Dear Fellow Traveler,

Did you know that researchers use darkness to measure trauma? Humans evolved to be afraid of the dark because when we were living as small tribes in the savannas and jungles of Africa, night time was when predators could more easily surprise and eat us because we couldn’t see them coming.

In the dark, our ears compensate for what our eyes cannot see. Researchers realized they could use darkness and sudden noises to measure baseline fear arousal caused by trauma to detect whether or not someone has Post-Traumatic Stress Disorder (PTSD) (Kamkwalala, et al, 2012).

C-PTSD includes, but is the much worse version of PTSD which I will discuss below.

It turns out that if you don’t have childhood trauma reaching the level of PTSD or C-PTSD, you calm down within minutes of the lights being turned off. This is because your brain has not been structurally damaged by traumatic events to stay alert for surprise threats in the dark.

But if you do have PTSD or C-PTSD, your brain can’t calm down. You can’t let go of the fear that something or someone is coming for you in the dark. You stay aroused because your brain is dumping adrenaline and cortisol to keep your heart rate up, your eyes dilated so you can see better in the dark, and your muscles tensed so you can fight or flee from whatever is about to attack you.

When researchers play an unexpected noise, people with PTSD and C-PTSD brains startle. They jump higher, duck lower, and yell exponentially louder than non-traumatized folk because our traumatized brains think the noise is an animal or person coming to hurt us.

In contrast, non-sufferers assume the noise is something innocuous like someone bumping into a desk on the way to get some water.

The correlation of darkness with the need to be ready for danger in severely traumatized parents and children is well documented as I found when I was reading a research review article titled, “Weaving Invisible Threads: The Impact of Caregiver Trauma on Parenting and Child Brain Development” ) (Riser, et al, 2025) for a client who has C-PTSD who I met with this week.

For confidentiality reasons, I won’t share much about their individual case except to say that they sent me this article with the question, “Is what we went through really this bad? This damaging?”

This article is a result of my research and work to fully answer their question.

*Side note: If you want to do a deep dive into C-PTSD before reading further, please check out my piece, “The UnShaming of C-PTSD.”

Trauma Causes PTSD, C-PTSD, and Physical Brain Damage

What I told them and what I am telling you if you have C-PTSD is that what you have is a condition that is much worse than what is described in the article. Not because the article is inaccurate but because the article only describe the impact of PTSD on survivors not C-PTSD.

70% of people will experience a traumatic event in their lifetime that could cause PTSD and of those it is estimated 5.6% will develop some form of PTSD.

Because C-PTSD is not an officially recognized psychiatric condition in the United States, rates for the prevalence of C-PTSD compared to prevalence PTSD here are not available; but they are for the UK and many countries in Europe who use the ICD-11 as opposed to the DSM-5 to diagnose psychiatric illnesses.

A person who is diagnosed with C-PTSD cannot also be diagnosed with PTSD because C-PTSD automatically means you have PTSD. (Lewis et al, 2021).

PTSD is defined as having experienced or witnessed an event so distressing and traumatic it causes: 1.) intrusions into your daily life - nightmares and flashbacks about the event that cause anxiety and disruptions to your daily life; 2.) avoidance of people, places and things that remind you of the traumatic events; 3.) arousal - feeling constantly on edge, irritable and easily startled.

C-PTSD is everything that PTSD is plus 4.) a loss of self-worth - intense and deep beliefs of worthlessness, shame and feeling permanently broken; 5.) emotional dysregulation - trouble controlling emotions, feeling emotionally numb, and severe mood shifts; and 6.) relationship difficulties - distrusting others, an inability to feel close to others, and/or avoidance of relationships entirely.

In other words, PTSD changes your reality. C-PTSD changes who you are. PTSD disrupts your faith in the goodness of the world. C-PTSD destroys it.

As I was researching this article, I assumed like most things in life that PTSD, the less severe of these two disorders, would be more common.

Around 15% of the 340 million people in the United States come down with the flu each year. Of the 51 million people who contract the flu, 52,000 die (around 0.001%).

But I was wrong, multiple studies in Sweden, Poland, and the UK show that rates of C-PTSD are higher than rates of PTSD.

When looking at 1300 firefighters who were exposed to traumatic events, 18.23% of them met criteria for C-PTSD while 5.26% met criteria for PTSD (Langtry, 2021).

Over 3x more firefighters met criteria for C-PTSD than for PTSD.

Please sit with that for a minute.

Once I got over the initial shock of my brain feeling microwaved by this fact, I started to make sense of this seeming contradiction.

With the flu, most of us actively work to try and keep the environments we live in free of the germs that can get us sick. We bleach surfaces, separate from others we perceive to be sick, and/or wear face masks to filter the air we breathe. When we do these things, other people around us don’t typically replace the bleach in our Lysol bottles with water, they don’t hug us closely when they are sick, making sure to cough in our faces while they knock our masks off of our faces.

But people who live and work in traumatic environments aren’t treated the same way. On the contrary, in traumatic environments dangers, abusers and assailants come for us repeatedly. Firefighters don’t just go into one burning building in their entire careers. Soldiers don’t just serve a one day tour of duty and are discharged. And abused people don’t just get hit or terrorized one time.

It is the repeated traumas of disaster, abuse or attack that cause C-PTSD.

Research has shown that combat veterans and children who have been abused show the same structural brain damage to the amygdala - the threat detection center of the brain; and the anterior insula - the part of the brain that is in charge of a.) interoceptive awareness - translating internal bodily signals like pain, heart rate, muscle tension and gut feelings into conscious awareness/feelings, b.) emotional and social processing - generating conscious emotions like disgust, pride, guilt, love, fear, and c.) the salience network hub - the part of the brain that shifts between internal thoughts and memories and external tasks and awareness.

Other studies show that C-PTSD and PTSD cause structural damage to the hippocampus - the part of the brain that consolidates, organizes and stores memories; and the medial prefrontal cortex - the part of the brain that controls working memory, decision making, planning, attention, and impulse control (Nutt & Malizia, 2004).

When you have C-PTSD, your amygdala gets larger, like a cancerous tumor, being fed by constant stress and fear. And as with cancer, it thinks it is doing a good job, growing to protect you from the abuse and trauma you are experiencing, but once the abuse stops, the amygdala doesn’t immediately shrink.

As a result, it reacts more strongly and more forcefully, treating safe and neutral actions in other people as though they are major threats/dangers. This increases the likelihood of losing friendships, partners, and relationships with trauma and it also makes a person more likely to engage in reactive abuse toward non-abusive partners.

People with C-PTSD usually do not want to be abusers - they have no desire or drive to be the kind of people, proactive abusers who are driven by a desire to control, hurt and dominate, who hurt them - but because they had to respond with force that rose to the level of domestic abuse to survive their proactive abusers, they are not aware of how harmful their reactions can be to non-abusive partners: screaming, yelling, striking their partners without thinking, threatening to harm themselves all because their traumatized brains can’t figure out any other solution when the FEEL they are being attacked.

One of the hardest conversations I have in therapy is having to help people understand that they have been reactively abusive to their non-abusive partner because of their childhood trauma.

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Dear Fellow Traveler,

A question I often get from followers is, “How do I identify a graduate program in counseling, social work, marriage and family therapy, and/or psychology that is inclusive of neurodivergence?” Because of this I thought I would dedicate an essay to it.

In framing this essay, the first question I would expect you to ask me is, “Why w…

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Dear Fellow Traveler,

As an AuDHD person and practitioner who often has to decode the unspoken rules and dismissals of dating, I am often asked questions like this one: “Why does it always seem like my relationships end because I’m too good for them?” “Because I am too much?” Or, “What does being too intense even mean?”

I work with a lot of survivors of Complex Post-Traumatic Stress Disorder (C-PTSD) who grew up constantly having to people-please and fawn after their caregivers to survive. As a result, these wonderful and caring people tend to engage in behaviors that stifle their partners because their behaviors are based on strategies they used to survive abuse and neglect as children.

As a result, the people-pleaser often finds themselves in a relationship with an idea of their partner based on their developmental history and not on the person in front of them; and they assume that their partner does not see their needs as part of their duty of care when the love someone but as burdens that will cause them to leave.

Sadly, the belief that they are a burden becomes a self-fulfilling prophecy not because they need too much but because they often cannot directly state their needs creating the unspoken expectation that their partner is a monster if they cannot intuit or mind read what the people-pleaser needs; and simultaneously they are unable to meet their partners specific needs because they are operating off of preconceived notions of what their partner wants and needs and not what they actually state that they need.

Here’s a descriptive matrix of the behaviors I see in my people-pleasing, Dependent Personality Disorder (DPD)-leaning clients that disrupt their relationships and how they developed from abusive and/or neglectful childhoods.

People-Pleasers as Children

In order to survive in hostile home environments, the people-pleaser:

Takes Hyper responsibility → Always the first person in a relationship to try and self-identify where miscommunication or mistakes happen, and often tries to control their actions and the actions/reactions of their caregiver. This pattern of behavior starts because the caregiver does not take responsibility for their actions, and thus any work the relationship needs becomes the responsibility of the child. This is one of the foundational building blocks of people-pleasing, DPD, and Borderline Personality Disorder (BPD) when the person is not split.

Engages in Self-Blame → Becomes hypercritical of self for two main reasons. 1.) If they can blame and criticize themselves first, it feels like when they are criticized by their parents, the criticism won’t hurt so bad (even though it does). 2.) There is not enough safety in the relationship with their caregiver to ask them to engage in any kind of accountability. This is the other building block of people-pleasing, DPD, and BPD when the person is not split.

Hyper responsibility and self-blame, while related, are not the same psychological mechanism. Self-blame is about self-flagellation and feeling bad about yourself. Hyper responsibility, in contrast, is about taking or trying to take actions in order to control the situation from a logistical or action-oriented standpoint.

While it might seem like hyper responsibility and self-blame always go hand in hand, some people are able to take hyper responsibility for survival while being well aware that they are not at fault. These tend to be people who feel more anger as opposed to sadness about their mistreatment as children.

