When Symptoms Overshadow a Diagnosis: Psychotherapy as Archeology

• Robbie Needs Anger Management
• Therapy with Robbie Begins
• A Hypomanic Personality Dynamic
• The Therapeutic Work with Robbie Deepens
• Effecting Deeper Therapeutic Changes
• Postscript

When a prospective client makes an appointment to “work on my anger,” I can never be sure what other, deeper issues might lie beneath that common presenting concern. In my clinical experience, anger rarely exists in a vacuum, leaving me to wonder if it is driven, for instance, by personality pathology, trauma reactivity, or rooted in a specific mood disorder that will also need addressing. The person might hyperbolize or downplay their anger problem details during the phone screening. I have also come to wonder if their anger could fuel hair-trigger sensitivity and reactivity, which might add an element of danger to the therapeutic relationship.

Early in my career, I worked in a jail where I intervened with many acutely angry individuals. I knew my way around potentially dangerous people. While their anger required more immediate address, often with solution-oriented methods, what had always interested me more deeply was discovering the person beneath the anger. However, given the nature of corrections, inmates frequently moved for programmatic and security reasons, so my time with them was short, and my interventions were symptom- and situation-focused.

An existentialist at heart, I always wondered about peoples’ internalized experiences. What kind of meaning do they assign to phenomena? What defenses are at play? How does that all affect the clinical picture and what kind of material is in there to work with for better gains? Thus, what I later came to appreciate about working in private practice rather than institutional settings was spending more time with people and really getting to know them. I was better able to contextualize and understand symptom functions and help clients learn about themselves and to relate more effectively with others — especially when anger entered the clinical frame.

Robbie Needs Anger Management

When Robbie’s mother, Jane, called for an appointment for him, I was expecting him to be a child, perhaps even a teen as opposed to being in his early 20s. “He lives with me and is doing OK, but he’s been diagnosed with ADHD for years and can get rageful. He’s got to clean this up and stop living in the fast lane if he hopes to hold a job,” she shared.

I learned that at one time Robbie was on ADHD medication, but discontinued it after he completed high school, and had no interest in restarting it. Jane shared that it was questionable whether the stimulant medication had much of an effect, anyway. She was hoping that meeting with a male therapist, someone he might relate to, who encouraged exploring his emotions and aspirations, would prove more effective.

For his first appointment, Robbie arrived with Jane. They sat next to each on the couch across from me and seemed to interact amicably, something that didn’t always happen when family members arrived together. Robbie nodded along to Jane’s historical details about his development and family matters. He sometimes reminded her of a detail or filled in a blank with his personalized recollection. While Robbie was fidgety at times, he did not exude a hyperkinetic or inattentive vibe. Throughout, he maintained a bit of brightness, as if there were some contained excitement, but it was too early to explore deeply.

At first glance, I considered the possibility of ADHD. Clients I’ve worked with who have been diagnosed with ADHD have low frustration tolerance that often led to angry outbursts. Further, like the prototypical class clown who has that ever-present grin, Robbie had an ongoing light smile of sorts, and he could be a little interruptive and fidgety. “Perhaps, if he indeed has ADHD, he’s just learned to manage well,” I thought as the interview went on.

Therapy with Robbie Begins

On the day of our first therapy appointment, I heard a motorcycle pull up out front, and a second later, in walked Robbie with his helmet. “What a day for riding,” he beamed, taking off his jacket and making himself comfortable on the couch. “What do you enjoy most about being on your motorcycle?” I asked.

“It’s the thrill,” replied Robbie. “King of the road! Just taking off and maneuvering. It’s harder for a cop to get you, too!” he laughed.

Settling into the session, I said, “I wanted to ask, how was it for you last week when we met for the first time with your mom here?” “It’s all good,” said Robbie. “We have a great relationship. She told you everything.”

“She gave me a lot of information, for sure. Given it’s your time to meet with me, I was hoping to hear more of your thoughts about what you’d like to get out of coming here.” Robbie admitted he wasn’t sure.

He explained he knew he was directionless, watching friends finish college or settle into long-term relationships and jobs. Nonetheless, he said he felt free and like he was having a good time and that it would all work out. “Maybe I’m a ‘live fast, die young’ kind of guy. My mother always tells me I can’t last if I don’t get some direction,” he finished, rolling his eyes.

