2/7/2009

there is no color bar or font choices.

i tried to use the mood journal and it kept asking for a sub mood and wouldn't save what i wrote where is the click thing for sub mood?

today i am anxious.  not enough hours in the day.

3 a.m. big keeps trying to go out so i slept with him in the spare room.  wonder if he is cold?  he slept under the down blanket.  i think he is just lonely and wants more attention but doesn't want to be in the cat room.  he wakes me up when he sleeps in there.

9 a.m. woke up and switched to the bedroom.  light sleep only.  brought michele down to go to the bathroom and then big wanted out and to go for a walk and so did the baby.  

10 a.m. took big for a walk down the street.  ran into the man from down the street who called me over to talk about big and told me he tried to come by at 7 a.m. but no one answered so he gave up.  i told him to call i will give him my phone number.  he says big is afraid of him, a surprise as big goes to that house all the time.  felt anxious talking because i know he will want to talk for a while and i am pressed for time.

11 a.m. got back and cleaned the spare room floor, fed the cats all of them, let the baby out, switched out the spare room carpet for a new piece and put the older one outside and cleaned and brushed it etc and then put it in the cat room.  went in the cat room to give out meds and realized it was too late to start that.  did their litter pans etc., 

12 p.m. made a hot bath, did a masque, switched out the bath rug.

12:30 ate brunch.

1:00   got dressed to leave.  time got away from me and left after 1:30 i don't know how or why, i felt very stressed.  i can only do real work up here as at home it is always too chaotic.  even an office at home wouldn't work because they would know i am there and wait at the door.  

1:45 actually got out the door and headed for my car.  i am fifteen minutes off schedule.  how did that happen, i thought i could get out by 1:20, 1:30 latest.  i get up here and b is here and he wants to talk, so i end up on the computer to destress.  which i shouldn't really do as i have real work to do.  then i go to the marina with a for an hour.  then k calls with an emergency and jf with one of his emergencies that are never emergencies except for his own yelling or nasty voice over absolutely NOTHING, he gives me an ulcer, and then two calls for rescue one is fixed up and the other needs more help on monday all of this i do for free and should be charging or getting funds because we have no funds and it freaks me out.  the stuff i make money at i keep putting off because it is more stress and i am trying to avoid stress.  i also need to think to do it and i can't with distractions and then deflating.  i need an office or something.  then i come on here to deflate, and instead i need to leave again to go take care of the animals and still no work is done and it freaks me out totally.  HELP!!! 

My life left in pieces, It seems so unfair,

Parts of my life that I just could not bare.

Lost in this world, not knowing which way to turn,

My mind always spinning, will I ever learn?

As I pick up the pieces, I'm reminded of the pain,

My teardrops falling, falling like rain.

When I see a tiny glimmer of light, 

A slight  and refreshing wind of hope,

The wind picks up, and dries my tears,

And carries away some of my fears.

I start to feel the strength that I need to fight,

To fight against this dark place where I reside,

To fight against the pain I feel inside!

Being Special

Chapter 1

We all fear to lose our identity and our uniqueness. We seem to be acutely aware of this fear in a crowd of people. "Far from the madding crowd" is not only the title of a book - it is also an apt description of one of the most ancient recoil mechanisms.

This wish to be distinct, "special" in the most primitive sense, is universal. It crosses cultural barriers and spans different periods in human history. We use hairdressing, clothing, behaviour, lifestyles and products of our creative mind - to differentiate ourselves.

The sensation of "being unique or special" is of paramount importance. It motivates many a social behaviour. A person feels indispensable, one of a kind, in a loving relationship. His uniqueness is reflected by his spouse and this provides him with an "independent, external and objective" affirmation of his special-ness.

This sounds very close to pathological narcissism, as it was defined in our Introduction. Indeed, the difference is of measure - not of substance.

A healthy person "uses" people around him to confirm his sense of distinctiveness - but he does not over-dose or over-do it. Feeling unique is to him of secondary importance. He derives the bulk of it from his well-developed, differentiated Ego. The clear-cut boundaries of his Ego and his thorough acquaintance with a beloved figure - his self - are enough.

Only people whose Ego is underdeveloped and relatively undifferentiated need ever larger quantities of external Ego boundary setting, of affirmation through reflection. To them, there is no distinction between meaningful and less meaningful others. Everyone carries the same weight and fulfils the same functions: reflection, affirmation, recognition, adulation, or attention. This is why everyone is interchangeable and dispensable.

The narcissist employs one or more of the following mechanisms in a loving relationship (say, in a marriage) ["he"-read: "he or she"]:

• He "merges" with his spouse/mate and contains him/her as a symbol of the outside world.

• He exerts absolute dominion over the spouse (again in her symbolic capacity as The World).

These two mechanisms substitute for the healthier forms of relationship, where the two members of the couple maintain their distinctiveness, while, at the same time, creating a new "being of togetherness".

• • To ensure a constant flow of Narcissistic Supply, the narcissist seeks to "replicate" his projected self. He becomes addicted to publicity, fame, and celebrity. Merely observing his "replicated self" - on billboards, TV screens, book covers, newspapers - sustains the narcissist's feelings of omnipotence and omnipresence, akin to the ones that he experienced in his early childhood. The "replicated self" provides the narcissist with an "existential substitute", proof that he exists - functions normally carried out by a healthy, well-developed Ego through its interactions with the outside world (the "reality principle").
  • In extreme cases of deprivation, when Narcissistic Supply is nowhere to be found, the narcissist decompensates and disintegrates, even up to having psychotic micro-episodes (common, for instance, in psychotherapy). The narcissist also forms or participates in hermetic or exclusive, cult-like, social circles, whose members share his delusions (Pathological Narcissistic Space). The function of these acolytes is to serve as a psychological entourage and to provide "objective" proof of the narcissist's self-importance and grandeur.

When these devices fail, it leads to an all-pervasive feeling of annulment and detachment.

An abandoning spouse or a business failure, for instance, are crises whose magnitude and meaning cannot be suppressed. This usually moves the narcissist to seek treatment. Therapy starts where self-delusion leaves off, but it takes a massive disintegration of the very fabric of the narcissist's life and personality organisation to bring about merely this limited concession of defeat. Even then the narcissist merely seeks to be "fixed" in order to continue his life as before.

The boundaries (and the very existence) of the narcissist's Ego are defined by others. In times of crisis, the inner experience of the narcissist - even when he is surrounded by people - is that of rapid, uncontrollable dissolution.

This feeling is life threatening. This existential conflict forces the narcissist to fervently seek or improvise solutions, optimal or suboptimal, at any cost. The narcissist proceeds to find a new spouse, to secure publicity, or to get involved with new "friends", who are willing to accommodate his desperate need for Narcissistic Supply (NS).

This sense of overwhelming urgency causes the narcissist to suspend all judgement. In these circumstances, the narcissist is likely to misjudge the traits and abilities of a prospective spouse, the quality of his own work, or his status within his social milieu. He is liable to make indiscriminate use of all his defence mechanisms to justify and rationalise this hot pursuit.

Many narcissists reject treatment even in the most dire circumstances. Feeling omnipotent, they seek the answers themselves and in themselves, and then venture to "fix" and "maintain" themselves. They gather information, philosophise, "creatively innovate", and contemplate. They do all this single-handedly and even when they are forced to seek other people's counsel, they are unlikely to admit it and are likely to devalue their helpers.

The narcissist dedicates a lot of his time and energy to establish his own specialness. He is concerned with the degree of his uniqueness and with various methods to substantiate, communicate and document it.

The narcissist's frame of reference is nothing less than posterity and the entirety of the human race. His uniqueness must be immediately and universally recognised. It must (potentially, at least) be known by everyone at all times - or it loses its allure. It is an all or nothing situation.

next: Chapter 2, The Soul of a Narcissist, The State of the Art

Uniqueness and Intimacy

Chapter 2

Uniqueness and intimacy are strong rivals.

Intimacy implies a certain acquaintance of one's partner with privileged information. Yet, it is exactly such partially or wholly withheld information that buttresses one's sense of superiority, uniqueness, and mystery which, inevitably, vanishes with disclosure and intimacy.

Additionally, intimacy is a common and universal pursuit. It does not confer uniqueness on its seeker.

When you get to know people intimately, they all seem unique to you. Personal idiosyncrasies surface with intimate acquaintance. Intimacy makes unique beings out of us all. It, therefore, negates the self-perceived uniqueness of the truly and exclusively unique - the narcissist.

Finally, the very process of getting intimate creates (false) sensations of uniqueness. Two people getting to intimately know each other, are made unique to one another.

These traits of intimacy negate the narcissist's notion of uniqueness. Intimacy may help distinguish us to our loved ones - but it also makes us common and indistinguishable to all others. Put crassly: if everyone is distinct, then no one is unique. Widespread acts or behaviours are anathema to uniqueness. Intimacy eliminates information asymmetries, obviates superiority and demystifies.

The narcissist does his damnedest to avoid intimacy. He constantly lies about every aspect of his life: his self, his history, his vocations and avocations, and his emotions. This false data guarantee his informative lead, asymmetry, or "advantage" in his relationships. It fosters disintimisation. It casts a pall of cover up, separateness, mystery over the narcissist's affairs.

The narcissist lies even in therapy. He obscures the truth by using "psycho-babble", or professional lingo. It makes him feel that he "belongs", that he is a "Renaissance man". By demonstrating his control of several professional jargons he almost proves (to himself) that he is superhuman. In therapy, this has the effect of "objectifying" and emotional detachment.

The narcissist's behaviour is experienced by his mate as frustrating and growth-cramping. To live with him is akin to living with an emotionally-absent non-entity, or with an "alien", a form of "artificial intelligence". The partners of the narcissist often complain of overwhelming feelings of imprisonment and punishment.

The psychological source of this kind of behaviour could well involve transference. Most narcissists fall prey to unresolved conflicts with their Primary Objects (parents or caregivers), especially with the parent of the opposite sex. The development of the narcissist's intimacy skills is hindered at an early stage. Punishing and frustrating the partner or spouse is a way of getting back at the abusive parent. It is a way of avoiding the narcissistic injury brought on by inevitable abandonment.

The narcissist, it seems, is still the hurt child. His attitude serves a paramount need: not to be hurt again. The narcissist anticipates his abandonment and, by trying to avoid it, he precipitates it. Maybe he does it to demonstrate that - having been the cause of his own abandonment - he is in sole and absolute control of his own relationships.