Alternatively, a person may learn to engage in self-blame while avoiding hyper responsibility because if they do not engage in the emotional performance of being blameworthy, they get punished even more by their parents. However, beyond reducing abuse by preforming self-blame or self-flagellation they come to find that no matter what they do, their attempts to take action to improve their relationship with their caregivers are flouted or struck down, such that they get stuck in self-blame decoupled from any kind of restorative action.

Engages in Negative Self-Talk → Self-blame is often reinforced not just by stating blameworthiness in front of the dismissive or abusive parent but also to the child’s internal headspace, in the quiet, alone time they have to themselves. It is a type of perseveration that, when left unchecked, causes negative self-concept and pessimism about oneself and what one deserves to metastasize.

Puts Others on Pedestals → Because the caretaker who is supposed to love them does not, or does not show it unconditionally, despite treating the child poorly, the people-pleasing/fawner learns to elevate their caregivers in order to best maintain the relationship for their survival. As such, negative and harmful actions that the caregiver perpetrates become decoupled from any kind of boundary or expectation of helpful or kind treatment.

Projects Feelings of Reciprocal Goodwill Even When Not Present → This elevation of an abusive or neglectful parent despite their mistreatment of the child causes the child to look for and imagine goodwill and feelings of love, attunement, and care even when none are present.

Expects Themselves to be a Mind reader of Others → Because abusers use information asymmetries to gaslight and abuse their children in order to keep them off balance, in order to survive, these children must become “mind readers,” guessing what their caregiver needs without ever being told and monitoring for minute changes in moods assuming that they are tied to their own behavior whether or not they are; otherwise, they are caught off guard when a mood shifts and punished for not being attuned to their caregiver. By constantly drawing them back to how they are feeling, the abusive caregiver maintains near constant psychological control.

Unable to Articulate Needs → The amount of space dedicated to the hypervigilance of trying to avoid abuse or neglect by simply not triggering their caregiver’s negative mood or attention forces the child’s own sense of needs from their mind and out of their conscious awareness. They are in a constant state of scanning the environment to figure out what their caregiver needs or wants from them in order to avoid being abused or neglected. The child has needs but is unaware of them.

Dissociation and Alexithymia → This inability to articulate needs often leads to dissociation and an actual lack of awareness of one’s needs and a disconnection from bodily sensations that would help them figure out their emotional needs. It can also lead to alexithymia, as the child learns to ignore their own emotional signals in order to function and fawn after their caregiver in order to survive.

Expects Others to Be as Conscientious and Perceptive as They Are → Because the abused and/or neglected child had to learn to mind-read and people-please to survive, they often come to expect others to form a level of hyper-attuned monitoring/caretaking response that could only have been formed in the crucible of abuse and C-PTSD. Unwittingly, these are the people who are hypercritical of others inability to read them or perceive them; they would never want others to have gone through the trauma they have, yet they don’t realize that their skills in caretaking came from their trauma and not solely an innate ability. This means they often feel out of sorts or sore with their partner when they are not as relationally sensitive as they are.

Abandons Societal and Interpersonal Standards and Expectations → In some people, there is an expectation that they deserve to be treated poorly no matter what they do, and this leads them to disengage from the world, looking out only for themselves regardless of how their actions impact others. On the DPD side, this is often where abused persons become liars or cheaters because they learned to people-please and avoid conflict but still need to get their needs met.

When pushed further due to a dysregulated relationship with shame, this is often where trauma-based Borderline Personality Disorder (BPD) splitting, Narcissistic Personality Disorder (NPD), Histrionic Personality Disorder (HPD), and Antisocial Personality Disorder (ASPD) arise. In BPD when split and in HPD and NPD, there is an extreme aversion to shame that comes out in an aggressive and discounting manner, resulting in the gaslighting and manipulation of others. There is no sense of shame in ASPD in seeking what they want no matter how it impacts others because they were never given any regard when others wanted things from them. While this is not the subject of this article, I wanted to include this aside for context.

Aversive to Feedback → People-pleasers and traumatic fawners learn to avoid, cower from, and resent feedback because it always came with unjust punishment in childhood.

Hates Open Conflict → People-pleasers come to hate open conflict because conflict was not about relationship negotiation, building, or repair; it was always about them being blamed and punished if things ever got to the point of direct disagreement.

Is Extremely Reliant on Others for Validation/Coregulation → People-pleasers learn to equate others’ opinions and judgments of their character with their caregivers’ opinions and not their own, because their caregivers’ judgment and subsequent treatment often meant the difference between life and death.

Complains to Others Not Involved in the Relationship → Many people-pleasers are “side talkers” who engage in side conversations with others not involved in the relationship to let off steam because there is a universal human need to have one’s emotions and perspectives seen, but the caregiver they actually had the issue with was not safe to talk to.

Holds a Great Deal of Unexpressed Resentment → All of this equates to a lot of extracted, unfair work related to caregiving that takes its toll on the child. They come to resent their caregiver even as they continue to engage in behaviors that look like caregiving and love toward that person in order to survive.

As you read this, you may think, “Ah, okay, this is all well and good, but how does it translate to adult romantic relationships and significant friendships?” No worries, I’ve got you.

Adult Context

People who develop some degree of DPD and/or people-pleasing strategies as mechanisms for survival often go one of two routes. In the first, they find adult relationships that are abusive in the same ways their childhood relationships were and don’t even realize it. If you think this might be you or someone you care about, I strongly encourage therapy. When you are trying to escape an abusive relationship, it is best to have live, in-person support when you are trying to make this kind of earth-shattering shift.

For the purposes of this article, I am focusing on people who grew up in abusive relationships who now find themselves in the unknown territory of mutual and non-abusive relationships. Here are the signs you are in one:

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Dear Fellow Traveler,

Something many of you asked about in the piece I wrote: “The Two Wolves of ADHD and Autism” was, “What about C-PTSD? How does it relate to this analogy?”

Here is my answer.

One of the reasons it is hard for AuDHDers to tell the difference between what is ADHD, what is Autism, what is ADHD+C-PTSD, and what is Autism+C-PTSD, is because we were all born with the fraternal twin wolves of Autism and ADHD; but then many of us, within a couple of weeks of being born, got another visitor – a third wolf who wasn’t us but became a shadow of us.

As you read this piece, please note that I have done my best to indicate which symptom/experience is (Autism), which is (ADHD), and which is (trauma/C-PTSD).

How C-PTSD Becomes Indistinguishable from AuDHD

C-PTSD didn’t start as part of us. In fact, it started as a stranger.

This wolf didn’t speak the same language as us at first, but as soon as it arrived it was right there for everything we went through. It was the negative reaction to our Autistic and ADHD reactions. It reacted to our overstimulation (typically Autism) to physical touch by telling our parents, “Oh he, she, they just don’t like hugs. No, no. Don’t try and figure out how to accommodate them, just stop holding or cuddling them entirely.” (Trauma)

This wasn’t at all what we wanted, we still wanted touch, we just wanted it differently. We needed it differently. And our terms were pretty simple: understand that touch can be painful, especially when we are already stressed, sick, or already emotional. Please don’t tickle us, or surprise us, or hold us longer than we can be held. We aren’t fussy, we’re in pain.

But what we got instead was often at best that we were not held (Trauma), worse we were yelled at for crying as an expression of our pain (Trauma), and even worse that they doubled down and gave us something to cry about – punishing or abandoning us when we could not stop crying (Trauma).

We got the message and learned to stop crying (Masking-Trauma). This masking of our pain by suppressing our cries became the first time we began to equate masking with Autism. Overtime, learning to override our want to cry to please our caregivers became so automatic, we learned to stop feeling our bodies in order to stop feeling pain. This was the start of our dissociation from ourselves both from our bodies and our emotions.

On top of potential congenital issues with interoception, we learned to layer on dissociation and survival-based lack of bodily awareness on top of our limited ability to sense our bladders or our skin (Masking and Dissociation Trauma) if those sensory issues were already present (Autism and ADHD).

Many of us weren’t destined to be bedwetters past early childhood, but when you are so scared to feel the discomfort of your bladder because it means you will be ignored, shamed or physically punished, you learn to shut off feelings of bladder discomfort really quick. But then, out of nowhere, you burst because you have no gradual warning and end up having accidents at sleepovers and in your bed. (Dissociation, Masking, and Shame based Trauma).

Emotionally, you get anxiety about having feelings. (Dissociation and Masking Trauma) So you stop having any feelings but anxiety. You keep anxiety around like an armored vest because your innate survival mechanism won’t quite let you give that up. If you do, you might let your guard down, become careless and get shamed or hit again (Self-Reinforcing, Chronic Hypervigilance Trauma)

And then this was repeated across any and all of our senses in which we were overestimated. Smell with two great a sensitivity and get dry heaves or headaches (Autism): ignored or punished (Trauma).

Sounds too loud and you cry out in pain or get migraines (Autism and ADHD): ignored, ridiculed and/or punished (Trauma).

Difficulty with chronoception and are late all the time(Autism and ADHD): ignored, screamed at, and/or spanked (Trauma).

Proprioception issues (Autism and ADHD): random bruises and inadvertently breaking things (Autism and ADHD) that led to things being hastily taken away or some other punishment, “GIVE ME THAT!” (Trauma)

Equilibrioception problems (Autism and ADHD): Kid at school: “What’s wrong with you, can’t throw?” “Nobody pick them if you want to win at dodgeball.” (Trauma)

Poor interoception (Autism and ADHD): Mom: “What’s the matter? You wet the bed AGAIN?!?” *Shame. *Spank. *Grounding. (Trauma)

Now we are 4 or 5 or 6 and the shadow wolf is getting stronger. At this state, we’ve not yet been beaten into the understanding that our neurodivergence is our fault, but we do have the bone-weary understanding that there is something, maybe multiple things, are deeply wrong with us that we cannot fix. And yet, we can’t stop trying to fix them.