Clasping his hands behind his head and looking about the room, Robbie circled back to my question. He wondered out loud what one does in therapy. “I mean, I do get frustrated easily, and bored quickly. Those medications I took way back didn’t do much. Maybe I focused a little more in school, which was cool, but, you know, this is me. Why do people get frustrated with me if I get frustrated or want to do something? That’s ADHD, right?” he grumbled.

“What can you tell me about people getting frustrated with you for getting frustrated?” I asked.

“People can get under my skin. It’s not just my mom about ‘getting direction.’ She just wants me to be successful. I’m not too irritated with her. I get it. But other people, it’s like they can’t keep up with me or something. I’ve had girlfriends say it, and when I get people together for ski trips or rock climbing, they can’t keep up. If I want to have fun, it seems it’s got to be on my own. I get pissed off. I don’t want to, but people come with me, know I go all out, then complain I’m wearing them out when we’re skiing at first light until dusk. I don’t want to waste time, you know? Make use of time on that vacation!”

“What exactly happens?” I asked.

“Err, I got really pissed one time last year and smashed my GoPro camera as I let my friend know what I thought about his whining,” Robbie said, irritably. “I mean, c’mon, you come on a ski trip and don’t want to ski? Then I’m like, ‘f*&k it, I’m still gonna have a good time,’ and skied off.”

Robbie quickly lit back into a bright expression.

“Are you still friends?” I continued.

“Yeah, he knows it’s just me. He’s seen it before. I guess I’m an acquired taste,” laughed Robbie.

Throughout, Robbie could veer off course, getting distracted by a topic that seemingly popped into his head. It never seemed he had much attachment to the discussion.

Over time, I learned more about other relationships, such as when Robbie told me that dating was tough. It wasn’t because of aggression, but rather he felt he burned out girlfriends. “I’ll find a girl who I really vibe with, and we’re climbing and stuff, and hanging out a lot at the start. A lot of energy, you know? But then, like this one girl, she wanted to do more chill stuff like typical dates to movies and dinner and family events. I really tried to accommodate. I liked her a lot. I tried to have my cake and eat it too by getting together during the week for after work cycling or going to the climbing gym. She told me she just couldn’t handle that activity load. We’re still friends though.” Robbie’s brightness flattened.

I replied, “I can’t help but notice your expression changed, Robbie.”

“Hell, I do get lonely,” he admitted. “I want someone to do stuff with! I like sex and all, but I can get that on demand with girls I’ve known over the years. Chicks dig me, haha! But those girls don’t have to deal with me like a relationship girl would, I guess.”

“What more can you tell me about this loneliness?” I followed.

Robbie explained that he never quite felt “full.” On one occasion when he seemed dull compared to his usual energized self, I acknowledged that I noticed he did not seem the usual Robbie. He said it was one of the “not full periods.” Robbie was able to liken it to a silo that gets filled with grain but has a leak, emptying it again, then hearing an echo within. After some exploration, it seemed that Robbie’s activity level was the grain, keeping him feeling full, but even that had its limits when he couldn’t keep up with it.

“What happens on the occasions you encounter the echoing silo? What’s it like? How long might it stay empty?” I inquired.

“Dang,” began Robbie, looking away. “I lose my excitement vibe, you know?” He continued that he force feeds himself activity to try and get back the momentum and fill the silo, but it’s a trudge. He might have days of feeling apathetic and stuck in his head, thinking too much. He described how he can get to belittling himself for probably being a disappointment to his mom, who had it tough and had dreams for him. “It’s all kind of exhausting,” he finished. With half of his usual energy, he grinned and said, “But I’ve learned to accept myself.”

It sounded to me that Robbie was prone to crashes into depression and that he had a polarized self-concept.

Between sessions, I found myself realizing Robbie’s restlessness and impulsivity weren’t so ADHD-like afterall. When I combined this with how Jane denied any clear early history of typical ADHD symptoms in Robbie, and that she denied having any perinatal ADHD risk factors, I began drawing a different conclusion.

A Hypomanic Personality Dynamic

Robbie was clearly a depressed young man, and it seemed he had a sort of “keep active” or “moving target defense.” He was living a duality—a depressed inner world that he kept suppressed with a hypomanic defense. Perhaps the ultimate denial!

I didn’t realize it at the time, but Robbie was exhibiting what some have called a hypomanic personality, sometimes referred to as a hyperthymic temperament. While not included in the DSM or ICD, the hypomanic or hyperthymic personality are nothing new, and, in fact, have remained of interest to various personality experts (see references).