To be in control - this unconquerable drive - is a direct reaction to having been abandoned, ignored, neglected, avoided, smothered, or abused at an early stage in life. "Never again" - vows the narcissist - "If anyone will do the leaving, it will be me."

The narcissist is devoid of empathy and incapable of intimacy with others as well as with himself. To him, lying is a second nature. A False Self takes over. The narcissist begins to believe his own lies. He makes himself to be what he wants to be and not what he really is.

To the narcissist, life is a jumbled amalgam of "cold" facts: events, difficulties, negative externalities, and predictions and projections. He prefers this "objective and quantifiable" mode of relating to the world to the much-disdained "touchy-feely" alternative. The narcissist is so afraid of the cesspool of negative emotions inside him that he would rather deny them and thus refrain from knowing himself.

The narcissist is predisposed to maintaining asymmetric relationships, where he both preserves and exhibits his superiority. Even with his mate or spouse, he is forever striving to be the Guru, the Lecturer, the Teacher (even the Mystic), the Psychologist, the Experienced Elder.

The narcissist never talks - he lectures. He never moves - he poses. He is patronising, condescending, forgiving, posturing, or teaching. This is the more benign form of narcissism. In its more malignant variants, the narcissist is hectoring, humiliating, sadistic, impatient, and full of rage and indignation. He is always critical and torments all around him with endless, bitter cynicism and with displays of disgust and repulsion.

There is no way out of the narcissistic catch: the narcissist despises the submissive and fears the independent, the strong (who constitute a threat) and the weak (who are, by definition, despicable).

Asked to explain his lack of ability to make contact in a true sense of the word, the narcissist comes up with a host of superbly crafted explanations. These are bound to include some "objective" difficulties, which have to do with the narcissist's traits, his history and the characteristics of his environment (both human and non-human).

The narcissist is the first to admit the difficulties experienced by others in trying to adapt or relate to him. To his mind, these difficulties make him unique and explain away the gap between his grandiose theories about himself - and the grey, shabby pattern that is his life (the Grandiosity Gap). The narcissist has no doubt who should adapt to whom: the world should adjust itself to the narcissist's superior standards and requirements (and, thus, incidentally, transform itself into a better place).

Inevitably, the sexuality of the narcissist is as disturbed as his emotional landscape.

We distinguish three types of Sexual Communicators (and hence, the same number of modes of sexual communications):

1. 1. The Emotional-Sexual Communicator - is, first, attracted sexually to his potential mate.
      He then proceeds to examine how compatible they are and only then does he fall in love and have sexual intercourse.
      He forms a relationship that is based on a perception of the other as a whole, as an amalgam of attributes and traits, good and bad.
      His relationships last reasonably long and they disintegrate as incremental changes in the psychological makeup of the two parties encroach upon their mutual appreciation and create emotional deficiencies and hunger which can be satisfied only by resorting to new partners.
   2. The Transactional Sexual Communicator - first examines whether he and the prospective mate are mutually compatible.
      If he finds compatibility, he proceeds to test the mate sexually and then forms habits, which, put together, present a fair semblance of love, though a dispassionate one.
      He forms relationships with people he judges to be reliable partners and good friends. Only a modicum of desire and passion is added to this brew - but its mettle is, usually, very strong and relationships formed on these bases are the longest.

1. The Purely Sexual Communicator - is first, attracted sexually to his potential mate.
   He then proceeds to sexually explore and test the counterparty.
   This interaction leads to the development of an emotional correlate, partly the result of a forming habit.
   This communicator has the shortest, most disastrous relationships. He treats his mate as he would an object or a function. His problem is a saturation of experiences.
   As any addict does, he increases the dose (of sexual encounters) as he proceeds and this tends to severely destabilise his relationships.

Summary Table: Types of Communicators

Notes to the Table:

The narcissist is almost always the Purely Sexual Communicator. This, obviously, is a gross over-simplification. Still, it provides insights into the mating mechanism of the narcissist.

The narcissist's is usually infantile, either because of a fixation (pre-genital or genital) or due to an unresolved Oedipal Conflict. The narcissist tends to separate the sexual from the emotional. He can have a lot of great sex as long as it is devoid of emotional content.

The narcissist's sexual life is likely to be highly irregular or even abnormal. He sometimes leads an asexual life with a partner who is merely a platonic "friend". This is the result of what I call "approach avoidance infantilism".

There are grounds to believe that many narcissists are latent homosexuals. Conversely, there are grounds to believe that many homosexuals are repressed or outright pathological narcissists. At the extreme, homosexuality may be a private case of (somatic) narcissism. The homosexual makes love to himself and loves himself in the form of a same-gender object.

The narcissist treats others as objects. His "meaningful" other performs ego substitution functions for the narcissist. This is not love. Indeed, the narcissist is incapable of loving anyone, especially not himself.

In his relationships, the narcissist is hard-pressed to maintain both continuity and availability. He promptly develops acutely felt saturation points (both sexual and emotional). He feels shackled and trapped and escapes, either physically or by becoming emotionally and sexually absent. Thus, one way or the other, he is never there for his significant other.

Moreover, he prefers sex with objects or object representations. Some narcissists prefer masturbation (objectifying the body and reducing it to a penis), group sex, fetish sex, paraphilias, or paedophilia to normal sex.

The narcissist treats his mate as a sex object, or a sex slave. Often a verbal, or emotional, or physical abuser, he tends to mistreat his partner sexually as well.

This separation of the emotional from the sexual makes it difficult for the narcissist to have sex with people that he believes that he loves (though he never really does love). He is terrified and repelled by the idea that he has to objectify the subject of his emotions. He separates his sexual objects from his emotional partners - they can never be the same people.

The narcissist is thus conditioned to deny his nature (as a Purely Sexual Communicator) and a cycle of frustration-aggression is set in motion.

Narcissists brought up by conservative parents, who castigated sex as dirty and forbidden, adopt the ways of the Transactional Communicator. They tend to look for someone "stable, to set up a home with". But this negates their true, repressed, nature.

True partnership, a veritable, equitable transaction, does not allow for the objectification of the partner. To succeed in a partnership, the two partners must share an insightful and multidimensional view of each other: strengths and weaknesses, fears and hopes, joy and sadness, needs and choices. Of this the narcissist is incapable.

So, he feels inadequate, frustrated, and, consequently, fearful that he might be abandoned. He transforms this internal turmoil into deep-seated aggression. Once in a while the conflict reaches critical levels and the narcissist has fits of rage, emotionally deprives the partner, or humiliates her/him. Acts of violence - verbal or physical - are not uncommon.

The narcissist's position is untenable and unenviable. He knows - albeit he normally represses this information - that his partner disagrees with being treated as an object, sexual or emotional. Merely gratifying the narcissist does not form an edifice for a long lasting relationship.

But the narcissist is in dire need of stability and emotional certainty. He craves not to be abandoned or abused again. So, he denies his nature in a desperate plea to cheat both himself and his partner. He pretends - and sometimes he succeeds in misleading himself into believing - that he is interested in a true partnership. He really does his best, careful not to broach touchy issues, always consulting the partner in making decisions, and so on.

But inside, he harbours growing resentment and frustration. His "lone wolf" nature is bound to manifest itself, sooner or later. This conflict between the act the narcissist puts on in order to secure the longevity of his relationships and his true character is likely more often than not to result in an eruption. The narcissist is bound to become aggressive, if not violent. The shift from benevolent lover-partner to a raging maniac - a "Dr. Jekyll and Mr. Hyde" effect - is terrifying.

Gradually, the trust between the partners is shattered and the way to the narcissist's worst fears - abandonment, emotional desolation and the dissolution of the relationship - is paved by the narcissist himself!

It is this sorry paradox - the narcissist is the instrument of his own punishment - that comprises the essence of narcissism. The narcissist is Sisyphically doomed to repeat the same cycle of pretension, wrath and hatred.

The narcissist is afraid to introspect. For, had he done so, he would have discovered a both dismaying and comforting truth: he is in need of no one on a long-term basis. Other people are, to him, just short-term solutions.

Avid protestations to the contrary notwithstanding, the narcissist is expedient and exploitative in his relationships. Denying this, he often marries for the wrong reasons: to calm his troubled soul, to pacify himself by conforming socially.

But the narcissist does not need companionship or emotional support, let alone true partnership. There is no beast on earth more self-sufficient than a narcissist. Years of unpredictability in his relationships with meaningful others, early on abuse, sometimes decades of violence, aggression, instability and humiliation - have eroded the narcissist's trust in others to the point of disappearance. The narcissist knows that he can rely only on one stable, unconditional source of love and nurturance: on himself.

True, when in need of reassurance (e.g., in crisis situations), the narcissist seeks friendship. But while normal people seek friends for companionship and support - the narcissist uses up his friends the way the sick consume medication or the hungry food. Here, too, a basic pattern emerges: to the narcissist, other people are objects to be used and tossed away. Here, too, he proves discontinuous and unavailable.

Moreover, the narcissist can make do with very little. If he has a spouse - why should he seek the added burden of friends? Other people to the narcissist are what a yoke is to the ox - a burden. He cannot fathom reciprocity in human relations. He is easily bored with other people's lives, their problems and solicitations. The need to maintain his relationships drains him.

Having fulfilled their function (by listening to the narcissist, by asking his advice in an ego-inflating manner, by admiring him) - others would do best to vanish until they are needed again. The narcissist feels encumbered when asked to reciprocate. Even the most basic human interaction requires a display of his grandiosity and consumes time and energy in careful dramatic preparations.

The narcissist limits his social encounters to situations which yield net energy contributions (Narcissistic Supply). Interacting with others involves the expenditure of energy. Narcissists are willing to oblige on condition that they are able to extract Narcissistic Supply (attention, adulation, celebrity, sex) sufficient to outweigh the energy they had expended.

This "perpetuum mobile" cannot be maintained for long. The narcissist's milieu (really, entourage) feels drained and bored and his social circle dwindles. When this happens, the narcissist springs to life and, using the vast resources of his undeniable personal charm, he recreates a social circle, knowing full well that it - in due course - will also take its leave and dissolve in disgust.

The narcissist is either terrified by the thought of children or absolutely fascinated by it. A child, after all, is the ultimate Source of Narcissistic Supply. It is unconditionally adoring, worshipping and submissive. But it is also a demanding thing and it tends to divert attention from the narcissist. A child devours time, energy, emotions, resources, and attention. The narcissist can easily be converted to the view that a child is a competitive menace, a nuisance, utterly unnecessary.