But every time we try and fix our unfixable ADHD/Autism we fail, or the fix comes at an exponential cost.

By the 3^rd or 4^th grade or 5^th grade, most of us don’t know what to call it, but we are sadder than we ever have been. In adulthood, we will have a name for this: major depressive disorder, recurrent and/or burnout, but as children, this is just what being 9, 10, and 11 is.

Having processed much of my own C-PTSD, I cry when I think back to third grade and realized my waking up and not wanting to be alive was actually passive death wish, one step away from suicidal ideation. (Trauma. If you are told you are so weird and made fun of so frequently that you feel the only solution is to change every part of yourself that people don’t like; but changing yourself i sso costly it makes you believe that death would be a greater relief than just being who you are, this is identity-based trauma from shame.)

Then adolescence hits, and you have all the awkwardness of any neurotypical teenager plus greater difficulty decoding increasingly complex and emerging social rules.

This is when things really start to sting because in a time when neurotypical children are encouraged to try and fail and to figure out who they are, you are being told to do the exact opposite. Stop doing the things that make you feel comfortable and regulated and torture yourself instead. Go ahead. We’ll even praise you for it (Trauma). And if you try and tell us how much you are hurting, we’ll say:

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Dear Fellow Traveler,

Have you ever wondered why there isn’t a cohesive link or understanding between Borderline Personality Disorder (BPD), Narcissistic Personality Disorder (NPD), Histrionic Personality Disorder (HPD), and Dependent Personality Disorders (DPD)?

I always try and give credit where credit is due. Were it not the mental health professionals who came before me, I know I would have no clear concept of what any of the disorders I have listed above are. I also would not be able to discuss them clearly and cogently enough to have a conversation with you about them. And yet, I believe the way we understand these disorders is woefully incomplete.

I see this incompleteness most acutely in that to me almost every personality disorder actually represents a disordered relationship to shame, yet shame is not talked about as an organizing concept for these diagnoses.

And yet, this tie is inextricable. A personality disorder by definition is an “enduring pattern of inner experience or behaviors that deviates markedly from the expectations of the individual’s culture…the enduring pattern leads to clinically significant distress or social impairment.” (APA, 5th Edition, p. 678).

Shame is a universal human experience that evolved to prevent and protect individuals from social devaluation, social exclusion, and the death that often comes with social ostracism. If all relationships were based on mutuality, a personality disorder left unchecked or unmasked would eventually push a person out of society and relationships. This is why all personality disorders use the tools of intimate control (i.e. abuse, manipulation, gas lighting) and or avoidance when interfacing with others.

For NPD, BPD, HPD, and DPD, an aberrant relationship with shame is what creates the conditions that drive people with these personality disorders to have difficulties with vulnerability and accountability.

Put another way, disordered relationships between shame and identity in people with personality disorders keep them from forming secure attachments with others and keep them from being able to share social realities with their partners that do not result in the abusive control, exploitation or abandonment of their partners.

To me, shame along with the concept of a “core fear” or “core anxiety” is how I organize these four personality disorders in relation to one another and explain how they can look both early similar to one another and completely different.

Shame! Shame! Shame!: Narcissistic and Histrionic Personality Disorders

Shame is a powerfully motivating force. For the sake of brevity, I won’t go into a fuller analysis of shame in this article except to say that I believe from my research that shame is necessary for a civil society to function.

I once hoped to figure out how I could teach others to rid themselves of shame and while there are many things that people experience shame for that I believe they should not, eliminating shame entirely is not the answer.

Epstein had no shame and because of that he felt empowered to abuse, rape, traffic, exploit, and hurt little girls without remorse. He and his cadre feared getting caught, but that is not the same as feeling bad or having shame for hurting someone. It is not the same as having a conscious.

Which is why, even after he was arrested and charged the first time, he didn’t stop. The survivors’ pains didn’t matter to him. Only the opinion of those who could stop him mattered and even then there wasn’t shame, his psychopathy wouldn’t allow that. There was only embarrassment that he was not able to influence or control others in the way that he wanted to coupled with frustration and anger that he could not continue to move through the world unimpeded by his want to harm others for his own pleasure.

It is clear that Epstein had Anti-Social Personality Disorder (ASPD) but he was also a Narcissist.

In narcissism, the core fear that the person is constantly trying to avoid is that they are not enough. And as such, their entire life is dedicated to showing others, proving to others, and proving to themselves that they are enough.

Their entire ethos in life becomes about achieving status, admiration, influence and power. Because of an inability to self-validate their own sense of worth, relationships become about extorting praise from others and can even go to the extent of undermining others to prove the narcissist’s superiority over others.

Narcissism at its core is an intolerance of shame that is so extreme, they will sacrifice and abuse others in the pursuit of protecting their fragile ego.

In NPD with a vulnerable presentation, the core fear is still, ‘I am not enough,’ but due to experiences that the person has had, the reason they are not enough is always due to external circumstance.

“Had this not happened to me I would be…”

“If you had experienced what I experienced, you wouldn’t be as successful as you are.”

There is always a reason why they are not at fault because to admit even partial fault at their less than state would be too shameful.

In close relationships, they too work to undermine their intimates so that they don’t leave or get better than them and to ensure that if they are feeding off them for material and emotional benefits, that they keep them psychologically enmeshed and stuck with them in order to be able to continue to exploit them.

Narcissists are not in relationships because they care for the person they are with but because they care about how that person can make them.

In HPD, the core fear is that I am not worthy of another’s time and attention. It is similar to grandiose narcissism except that being located in white womanhood.

Reading the description of Histrionic Personality Disorder in the DSM feels like reading a job description for Narcissistic Personality Disorder but with a glass ceiling.

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For accessibility issues on these longer videos, I am working to publish companion scripts so that if you are a reader, this may make these materials more accessible. And on platforms where I have to split these videos to meet algorithm limits aka YouTube shorts, Facebook, and Instagram, this allows you to see in script where each v…

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Dear Fellow Traveler,

This article is an expanded companion piece to a video I created describing what undiagnosed ADHD and Autism (AuDHD) actually feels like. It explores how these experiences are often described in non-neurodivergent terms by individuals who may believe they are neurotypical.

I am creating this companion piece because I realized that ma…

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Dear Fellow Traveler,

It has taken me a long time to formulate words about toxic masculinity that ring true to the impact I see it carry out not just on its intended victims: women, children, queer people, and people of color but on its hosts: white men.

I am aware from some of my interactions with my cisgender, male friends of color and from loved ones a…

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Dear Fellow Traveler,

Do you ever have those moments where you think you know the depth of someone’s ignorance or bias against people with ADHD only to realize you don’t?

In a recent clinical consultation, I listened as colleagues discussed a client with ADHD. The client was a successful owner of a mid-sized, multimillion-dollar company. His primary concern in therapy was that he felt bad about himself; he knew he could not continue living in such negativity, yet he struggled to integrate concepts discussed in therapy around positive self-talk and positive self-belief.

The client reported to the clinician that he suffers from a great deal of negative self-talk despite his success in business. The presenting clinician was baffled, as was the entire room, as to why he couldn’t simply give up his negative self-beliefs.

Rather than looking at the problem from the ADHD perspective of using negative self-talk to drive a negative cycle of dopamine and norepinephrine generation—in order to help improve functioning—or considering his childhood of chronic and pervasive criticism (which helped drive his success in business), the group completely ignored the ADHD tactic of using negative self-talk to function. Consequently, the case study focused only on the client’s inability and lack of readiness to confront his childhood trauma.

The room was filled with well-meaning frustration, but also a tacit agreement that the client’s problem was solely one of trauma and negative self-belief.

I did what I believe we are supposed to do in these sessions and described the negative-cycle dopamine generation. The presenting clinician thanked me, but then quickly said, “I am not specialized in ADHD.” To her credit, she had already made a referral within her practice to an ADHD specialist, though that referral was going to take time.

The presenting clinician, who identifies as neurotypical, then turned to her frustration that the client was using AI in sessions to record their conversations. Presumably, she thought he was trying to “steal” her words for his tech startup, so she had him sign an agreement stating that he would not use any session material for anything other than his own therapeutic work and introspection.

I respect clinicians who want to protect their likeness, but what bothered me was that she was looking for affirmation regarding this document, rather than being curious about why he was using AI recording, synthesis, and analysis software.

When I asked her about his reasoning, she shared that he was having difficulty remembering what they talked about, connecting her insights to his own self-understanding, and figuring out ways to take concrete action based on those insights.

The presenting clinician appeared to be in complete disbelief. She made the point repeatedly that she did not believe he lacked the capacity to understand her advice regarding positive self-talk, simply because he is a successful business person.

This disbelief and discrediting of his reasoning became a focal point that resounded through the group:

“He is just being lazy.”

“He sounds like he doesn’t actually want to change.”

“He’s taking the easy way out.”

“You’re right. If he can run a business, he should be able to do the work you are asking him to do in therapy.”

Then someone asked:

“Is he even referencing what you’ve said in past sessions?”

“Well, yes,” the clinician admitted.

As a clinician who specializes in ADHD, I sat back at first, baffled as I watched this incredibly unhelpful, dangerous, and fundamentally flawed dynamic unfold. These assumptions—that an ADHD client’s inability to change is due solely to a lack of motivation or an unwillingness to examine trauma, that a person cannot be successful and have ADHD, and that a client with ADHD is lying about the functional limitations their ADHD imposes—are devastating.

When clinicians misunderstand ADHD in these ways, it isn’t just a lack of understanding; it is malpractice.

I went on a tear in that consultation group, which I will summarize below.

Misunderstanding the Negative Stress Cycle of Dopamine Generation

For many neurotypical practitioners, the prescription is simple: Replace negative self-talk with positive affirmations, and motivation will follow.

They don’t realize that for an unmedicated and environmentally unsupported brain with ADHD, “negative” self-talk—the crushing anxiety, the feeling of being a failure—is often a damaging yet highly effective coping mechanism. In this cycle, the brain creates internal feelings of threat that trigger the release of adrenaline, which in turn spikes dopamine and norepinephrine, allowing the person with ADHD to focus and execute.