Millon provided descriptions of this personality style from historical giants. Kraepalin, for instance, said that these are patients who, “...throughout their entire lives display a ‘hypomanic personality’ pattern without severe pathogenic developments [i.e., crashes into full affective disorder episodes].” Schneider wrote, “hyperthymic personalities are cheerful, kindly-disposed, active, equable, and great optimists. Often, however, they are shallow, uncritical, happy-go-lucky, cocksure, hasty in the decision, and not very dependable.” McWilliams, perhaps the modern authority on this personality 100 years later, provides similar descriptions.

A movie character fitting a hypomanic personality that readers may be familiar with is Paul Mclean, played by Brad Pitt, in A River Runs Through It. Also, the portrayal of Scott Scurlock, an infamous 1990s bank robber, featured in the recent Netflix show called How to Rob a Bank, exemplifies a more intense case in that Scurlock’s personality also entailed sociopathic characteristics.

In time, I learned that those with what could be considered a hypomanic/exuberant personality may feel more alive chasing rainbows than the idea of long-term success, for this would require a type of settling, and thus, stagnation in their eyes. This is dangerous because they depend on being a moving target, lest their depressive ghosts catch up with them. Unfortunately, while an immediate salve, this perpetual motion encourages the cycle, for lack of success engenders a sense of failure, feeding depression, which the hyperthymic activity defends against.

Their solution to troubling emotions is the problem. As described by McWilliams, living this energized, unstable existence can become exhausting. Thus, the defense becomes weakened enough that the suppressed internal depressive experience crashes the gate until the energized state reconstitutes and corrals the depressive escapee back to the sidelines where it can only shout insults, which the guard ignores via enthusiastic distraction once again.

The Therapeutic Work with Robbie Deepens

After spending numerous sessions learning about Robbie and encouraging him to engage in sharing/self-revelation, we began more pointed work.

“Robbie,” I began, “from what you shared, correct me if I’m wrong, but it seems like that ‘being active’ protects you from having to deal with that hollow feeling?”

He agreed that it’s the pattern. “It seems like, if you really look at it, life has become a defensive act against feeling that hollowness,” I continued.

“I’m curious,” I began again, “have you ever thought about what life would look like when it’s really going your way?”

“Yeah, not having this moody stuff. Finishing things.”

I asked, “When can you recall that you weren’t moody?”

“I’m not sure. Maybe when I was pretty little. I remember playing and being happy with my dad and brother, the whole family.” Robbie had shared that his father eventually cheated on his mother and left, and she had to work, so wasn’t around as much. Eventually she got a divorce settlement and was able to stay at home more.

It became clear that Robbie harbored a lot of feelings of rejection and subsequent sadness; he was living two sides of the same coin with the ever-present sadness being defended against by an exuberant denial.

In order to stop this rollercoaster, since the hypomanic defense was a product of his bleak internal world, therapy would need to resolve his feelings of rejection that encourage the sadness.

“Like I said, I want a steady girlfriend,” explained Robbie.

“You’d like a meaningful relationship, some real intimacy?”

“Of course.”

“Strictly romantically, or?”

“I don’t want to have arguments with people like what happened with my friend, either.”

As if Jokey Smurf entered the room, Robbie laughed about breaking the Go-Pro camera and the horrified look on his friend’s face. “It’s crazy! I’m like some f**ked up movie character sometimes. But that’s being human, right?”

“Humans can act f**cked up sometimes, for sure, but I recall you saying you really didn’t want it to keep happening for you. I’m curious about what’s behind the laugh about it,” I inquired.

“Man, you therapists find stuff under every rock, don’t you?” asked Robbie, trying to evade my question.

“Hey, you told me you want to learn to make some changes, so it’s my job to notice things that might get in the way. To me, if someone has a contradictory response, it tells me they could be struggling to be real with themselves. Make sense?”

“So, what, I can’t laugh at myself?” he followed.

"Not taking oneself too seriously can ease the pain, can’t it?” I continued.

“It’s the best medicine!” Robbie added.

“Robbie, what are you medicating?”

With that, Robbie said he can’t escape some frustrations so laughs about them. Upon examination, his frustrations were rooted in painful ruminations, coupled with the exhaustion inherent in not being able to stop running if he is to “deal” with them. Distraction was corroding him, but admitting he had little steam left made Robbie feel vulnerable. He would often run on fumes, only to discover some psychological alchemy that provided fuel for the escape rides, which, over time, we saw were getting shorter, almost episodic. Whether this was the result of something therapeutic, such as feeling there was someone to help him manage what lay beneath, incrementally lowering his defenses, or a natural dip in childish energy that occurs as one eases into adulthood, it is hard to say. Regardless, Robbie’s more frequent low points were taken advantage of, where he would become more revealing of his years-long festering conflicts.

