Whoever writes on shame knows as much about pain and failure as about the healing balm of love
Few experiences in life are so pleasant as the moment of release from shame or the realization that our foibles are accepted with love
~ Donald L. Nathanson ~
Most people, clinicians included, have difficulty differentiating the "narcissistic" from the "sociopathic" personality, based upon the unscientific, unproven, and ultimately false distinction of ability to experience emotional pain, sadness, or empathy, and the inability to learn from their prior bad acts. Ok, but first, let us be clear in our terminology. I am not referring to narcissistic people. Most successful people are narcissistic on some level. I am referring to Narcissistic Personality Disorder (NPD) and Antisocial Personality Disorder (APD). Personality disorders are by definition, chronic, enduring, pervasive, and color the way in which one perceives, feels and acts upon their world and everything in it. A personality disorder is a severe distortion of aspects of the personality, deviating widely from normal personality functioning. It is not to be confused with "traits" or aspects of a persons personality or mood. Having a personality disorder is serious business. Of all the personality disorders, the "dramatic cluster" are the most difficult for clinicians to treat, and most do not. Included in this "cluster" are the two disorders mentioned here.
There are good reasons why most clinicians do not treat these personality disorders - of all the possible disorders, these are the two that are not in touch with having any problems, other than having to deal with the rest of the world and their problems and as such, will not generally be seen in treatment. For what? Those with NPD and APD are not at all aware they have a disorder of any kind and will argue this in the face of evidence to the contrary. Part of the problem. These folks are not going to waltz into anyone's office and ask for help. Won't happen. Unless of course one is being treated for a sex addiction and/or sexual offense. I do not believe in God. But if I did, this is where I would say how "God works in mysterious ways".
The thing (or things) that separate the two personality disorders is not, as I began by stating, a litany of traits that prevent one from feeling bad for acting bad, for hurting others, and/or not learning from prior bad behavior and repeating the error of their ways over and over and over again - all of these by the way referring to the Antisocial Personality. A sex addicted individual is by definition someone with a Narcissistic Personality Disorder, sometimes accompanying a Borderline Personality Disorder, or traits of the later, particularly as it pertains to an intense and unrealistic fear of abandonment and perceived rejection, and characterized by highly unstable relationships of approach and avoidant behaviors. Sex addicts and those with NPD share many commonalities as those with APD. And in fact, anyone who has ever been involved in an intimate relationship with someone who has a NPD, with or without a sexual addiction can tell you all the war stories. Ok, so what exactly is the difference? First allow me to muddy the waters just alittle further...
The psychopathic individual as we used to call these folks, are quite capable of feeling not just their pain, but pain and longing, sadness, and even empathy. Is it true that there is a virulent version of psychopathy wherein the individual does not appear to have the ability to empathize? Yes, with emphasis on "appear" however. That said, there is a virulent version of NPD as well and I am not referring to what Vaknin and others call a "malignant" narcissism. There are plenty of NPD individuals, many of which I have and do treat, that appear not to be capable of empathizing and simply go through the motions. It isn't that they can't, it is that they don't. And they don't because they won't - they are scared to death, very well psychologically defended, and for pretty good reason at that. What then is the distinguishing factor between the two personality disorders? Better yet, IS there a distinguishing factor or are they as many suggest, just two sides of the same coin?
There is intriguing new evidence suggesting that in fact, one of the very definitive qualities that characterize the sociopathic personality - their inability to learn from their mistakes - may not at all be accurate. I think they are on to something. I do not think either APD or NPD individuals are somehow hardwired to "not learn from prior acts", because neuropsychologically speaking, and from the standpoint of classical conditioning and operant conditioning paradigms, I am not certain this even makes sense to suggest that it is not possible. So, what, are we saying ,that they can learn SOME things just not things that have to do with people being in pain? That would mean there is a very special part of the brain that can distinguish between learning related to emotional pain and learning related to every thing else. Is this possible? That they can learn from the "good" things they have done, but they just cannot learn from the "bad" things they have done? Is there a part in the brain that is specific to "bad" things as opposed to "good" things? I am not saying that NPD and APD are one and the same diagnosis and that we have gotten it all wrong. No, I am quite aware that they are distinct disorders, but I am challenging, as have others, that the clinical distinctions we are using are not entirely all correct. I think the problem lies in some of our faulty diagnostic criteria and the often difficult distinction between these two personality disorders. What is that magical distinction? Shame. Shame is the answer and it is the answer because there IS a specialized part or parts of the brain that distinguish between these "good" and "bad" emotions and learning has everything to do with it, not just psychologically, but biochemically.