When a therapist asks a client to simply drop that negative self-talk without first providing an alternative process for dopamine generation (or explaining the consequences of abandoning that process without appropriate medical or environmental interventions), they are asking the client to lose their only source of functional fuel.

If the client refuses to change, it isn’t resistance; it is survival. Non-ADHD-trained therapists often fail to realize that leaving behind self-criticality is not a net positive or even neutral—it is devastating. If the cost of dropping a self-critical coping mechanism is total functional collapse, any client in their right mind would resist.

Why the Neurotypical Focus on Insight with ADHDers Isn’t Enough

Leverage in therapy is the motivation provided by enough pain or pleasure to change—to either get more pleasure or avoid more pain.

Neurotypical therapy often operates on the assumption that if we can help a client identify the why of their pain or the reason they “should” change, they will automatically find the leverage to do so. This model fails the ADHD brain on two fronts:

1. The “Lack of Insight” Myth: Neurotypical clinicians often assume a lack of progress in therapy stems from a lack of self-awareness and an unwillingness to confront one’s faults. However, most people with ADHD—especially those with Rejection Sensitive Dysphoria—have intense, constant self-awareness. The problem isn’t knowing that they need to change; the problem is making meaning of that pain and translating that awareness into strategic, concerted effort.

2. Difficulty in Prioritizing Pain Data: People with ADHD are often flooded with data, especially when it comes to pain. In addition to struggling to organize, synthesize, and categorize the overwhelming influx of information, they need help prioritizing it to determine what is causing them the greatest pain and, therefore, what to tackle first.

For ADHDers, painful self-awareness is like fighting a forest fire. You know you need to work on putting out the fire, but you don’t know where to start, and if you focus on any one area, you still get engulfed in flames.

When clinicians focus on positive self-talk without acknowledging the functional deficits of this strategy, they set their clients up for failure. Many neurotypical therapists miss this because their brains tend to be better at automatically sorting, categorizing, and prioritizing which pains to tackle first.

A Neurodivergent Therapeutic Change Framework

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Dear Fellow Traveler,

Please know this is not an easy article to read nor was it an easy one to write but once I got started with it, I had to see it through to completion. I hope you do too,

This piece is in reaction to a conversation I had with a white therapist who was doing a case consultation on a black client they were assessing for Autism. As part…

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Dear Fellow Traveler,

One of the hardest types of clients for me to work with are high-conflict couples. These are relationships where the Gottman ‘Four Horsemen’—criticism, contempt, stonewalling, and defensiveness—have moved in, pushing the relationship toward a breaking point that will either disintegrate or become abusive without intervention.

These are not my favorite relationships to work with, mainly because to be an effective couples therapist, you have to hold unconditional positive regard, congruence, and empathy for both people. When they fight with each other, it is awful.

And these couples fight a lot. Individuals in high-conflict couples tend to be high-certain in many parts of their lives, are described by themselves or others as stubborn, and are not afraid to stand up for themselves. As such, these are not clients where you typically see one partner holding dramatically more power than the other.

They tend to have strong senses of right and wrong. Where they and their partners align, they are rock solid, but where they differ, the ground feels like a volcano about to explode.

They are also relationships where one or both partners tend to not see themselves as controlling, yet have specific areas, like housekeeping, childrearing, trip planning, or financial organization, where they are highly critical. They believe there is a ‘right’ way of doing things and will often criticize their partner for not doing things their way.

These couples are often passionate about their interests and careers and struggle with balancing interdependence and independence. They tend to feel like the victims of their partner’s judgment in areas where they are not happy or don’t live up to their partner’s expectations, yet they have difficulty seeing when they are judgmental toward their partner. When they do recognize their judgment, they tend to see it as healthy and reasonable, rather than disruptive and hurtful.

They can sound hypocritical, as in one moment or topic, they will be venomously and unfairly criticizing their partner, and in the next, they will be rightfully defensive about their partner being unfair and venomous in their criticism of another area of their lives.

They know each other’s buttons and they push them. While it is good that each person feels they can ‘fight back,’ the constant fighting presents a dilemma. If they were to stop fighting without finding other means of communication, they might lose their passion and sense of connection. However, the frequency of these fights that happen: daily, every other day, semi-weekly, or weekly, takes its toll and almost always leads to an escalation toward abuse or the disintegration of the relationship.

In these high-conflict couples, fighting especially if one or both partners has ADHD provides a dopamine hit and is mistakenly used as a proxy for healthy intimacy and reassurance that the other cares. Each partner may even do things to try and make the other one jealous.

Fighting, resentment, past hurts, trauma, and negative engagement patterns do not resolve overnight, especially the longer the couple has been together.

As a couples therapist, you try to establish rapport and figure out how to challenge each of them without shutting either of them down or having them withdraw and leave therapy. You want to validate but also hold each of them accountable but you also sometimes have to watch someone you deeply care about tear down another person you also deeply care about, and vice versa.

Unlike individual therapy where you don’t often witness the mean, damaging, and toxic things your client can do, in couples therapy, sometimes you have to see it. You don’t want it to happen, but you sometimes need to see a dynamic that one or both are trying to hide, or hear a tone or see a face that is contemptuous or critical in ways words cannot convey. Sometimes they are so riled up, tense, and stuck in their own hurt that they have to get some of it out to feel heard before you can help them regulate.

Interjecting is an art and a skill because sometimes one or both of them can feel such a history of being unheard that they don’t see your interruptions as helpful but as an attempt to silence them and side with the other person. Conversely, they may see you as unsafe if you don’t work to actively curb their partner’s attacks in the right measure.

It’s ironic that most of the therapists I know hate couples therapy due in large part from what I have stated above and most non-therapists I know seem to imagine that couples therapy is like watching ‘The Real Housewives’ where you have no connection to the people and they are making money off disrespect and drama. In reality, watching a couple fight is some of the hardest work I do. I hate it. It is not entertaining; it is draining. It is having to watch someone you love get beat up by someone else you love, all while not losing respect or regard for the person who is attacking.

First, it is not entertaining because when a fight occurs, I am always monitoring for intentional abuse, which is immediate grounds for termination. Or, I am checking for a pervasive pattern of unintentional abuse that is so widespread it constitutes a system of abuse that goes beyond mere toxicity and would also result in termination of couples therapy or a forced pause in couples therapy followed by remediation plans for each person to complete individually before resuming couples therapy.

I had a couples session the other day that stopped me in my tracks. They were in the middle of an argument, and as one partner was digging in on something that angered him, the other turned to me and said, “I think he does these things to spite me, to undermine me.”

This phrase stopped me cold. It wasn’t because the feeling wasn’t valid, or that the argument hadn’t been productive up until that moment. I only let arguments continue if it allows me to see a dynamic that one or both partners have been trying to hide—related to how they criticize, attack, defend, and withdraw from one another so I can accurately address it to resolve it.

But when this was said to me, I had to stop and tell them both, “I want to make it very clear. I do not think that he does things to spite you, or that you do things to spite him. I think that you do things to spite his criticism, and he does things to spite your criticism. There is a fundamental difference between these reasons for spite. Do you see the difference?’

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Sometimes when trying to describe how psychological concepts intertwine with Autism and AuDHD and how a couple with mixed neurotypes can misunderstand one another feels like navigating a maze in a Lewis Carol novel. It is both frustrating and fascinating and only makes sense once you have the correct cipher.

This is how I feel when I hear non-Autistic people overuse the term narcissism to describe many autistic behaviors. I get why people do it, but also it is mostly wrong.

I once heard a psychologist say, “The heart of mental health is flexibility.” While I believe this is true in many regards, when it comes to Autism, I struggle with such an essentializing statement.

In instances with Autism, rigidity can be disabling: when it interferes with activities of daily living that are essential to life like being able to eat enough food, consistently to maintain one’s life force; but in other instances, rigidity and its cousin black-and-white thinking can be protective factors as they help reduce stimulus and cognitive loads and thus emotional, physical and psychological overwhelms.

I have a friend who is struggling with his partner who is AuDHD. His partner in my friend’s words is “amazing, incredibly generous and giving” in the parts of their relationship where their autistic partner does not have sensory issues or where things aren’t important to them.

But in the parts of their relationship where they perceive their Autistic partner to be rigid, they see them as very rigid and find them controlling and even domineering.

This is something I have come to learn about my partner and myself who are both late identified AuDHDers: we are incredibly flexible in some parts of our lives and rigid in others. Where we are flexible, I think we seem neurotypical, especially in how well we can take the other person’s perspective and manage our tones when talking. But when you hit one of our areas of rigidity, our tones get very stern and we tend to enter into a bristle response.

This is where people who are autistic, but not narcissistic, often get mislabeled as narcissistic.

At its core, narcissism is a maladaptive response to an inability to generate an internal sense of self-worth.

For many autistic people, I find it to be quite the opposite. In the areas where we are rigid—where we set boundaries, where we say “this is not us” or “this is not for us”—we are so absolutely sure of ourselves that it can be off-putting to our loved ones.

There is a characteristic within many autistic people, especially for those of us who are not dissociated and know ourselves, that is a kind of sanctity that you don’t mess with. It’s a sanctity that makes neurotypical people say, “Come on, ease up. If you would just ease up on this one thing that seems relatively innocuous to me, our relationship would be infinitely better.” But to the autistic partner, that issue is often a mountain; it is a make-or-break point.

And it can often be something that to a neurotypical person or another neurodivergent person who has a more muted emotional or sensory experience about that thing seems trivial. For me, one example of this was: I would not live with my boyfriend who just bought a new house because I could not handle a walking or driving commute that is more than 10 min; and his house was a 40 minute commute each way. When I would make the drive, I realize now I was having autistic meltdowns every morning and every night because of the stress of driving, of worrying about getting in an accident, of waiting in pointless traffic, of being afraid I was going to be late.