These make for a very shaky foundation of marital life. The narcissist does not need or seek companionship or friendship. He does not mix sex and emotions. He finds it hard to make love to someone that he "loves". He ultimately abhors his children and tries to limit and confine them to the role of Narcissistic Supply Sources. He is a bad friend, lover and father. He is likely to divorce many times (if he ever gets married) and to end up in a series of monogamous (if he is cerebral) or polygamous (if he is somatic) relationships.

Most narcissists had a functioning parent, but one that was indifferent to them and used them for his or her own narcissistic ends. Narcissists tend to breed narcissists and perpetuate their condition. The conflict with the frustrating parent is carried forward and reconstructed in intimate relationships. The narcissist directs all the major transformations of aggression towards his spouse, partner, and friends. He hates, hates to admit it, sublimates and explodes in an occasional outburst of rage.

The more intimate the relationship, the more the other party has to lose by severing it, the more dependent the narcissist's partner is on the relationship and on the narcissist - the more likely is the narcissist to be aggressive, hostile, envious, and hating. This serves a dual function: as an outlet for pent-up aggression and as a kind of test.

The narcissist is putting meaningful people in his life to a constant test: will they accept him "as he is", however obnoxious? In other words, do people love him for what he really is - or are they infatuated with the image that he so elaborately projects? The narcissist cannot understand - or believe - that as far as normal people go, the difference between who they "really" are and their public persona is negligible. In his case, the gap between the two is so substantial that he resorts to extreme means to ascertain which of the two do people around him really love - or, rather, who is it that they profess to love: the False Self or the real person.

The fact that people choose to hang on to their relationships with him, despite his intolerable behaviour, proves to the narcissist his uniqueness and superiority. The narcissist's aggression thus serves to reassure him.

When he doesn't have access to willing victims, the narcissist indulges in fantasies of unmitigated aggression and sadism. He might find himself identifying with figures of outstanding cruelty in human history or with periods, which represent peaks of human degradation.

So, the narcissist's intimate relationship are fraught with ambivalence and contradiction: love-hate, well-wishing and envy, fear of being abandoned with a wish to be left alone, control-freakery and paranoid fears of persecution. The narcissist's psyche is torn in an all-pervasive conflict which never ceases to torment him, regardless of external or extenuating circumstances.

Mental Map # 1

Bad, unpredictable, inconsistent, threatening object leads to defective internalisation (introjection of bad objects) and to an unresolved Oedipal Conflict.

Damaged object relations aggression, envy, hatred
Low self-esteem
Fear that these emotions will erupt
Narcissistic defence mechanisms
Repression of all emotions, good and bad (the self as object)
Compensatory functions
Redirection of negative emotions at the self
Grandiosity, fantasies
Avoidance of emotional situations
Uniqueness, demands adulation, "I deserve" (entitlement)
Intellectual compensation, exploitativeness, envy, lack of empathy, haughtiness
Objectification of the OTHER
Formation of False Self (FS)
Defective interpersonal relationships (transference relationships)
Narcissistic Supply Sources (NSS)
Fear that the (potentially) meaningful other (external reinforcement of FS):
1. Will invoke deep emotions and provoke negative ones
2. Fear of abandonment (result of malnourished True Self - TS)
3. Narcissistic vulnerability: True Self (TS)
a. Negation of uniqueness
b. Ego hurt when abandoned
Anhedonia and dysphoria
Feeling of annulment, disintegration (of TS)
Fear of exposure, condemnation, persecution (FS)
Ego-dystonia (stress)

The above mental map includes three basic building blocks of the soul of a typical narcissist: the True Self, the False Self and the Narcissistic Sources of Supply.

Appendix: Libido and Aggression

Narcissism is a direct result of the aggression the narcissist experienced in early life. To better understand the narcissist's intimate relationships, we must first analyse this facet of narcissism: aggression.

Emotions are instincts. They form part of human behaviour. Interactions with other people provide a framework, an organisational structure into which emotions fit nicely. Emotions are organised by object relations to the libido (the positive pole) or to aggression (which is negative and associated with hurt).

Anger is the basic emotion underlying aggression. As it fluctuates, it is transformed. Janus-like, it has two faces: hatred and envy. The libido has sexual excitation as its basic emotion. It is an ancient tactile remembrance of the mother's skin and the wholesome feeling and smell of her breasts that provoke this excitement.

So important are these early experiences, that an early age pathology of object relations - a traumatic experience, physical or psychological abuse, abandonment - move aggression to a dominant position over the libido. Whenever aggression rules over libidinal drives, we have a psychopathology.

The emotional twins - libido and aggression - are inseparable. They characterise all references of the self to an object. A world of emotionally-invested object relations is formed with each such reference.

The dynamic unconscious is made of basic mental experiences, which are really dyadic relations between self-representations and object representations in either of two contexts: elation or rage.

A subconscious fantasy of merging or unification of the self and the object prevails in symbiotic relationships - both in euphoric moods and in aggressive and wrathful ones.

Anger has evolutionary and adaptive functions. It is intended to alert the individual to a source of pain and irritation and to motivate him to eliminate it. It is the beneficial outcome of frustration and pain. It is also instrumental in the removal of barriers to the satisfaction of needs.

As most sources of bad feelings are human, aggression (in the form of rage) is directed at (human) "bad" objects - people around us who are perceived by us to be deliberately frustrating our wishes to satisfy our needs. At the furthest end of this range we find the will and wish to make such a frustrating object suffer. But such desire is a different ball game: it combines aggression and pleasure, therefore it is sadistic.

Rage can easily convert to hatred. There is a wish to control the bad object in order to avoid persecution or fear. This control is achieved by the development of obsessive control mechanisms, which psychopathologically regulate the repression of aggression in such an individual.

Aggression can assume many forms, depending on the sublimatory venues of the aggressive reaction. Biting humour, excessive candour, the search for autonomy and personal enhancement, a compulsive effort to secure the absence of any kind of outside intervention - are all sublimations of aggression.

Hatred is a derivative of anger which is intended to facilitate the destruction of the bad object, to make it suffer and to control it. Yet, the process of transformation alters the characteristics of rage in its manifestation as hatred. The former is acute, passing and disruptive - the latter is chronic, stable and connected to character. Hatred seems justified on the grounds of revenge against the frustrating object. The wish to avenge is very typical of hatred. Paranoid fears of retaliation accompany hatred. Hatred thus has paranoid, sadistic and vengeful characteristics.

Another transformation of aggression is envy. This is a greedy wish to incorporate the object, even to destroy it. Yet, this very object which the envious mind seeks to eliminate by incorporation or by destruction is also an object of love, the object of love without which life itself will not have existed or will have lost its taste and impetus.

The narcissist's mind is pervaded by conscious and unconscious transformations of enormous amounts of aggression into envy. The more severe cases of Narcissistic Personality Disorder (NPD) display partial control of their drives, anxiety intolerance and rigid sublimatory channels. The magnitude of hatred in such individuals is so great, that they deny both the emotion and any awareness of it. Alternatively, aggression is converted to action or to acting out.

This denial affects normal cognitive functioning as well. Such an individual has intermittent bouts of arrogance, curiosity and pseudo-stupidity, all transformations of aggression taken to the extreme. It is difficult to tell envy from hatred in these cases.

The narcissist is constantly envious of people. He begrudges others their success, or brilliance, or happiness, or good fortune. He is driven to excesses of paranoia, guilt, and fear that subside only after he "acts out" or punishes himself. It is a vicious cycle in which he is entrapped.

The New Oxford Dictionary of English defines envy as:

"A feeling of discontented or resentful longing aroused by someone else's possessions, qualities, or luck."

And an earlier version (The Shorter Oxford English Dictionary) adds:

"Mortification and ill-will occasioned by the contemplation of another's superior advantages."

Pathological envy - the second deadly sin - is a compounded emotion. It is brought on by the realisation of some lack, deficiency, or inadequacy in oneself. It is the result of unfavourably comparing oneself to others: to their success, their reputation, their possessions, their luck, their qualities. It is misery and humiliation and impotent rage and a tortuous, slippery path to nowhere. The effort to break the padded walls of this self-visited purgatory often leads to attacks on the perceived source of frustration.

There is a spectrum of reactions to this pernicious and cognitively distorting emotion:

Subsuming the Object of Envy through Imitation

Some narcissists seek to imitate or even emulate their (ever changing) role models. It is as if by imitating the object of his envy, the narcissist becomes that object. So, narcissists are likely to adopt their boss' typical gestures, the vocabulary of a successful politician, the dress code of a movie star, the views of an esteemed tycoon, even the countenance and actions of the (fictitious) hero of a movie or a novel.

In his pursuit of peace of mind, in his frantic effort to alleviate the burden of consuming jealousy, the narcissist often deteriorates to conspicuous and ostentatious consumption, impulsive and reckless behaviours, and substance abuse.

Elsewhere I wrote:

"In extreme cases, to get rich quick through schemes of crime and corruption, to out-wit the system, to prevail, is thought by these people to be the epitome of cleverness (providing one does not get caught), the sport of living, a winked-at vice, a spice."

Destroying the Frustrating Object

Other narcissists "choose" to destroy the object that gives them so much grief by provoking in them feelings of inadequacy and frustration. They display obsessive, blind animosity and engage in a compulsive acts of rivalry often at the cost of self-destruction and self-isolation.

In my essay "The Dance of Jael", [Vaknin, Sam. After the Rain - How the West Lost the East. Prague and Skopje, Narcissus Publications, 2000 - pp. 76-81] I wrote:

"This hydra has many heads. From scratching the paint of new cars and flattening their tyres, to spreading vicious gossip, to media-hyped arrests of successful and rich businessmen, to wars against advantaged neighbours.

The stifling, condensed vapours of envy cannot be dispersed. They invade their victims, their rageful eyes, their calculating souls, they guide their hands in evil doings and dip their tongues in vitriol (The envious narcissist's existence is) a constant hiss, a tangible malice, the piercing of a thousand eyes. The imminence and immanence of violence. The poisoned joy of depriving the other of that which you don't or cannot have.

