emotions, constantly reacting to outside events in the heat of the moment, you cannot develop an overall sense of who you are, what you want, and how you will get it. Contemplation is important to developing a sense of right and wrong, what is good and bad for you and for others. Likewise, being enslaved by impulses and reactions denies you the opportunity to build a strong sense of self-esteem. When you can control what you do, you can feel greater certainty about your identity. It’s rewarding to be able to clarify your personal values and to stick to them, to know that you and you alone are in charge of your life.

It’s hard to build a sense of security and of being loved when you find yourself attaching unrealistic expectations to people to whom you’re attracted and then ending friendships before they’ve had a chance to develop. Social connectedness takes work: It implies forgiving and flexibility. It’s important for all of us to try to develop greater empathy for others by asking ourselves about another’s point of view and not to automatically assume we know what others feel and think.

When Is It Time to See a Professional About My Brain?

This question is relatively easy to answer. People should seek professional help for themselves or a family member when their behaviors, feelings, thoughts, or memory (all brain functions) interfere with their ability to reach their potential in their relationships or work. If you are experiencing persistent relationship struggles (parent-child, sibling, friend, partner), it’s time to get help. If you have ongoing work problems related to your memory, moods, actions, or thoughts, it is time to get professional help. If your impulsive behavior, poor choices, or anxiety are causing consistent monetary problems, it’s time to get help. Many people think they cannot afford to get professional help. I think it is usually much more costly to live with brain problems than it is to get appropriate help.

Pride and denial can get in the way of seeking proper help. People want to be strong and rely on themselves, but I am constantly reminded of the strength it takes to make the decision to get help. Also, getting help should be looked at as a way to get your brain operating at its full capacity.

Angela came to see me for temper problems. Even though she was very competent at work, her behavior at home often caused problems with her husband. When her husband suggested she see me, she resisted. There was nothing wrong with her, she thought, it was everyone else. One day, after exploding at one of her children, she realized it was, at least partly, her fault and agreed to come for help. She resisted because she did not want to be seen as weak or defective. The brain-SPECT scan helped her to see that her brain needed to be balanced. With the appropriate help, she got better and didn’t have to suffer from mood swings, and she and her family suffered less stress as a result of her better-balanced brain.

What to Do When a Loved One Is in Denial About Needing Help

Unfortunately, the stigma associated with a “mental illness” prevents many people from getting help. People do not want to be seen as crazy, stupid, or defective and do not seek help until they (or their loved one) can no longer tolerate the pain (at work, in their relationships, or within themselves). Most people do not see psychiatric problems as brain problems, but rather as weak character problems. Men are especially affected by denial.

Many men, when faced with obvious troubles in their marriages, their children, or even themselves, are often unable to really see problems. Their lack of awareness and strong tendency toward denial prevent them from seeking help until more damage than necessary has been done. Many men have to be threatened with divorce before they seek help. Some people may say it is unfair to pick on men. And, indeed, some men see problems long before some women. Overall, however, mothers see problems in children before fathers and are more willing to seek help, and many more wives call for marital counseling than do husbands. What is it in our society that causes men to overlook obvious problems, or to deny problems until it is too late to deal with them effectively or until more damage was done than necessary? Some of the answers may be found in how boys are raised in our society, the societal expectations we place on men, the overwhelming pace of many men’s daily lives, and in the brain.

Boys most often engage in active play (sports, war games, video games, etc.) that involves little dialogue or discussion. The games often involve dominance and submissiveness, winning and losing, and little interpersonal communication. Force, strength, or skill handles problems. Girls, on the other hand, often engage in more interpersonal or communicative types of play, such as dolls and storytelling. Fathers often take their sons to throw the ball around or shoot hoops, rather than to go for a walk and talk.

Many men retain the childhood notions of competition and the idea that one must be better than others to be any good at all. To admit to a problem is to be less than other men. As a result, many men wait to seek help until their problem has become obvious to the whole world. Other men feel responsible for all that happens in their families, so admitting to a problem is the same as admitting that they have in some way failed.

Clearly, the pace of life prevents many people and particularly men from taking the time to look clearly at the important people in their lives and their relationships with them. When we spend time with fathers and husbands and help them slow down enough to see what is really important to them, more often than not they begin to see the problems and work toward helpful solutions. The issue is generally not one of being uncaring or uninterested; it is not seeing what is there. Men are wired differently than women. Men tend to be more left brained, which gives them better access to logical, detail-oriented thought patterns. Women tend to have greater access to both sides of their brains, with the right side being involved in understanding the gestalt or big picture of a situation. The right side of the brain also seems to be involved in being able to admit to a problem. Many men just don’t see the problems associated with anxiety or depression even though the symptoms may be very clear to others.