My boyfriend didn’t mind long commutes and for many people long commutes are default expectations in their relationships to have the house they want. But for me, the commute was so dysregulating and exhausting that I made this a deal breaker for living together. My boyfriend who is now my husband sold his house a couple years later to move in with me downtown.

When you are autistic and have areas of rigidity that you know are necessary for you, operating from that rulebook is not narcissism. These are either costs of admission or deal-breakers for people to be in a relationship with you. Because we can be less accommodating in these areas, it can seem like we are being selfish or narcissistic. However, if we are not compelling you to stay in a relationship with us, this selfishness isn’t narcissism or being controlling, It is a boundary.

Because of my complex PTSD and the ways in which trauma forced me to work against my neurotype, I sometimes find that my hyper-flexibility isn’t because of love; it’s because of trauma. I used to resent my partner’s self-knowledge regarding what he would and would not do. I would say, “I am flexible in that area, how hard can it be?” I didn’t connect it to my own fears: the fear that I would be punished severely if I did not learn to be flexible, the fear that I would be abandoned if I didn’t comply.

I think the whole “cool girl” trope of the 90s and aughts was really about a fear of abandonment. Let me be cool, let me be flexible, even about things that deeply concern me and do not align with my values because I don’t want to make a demand or request for my needs that causes you to leave.

I told my friend last night about realizing I was “unlikeable” in third grade and making a list of target behaviors within myself to eliminate. On one hand, I was proud that I could eliminate them and get better social responses from others. I felt pride in having learned to betray myself, though I didn’t call it that then; I called it “self-improvement.” Yet the shadow cost was a childhood depression that lasted until college, when I finally started to unmask again.

Some autistic individuals do struggle with self-worth and may express narcissism, typically through a vulnerable presentation.

However, many autistics know what they need, either consciously or unconsciously because their bodies rebel against them when they try to go against those needs. It is the suppression of these needs that leads to burnout, masking, and fawning.

Some autistic people are less invested in relationships than neurotypical people. I understand this because, as I have asserted my needs more, I have become less flexible and, therefore, often less available or “pleasant” to be around. If I still desperately craved being around people with the intensity I did when I was chronically masking and people pleasing, I would be very sad right now. At first, I was sad, because it felt like I was losing so much. But as I’ve gotten in touch with myself, I probably do seem “narcissistic” simply because I have healthier boundaries and chose me and my needs sometimes as opposed to always defaulting to others.

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Dear Fellow Traveler,

The anecdotal reports I get from clients and people I interact with on social media around ADHD and Autism continue to highlight a common issue: people who are coming to understand their own ADHD/Autism report experiencing parents who are neurodivergent (some combination of ADHD/Autism) and narcissistic.

Because I work in mental health there is likely an attraction bias in which neurodivergent persons who have difficult and/or dysfunctional relationships with their parents are more likely to seek me out in the hopes of working through these concerns.

The other underlying fear that is often expressed by people who are coming to talk about the neurodivergence in their families and themselves is that they too may be acting in narcissistic ways - specifically that they are being selfish or that they have oversights that are causing them to preference themselves in harmful ways over their children and loved ones.

As a late diagnosed AuDHDer with a narcissistic father, I relate to these concerns.

Even though I am AuDHD, these two huge parts of myself were hidden from me until my late 30s by popular culture’s portrayals of Autism, mainstream school’s lack of understanding about ADHD, a lack of mental health education related to these two conditions in my graduate program, my own issues with C-PTSD, and alcohol use. As such, I am having to unlearn so much misinformation about these two conditions.

ADHD and Narcissism

One of the first books I read when I learned I had ADHD was the ADHD Effect on Marriage. While I learned many helpful things from this book and was grateful for the compassionate ways in which it framed many unintentional ADHD behaviors that look like narcissism in ways that made me feel less guilty, the book also introduced a question that has come up again and again: What are the convergences and divergences of ADHD and narcissism?

There are limited studies on the relationship between ADHD and pathological Narcissism (also called NPD). Having ADHD is correlated with a significantly increased likelihood of also having NPD. Research suggests that around 9.5% of persons with ADHD have NPD compared with 1% of the general population.

The core issue people with NPD struggle with is difficulty maintaining an internally generated sense of self-worth. This leads to feelings of entitlement, self-absorption, and a lack of empathy.

Entitlement is thought to come as an unconscious reaction to feelings of shame around self-worth. When people are grandiose in their narcissism, they are entitled to things because they are better than others. In vulnerable narcissism, they are entitled to things to make up for the fact that they have been wronged by others.

Narcissistic self-absorption comes from a hyperfocus on what the narcissists does or does not lack. They come to think about themselves first in every interaction. In grandiose narcissism, this looks like getting praise for their accomplishments and rewarded for doing better than others.

In vulnerable narcissism, this can manifest in a constant fixation of how they are the victim and how it is due to the mistreatment by others that they have not risen or achieved as much as they should have.

People with NPD have an abnormal relationship to empathy. It is thought that grandiose narcissists tend to lack emotional empathy, meaning that they are able to understand others perspectives but are either not able to feel them or are dismissive of them. In working to manage self-worth through grandiosity, narcissists show up in overtly controlling and dominating ways and are often perceived as arrogant, self-centered, and domineering.

Conversely, vulnerable narcissists also show an ability to utilize cognitive empathy but it is difficulty with affect regulation, not dismissiveness, that leads to affective empathy deficits. An example of this would be when a person is overwhelmed or vulnerable they are less likely to have affective empathy for others and become more self focused due to a lack of affective capacity

In working to manage self-esteem through vulnerability, narcissists show up using passive aggression to try and control situations, devalue things others are good at that they are not, and being avoidant of others emotions entirely. They tend to have low self-esteem, anger, shame, and suicidality.

High functioning narcissists are thought to be able to utilize affective empathy when they are in situations in which they feel secure and in control but experience affective impairments when the security of their superior position is under threat.

I had this experience with a narcissist who was very empathetic to me as long as they saw me as someone they could mentor or who was not as professionally respected or as financially well off as they were; but as I grew in my career and financial security their narcissistic traits began to emerge. In the last year of our friendship, I experienced jealousy, devaluing, mind games and increased insults and questions of my competency I had never before experienced with them.

However, I did learn that although they had not shown their narcissistic jealousy and devaluing of me, to me before I became a threat in their eyes, I learned from conversations with common friends that they had been quick to disparage me behind my back.

This made me realized that the abusive mind game of a narcissist isn’t with their target. It can also be with others who they work to disparage you to long before they are disparaging directly to you.

This is one of the reasons narcissists are insistent on you respecting their boundaries when they have no regard for yours - especially around information sharing and talking with other people in their life. By keeping you from talking with others they are talking about you to, they are able to act as though they are your friend, confident, and advocate while socially undermining you.

A classic example of this is when a narcissistic boyfriend begins to isolate his girlfriend from her friends while talking about his concerns for her mental health to his friends and their shared friends while at the same time gas lighting and abusing her. This creates a trap so that when she finally confronts him and reaches out to their friends and his friends for support, they side with him because he has already led a smear campaign against her.

In contrast to narcissism, the core issues of ADHD are under stimulation, disorganized attention and emotional reactivity. It is important to note the distinction in these core issues because ADHD can play into issues with a person’s self-worth, but it is not inherently a disorder of self-worth.

ADHD tends to impact a person’s self-worth negatively in two ways:

One, due to disorganized attention there can be feelings of unfulfilled potential.

Two, the emotional dysregulation of ADHD can add to the intensity of the emotional reactions a person with Narcissism already experiences related to threat detection and shame.

ADHD can look like narcissism in that due to executive dysfunction, it can be difficult for people with ADHD to engage in tasks around active listening and attending to the wants and needs of others due to distractibility.

ADHDers can seem like grandiose narcissists when, due to impulsivity, they interrupt others or talk over them. This can make them seem like they don’t care when, in actuality, they do care and feel horrible when people tell them the ADHDer has made them feel devalued.

Both of these ADHD behaviors when paired with narcissism can further erode empathy. A person with NPD+ADHD already struggles to care about others and also finds it difficult to engage in the behaviors that would give them the information they need to try and care about the other person like active listening.

ADHDers can become annoyed or angry when their own stories are interrupted because speaking aloud is how many ADHDers consolidate and convert thoughts to long term memory. At the same time, speaking aloud can be a way for ADHDers to catch thoughts they would otherwise lose. This means that ADHDers who are external processors are also more likely to interrupt others.

When paired with NPD, this pattern can exacerbate self-absorption because in addition to talking out loud and interrupting to consolidate memories, they also enjoy when the attention and the conversation is focused on them.

One key differentiator I have found to understand if a behavior is being driven by ADHD or NPD comes from when you confront someone and tell them that them interrupting you made you feel unimportant.

If they express remorse and work to understand what they did and then make changes to interrupt you less, it is ADHD. If they continue to interrupt you with no regard for your feelings and even worse double down that they should get a pass to interrupt you simply because they have ADHD, this indicates NPD.

In vulnerable narcissism, the additional emotional dysregulation caused by ADHD may increase shame, anger, and suicidality. In grandiose narcissism, impulsive and emotional reactivity may make narcissistic entitlement rage more intense.

Conversely, given that cognitive empathy and understanding how people are feeling from an intellectual perspective requires the ability to focus and attend to others. ADHD may disrupt a person with NPD’s ability to engage in cognitive empathy for the purposes of manipulating them.

Interestingly, one small study found that ADHD stimulant medications improve scores related to empathy and pathological narcissism. It is theorized that ADHD medications improve signaling in participants’ frontostriatal pathway - a part of the brain involved in task planning, intrinsic motivation to do tasks, and creating and maintaining a positive sense of self-esteem and self worth.

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Dear Fellow Traveler,

One of the most important comment threads arising from discussions about part one of this series concerned the extent to which Narcissistic Personality Disorder (NPD) is a neurodevelopmental disorder versus a personality disorder.