Effecting Deeper Therapeutic Changes

In months that followed, Robbie continued with an almost cyclothymic presentation. But the nature of the moods changed. There were peeks at more vulnerable parts of him. He kept up an energetic cheerfulness, but it wasn’t so charged. There were often peeks at actual lamentation and sadness that accented what was left of the hypomanic demeanor. At times, it was more of a reactive, temperamental mood. This seemed corollary to being more in touch with the depressive foundation; making contact with painful memories can be anger-provoking, and great therapy material.

There was still restlessness at times, but not in the old hypomanic sense. It was rather a more nebulous anxiety as Robbie edged into being more self-revealing and exposing his internal landscape. We seemed to be contacting bedrock issues, which, like in geology, would seem like stable turf, but if there are nearby fault lines, that could all change.

But Robbie learned more about the language of emotions and being real with himself. He realized that under it all, he hoped someday to discover it all never happened, but eventually accepted the idea he can’t somehow have a better best. With the disintegration of the denial, the smoke screen of exuberance he made for himself continued to lift. Relationships improved. When he felt more in them, he related better, leading to people being able to have more constructive, stable relationships with him and his fear of rejection no longer had a leg to stand on.

Over this two-year span of meeting with Robbie, I was never sure of how tenuous progress was. Would his psychological fault lines quake? He was invested, rarely missing an appointment, and had made strides in reducing the initial concerns and being more real. It often felt like skiing in avalanche country where anything could upset the delicate structure of snowfall and off it goes, taking everything established in its path with it.

As we wrestled with his long-simmering conflicts and learning to better understand himself and relate to others, Robbie began taking non-matriculated college classes to see what school was like. This was good grist for the therapy mill. Productive, real-world structure. In the meantime, Robbie still enjoyed his interests. Along came a part time job, then a girlfriend. Then the end of our sessions. Sometime after, Robbie left a voicemail asking for a letter about his having been in therapy and if he was ever a danger to anyone. Apparently, he was moving in with his girlfriend, who had a child whose father was contentious and heard Robbie had been in mental health care for being explosive in the past.

Postscript

I can’t help but feel that Robbie wouldn’t have reached this stage if his encounter with mental health care continued to see him as having ADHD, or as having problems with anger control. Some people say diagnoses don’t matter, that “we treat symptoms and not diagnoses,” which has the implication that symptoms can always be treated similarly. This can be a specious and dangerous outlook. Symptoms may occur across diagnoses, but that doesn’t mean they’re treated similarly. This diagnostic consideration of hypomanic personality, despite the debates about its legitimacy, allowed me to contextualize the nature of Robbie’s symptoms, which guided my approach to intervening with him. If merely addressing symptoms was sufficient, it wouldn’t have mattered if Robbie’s presentation was chalked up to ADHD or a hypomanic personality. The ADHD medications in theory would’ve fixed him.

We generally never know how our patients fare in the long term. Robbie’s hypomanic presentation was deconstructed, and an honesty about his life settled in. Consistent structure followed, highlighted with the activities he’d escape through, but now in more moderation. A semblance of a well-balanced interaction with himself and the world took form. Chances are, spot-reducing symptoms wouldn’t have allowed such a rich experience. Symptom reduction is great, but how does the person now live with their newfound experience? Does it have stability?

Personality is important, whether it’s pointedly treating personality disorders or helping someone integrate updated parts of existence into their being and work that into the world around them. Hopefully, Robbie is a reminder about the intricacies of therapy. It certainly was to me! It’s more than what’s observable, and what’s observable isn’t always what it seems.

References

Akiskal, H., Placidi, G., Maremmani, I., Signoretta, S., Liguori, A., Gervasi, R., Mallya, G., &Puzantian V.R. (1998). TEMPS-I: Delineating the most discriminating traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population. Journal of Affective Disorders (51),1, 7-19.

Jamison, K. (2005). Exuberance: The passion for life. Vintage.

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. Guilford Press.

Millon, T. (2011). Disorders of personality (3rd ed). Wiley.

Oser, D. (2019) Hyperthymic temperament. Psychiatric Times, 36(9). https://www.psychiatrictimes.com/view/hyperthymic-temperament  

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