Psychopaths, or what we nowadays call the Antisocial Personality Disordered individual - sounds much tamer by comparison - has no idea, no clue that they are sociopathic. Those around them might indeed, but trust me, they are the very last to know and in fact, until confronted with the evidence, will genuinely fight you tooth-and-nail, trying to convince both you and them, not necessarily in that order, that they are not the monsters that the word implies. Nor by the way, do NPD individuals know they are narcissistic, and nowhere have I seen more evidence of narcissistic rage, as when I present and explain, with MMPI-2 held firmly in hand and in as soft and empathic a voice as possible, the diagnostic information. The problem is that by clinical definition, those with APD and NPD will never provide you the opportunity to explain because they will never have stepped foot in your office in the first place. Unless of course you work with sex offenders and/or sex addicts, both of which make up the majority of my clinical practice and research efforts. What then brings them to the attention of the clinician is not their personality disorder as I have made mention. Rather, it is the behaviors which are the direct byproduct of the PD. If you are all sniffly and miserable, what you have is probably a cold or the flu (of course it could also be inhalation Anthrax or early morning symptoms of heart failure). What brought you to the doctor's office however, was all the sniffly miserable stuff so that you can 1, be rest assured that it was not Anthrax or heart failure and rejoice in confirmation that it is in fact simply a rotten cold, and 2, that you are given a means to reduce/eliminate the sniffly miserable symptoms. and get on with your life.
In what is unquestionably the most famous and well-read account of psychopathy, The Mask of Sanity (1982), Cleckley was among the first to operationalize the psychopath. The Mask of Sanity was a fascinating read - an eye-opener into the deep dank recesses of the mind of the psychopathic personality as it was called, even though he used the term "antisocial personality". We are horrified by the accounts he presents of the cold, empty, emotionally vacuous shells that look just like the rest of us. Cleckley, and his heir apparent, Robert Hare, talk about the absence of "guilt". The problem, and how we all have such difficulty separating the two PD's, is because of our cultural difficulty distinguishing between "shame" and "guilt". In fact, more clinicians, psychologists and psychiatrists, those that should know better, continue to this very day, to use the word interchangeably. SHAME and GUILT are NOT interchangeable. In fact, they could not be more different psychologically, neurologically, or biochemically. And therein lies the proverbial rub. Period.
The brilliant psychiatrist Donald L. Nathanson speaks of the difference between "shame" and "guilt" in that "often shame is confused with guilt, a related but quite different discomfort. Whereas shame is about the quality of our person or self, guilt is the painful emotion triggered when we become aware that we have acted in a way to bring harm to another person or to violate some important code. Guilt is about action and laws" (1992, p.19). In the most recognized and first work to distinguish between the two emotions, Lewis in 1971 described "shame" as an "acutely painful emotion accompanied by a sense of shrinking or of "being small" and by a sense of worthlessness and powerlessness. Shamed people also feel exposed" (Tangney & Dearing, p. 19, 2002). While guilt-prone persons may also experience a fear of exposure, it is in a decidedly different context. Shame-based persons are afraid of SELF exposure, whereas guilt-based persons are afraid of OTHER exposure. Shame-based persons feel horrible about themselves. Guilt-based persons feel horrible about what they did to harm another and what the discovery of that action or actions will do to harm still others in a dominoes-knock-the-one-down-and-you-knock-them-all-down kind of effect. Sex addiction is a disorder of shame - more of a disease process really, in that it follows a progressive course. Shame can FEEL lethal but to the sex addict, is generally a symptom of the larger more pervasive narcissistic personality style, such that no matter how painful or intolerable their shame may feel or be, they are expert at very swiftly and deftly detaching themselves with a cool and quite calculated precision, from the source of that shame and moving on - not healing mind you, and not necessarily absent feeling entirely, just moving on. Individuals with NPD do not allow themselves to wallow in misery, a trait I often wish I had a tad more of. They pay a heavy price for this particular skill mind you, but it serves them quite well in the short run. The ability to cut loose with spectacular precision and efficiency does exact a pay-off, you must admit. Like I said, there are times I wish I could borrow or bottle some of it.
In all, it would be fair and accurate to say that the single most distinguishing feature between shame and guilt is that shame is about the self and guilt is about the other. Shame is a fairly foreign concept for me - I am hard-pressed to think of anything that I feel or have felt much if any shame over, not in any outrageous way, certainly. Guilt however, now there is something I am intimately familiar with. Guilt definitely continues to guide my life and much of what I do, say, think, act on, and feel. Both good and bad. Is guilt the other side of the shame coin? Not at all, but they are complimentary in both healthy and maladaptive ways. As I made mention in my last post, when treating a sexual addiction, it is important to move a shame-prone person to a guilt-prone place, in order to heal their deep and painful wounds. Although shame and guilt, alongside pride, embarrassment, rejection, humiliation, abandonment, disgust, and lust are all considered the primitive social emotions, they are in important ways, neurologically quite distinct. They come from entirely different places and those that are shame-based think, feel, and view the world in very different ways than the guilt-based person. The beauty, if it can be stated in such terms, is that the guilt-based person has a gift to offer the shame-based person if they can figure out a way to work together.