Self-Deprecation

From my essay, "The Dance of Jael":

"There are those narcissists who idealise the successful and the rich and the lucky. They attribute to them super-human, almost divine, qualities

In an effort to justify the agonising disparities between themselves and others, they humble themselves as they elevate the others. They reduce and diminish their own gifts, they disparage their own achievements, they degrade their own possessions and look with disdain and contempt upon their nearest and dearest, who are unable to discern their fundamental shortcomings. They feel worthy only of abasement and punishment. Besieged by guilt and remorse, voided of self-esteem, perpetually self-hating and self-deprecating - this is by far the more dangerous species of narcissist.

For he who derives contentment from his own humiliation cannot but derive happiness from the downfall of others. Indeed, most of them end up driving the objects of their own devotion and adulation to destruction and decrepitude

Cognitive Dissonance

But the most common reaction is the good old cognitive dissonance. It is to believe that the grapes are sour rather than to admit that they are craved.

These people devalue the source of their frustration and envy. They find faults, unattractive features, high costs to pay, immorality in everything they really most desire and aspire to and in everyone who has attained that which they so often can't. They walk amongst us, critical and self-righteous, inflated with a justice of their making and secure in the wisdom of being what they are rather than what they could have been and really wish to be. They make a virtue of jejune abstention, of wishful constipation, of judgemental neutrality, this oxymoron, the favourite of the disabled."

Avoidance - The Schizoid Solution

And then, of course, there is avoidance. To witness the success and joy of others is too painful and too high a price to pay. So, the narcissist stays away, alone and incommunicado. He inhabits the artificial bubble that is his world where he is king and country, law and yardstick, the one and only. The narcissist becomes the resident of his own burgeoning delusions. He is happy and soothed.

But the narcissist must justify to himself - on those rare occasions that he does catch a glimpse of his internal turmoil - why all this hatred and why the envy. The object of envy and hatred has to be magnified, glorified, idealised, demonised or elevated to superhuman levels to account for the narcissist's strong negative emotions. Outstanding qualities, skills and abilities are imputed to it and the object of these emotions is perceived to possess all the traits that the narcissist would have liked to have but doesn't.

This is very different from the purer, healthier, forms of hate directed at an object, which is genuinely - or is genuinely perceived to be - ominous, dangerous, or sadistic. In this healthy reaction, the properties of the hated object are not ones the person doing the hating would have liked to possess!

Hatred is thus used to eliminate a source of frustration, which sadistically attacks the self. Jealousy is aimed at another person, who sadistically - or provocatively - prevents the jealous self from obtaining what it desires.

next: Chapter 3, The Soul of a Narcissist, The State of the Art

The Workings of a Narcissist a Phenomenology

Chapter 3

Money is not the narcissist's only compulsion. Many narcissists are inordinately orderly and clean, or they may be addicted to knowledge, or obsessed with time. Some suffer from compulsive ticks and more complex repetitive, ritualistic movements. They might even become criminally compulsive, kleptomaniacs, for instance.

Narcissists are very misleading. They are possessed of undeniable personal charm and, usually, of sparkling intellect. Other people tend to associate these traits with maturity, authority and responsibility. Yet, as far as narcissists go, this association is a grave mistake. The Dorian Grays of this world are eternal children (puer aeternus, Peter Pans), immature, puerile even, irresponsible, morally inconsistent (and in certain areas of life, morally non-existent). Narcissists actively encourage people to form expectations - only to disappoint and frustrate them later. They lack many adult skills and tend to rely on people around them to make up for these deficiencies. 

That people will obey him, cater to his needs, and comply with his wishes is taken for granted by the narcissist, as a birth right. At times the narcissist socially isolates himself, exuding an air of superiority, expressing disdain, or a patronising attitude. At times he verbally lashes his nearest and dearest. Yet the narcissist expects total allegiance, loyalty, and submissiveness in all circumstances.

Abuse has many forms apart from the familiar ones sexual, verbal, emotional, psychological, and physical (battering and assault). Some narcissists are the outcomes of insufficient or erratic love - others the sad consequences of too much love.

Forcing a child into of adult pursuits is one of the subtlest varieties of soul murder. Very often we find that the narcissist was deprived of his childhood. He may have been a Wunderkind, the answer to his mother's prayers and the salve to her frustrations. A human computing machine, a walking-talking encyclopaedia, a curiosity, a circus freak - he may have been observed by developmental psychologists, interviewed by the media, endured the envy of his peers and their pushy mothers.

Consequently, such narcissists constantly clash with figures of authority because they feel entitled to special treatment, immune to prosecution, with a mission in life, destined for greatness, and, therefore, inherently superior.

The narcissist refuses to grow up. In his mind, his tender age formed an integral part of the precocious miracle that he once was. One looks much less phenomenal and one's exploits and achievements are much less awe-inspiring at the age of 40 - than at the age of 4. Better stay young forever and thus secure one's Narcissistic Supply.

So, the narcissist refuses to grow up. He never takes out a driver's licence. He does not have children. He rarely has sex. He never settle-down in one place. He rejects intimacy. In short, he refrains from adulthood and adult chores. He has no adult skills. He assumes no adult responsibilities. He expects indulgence from others. He is petulant and haughtily spoiled. He is capricious, infantile and emotionally labile and immature. The narcissist is frequently a 40 years-old brat.

Narcissists suffer from repetition complexes. Like certain mythological figures, they are doomed to repeat their mistakes and failures, and the wrong behaviours which led to them. They refrain from planning and conceive of the world as a menacing, unpredictable, failure-prone, and hostile place, or, at best, a nuisance.

This culminates in self-destruction. Narcissists engage in conscious - and unconscious - acts of violence and aggression aimed at restricting their choices, gains, and potentials. Some of them end up as criminals. Their criminality usually satisfies two conditions:

1. It is Ego enhancing. The act(s) are - or must be perceived as - sophisticated, entailing the use of special traits or skills, incredible, memorable, unique. The narcissist is very likely to be involved in "white collar crime". He harnesses his leadership charisma, personal charm, and natural intelligence to do the "job".
2. The criminal act includes a mutinous and contumacious element. The narcissist, after all, is mostly recreating the relationship that he has had with his parents. He rejects authority the way an adolescent does. He regards any kind of intrusion on his privacy and his autonomy - however justified and called for - as a direct and total threat to his psychic integrity. He tends to interpret the most mundane and innocuous gestures, sentences, exclamations, or offers - as such threats. The narcissist is paranoiac when it comes to a breach of his splendid isolation. He reacts with disproportionate aggression and is thought of by his environment to be a dangerous type or, at the very least, odd and eccentric.

Any offer of help is immediately interpreted by the narcissist to imply that he is not omnipotent and omniscient. The narcissist reacts with rage to such impudent allegations and, thus, rarely asks for succour, unless he finds himself in a critical condition.

A narcissist can roam the streets for hours, looking for an address, before conceding his inferiority by asking a passer-by for guidance. He suffers physical pain, hunger and fear, rather than ask for help. The mere ability to help is considered proof of superiority and the mere need for help - a despicable state of inferiority and weakness.

This is precisely why narcissists appear, at times, to be outstanding altruists. They enjoy the sense of power which goes with giving. They feel superior when they are needed. They encourage dependence of any kind. They know - sometimes, intuitively - that help is the most addictive drug and that relying on someone dependable fast becomes an indispensable habit.

Their exhibitionistic and "saintly" altruism disguises their thirst for admiration and accolades, and their propensity to play God. They pretend that they are interested only in the well-being of the happy recipients of their unconditional giving. But this kind of representation is patently untrue and misleading. No other kind of giving comes with more strings attached. The narcissist gives only if and when he receives adulation and attention.

If not applauded or adulated by the beneficiaries of his largesse, the narcissist loses interest, or deceives himself into believing that he is, in fact, revered. Mostly, the narcissist prefers to be feared or admired rather than loved. He describes himself as a "strong, no nonsense" man, who is able to successfully weather extraordinary losses and exceptional defeats and to recuperate. He expects other people to respect this image that he projects.

Thus, the beneficiaries are objects, silent witnesses to the narcissist's grandiosity and magnanimity, the audience in his one-man show. He is inhuman in that he needs no one and nothing - and he is superhuman in that he showers and shares the cornucopia of his wealth or talents abundantly and unconditionally. Even the narcissist's charity reflects his sickness.

Even so, the narcissist is more likely to donate what he considers to be the greatest gift of all - himself, his time, his presence. Where other altruists contribute money - he avails of his time and of his knowledge. He needs to be in personal touch with those aided by him, so as to be immediately rewarded (narcissistically) for his efforts.

When the narcissist volunteers he is at his best. He is often cherished as a pillar of civic behaviour and a contributor to community life. Thus, he is able to act, win applause, and reap Narcissistic Supply - and all with full legitimacy.

next: Chapter 4, The Soul of a Narcissist, The State of the Art

Brand Name: Orinase
Generic Name: Tolbutamide

Orinase, Tolbutamide, full prescribing information

Why is Tolbutamide Prescribed?

Orinase is an oral antidiabetic medication used to treat type 2 (non-insulin-dependent) diabetes. Diabetes occurs when the body does not make enough insulin, or when the insulin that is produced no longer works properly. Insulin works by helping sugar get inside the body's cells, where it is then used for energy.

There are two forms of diabetes: type 1 (insulin-dependent) and type 2 (non-insulin-dependent). Type 1 diabetes usually requires taking insulin injections for life, while type 2 diabetes can usually be treated by dietary changes, exercise, and/or oral antidiabetic medications such as Orinase. Orinase controls diabetes by stimulating the pancreas to secrete more insulin and by helping insulin work better.

Occasionally, type 2 diabetics must take insulin injections temporarily during stressful periods or times of illness. When diet, exercise, and an oral antidiabetic medication fail to reduce symptoms and/or blood sugar levels, a person with type 2 diabetes may require long-term insulin injections.

Most important fact about Tolbutamide

Always remember that Orinase is an aid to, not a substitute for, good diet and exercise. Failure to follow a sound diet and exercise plan can lead to serious complications, such as dangerously high or low blood sugar levels. Remember, too, that Orinase is not an oral form of insulin, and cannot be used in place of insulin.

How should you take Tolbutamide?

In general, Orinase should be taken 30 minutes before a meal to achieve the best control over blood sugar levels. However, the exact dosing schedule, as well as the dosage amount, must be determined by your physician. Ask your doctor when it is best for you to take Tolbutamide.