As a result, what had been a much shorter section examining the relationship of narcissism to neurodiver…

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Dear Fellow Traveler,

What started out as a six-page, mostly personal and anecdotal article morphed over the Memorial Day weekend into a twenty-four-page exploration and analysis of the nature of Narcissistic Personality Disorder (NPD), differentiating it from Borderline Personality Disorder (BPD), and looking at NPD interactions with ADHD and Autism.

To capstone all of these parts and concepts, I present a case study in part three for integration. This is post is the first of three.

In part one today, I am sharing my personal experience growing up with a dad who is a vulnerable narcissist and defining what narcissism is and isn’t.

This series is not about diagnosing NPD or BPD or making the case that ADHDers, AuDHDers, and Autistics do or do not have personality disorders.

Rather, it is a response to many of the comments and DMs I have heard from you about narcissists and suspected narcissists in your lives alongside ADHD and Autism.

Narcissists hide in plain sight with some using their ADHD, Autism, and AuDHD as invisibility cloaks.

Many of you are children of narcissists. So am I.

I grew up in the shadow of a vulnerable and covert narcissist. He was vulnerable because his control was through victimhood and not through claims of superiority. He was covert because he seemed to lack the self-awareness that, in his perpetual state of victimhood, he used his pain to legitimate a blindness to ours.

It’s hard to tell if he had moments of lucidity, though I can’t imagine he didn’t. While he never attended college, George fancied himself a scholar of Tennyson and a brilliant mechanic. He once attempted to use a “poor man’s patent” for his design of a pontoon boat he claimed contained innovations better than anything on the market.

His was a life unfulfilled, and he was desperately bitter about it. Maybe he would have become a grandiose narcissist had he had an accomplishment he felt worthy of standing on, but instead, he focused on turning avoiding accountability into an art form.

What he lacked in accomplishment, he made up for in temper, alcohol, and an inability to truly celebrate the successes of his children except when he could frame them as extensions of his own.

I could tell there was a raw intelligence between his drunken, numbed-out, and distracted stupors. The compulsive gambling, spending, and binge drinking served to block out a past of trauma grounded in early childhood neglect alongside physical and emotional abuse.

This was quickly followed by the horrors he witnessed in Vietnam and capstoned by an adulthood filled with chronic illness due to Agent Orange exposure and PTSD. I am sure he has undiagnosed and untreated ADHD.

I believe my dad deserves compassion. He deserves it from his hospice nurse, from his therapist, from his psychiatrist, and from the people in his life he did not take his narcissism and trauma out on.

As a therapist, I give compassion to my fellow humans who have ADHD, Autism, narcissistic tendencies, Borderline Personality Disorder, and other psychiatric conditions every day. But I do not expect the same from the people they have hurt.

With my dad, as I wrote in the piece, “My Father is Dying,” from a distance, I am able to release my hurt and anger towards him. But up close, respectfully, f*ck you, George Marshall.

You weaponized your pain against me to legitimate your neglectful, emotionally violent, and destructive behaviors. You extracted caretaking from me when I was a child. When I failed at it, you guilted me. You were the parent. I was the child. It was never supposed to be this way.

But I blamed myself when I failed to take care of you. I knew about the terrible events and horrific abuse you suffered from because you and Mom made sure I knew it was pain that was the underlying reason for your anger and avoidance, not cruelty.

I thought that I loved you, but whatever good moments we had are so muddied with fear and instability that I am not sure it was love so much as Stockholm syndrome.

Love is a deep feeling of affection, connection, and mutual appreciation free from fear, and that is not what I had for you. I wasn’t afraid that you would intentionally or maliciously hurt me, but I was afraid of the terrible things you would do in your state of perpetual desperation.

Like a prey animal caged with a predator, I learned to fawn after you. I tuned into your dark and stormy moods as best I could to try and lift your spirits.

What I thought was a connection on his part now feels more like indifference. He mostly left me alone, which felt better than being the target of his anger.

He did not ask how my day went when I came home from school unless I prompted it, which I did every day to check on him to make sure he was alive. I’d usually find him drunk at 3:30, sitting in his computer chair playing a racing game, gambling, or watching porn. He rarely, if ever, bothered to look at me when I said hello.

His suicidality hung over the house like a dense, toxic smog.

George was far more self-centered and narcissistic when he was drunk which was constant.

This was worsened by the frequent reassurances that his drunk self was not his true self. As we went along in our relationship, he took less and less accountability for his uncaring behavior. He was a mean son of a b!tch, and I don’t use that word lightly because his mother was a mean woman too.

By the time I came along, my grandmother Betty had mellowed but my mom told me of the time when George was very young and he burnt himself on a radiator he was laying next to in his bed. The radiator caused a severe open wound on his arm.

He went to his mom and dad who were asleep in their room. His dad didn’t respond, and Betty, despite being a nurse, refused to take him to the hospital or administer care by bandaging it. She told him to stop crying and go back to sleep. When I think of my father as a child with an open, bleeding, seeping wound on his arm trying to cradle it and himself to sleep in pain, I weep.

My sister often told me how lucky I was that I had gotten this version of grandma Betty because one time when she was a child, Betty had beaten her with a hairbrush so hard she broke the handle across the back of her legs. This was not the only time she was beaten but the only time a hairbrush was broken.

Can you imagine being beaten so hard with a plastic hairbrush that it breaks? As a person who was spared physical abuse, it makes me shiver. I weep for my sister when I think of her going through that. And yet, she too would later on turn out to be a vulnerable, covert narcissist who formed a narcissistic alliance with my father.

In remembering how he used his pain and substance abuse to excuse his anger and neglect, I have no doubt that if he had known about ADHD and its symptoms, he would have used impulsivity as an additional shield for his gambling and drinking and executive dysfunction to excuse his lack of care and follow through.

This is in contrast to my mom who built extensive systems to mitigate the negative and relational impacts of her undiagnosed ADHD.

My sweet mother who was also the victim of this vulnerable narcissist living in our home; and who because of her own childhood abuse had firm bright lines around physical abuse but had no idea she was being emotionally abused by this man.

One of the most heartbreaking parts of growing up in that house was seeing how my vibrant and beautiful mother slowly succumbed to the demands of George and his narcissism: take care of me, excuse my horrific treatment of you and my neglect of our children, work a second and third job to pay off the bankruptcy I caused, sacrifice your health, hobbies, passions, and joys so that I can sink even more deeply into my “woe is me” existence.

And yet her enablement, something I spent years in therapy trying to sort through, caused hurt and damage too. In her own need to preserve her self-concept as the strong caretaker and dutiful wife, she had learned to downplay his bad behavior while emphasizing the rare moments when he fought through his inner turmoil to show up.

I was much less forgiving than she but nevertheless carried this pattern of seeing the best in people despite their intentional and unintentional hurtfulness. My mom and I have talked long and repeatedly about this, and she has navigated her own fragility to get to the point where she has taken accountability for much of her inaction. She was a tortured soul too in that house controlled by our narcissist, but she was an adult. I was not.

I share all of this to begin this history of my own experience with the interplay of narcissism and neurodivergence to point out seven truths about narcissism that can keep us from recognizing narcissists:

One: Narcissism is a form of neurodivergence. As much as 50% of the appearance of narcissism is due to genetics alone, with shared family environments having a negligible impact on the development of narcissistic traits. Evolutionary psychologists postulate that narcissism evolved for two reasons. The first, status ascension, which helped narcissists rise in the social hierarchy of groups, thus improving the odds of their survival through greater access to resources. And two, greater success in short-term mating through attractiveness and sexual dominance, ensuring a greater survivability of the narcissist’s genes.

This evolutionary history aligns with the cycle of narcissistic abuse in which narcissists begin relationships by love-bombing their mates and partners before turning on them.

Two: Narcissists are heterogeneous. They can be grandiose, covert-vulnerable, malignant, communal, neglectful, benign, and entitled. These guises are effective because other manifestations use grandiose narcissism as a foil to distract from their own narcissism. However, the underlying motivation in each presentation is a masked, fragile ego focused on the extraction and exploitation of others.

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My mom and I were running errands a couple of months ago and, as always seems to happen with our rambling ADHD minds, she asked me an incredibly profound question on our way to return a shopping cart: “What does being non-binary mean to you now?”

Me: “What do you mean now? Like right now?”

Mom: “I mean two years in. Now that you’ve ha…

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I was angry the other day when I posted the video “Therapist reacts to the advice: There’s no point in getting an adult ADHD and/or Autism diagnosis“ and I am still angry.

I am angry because of the ageism, sexism, and racism inherent in that statement. Saying that there is no point in getting an adult ADHD/Autism diagnosis signifies that many mental health professionals lack a fundamental understanding of how these conditions actually show up.

This line of reasoning positions ADHD and Autism as childhood and/or academic disorders and not life-long conditions impacting relationships, work life, overall mental health, and mortality.

It also ignores the fact that Autism and ADHD are more likely to be diagnosed in boys than girls and that girls often have to wait until adulthood to receive a correct diagnosis. Following the logic that adulthood is too late for an Autism or ADHD diagnosis, most girls and women would never get a correct diagnosis or treatment despite seeking help.

People of color are even less likely to be diagnosed with ADHD and Autism as children when compared to their white peers and black children are more likely to be misdiagnosed with conduct disorder - setting them up for a greater likelihood of encountering the penal system in comparison to their white peers.

This means they too may be more likely to seek Autism and ADHD diagnoses in adulthood but this line of reasoning would dismiss them from treatment as well.

Saying that there is no point in getting an adult ADHD/Autism diagnosis also signifies that many mental health professionals have no idea how to treat ADHD and Autism.

This is terrifying because as I wrote in the Standardized Mistreatment of Neurodivergents and Mental Health is Rigged Against ADHD/AuDHD Girls and Women when therapists and medical professionals are unaware of ADHD, Autism, and AuDHD, they are far more likely to misdiagnose and mistreat neurodivergent individuals with Bipolar Disorder, Borderline Personality Disorder, neurotypical Depression and neurotypical Anxiety and deny or downplay the role that Complex-Post Traumatic Stress Disorder plays in the lives of neurodivergent folk.