Here are several suggestions to help people who are unaware of or unwilling to get the help they need. Try the straightforward approach first (but with a new brain twist). Clearly tell the person what behaviors concern you, and explain that the problems may be due to underlying brain patterns that can be easily tuned up. Tell them help may be available—not help to cure a defect but rather help to optimize how their brain functions. Tell them you know they are trying to do their best, but their behavior, thoughts, or feelings may be getting in the way of their success (at work, in relationships, or within themselves). Emphasize better function, not defect.

Give them information. Books, videos, and articles on the subjects you are concerned about can be of tremendous help. Many people come to see us due to a book, video, or article. Good information can be very persuasive, especially if it is presented in a positive, life-enhancing way.

When a person remains resistant to help, even after you have been straightforward and given them good information, plant seeds. Plant ideas about getting help and then water them regularly. Drop an idea, article, or other information about the topic from time to time. If you talk too much about getting help, people become resentful and stubbornly won’t get help, especially the overfocused types. Be careful not to go overboard.

Protect your relationship with the other person. People are more receptive to people they trust than to people who nag and belittle them. Work on gaining the person’s trust over the long run. It will make them more receptive to your suggestions. Do not make getting help the only thing that you talk about. Make sure you are interested in their whole lives, not just their potential medical appointments.

Give them new hope. Many people with these problems have tried to get help and it did not work or it made them even worse. Educate them on new brain technology that helps professionals be more focused and more effective in treatment efforts.

There comes a time when you have to say enough is enough. If, over time, the other person refuses to get help, and his or her behavior has a negative impact on your life, you may have to separate yourself. Staying in a toxic relationship is harmful to your health, and it often enables the other person to remain sick as well. Actually, I have seen that the threat or act of leaving motivates people to change, whether it is about drinking, drug use, or treating ADD. Threatening to leave is not the first approach I would take, but after time it may be the best approach. Realize you cannot force a person into treatment unless they are dangerous to themselves, dangerous to others, or unable to care for themselves. You can only do what you can do. Fortunately, there is a lot more we can do today than even ten years ago.

Finding a Competent Professional Who Uses This New Brain Science Thinking

The Amen Clinics get many calls, faxes, and e-mails each week from people all over the world looking for competent professionals who think in similar ways to the principles outlined in this book. Because this approach is on the edge of what is new in brain science, other professionals who know and practice this information may be hard to find. However, finding the right professional for evaluation and treatment is critical to the healing process. The right professional can have a very positive impact on your life. The wrong professional can make things worse.

There are a number of steps to take in finding the best person to assist you. The right help is not only cost effective but saves unnecessary pain and suffering, so don’t rely on a person simply because they are on your managed care plan. That person may or may not be a good fit for you. Search for the best. If he or she is on your insurance plan, great, but don’t let that be the primary criteria. Once you get the names of competent professionals, check their credentials. Very few patients ever check a professional’s background. Board certification is a positive credential. To become board certified, physicians must pass additional written and verbal tests. They have had to discipline themselves to gain the skill and knowledge that was acceptable to their colleagues. Don’t give too much weight to the medical school or graduate school the professional attended. I have worked with some doctors who went to Yale and Harvard who did not have a clue on how to appropriately treat patients, while other doctors from less prestigious schools were outstanding, forward thinking, and caring. Set up an interview with the professional to see whether or not you want to work with him or her. Generally you have to pay for their time, but it is worth spending the money to get to know the people you will rely on for help.

Many professionals write articles or books or speak at meetings or local groups. Read the work of or hear the professional speak, if possible. By doing so, you may be able to get a feel for the person and his or her ability to help you. Look for a person who is open-minded, up-to-date, and willing to try new things. Look for a person who treats you with respect, who listens to your questions, and responds to your needs. Look for a relationship that is collaborative and respectful. I know it is hard to find a professional who meets all of these criteria who also has the right training in brain physiology, but these people can be found. Be persistent. The caregiver is essential to healing.

Do not let pride get in the way of getting the help you need. In order to make a good brain great, you have to admit when you need help.

Lesson #11: Fix the issues that get in the way of great sex.