To help prevent low blood sugar levels (hypoglycemia) you should:

Understand the symptoms of hypoglycemia.
Know how exercise affects your blood sugar levels.
Maintain an adequate diet.
Keep a product containing quick-acting sugar with you at all times.
Limit alcohol intake. If you drink alcohol, it may cause breathlessness and facial flushing.

--If you miss a dose...

Take it as soon as you remember. If it is almost time for the next dose, skip the one you missed and go back to your regular schedule. Do not take 2 doses at the same time.

--Storage instructions...

Store at room temperature.

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Tolbutamide Side Effects

Side effects cannot be anticipated. If any develop or change in intensity, inform your doctor as soon as possible. Only your doctor can determine if it is safe for you to continue taking Orinase.

Side effects from Orinase are rare and seldom require discontinuation of Orinase.

• Side effects may include:
  Bloating, heartburn, nausea

Orinase, like all oral antidiabetics, may cause hypoglycemia (low blood sugar). The risk of hypoglycemia can be increased by missed meals, alcohol, other medications, fever, trauma, infection, surgery, or excessive exercise. To avoid hypoglycemia, you should closely follow the dietary and exercise plan suggested by your physician.

• Symptoms of mild hypoglycemia may include:
  Cold sweat, drowsiness, fast heartbeat, headache, nausea, nervousness.

• Symptoms of more severe hypoglycemia may include:
  Coma, pale skin, seizures, shallow breathing.

Contact your doctor immediately if these symptoms of severe low blood sugar occur.

Ask your doctor what you should do if you experience mild hypoglycemia. Severe hypoglycemia should be considered a medical emergency, and prompt medical attention is essential.

Why should Tolbutamide not be prescribed?

You should not take Orinase if you have had an allergic reaction to it.

Orinase should not be taken if you are suffering from diabetic ketoacidosis (a life-threatening medical emergency caused by insufficient insulin and marked by excessive thirst, nausea, fatigue, pain below the breastbone, and fruity breath).

In addition, Orinase should not be used as the sole therapy in treating type 1 (insulin-dependent) diabetes.

Special warnings about Tolbutamide

It's possible that drugs such as Orinase may lead to more heart problems than diet treatment alone, or diet plus insulin. If you have a heart condition, you may want to discuss this with your doctor.

If you are taking Orinase, you should check your blood or urine periodically for abnormal sugar (glucose) levels.

It is important that you closely follow the diet and exercise plan recommended by your doctor.

Even people with well-controlled diabetes may find that stress, illness, surgery, or fever results in a loss of control over their diabetes. In these cases, your physician may recommend that you temporarily stop taking Orinase and use injected insulin instead.

In addition, the effectiveness of any oral antidiabetic, including Orinase, may decrease with time. This may occur because of either a diminished responsiveness to Orinase or a worsening of the diabetes.

Like other antidiabetic drugs, Orinase may produce severe low blood sugar if the dosage is wrong. While taking Orinase, you are particularly susceptible to episodes of low blood sugar if:

You suffer from a kidney or liver problem;

You have a lack of adrenal or pituitary hormone;

You are elderly, run-down, malnourished, hungry, exercising heavily, drinking alcohol, or using more than one glucose-lowering drug.

Possible food and drug interactions when taking Tolbutamide

If Orinase is taken with certain other drugs, the effects of either could be increased, decreased, or altered. It is especially important to check with your doctor before combining Orinase with the following:

Adrenal corticosteroids such as prednisone (Deltasone) and cortisone (Cortone)
Airway-opening drugs such as Proventil and Ventolin
Anabolic steroids such as testosterone
Barbiturates such as Amytal, Seconal, and phenobarbital
Beta blockers such as Inderal and Tenormin
Blood-thinning drugs such as Coumadin
Calcium channel blockers such as Cardizem and Procardia
Chloramphenicol (Chloromycetin)
Cimetidine (Tagamet)
Clofibrate (Atromid-S)
Colestipol (Colestid)
Epinephrine (EpiPen)
Estrogens (Premarin)
Fluconazole (Diflucan)
Furosemide (Lasix)
Isoniazid (Nydrazid)
Itraconazole (Sporanox)
Major tranquilizers such as Stelazine and Mellaril
MAO inhibitors such as Nardil and Parnate
Methyldopa (Aldomet)
Miconazole (Monistat)
Niacin (Nicobid, Nicolar)
Nonsteroidal anti-inflammatory agents such as Advil, aspirin, ibuprofen, Naprosyn, and Voltaren
Oral contraceptives
Phenytoin (Dilantin)
Probenecid (Benemid)
Rifampin (Rifadin)
Sulfa drugs such as Bactrim and Septra
Thiazide and other diuretics such as Diuril and HydroDIURIL
Thyroid medications such as Synthroid

Be cautious about drinking alcohol, since excessive alcohol can cause low blood sugar.

Special information if you are pregnant or breastfeeding

The effects of Orinase during pregnancy have not been adequately established in humans. Since Orinase has caused birth defects in rats, it is not recommended for use by pregnant women. Therefore, if you are pregnant or planning to become pregnant, you should take Orinase only on the advice of your physician. Since studies suggest the importance of maintaining normal blood sugar (glucose) levels during pregnancy, your physician may prescribe injected insulin during your pregnancy. While it is not known if Orinase enters breast milk, other similar medications do. Therefore, you should discuss with your doctor whether to discontinue Orinase or to stop breastfeeding. If Orinase is discontinued, and if diet alone does not control glucose levels, your doctor will consider giving you insulin injections.

Recommended dosage for Tolbutamide

Dosage levels are based on individual needs.

ADULTS

Usually an initial daily dose of 1 to 2 grams is recommended. Maintenance therapy usually ranges from 0.25 to 3 grams daily. Daily doses greater than 3 grams are not recommended.

CHILDREN

Safety and effectiveness have not been established in children.

OLDER ADULTS

Older, malnourished, or debilitated people, or those with impaired kidney or liver function, are usually prescribed lower initial and maintenance doses to minimize the risk of low blood sugar (hypoglycemia).

Overdosage

Any medication taken in excess can have serious consequences. An overdose of Orinase can cause low blood sugar (see "Special warnings about Orinase"). Eating sugar or a sugar-based product will often correct mild hypoglycemia. If you suspect an overdose, seek medical attention immediately.

Last Updated: 02/2009

Orinase, Tolbutamide, full prescribing information

Detailed Info on Signs, Symptoms, Causes, Treatments of Diabetes

back to:Browse all Medications for Diabetes

Brand Name: Orinase
Generic Name: (Tolbutamide)

Contents:

Description
Pharmacology
Indications and Usage
Contraindications
Warnings
Precautions
Adverse Reactions
Overdose
Dosage and Administration
How Supplied

Orinase (tolbutamide) Patient Information (in plain English)

Description

Tolbutamide is an oral blood-glucose-lowering drug of the sulfonylurea class. Tolbutamide is a pure, white, crystalline compound which is practically insoluble in water. The chemical name is benzenesulfonamide, N-[(butylamino)-carbonyl]-4-methyl-. Its structure can be represented as follows:

M.W. 270.35           C₁₂H₁₈N₂O₃S

Tolbutamide is supplied as compressed tablets containing 500 mg of Tolbutamide, USP.

Each tablet for oral administration contains 500 mg of Tolbutamide and the following inactive ingredients: colloidal silicon dioxide, magnesium stearate, microcrystalline cellulose, sodium lauryl sulfate and sodium starch glycolate.

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Clinical Pharmacology

Actions

Tolbutamide appears to lower the blood glucose acutely by stimulating the release of insulin from the pancreas, an effect dependent upon functioning beta cells in the pancreatic islets. The mechanism by which Tolbutamide lowers blood glucose during long-term administration has not been clearly established. With chronic administration in Type II diabetic patients, the blood-glucose-lowering effect persists despite a gradual decline in the insulin secretory response to the drug. Extrapancreatic effects may be involved in the mechanism of action of oral sulfonylurea hypoglycemic drugs.

Some patients who are initially responsive to oral hypoglycemic drugs, including Tolbutamide, may become unresponsive or poorly responsive over time. Alternatively, Tolbutamide may be effective in some patients who have become unresponsive to one or more of the other sulfonylurea drugs.

Pharmacokinetics

When administered orally, Tolbutamide is readily absorbed from the gastrointestinal tract. Absorption is not impaired and glucose lowering and insulin releasing effects are not altered if the drug is taken with food. Detectable levels are present in the plasma within 20 minutes after oral ingestion of a 500 mg Tolbutamide tablet, with peak levels occurring at 3 to 4 hours and only small amounts detectable at 24 hours. The half-life of Tolbutamide is 4.5 to 6.5 hours. As Tolbutamide has no p-amino group, it cannot be acetylated, which is one of the common modes of metabolic degradation for the antibacterial sulfonamides. However, the presence of the p-methyl group renders Tolbutamide susceptible to oxidation, and this appears to be the principal manner of its metabolic degradation in man. The p-methyl group is oxidized to form a carboxyl group, converting Tolbutamide into the totally inactive metabolite 1-butyl-3-p-carboxy-phenylsulfonylurea, which can be recovered in the urine within 24 hours in amounts accounting for up to 75% of the administered dose.

The major Tolbutamide metabolite has been found to have no hypoglycemic or other action when administered orally and IV to both normal and diabetic subjects. This Tolbutamide metabolite is highly soluble over the critical acid range of urinary pH values, and its solubility increases with increase in pH. Because of the marked solubility of the Tolbutamide metabolite, crystalluria does not occur. A second metabolite, 1-butyl-3-(p-hydroxymethyl) phenyl sulfonylurea also occurs to a limited extent. It is an inactive metabolite.

The administration of 3 grams of Tolbutamide to either nondiabetic or Tolbutamide-responsive diabetic subjects will, in both instances, occasion a gradual lowering of blood glucose. Increasing the dose to 6 grams does not usually cause a response which is significantly different from that produced by the 3 gram dose. Following the administration of a 3 gram dose of Tolbutamide solution, non-diabetic fasting adults exhibit a 30% or greater reduction in blood glucose within one hour, following which the blood glucose gradually returns to the fasting level over 6 to 12 hours. Following the administration of a 3 gram dose of Tolbutamide solution, Tolbutamide responsive diabetic patients show a gradually progressive blood glucose lowering effect, the maximal response being reached between 5 to 8 hours after ingestion of a single 3 gram dose. The blood glucose then rises gradually and by the 24^th hour has usually returned to pretest levels. The magnitude of the reduction, when expressed in terms of percent of the pretest blood glucose, tends to be similar to the response seen in the nondiabetic subject.