A medical professional treating childhood ADHD/Autism while denying or downplaying adult ADHD/Autism is the same as them treating Type I Diabetes and denying or downplaying Type II Diabetes. It constitutes a failure to diagnose which is malpractice.

While ADHD and Autism are not inherently pathologies, their identification as distinct conditions within the human experience was driven in large part by the eugenics movements of Nazi Germany and 20th century America which sought to exterminate us.

Because of this, ADHD and Autism exist not only as ways of naming shared experiences and social identities and as conditions subject to mistreatment, discrimination and persecution but also as medical disabilities with access to special resources.

Anyone can claim to be a part of the neurodivergent community but unless you have an “official diagnosis” you cannot access certain medical treatments or accommodations reserved for those ADHDers and Autistics with medical diagnoses.

This gatekeeping creates a tension within the neurodivergent community, a type of have and have-nots split - the haves get to claim their neurodivergent identities and work with providers and advocates within the system for additional help, the have-nots don’t and what’s worse, other neurodivergents who are the haves often dismiss their experiences.

I don’t have an answer to the larger question of how we build a society that allows people to access care if they see a need within themselves without going through an external gatekeeper except: dismantle capitalism and create a society in which the ultimate goal of all structures is human thriving not subjugation for the purpose of profit.

Short of that, we need more diagnosticians to be trained on identifying adult ADHD and Autism and to be educated on the benefits of being diagnosed as an adult with these conditions.

The Benefits of an Adult ADHD and/or Autism Diagnosis

There are seven main reasons that an adult ADHD/Autism diagnosis is helpful: recognition and explanation of neurodivergence, diagnostic issues related to being diagnosed correctly as ADHD and/or Autistic, specific therapeutic treatments and interventions for ADHD and Autism, medical treatments for ADHD and Autism, hormonal issues related to ADHD and Autism, specific ADHD and Autistic comorbidities, and work and school accommodations for ADHD and Autism.

One, Recognition and Explanation: Before we have an official assessment, some kind of outside perspective to examine our lives and look at the patterns that we take part in that resemble ADHD and Autistic behaviors, we are often unknown to ourselves.

When someone is able to help us see frameworks within our feelings of awkwardness, discomfort, issues with functioning, feelings of shame and histories of social rejection, there is power in that contextualization. Unlike what many of us were told, we did not choose to make our lives harder.

We were not difficult for the sake of being difficult. We were not making our symptoms up. And it is not our fault that people do not like us. The truth is, many of us were trying desperately to fit in and figure out how to chameleon our appearance and behaviors to feel worthy in social and family situations. We did so out of desperation and as such were set up for failure.

You cannot convince others of your worth. You are worthy. Full stop.

Recognition of our neurodivergence gives us the space and the permission to unapologetically be our true selves. In doing this, we stop playing the losing game of shrinking ourselves to fit in.

Finding explanations for our seemingly random neurodivergent behaviors allows us to stop looking at them as failings to be fought and instead as instructions on how to be with ourselves.

There is no greater war than the war we wage against ourselves. For many of us until we were diagnosed, it is a war we don’t even know we were fighting.

Two, Diagnostic Issues: For people diagnosed with Autism in late adolescence and adulthood who were missed in childhood, there is a growing body of research that when ADHD and Autism co-occur, they tend to express themselves in ways that are only behaviorally detectable in adulthood.

I have found that because diagnostic recognition of the varied presentations of Autism seem to be even further behind those of ADHD, clients often have ADHD diagnoses from childhood but not Autism diagnoses.

This often meant that when they took ADHD meds as children, they quickly stopped taking them because in treating their ADHD symptoms, their negative Autism symptoms became worse.

Understanding the interplay and contradictions between ADHD and Autism as well as the functional ways they can be adaptive to one another is critical for guiding medical, behavioral, and environmental interventions.

Three, Therapeutic Treatments: in working with adult ADHDers, Autistics, and AuDHDers, there is much to unpack in regards to how to specifically work with and treat their individual manifestations of neurodivergence.

First, official ADHD and Autism diagnoses allow a person to use insurance to help pay for therapeutic and medical treatments. This is important because establishing a diagnosis therapeutically creates a case history that can later be referenced to justify prescriptions and medical interventions.

For ADHD, an essential question must be answered: Is the person more hyperactive, inattentive or combined? These different variations have huge implications for how the person does or does not use urgency to function, how they show up in relationships, and the ways in which ADHD related anxiety may manifest.

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Dear Fellow Traveler,

I start this article with a caveat. I have read that Borderline Personality Disorder (BPD) can exist without a history of abuse, but I have not encountered those people in my practice or in my daily life. This article is for the overwhelming majority of BPD sufferers whose condition is a result of abuse.

What if we called BPD in abu…

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There is a systemic bias against neurodivergent people in our mental health system. Most therapists assume and treat ADHDers, AuDHDers, and Autistics as neurotypical rather than first assessing for ADHD and /or Autism.

This is malpractice.

I touched on this in my article “Mental Health is Rigged Against ADHD/AuDHD Girls and Women,” in which I discussed the all too common misdiagnosis and subsequent therapeutic and medical mistreatment of ADHD and AuDHD women and girls as having Bipolar instead of being recognized as neurodivergent. Another study estimated that as many as 80% of Autistic girls are missed for an Autism diagnosis.

When this happens, rather than screening first for ADHD and/or Autism, these diagnoses are not considered. This is due to the clinician’s bias against these disorders or a lack of education on how to recognize and assess for them or both.

As a result, girls and women who have symptoms of Bipolar disorder that are shared with ADHD and AuDHD are automatically classified as a.) neurotypical and b.) Bipolar and given medicines that treat Bipolar in a neurotypical person but actually make these neurodivergent girls and women’s mental health worse.

This mistreatment by mental and medical health professionals sets these girls and women up for years if not lifetimes of poor mental, physical, and relational health outcomes including increased rates of depression, anxiety and suicidal ideation.

This has to stop.

We need a neurodivergence first care protocol to prevent the misdiagnosis of ADHD, AuDHD and Autism from happening.

Neurotypical mental health protocol makes the assumption that all disorders, including neurodevelopmental disorders are equal in terms of the extent of their impact and influence on an individual’s nervous system and personality development.

This is not the case.

When the DSM-V was created, it did two important things for Autism and ADHD as diagnoses. First, it acknowledged that these disorders could be co-occurring as opposed to stating that Autism, when present, automatically subsumed and negated ADHD. (Prior to this change, you could not be diagnosed as ADHD and Autistic, only ADHD or Autistic.)

This kept AuDHDers, like myself, from having accurate representations of their symptoms, challenges, and lived experiences represented in the diagnostic literature, treatment protocols and research.

We now know that AuDHD is increasingly recognized as a distinct neurotype from ADHD or Autism because when both present, these two conditions create a third type of neurological experience that is fundamentally different from either ADHD or Autism.

Second, the DSM-V changed the classification of Autism and ADHD from conditions usually diagnosed in infancy, childhood or adolescence and moved them into a new category of disorders titled, “neurodevelopmental disorders.”

Neurodevelopmental disorders were created to recognize that unlike depression, anxiety, bipolar disorder, and even Borderline Personality Disorder, ADHD and Autism shape how the brain grows and functions.

A neurodivergence first protocol would honor the global and identity level impact of ADHD and Autism and help ensure that other disorders like Bipolar and Borderline are correctly and differentially or dually diagnosed with ADHD and Autism as opposed to being mistakenly diagnosed or missed entirely.

We need a neurodivergent care protocol that assesses for neurodevelopmental disorders like ADHD and Autism first, no matter the presenting condition.

How the Misdiagnosis and Mistreatment of ADHD and Autism became Standardized

Two major forces have worked to prevent a neurodivergence first care framework.

The first is the overpathologization of ADHD and Autism in order for profiteers to gouge neurodivergents for diagnostic assessments.

Rather than training all mental health practitioners on recognizing and diagnosing ADHD and Autism, an aura of rarefication and alienness is projected onto these disorders creating the false dichotomy that unlike all other psychiatric conditions, these disorders are beyond the scope of a standard counselor or social worker’s training and ability.

As opposed to expanding the standard diagnostic and assessment curriculum of master’s trained therapists to include more intensive studies of these disorders, they are instead typically removed from masters level coursework and shifted to post-graduate specializations.

The result: fewer practitioners who are trained to competently assess for ADHD and Autism This creates a pricing model driven by scarcity which enables so-called ADHD and Autism “experts” to charge thousands of dollars for these assessments.

This is in contrast to the standardized, 5-10 minute screening tools used by mental health providers and medical professionals to assess for depression and anxiety at no additional expense beyond the cost of an annual checkup visit.

This is not to say that ADHD and Autism don’t require more training than administering a standardized screening tool, they do. But they also do not require hyperspecialized, exorbitantly priced assessment batteries.

Despite also being a neurodevelopmental disorder, testing for and identifying Intellectual Development Disorder (IDD) is often part of a masters level psychometrics and assessments course.

In my assessment class, we were required to be trained on not one but two different intelligence tests to assess for above average, average, and below average intelligence ranges in clients.

While this did not teach us how to treat or modify therapy for someone with an intellectual development delay (IDD), it did teach us how to identify IDD alongside depression, anxiety, etc.

We were also taught how to identify and diagnose Schizophrenia, Borderline Personality Disorder, Gender Identity Disorder, and Bipolar Disorder.

We were not taught how to treat these disorders nor any disorder in our diagnosis and assessment classes, because lessons on treatment were part of our individualized practicum, internship, and supervised post-graduate training leading up to independent licensure.

But because we were taught the rudiments of how to diagnose all of these disorders and were allowed and encouraged to specialize in treating any of the disorders we were taught to diagnose.

ADHD and Autism were the only psychological disorders excluded from our diagnosis and treatment training.