From a neurological perspective, different parts of the brain light up when a shame-based person experiences shame, then when a guilt-prone person experiences guilt. Early on, Nathanson was the first to point out that "classical depression involved the thinking, the feeling, and the chemistry of guilt, and that the atypical depressionswere about shame" (1992, p. 22). Suffice it to say, diffferent antidepressant medications work for the "classical" vs the "atypical" depressions as they target a different symptom picture. This is rather remarkable - think about it, we are saying that clinical depresssion is different, and the brain of the clinically depressed individual is different depending on whether they are shame- or guilt-based. Incredible! What causes the brain to become "shame-based" as opposed to "guilt-based"? Does brain impairment cause shame or rather, does shame change the brain? Is this a nature-nurture thing? Does experience decide? And if so, then is it early childhood experience? Is it genetics or biology or both? Does our early childhood dictate which style we will adopt? The answer, as Daniel J. Siegel and others tell us, is "yes". Through the plasticity of the brain, our very earliest childhood relationships, mostly with our caregivers, interact to make us who we are and whether or not we become shame- or guilt-based adults. Let us take a closer look...
Specifically, the orbitofrontal cortex (OFC), the anterior cingulate (AC), and the amygdala, a part of the limbic system, are involved in emotional memory, empathy, and affect regulation (especially impaired in the Borderline and Narcissistic Personality Disorders). Additionally, the medial and the ventral lateral prefrontal cortex areas are known to be involved in the ability to perceive the mental state of others, an area impaired in the autism-spectrum disorders. Further, the insula, a region located deep within the cerebral cortex, picks up messages bi-directionally from the cortical areas to and from the body, the limbic system and the brain stem, and integrates interoceptive states into conscious feeling states and decision-making processes that involve things like risk and reward. All of these areas play a part, one way or another in the social emotions which of course include shame and guilt.
The insula receives signals from the body that correspond to more intense emotions such as panic or love that the brain then interprets as such. Of particular interest, the insula processes and gives us interpretive information about future things that have not actually happened yet enabling us to act in an "as-if" fashion, or said another way, in anticipation. Meaning, a sex addicted individual who walks around in a fairly constant state of shame for their prior bad acts of utilizing the services of a prostitute for example, while even passing through a neighborhood or section of town that is known for prostitution, will light up their insula like the fourth of July in anticipation of seeing the prostitute, knowing, on a non-intuitive but somewhat aware level, that once the insula is lit, a deep co-mingling of sexual excitement and intense shame will be triggered based upon the memory of having visited with prostitutes before. This is all about the "people, places, things" of the 12-step vernacular. But which areas of the brain are more responsible, or said another way, more active, in shame versus guilt?
Stein & Kaminer (2006), Clark (2005), Farrow, et al (2001), Newberg, et al (2000), and a host of other neuroscience researchers have empirical support that the frontal-limbic areas - no surprise here - are responsible not just for the processing of guilt and shame, but for empathy and forgiveness. Specifically however, the posterior cingulate is also involved in the self-evaluation of behaviors. If you have been following my posts the past year, you have already learned that my research and the research of many others that have followed, all support various aspects of the prefrontal cortex as being intricately involved in being able to moderate the emotionality of the limbic areas, specifically the amygdala. It is the role of the prefrontal cortex, and ultimately the health of the prefrontal cortex that seems to determine whether an individual can be shame- or guilt-based.
Sex addiction is a disruption and damage of the right prefrontal cortex, mostly in the dorsolateral and orbital frontal areas of the prefrontal cortex, as a direct result of a rattled and impaired limbic system secondary to a very toxic childhood. When the limbic system is disrupted, but there is no prefrontal damage, then an individual can experience guilt, and generally, copious amounts of it, sometimes in a pathological manner. But shame occurs when the limbic system is disrupted AND it causes prefrontal cortex damage as well. When the prefrontal cortex is damaged, then the higher-order emotion of GUILT cannot be expressed, and it stays at SHAME, a lower, more primitive emotion. Shame feeds on itself in a never-ending feedback loop and so it continually self-feeds. Sex addiction treatment as I have always maintained, should be about the healing of the frontal lobe. When the frontal lobe is healed, then the sex addicted individual can move from shame to guilt and begin to live the life they are entitled to live, free of the ties that bind and free to feel love, free to experience forgiveness of self and others, and free to experience the range of emotions that make life worth living, then they have indeed changed their brain and the lives of all they touch.
Daniel J. Siegel reminds us that "Repeated patterns of children's interactions with their caregivers become "remembered" in the various modalities of memory and directly shape not just what children recall, but how the representational processes develop" (1999, p.5). Healing the adult sex addicted brain is accomplished by gently and lovingly and painstakingly providing new memories, healthy, loving memories from those with expertise and in positions of primary emotional support - replacing the old with the new, and healing the brain within. The heart will surely follow.