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Indications and Usage

Tolbutamide tablets are indicated as an adjunct to diet to lower the blood glucose in patients with non-insulin-dependent diabetes mellitus (type II) whose hyperglycemia cannot be controlled by diet alone.

In initiating treatment for non-insulin-dependent diabetes, diet should be emphasized as the primary form of treatment. Caloric restriction and weight loss are essential in the obese diabetic patient. Proper dietary management alone may be effective in controlling the blood glucose and symptoms of hyperglycemia. The importance of regular physical activity should also be stressed, and cardiovascular risk factors should be identified and corrective measures taken where possible.

If this treatment program fails to reduce symptoms and/or blood glucose, the use of an oral sulfonylurea or insulin should be considered. Use of Tolbutamide tablets must be viewed by both the physician and patient as a treatment in addition to diet, and not as a substitute for diet or as a convenient mechanism for avoiding dietary restraint. Furthermore, loss of blood glucose control on diet alone may be transient, thus requiring only short-term administration of Tolbutamide tablets.

During maintenance programs, Tolbutamide tablets should be discontinued if satisfactory lowering of blood glucose is no longer achieved. Judgments should be based on regular clinical and laboratory evaluations.

In considering the use of Tolbutamide tablets in asymptomatic patients, it should be recognized that controlling the blood glucose in non-insulin dependent diabetes has not been definitely established to be effective in preventing the long-term cardiovascular or neural complications of diabetes.

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Contraindications

Tolbutamide tablets are contraindicated in patients with:

1. Known hypersensitivity or allergy to the drug.
2. Diabetic ketoacidosis, with or without coma. This condition should be treated with insulin.
3. Type I diabetes, as sole therapy.

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Warnings

SPECIAL WARNING ON INCREASED RISK OF CARDIOVASCULAR MORTALITY

The administration of oral hypoglycemic drugs has been reported to be associated with increased cardiovascular mortality as compared to treatment with diet alone or diet plus insulin. This warning is based on the study conducted by the University Group Diabetes Program (UGDP), a long-term prospective clinical trial designed to evaluate the effectiveness of glucose-lowering drugs in preventing or delaying vascular complications in patients with non-insulin-dependent diabetes. The study involved 823 patients who were randomly assigned to one of four treatment groups (Diabetes, 19 (supp.2):747-830, 1970).

UGDP reported that patients treated for 5 to 8 years with diet plus a fixed dose of Tolbutamide (1.5 grams per day) had a rate of cardiovascular mortality approximately 2 ½ times that of patients treated with diet alone. A significant increase in total mortality was not observed, but the use of Tolbutamide was discontinued based on the increase in cardiovascular mortality, thus limiting the opportunity for the study to show an increase in overall mortality. Despite controversy regarding the interpretation of these results, the findings of the UGDP study provide an adequate basis for this warning. The patient should be informed of the potential risks and advantages of Tolbutamide and of alternative modes of therapy. Although only one drug in the sulfonylurea class (Tolbutamide) was included in this study, it is prudent from a safety standpoint to consider that this warning may also apply to other oral hypoglycemic drugs in this class, in view of their close similarities in mode of action and chemical structure.

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Precautions

General

Hypoglycemia

All sulfonylurea drugs are capable of producing severe hypoglycemia. Proper patient selection, dosage, and instructions are important to avoid hypoglycemic episodes. Renal or hepatic insufficiency may cause elevated blood levels of Tolbutamide and the latter may also diminish gluconeogenic capacity, both of which increase the risk of serious hypoglycemic reactions. Elderly, debilitated or malnourished patients, and those with adrenal or pituitary insufficiency are particularly susceptible to the hypoglycemic action of glucose-lowering drugs. Hypoglycemia may be difficult to recognize in the elderly, and in people who are taking beta-adrenergic blocking drugs. Hypoglycemia is more likely to occur when caloric intake is deficient, after severe or prolonged exercise, when alcohol is ingested, or when more than one glucose-lowering drug is used.

Loss of Control of Blood Glucose

When a patient stabilized on any diabetic regimen is exposed to stress such as fever, trauma, infection, or surgery, a loss of control may occur. At such times, it may be necessary to discontinue Tolbutamide and administer insulin.

The effectiveness of any oral hypoglycemic drug, including Tolbutamide, in lowering blood glucose to a desired level decreases in many patients over a period of time, which may be due to progression of the severity of the diabetes or to diminished responsiveness to the drug. This phenomenon is known as a secondary failure, to distinguish it from primary failure in which the drug is ineffective in an individual patient when first given. Adequate adjustment of dose and adherence to diet should be assessed before classifying a patient as a secondary failure.

Hemolytic Anemia

Treatment of patients with glucose 6-phosphate dehydrogenase (G6PD) deficiency with sulfonylurea agents can lead to hemolytic anemia. Because Tolbutamide belongs to the class of sulfonylurea agents, caution should be used in patients with G6PD deficiency and a non-sulfonylurea alternative should be considered. In post-marketing reports, hemolytic anemia has also been reported in patients who did not have known G6PD deficiency.

Information for Patients

Patients should be informed of the potential risks and advantages of Tolbutamide and of alternative modes of therapy. They should also be informed about the importance of adherence to dietary instructions, of a regular exercise program, and of regular testing of urine and/or blood glucose.

The risks of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and responsible family members. Primary and secondary failure should also be explained.

Laboratory Tests

Blood and urine glucose should be monitored periodically. Measurement of glycosylated hemoglobin may be useful.

A metabolite of Tolbutamide in urine may give a false positive reaction for albumin if measured by the acidification-after-boiling test, which causes the metabolite to precipitate. There is no interference with the sulfosalicylic acid test.

Drug Interactions

The hypoglycemia action of sulfonylurea may be potentiated by certain drugs including non-steroidal anti-inflammatory agents and other drugs that are highly protein bound, salicylates, sulfonamides, chloramphenicol, probenecid, coumarins, monoamine oxidase inhibitors, and beta-adrenergic blocking agents. When such drugs are administered to a patient receiving Tolbutamide, the patient should be observed closely for hypoglycemia. When such drugs are withdrawn from a patient receiving Tolbutamide, the patient should be observed closely for loss of control.

Certain drugs tend to produce hyperglycemia and may lead to loss of control. These drugs include the thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid. When such drugs are administered to a patient receiving Tolbutamide, the patient should be closely observed for loss of control. When such drugs are withdrawn from a patient receiving Tolbutamide, the patient should be observed closely for hypoglycemia.

A potential interaction between oral miconazole and oral hypoglycemic agents leading to severe hypoglycemia has been reported. Whether this interaction also occurs with the intravenous, topical or vaginal preparations of miconazole is not known.

Carcinogenicity and Mutagenicity

Bioassay for carcinogenicity was performed in both sexes of rats and mice following ingestion of Tolbutamide for 78 weeks. No evidence of carcinogenicity was found.

Tolbutamide has also been demonstrated to be nonmutagenic in the Ames salmonella/mammalian microsome mutagenicity test.

Pregnancy

Teratogenic Effects: Pregnancy Category C

Tolbutamide has been shown to be teratogenic in rats when given in doses 25 to 100 times the human dose. In some studies, pregnant rats given high doses of Tolbutamide have shown ocular and bony abnormalities and increased mortality in offspring. Repeat studies in other species (rabbits) have not demonstrated a teratogenic effect. There are no adequate and well controlled studies in pregnant women. Tolbutamide is not recommended for the treatment of pregnant diabetic patients.

Serious consideration should also be given to the possible hazards of the use of Tolbutamide in women of childbearing age and in those who might become pregnant while using the drug.

Because recent information suggests that abnormal blood glucose levels during pregnancy are associated with a higher incidence of congenital abnormalities, many experts recommend that insulin be used during pregnancy to maintain blood glucose levels as close to normal as possible.

Nonteratogenic Effects

Prolonged severe hypoglycemia (4 to 10 days) has been reported in neonates born to mothers who were receiving a sulfonylurea drug at the time of delivery. This has been reported more frequently with the use of agents with prolonged half-lives. If Tolbutamide is used during pregnancy, it should be discontinued at least 2 weeks before the expected delivery date.

Nursing Mothers

Although it is not known whether Tolbutamide is excreted in human milk, some sulfonylurea drugs are known to be excreted in human milk. Because the potential for hypoglycemia in nursing infants may exist, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. If the drug is discontinued and if diet alone is inadequate for controlling blood glucose, insulin therapy should be considered.

Pediatric Use

Safety and effectiveness in children have not been established.

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Adverse Reactions

Hypoglycemia

See PRECAUTIONS and OVERDOSE.

Gastrointestinal Reactions

Cholestatic jaundice may occur rarely; Tolbutamide should be discontinued if this occurs. Gastrointestinal disturbances, e.g., nausea, epigastric fullness, and heartburn, are the most common reactions and occur in 1.4% of patients treated during clinical trial. They tend to be dose related and may disappear when dosage is reduced.

Dermatologic Reactions

Allergic skin reactions, e.g., pruritus, erythema, urticaria, and morbilliform or maculopapular eruptions, occur in 1.1% of patients treated during clinical trials. These may be transient and may disappear despite continued use of Tolbutamide; if skin reactions persist, the drug should be discontinued.

Porphyria cutanea tarda and photosensitivity reactions have been reported with sulfonylureas.

Hematologic Reactions

Leukopenia, agranulocytosis, thrombocytopenia, hemolytic anemia, aplastic anemia, and pancytopenia have been reported with sulfonylureas.

Metabolic Reactions

Hepatic porphyria and disulfiram-like reactions have been reported with sulfonylureas.

Endocrine Reactions

Cases of hyponatremia and the syndrome of inappropriate antidiuretic hormone (SIADH) secretion have been reported with this and other sulfonylureas.

Miscellaneous Reactions

Headache and taste alterations have occasionally been reported with Tolbutamide administration.