The impact of this exclusion was monumental. As, one of my colleagues who was working at a substance use disorder clinic quickly found out, he was able to not only help his clients with alcohol dependence, but he also helped one woman identify that she was suffering from Schizophrenia due to the voices she reported were talking to her in her head. And he was able to do this because of his diagnosis class in which he was taught about Schizophrenia.

Another woman, working in a college center treating a college student for generalized anxiety disorder was able to also recognized that her client had OCD because of our diagnosis class.

Never in my Master’s program did someone mention noticing and diagnosing ADHD or Autism. We couldn’t because we had no idea what they looked like.

Masters-level therapists are often the generalists of the mental health system who identify and direct individuals to more specialized therapists; but when you deny these professionals information and tools for the assessment and diagnosis of Autism and ADHD, these people become misdiagnosed and mistreated by the entire system.

It is only through persistence and often extreme hardship that these individuals are able to have misdiagnoses corrected especially as the disorders commonly tacked onto undiagnosed ADHDers and Autistics are often considered disruptive or “difficult to deal with” by many providers. These are: Borderline Personality Disorder, Bipolar Disorder, and Oppositional Defiant Disorder.

I once sat in a mental health CEU that purported to train clinicians on how to avoid litigation and the speaker actually said, “If someone self-reports Borderline Personality Disorder (BPD) or you receive paperwork from a former provider that discloses this, unless you are trained on Dialectical Behavioral Therapy, your best course of action is to deny service.” The reason given was, “These clients are difficult and litigious.”

I was appalled and said as much to which the lawyer responded, “It’s your choice to engage in actions that may increase your chances of a litigation. I am simply here to educate and advise.”

I was appalled by the negative and harmful stereotype of persons with BPD; I was struck by the blanket directive to deny care; and knowing what I know now, I see a complete lack of awareness in the trainer and the audience, myself included, of how commonly BPD is misdiagnosed.

This is the structural discrimination persons with BPD and ADHD and Autism face.

The second major force is that due to the history of Nazi and American eugenics and the Ugly Laws, neurodivergence, which may be up to a ⅓ of the human population, has not been treated as difference but as conditions marking a person as less than, as broken.

I’ve come to the realization that many neurotypical practitioners don’t see Borderline Personality Disorder or Bipolar Disorder as a harmful misdiagnosis, but as a kindness.

No matter how badly these disorders are spoken of, they are treatable and in some instances fully remit. ADHD and Autism do not.

Rather than seeing ADHD and Autism diagnoses as frameworks of liberation and self-discovery, many neurotypical therapists see them only as scarlet letters, as endings, as diagnoses of last resort.

ADHD and Autism are Beginnings not Endings

Our path to liberation has already begun. Contrary to the mistaken belief by many mental health professionals a couple of years ago that social media would lead to mass misdiagnoses, in my experience they have only led to more accurate diagnoses, an expansion of our understandings of the lived experiences of ADHDers, Autistics, and AuDHDers, and the creation of neurodivergent communities of support made possible through online interactions.

We have also seen an important reclassification of Autism and ADHD. Rather than calling them “disorders usually diagnosed in childhood” the DSM-V reclassified ADHD and Autism as “neurodevelopmental disorders” alongside Intellectual Development Disorder and Global Developmental Delay (APA, 2013).

Prior to this reclassification, there was an incorrect but endlessly restated assertion that children eventually outgrew ADHD which meant that adults with ADHD were often turned away from mental health care or told they were experiencing anxiety and/or depression.

This reclassification also tracked with what we’ve found in the years since the DSM-V was published that from 2021-2024 the highest rates of first time ADHD diagnoses were in adults, not children.

Autism too has been found to be a disorder that not only expresses itself in childhood as was historically thought, but also can become behaviorally emergent in late adolescence and adulthood.

The framing of ADHD and Autism as a neurodevelopmental disorder is meant to help clinicians and researchers think of Autism and ADHD not as disorders of equal magnitude to mood disorders but as disorders more likely to be wedded to the very essence of who a person is.

This is reflected in the many anecdotal reports I have heard from my clients. For many of them, depression is a disorder that they can get their mind around. They had a time before they experienced depression and many who are experiencing mild or moderate depression can still envision themselves without it.

ADHDers, Autistics and AuDHDers, regardless of how “mildly” they experience their ADHD, Autistic or AuDHD symptoms make no such distinction.

This is why “person first” language like I have Autism or ADHD has largely been abandoned for identity first language like I am Autistic. I am AuDHD. I am an ADHDer. Rarely do I hear someone make the shift from I have depression to I am a Depressant.

While the DSM-V made this important shift in classifying these two disorders as neurodevelopmental, it took away a standard practice that I believe helped preference neurotypical first treatment protocols: the multiaxial coding system.

I believe a crucial next step in combating the systemic, neurotypical bias against neurodivergents is to reintroduce a revised version of this diagnostic tool.

The Multiaxial Coding System

In 2009, when I was trained on the DSM-IV, we were taught as emerging clinicians to think about our client not only by their presenting condition/diagnosis (depression, anxiety) but also about their whole lives including what were framed as more global issues: Personality Disorders and Intellectual Development Disorder, environmental factors, medical conditions, life circumstances impacting their personhood, and what was termed a Global Assessment of Functioning.

The five Axes were:

“Axis I: Mental Health and Substance Use Disorders

Axis II: Personality Disorders and Mental Retardation (now Intellectual Development Disorder)

Axis III: General Medical Conditions

Axis IV: Psychosocial and Environmental Problems

Axis V: Global Assessment of Functioning (GAF)” (APA, 2000)

Each axis in this system was meant to focus the clinician on a different type of information about the person being assessed to try and give a clinician a quick but robust snapshot of the person at that moment in time.

Looking back at this system, it is clear that it was imperfect, but the reasoning behind it from my a diversity, equity and inclusion perspective was sound.

At present, without this system, people come to therapy with what they see as their presenting condition. This is often related to a problem they are experiencing for which they want help in understanding and alleviating.

Case Study: For the purposes of this discussion, let’s say I have a 32-year-old AFAB, non-binary person named Amiee. Aimee states she/they have been cheated on by her spouse after she stopped having interest in sex due to sensory issues she experiences during sex. These sensory issues became apparent to her once she stopped drinking 9 months ago, “It’s like now that I don’t drink, I can’t get out of my head enough to have sex and being touched intimately feels all wrong now.”

As a clinician, to categorize this in DSM-V terms, I would use a V or Z code such as V61.10 to denote that this person is seeking therapy due to “relational distress with spouse or intimate partner.”

However, insurance will often not reimburse for V and Z codes because these are interpersonal problems and not psychiatric ones.

To make it billable, the problem has to be framed as originating within the individual and therefore treated as psychological. To make this transformation occur, another level of abstraction from the client’s concern must be added beyond the Z/V code language.

This next level of abstraction focuses on the anxiety this relational problem causes the client. If it is a new stressor, one that has occurred within the past 3 months, I would likely code this person as having F.43.22 an “Adjustment disorder with anxiety.” I would use this billing code because it is as close as I can get to her presenting issue, while still being able to get paid for the work I am doing with her.

To meet the criteria for an adjustment disorder with anxiety, the behavioral or emotional response to the stressor must cause “marked distress or impairment in functioning” and must not last longer than 6 months after the stressor ends (beyond six months people are typically reclassified as having freestanding Generalized Anxiety Disorder).

If she is repeatedly cheated on, I can treat each instance of cheating as the start of that adjustment disorder clock.

In the present system, a person is flattened to one dimension: their billable diagnosis.

Depending on the training of the clinician, their method of intervention: Cognitive Behavioral Therapy, Existential, Solution Focused Brief Therapy, etc., they may zoom out enough to focus on the presenting issue of the client and other factors that may be driving that as the reason the client came to therapy, or they may focus only on the anxiety related to their partner’s infidelity and end up truncating their therapeutic work to that singular issue. This would certainly be ineffective and likely frustrate the client.

I see this in a lot of therapists in training and in many clinicians who either were not trained in the multiaxial coding system or never became comfortable with it.

Here is how I would conceptualize Aimee using a neurodivergence first protocol along with a modified multiaxial coding system. This is also how I have started helping my supervisors conceptualize clients.

A Revised Multiaxial Coding System for Effective Neurodivergent Care

In order to more effectively treat neurodivergents from a premise that their ADHD and/or Autism are neurodevelopmental and therefore foundational to how they see themselves and operate in the world, I look at other mental health disorders as being infused with a person’s neurodivergence as opposed to being standalone entities alongside their other mental health conditions.

As opposed to someone experiencing ADHD and Anxiety, I conceive of them as experiencing ADHD-Anxiety which has many similarities to neurotypical-anxiety but is also qualitatively different.

This distinction might be how one thinks of the human immunodeficiency virus (HIV) and the feline immunodeficiency virus (FIV). If anxiety is the immunodeficiency virus, ADHD vs neurotypical is the human vs the feline.

In these two different species, immunodeficiency may show up very similarly, have a similar disease progressions, and may have similar treatment protocols, but they are in no way the same treatment protocols.

While some HIV treatment medications work on felines, other HIV medications do not. This is due to the structural differences in the enzymes between FIV and HIV.

For both neurotypicals and ADHDers, the experience of anxiety is often reported as the same - irritability, sleep issues, feeling fatigued, feeling restless. But the underlying causes and subsequent treatment are radically different.

In neurotypical anxiety, the goal of therapy is to reduce anxiety because the neurotypical person is in such distress that the anxiety is making them non-functional.

In ADHD anxiety, the goal is not to reduce anxiety but to better understand when anxiety is being used to trigger a negative-dopamine stress response that allows a person to function in their daily life vs when anxiety is making them non-functional.

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It is the first week of the month. Is it your time to search for your ADHD meds too?

I sometimes think that the reason ADHD stimulant medications are so tightly controlled is because they work too well for some of us. They provide too much relief and work too quickly so they must be bad, immoral, and/or addictive.

Because despite surg…

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