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Overdose

Overdosage of sulfonylureas including Tolbutamide can produce hypoglycemia. Mild hypoglycemic symptoms without loss of consciousness or neurologic findings should be treated aggressively with oral glucose and adjustments in drug dosage and/or meal patterns. Close monitoring should continue until the physician is assured that the patient is out of danger. Severe hypoglycemic reactions with coma, seizure, or other neurological impairment occur infrequently, but constitute medical emergencies requiring immediate hospitalization. If hypoglycemic coma is diagnosed or suspected, the patient should be given a rapid intravenous injection of concentrated (50%) dextrose injection. This should be followed by a continuous infusion of a more dilute (10%) dextrose injection at a rate that will maintain the blood glucose at a level above 100 mg/dL. Patients should be closely monitored for a minimum of 24 to 48 hours since hypoglycemia may recur after apparent clinical recovery.

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Dosage and Administration

There is no fixed dosage regimen for the management of diabetes mellitus with Tolbutamide tablets or any other hypoglycemic agent. In addition to the usual monitoring of urinary glucose, the patient's blood glucose must also be monitored periodically to determine the minimum effective dose for the patient; to detect primary failure, i.e., inadequate lowering of blood glucose at the maximum recommended dose of medication; and to detect secondary failure, i.e., loss of an adequate blood glucose lowering response after an initial period of effectiveness. Glycosylated hemoglobin levels may also be of value in monitoring the patient's response to therapy.

Short-term administration of Tolbutamide tablets may be sufficient during periods of transient loss of control in patients usually controlled well on diet.

Usual Starting Dose

The usual starting dose is 1 to 2 grams daily. This may be increased or decreased, depending on individual patient response. Failure to follow an appropriate dosage regimen may precipitate hypoglycemia. Patients who do not adhere to their prescribed dietary regimens are more prone to exhibit unsatisfactory response to drug therapy.

Transfer from Other Hypoglycemic Therapy

Patients Receiving Other Antidiabetic Therapy

Transfer of patients from other oral antidiabetes regimens to Tolbutamide tablets should be done conservatively. When transferring patients from oral hypoglycemic agents other than chlorpropamide to Tolbutamide, no transition period and no initial or priming doses are necessary. When transferring patients from chlorpropamide, however, particular care should be exercised during the first 2 weeks because of the prolonged retention of chlorpropamide, in the body and the possibility that subsequent overlapping drug effects might provoke hypoglycemia.

Patients Receiving Insulin

Patients requiring 20 units or less of insulin daily may be placed directly on Tolbutamide tablets and insulin abruptly discontinued. Patients whose insulin requirement is between 20 and 40 units daily may be started on therapy with Tolbutamide tablets with a concurrent 30% to 50% reduction in insulin dose, with further daily reduction of the insulin when response to Tolbutamide tablets is observed. In patients requiring more than 40 units of insulin daily, therapy with Tolbutamide tablets may be initiated in conjunction with a 20% reduction in insulin dose the first day, with further careful reduction of insulin as response is observed. Occasionally, conversion to Tolbutamide tablets in the hospital may be advisable in candidates who require more than 40 units of insulin daily. During this conversion period when both insulin and Tolbutamide tablets are being used hypoglycemia may rarely occur. During insulin withdrawal, patients should test their urine for glucose and acetone at least 3 times daily and report results to their physician. The appearance of persistent acetonuria with glycosuria indicates that the patient is type I diabetic who requires insulin therapy.

Maximum Dose

Daily doses of greater than 3 grams are not recommended.

Usual Maintenance Dose

The maintenance dose is in the range of 0.25 to 3 grams daily. Maintenance doses above 2 grams are seldom required.

Dosage Interval

The total daily dose may be taken either in the morning or in divided doses through the day. While either schedule is usually effective, the divided dose system is preferred by some clinicians from the standpoint of digestive tolerance.

In elderly patients, debilitated or malnourished patients, and patients with impaired renal or hepatic function, the initial and maintenance dosing should be conservative to avoid hypoglycemic reactions (see PRECAUTIONS).

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How Supplied

Tolbutamide Tablets, USP are available containing 500 mg of Tolbutamide, USP. The tablets are white to off-white round, scored tablets debossed with M to the left of the score and 13 to the right of the score on one side of the tablet and blank on the other side. They are available as follows:

NDC 0378-0215-01
bottles of 100 tablets

NDC 0378-0215-05
bottles of 500 tablets

Store at 20° to 25°C (68° to 77°F). [See USP for Controlled Room Temperature.]

Protect from light.

Dispense in a tight, light-resistant container as defined in the USP using a child-resistant closure.

Mylan Pharmaceuticals Inc.
Morgantown, WV 26505

Last Updated: 02/2009

Orinase (tolbutamide) Patient Information (in plain English)

Detailed Info on Signs, Symptoms, Causes, Treatments of Diabetes

The information in this monograph is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects. This information is generalized and is not intended as specific medical advice. If you have questions about the medicines you are taking or would like more information, check with your doctor, pharmacist, or nurse.

back to: Browse all Medications for Diabetes

Holli Marshall & Niki Delson on "Survivors of Sexual Abuse", Online Conference Transcript

Bob M is Bob McMillan, editor of the online magazine CCI Journal at Concerned Counseling.
Holli Marshall: Is a sexual abuse survivor.
Niki Delson: Licensed Clinical Social Worker specializing in treatment of children and adult survivors of sexual abuse. 
The people color-coded in blue are audience members who had questions.

BEGINNING

Bob M: Good evening everyone. Our guest is here, so we are ready to begin. Our topic tonight is Adult Survivors of child abuse. Our first guest is Holli Marshall. You may have seen her site entitled "Holli's Triumph Over Tragedy". Holli endured many years of abuse and fortunately sought out treatment and according to her, she has made a significant and successful effort towards recovery. Our second guest tonight, coming in about 50 minutes, will be Niki Delson, LCSW, who works with survivors of abuse. In fact, I believe that constitutes almost her entire practice. So again, I want to welcome everyone to the Concerned Counseling website and say good evening to our first guest, Holli Marshall.

Holli Marshall: Thank you, Bob. Good evening everyone. I'm glad to be here tonight and thank you for the invitation. I appreciate the opportunity to share my story and to hopefully let everyone know that you can recover and lead a reasonably happy life.

Bob M: Thanks, Holli. Can you start off by telling us a bit about yourself and give us some background on the abuse you have suffered?

Holli Marshall: I'm 27 years old. Obviously, I'm female. I'm disabled because of the abuse. Before I became disabled, I was a professional television engineer. I live in Minnesota now. At 5 years old I was raped by an 18-year-old male babysitter. Since then, in separate incidents, I was abused, raped, and incested by my brother and several neighborhood boys. This happened between the ages of 5-13. My mother has dissociative identity disorder (DID). She was physically, emotionally and verbally abusive to me while I was growing up. My mother constantly tried to commit suicide. So, she couldn't take care of me, much less herself. I'd go days without food, having my clothes changed, and without being held or nurtured. My father was an alcoholic and verbally abusive. My sister used to be a drug addict and ran away when I was very young, so I don't know much about her. So you can imagine, to sum it up, I had a nightmare of a childhood.

Bob M: Holli, you mentioned that you are now disabled. In what way?

Holli Marshall: I have stickler's syndrome. It's a tissue disorder. I was born with a cleft pallet. I am deaf because of the abuse I sustained. I also have had to go through many types of physical therapies because my bones aren't healthy. In addition, I became anorexic because I felt I needed to be fit and perfect in order to be loved.

Bob M: So, your earlier life was horrific and you live daily with the reminders of your abuse. Initially, as a teenager, how did you deal with all this?

Holli Marshall: I think I went "out of my head"...or I would've gone mad. Listening to music was very important. Being involved in track. And because there was simply no way out, suicide wasn't a choice or option, I just had to deal with it. So mentally, I tried to "step outside" of my reality. My diagnosis is posttraumatic stress disorder (PTSD). It's as if I've been through the Viet Nam war and I experienced all the symptoms of PTSD. For instance, I had nightmares, flashbacks, hot and cold sweats, anorexia, abdominal distress, stomach pain, migraines and I'm a very nervous and anxious person.

Bob M: For those of you just entering, we are speaking with Holli Marshall, from the website "Triumph over Tragedy", about her experiences with abuse and how she has dealt with it. In about 30 minutes, our next guest, Niki Delson, licensed clinical social worker, will be along to give us her professional insight into abuse issues. Most of her practice consists of working with survivors. We will be taking questions for our guest in 5 minutes. Holli, can you tell us a bit about the treatment you have received over the years and how effective was it?

Holli Marshall: I've been through "talk" therapy, doing some hypnosis, meditation, relaxation and breathing techniques. I've also been put on medications, Prozac, Klonopin, Vistoril. All have been very helpful combined together. I also have a wonderful psychologist who specializes in working with those with posttraumatic stress disorder (PTSD). The therapy, the healing process, creates safety about you and teaches you how to create a support system. You learn how to cope, nurture yourself, build self-esteem and confidence, build better relationships and boundaries within those relationships. You learn how to live with the feeling of "impending doom". Basically, you learn to live a better quality of life. It's the quality that counts. I AM NOT A VICTIM. I AM A SURVIVOR!! It's empowerment. And I like living my life that way, rather than considering myself a victim.

Bob M: How many years of therapy did it take to reach this point? And are you still in therapy?

Holli Marshall: I started 5 years ago and I'm still going.

Bob M: And would you say that you are "recovered" now? And could you have done this on your own without professional help?

Holli Marshall: I would say that I am deep into the recovery stage, but not done. Probably a few more years to go. It's hard to reverse 20 years of abuse and neglect overnight. I could not have done this or gotten as far as I am now, without professional help. I strongly believe people have to talk to one and other, and be heard, to aid in the recovery and to heal.

Bob M: Here are some questions from the audience Holli:

Pandora: Are you diagnosed with MPD/DID Holli? I have been told by both my psychiatrist and psychologist that I shouldn't mention this to people. It is difficult to be treated for a disorder that isn't readily acknowledged by the public and even many professionals.

Holli Marshall: MPD/DID is different than posttraumatic stress disorder in that I am dissociated, but not to the point that I lost touch with reality in myself. DID creates new people to take over the pain. I would suggest that you tell people that you have DID. I think the silence is very hurtful. If you've been diagnosed with DID, then you need to find a professional who acknowledges it and then get treatment. My experiences have shown me that the general public turns it's head away from abuse issues because it's difficult to hear and digest. That's why I created the "mint green ribbon campaign" for the awareness of abuse.

Journey: Holli, I read your web page earlier today! Great Page!!! My question is: how are the flashbacks different now from before when you first went through them; and also, does your anorexia get better as you go through your healing process?

Holli Marshall: Re: the flashbacks. I still have them. They range in severity depending on what I am going through at that moment. For instance, if I'm dealing with extra stress, that can trigger a flashback. But they are less frequent now than before and I now know how to handle them. The anorexia did get better for me as time went along because I was able to gain more self-esteem and awareness of myself and my needs as therapy progressed. Since I was a child, neglected, not fed food because my mom didn't feed me properly, I didn't develop a sense of hunger, like normal hunger pains. I would go on and on without eating. And because of the sexual abuse and incest, I didn't want people to see my womanly curves. But now I realize that's normal and natural and you should feel good about yourself and proud of yourself no matter what you've been through.

Robinke: How old were you when you began counseling and how many counselors did it take before you found the right person?

Holli Marshall: I was 22 when I began and it took me until my third counselor to get it right. I finally found a psychologist who I could work with and who specialized in PTSD. But it was frustrating during the interim periods before I found the right person. So please hang in there and find a good person who works for you.

Gryphonguardians: Did you have to remember everything in a lot of detail to heal?

Holli Marshall: No. I think it's impossible to remember everything in detail when going through the therapy process. And basically, I think you should just pick and choose what you know is going to work for you.

Precious198: Did you have to confront your abusers to heal or did the healing take place without that?

Holli Marshall: I had to confront my abusers which was very hard and did not go well. But I went into it with no expectations of it either going or not going, well.

Bob M: What was that like for you Holli--facing your abusers? And how did your abusers respond?

Holli Marshall: For me, it was very scary because I didn't exactly know what to expect. I tried to stay neutral, but obviously, you're worried if this person is going to physically and verbally attack you and try and discredit you. And they responded in multiple ways. Some acknowledged what happened and said they were sorry. Some said that's the past, get over it. Some denied it. And I also tried to pursue some of my abusers in a legal way. But because the case was so old, I found out I couldn't do it, even though they acknowledged it happened.

Rachel2: The ones who wouldn't admit that they abused you, did that cause doubt in your own mind about what happened?

Holli Marshall: My parents said they were sorry about the neglect and abandonment and they should've handed me over to someone responsible to take care of me. As far as the people who denied it, no it never caused me any doubt about what happened. I live in a "total reality" situation. Unfortunately, I remember everything.

albinoalligator: For the ones who didn't acknowledge the abuse, how do you feel about them?

Holli Marshall: I feel no mercy for them, but I do feel pity for them because they have to deal with it in their own minds. And if they believe in a higher power, they'll have to deal with it then. And whatever demons they live with, that's their problem. I don't believe you have to forgive people for what they've done. That's why I say I have no mercy.

Patty Cruz: Holli Marshall, I received an email inviting me to this chat. Has it been your experience that women who have been sexually abused hide their bodies as you mentioned?

Holli Marshall: Yes Patty. I have met more that do hide their bodies because of sexual abuse, than those who don't.

Bob M: Holli, you are married now. How have you been dealing with the sexuality involved in that?

Holli Marshall: I've been married since I was 21. I'm now 27. I never experienced sexual problems and I'm fortunate I guess. I don't know why I was able to get through that, but I'm glad I was. Within the first two dates with my husband to be, I spilled my guts. I told him everything. And it basically overwhelmed him, but he looked beyond that and saw me for what I am inside and fell in love with that. I was never scared to tell him. I've been very open about my abuse issues since I was 13. I told my friends and therapists. I actually found it very helpful and therapeutic to do that.

Bob M: Thank you Holli for being here tonight and sharing your story and experiences with us. Our next guest, Niki Delson is here. And I'll be introducing her in a second.

Holli Marshall: Thank you Bob and I appreciate having the opportunity to be here. Good night everyone.

Bob M: Our next guest is Niki Delson. Ms. Delson is a licensed clinical social worker and most of her practice involves working with people who suffered sexual abuse. Good evening Niki and welcome to the Concerned Counseling website. Can you briefly tell us a bit more about your expertise?

Niki Delson: I work in a private practice that specializes in family violence. We treat victims, family members, and perpetrators. I am also an instructor for the University of California and train social workers in investigating abuse and neglect.

Bob M: I know you saw part of the conversation we had with Holli Marshall. Is it typical for people who are abused as children to suffer the after-effects in adult life?

Niki Delson: Many children who were molested, or had other traumatic experiences in childhood, continue to suffer or experience a variety of symptoms as adults. There are, however, victims of sexual abuse who are asymptomatic all of their life.

Bob M: How is it possible that after an experience of being raped or molested as a child, one can be without symptoms then and later in life?

Niki Delson: Children who are molested don't have the cognitive ability to understand a lot of what was done to them. It's important to remember that most molestation experiences are not rape. Children are mostly confused when they realize that what was being done to them was not okay and the disclosure of the abuse sometimes creates more symptoms, depending on the reactions of parents and others involved in the process of dealing with the disclosures. The aftermath of disclosure and the fallout from that is usually what we deal with in therapy first. Children can be asymptomatic before puberty and develop symptoms when sex takes on a different meaning in their life.

Bob M: What role do the parents play in the ability of a child to heal after a child is sexually abused?

Niki Delson: If it is a family member, an incestuous relationship, then the mother is the key to the healing. Research clearly demonstrates that children who have supportive mothers who acknowledge the molestation experience and clearly hold the perpetrator accountable will heal faster. The perpetrator's admission is also a key factor in health.

Bob M: I'm wondering, in many abuse cases, there is a legal process. What is your feeling about bringing the abused child into the legal process and having them testify and go through extensive exams, etc.? Is it better to do this or not do this in terms of the healing process?

Niki Delson: That all depends on the child. I have worked with teenagers who clearly wanted to go to court and testify. They believed that was the only way to get their father to be held accountable and they wanted to do it publicly. I have worked with teenagers who wanted to have a sexual trauma exam because their mothers didn't believe them and they hoped it would give her the wake-up call she needed. I have also worked with children who were as traumatized by the sexual trauma exam as they were by sexual trauma.

Bob M: Let's say the abused child doesn't get the professional treatment needed during childhood. What is the key to the healing process in adulthood?

Niki Delson: Clarity in their minds that it was nothing about them, not their body, not their mind, not their soul that caused them to be "chosen" by the perpetrator. Sometimes that comes from psychological counseling, other times it comes from family, a minister, a mentor, a teacher, a good friend. etc.

Bob M: Here are some questions from the audience:

Precious198: Is it necessary in healing to confront the abusers- especially if it involves mom, dad, and brother if you know they will not acknowledge that any abuse happened?

Niki Delson: If you know they will not acknowledge it, what would be your purpose? You have to be clear about that, because otherwise you just put yourself in a position to feel victimized again.

Robinke: I guess you have had victims where the family (parents) doesn't believe them. How do you deal with them?

Niki Delson: It depends on whether they are children or adults. If they are children and not believed, they are usually removed from the family, and it is the separation and abandonment issues that we deal with first. That is usually way more painful than being molested.

BobM: And what about as an adult, finally confronting your abusers? How does one deal with the situation of confronting your parents or abuser and they deny it?

Niki Delson: I have seen that backfire many times. And it takes a lot of preparation. Some women say that they just wanted to experience the power of confrontation and did a confrontation with supportive women or family. They experienced a sense of completion when the perpetrator no longer had power over them, even though there was no admission.

BobM: What about men who are abused? Is it a different experience for them than women and the way they handle it? And is the treatment different?

Niki Delson: It is different for many men. When they are children, they are dealt with differently. There is the issue of homophobia if they were molested by a man, and if they were molested by a woman, and they are adolescent, they are supposed to feel like they had a great sexual experience. As little boys, they are expected to take it like a man, not have sad feelings, not cry, etc. And for many boys, unless there is sodomy, and usually there is not, they find the experience pleasurable and do not want the offender to get in trouble. The offender, with both males and females, creates confusion by getting the victim to think that because they complied, they really consented. Then when they are adults, they have no clarity about what consent means. Victims get compliance and consent confused.

Rachel2: How do you ensure personal safety when having an abreaction, a real-life remembrance of the abuse, where it feels like you are actually there? What steps do you take to ensure that safety?

Niki Delson: It is important to work with a therapist and get clarity where you are trauma bonded. There are certain triggers that link certain aspects of your environment to memories. Each molestation experience is unique and so for each individual, understanding the experience means untangling those reminders. Trauma bonding is where the trauma, is cemented so to speak, in your mind with other things that you experienced, could be smells, something visual, etc, and the triggers bring about the memory.

BobM: Can you talk a little about the different types of therapy that would be effective in helping adult survivors?

Niki Delson: The most successful form of therapy seems to be cognitive behavioral, where you work with the therapist to understand your thinking, and feeling, and how your thoughts generate your behaviors. There is some research on EMDR (Eye Movement Desensitization and Reprocessing) as a very useful intervention in untangling the traumatic memory.

Precious198: If you have multiple personality disorder/DID, how do you get to the point that the personalities/voices get under control and you can live a semi-normal life again?

Niki Delson: If work with a therapist isn't helping, some victims find various forms of medications very helpful with quieting the mental conversations that disrupt everyday functioning. Medication along with psychotherapy has been shown to be successful in dealing with depression.

Gloria: I don't know if this is allowed, but I have grandparents who think that I should just forget it and a father who thinks what happened is my fault.

Niki Delson: Well, your father is wrong, and telling you to forget it is not useful. It is useful to find a way to package the memory and have it exist as a memory of a very bad experience, and not have the memory be in the driver's seat of your life.

Bob M: One last audience question Niki because I know you have to leave: There are some adults who "think" they may have been abused, but aren't sure. Maybe they have dissociated the memory or don't have a clear memory of the incident(s). How do they deal with that?

Niki Delson: I worry about people, who have no clear memory, "thinking" they have been abused. It is a dangerous road to walk down, because sometimes one can look for an explanation for an unhappy life, and molestation may not be at the root. I deal with what people bring into the therapy office. I ask them to define what their "life is not" and help them look for how they would like their life to be and what is stopping them from achieving fulfillment in life. Defining yourself as a victim, and having that as an identity, does not lead to fulfillment.

Bob M: Thank you, Niki, for being here tonight. We appreciate it. I also want to thank the audience for coming.

Niki Delson: Thank you. I hope everyone found it informative. Good night.

Bob M: Thanks to everyone for being here. Good night.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

back to: Abuse Conference Transcripts ~ Other Conferences Index ~ Abuse Home

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