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Narcissism and Other Mental Health Disorders

By: Sam Vaknin, author of Malignant Self Love - Narcissism Revisited

Does narcissism often occur with other mental health disorders (co-morbidity) or with substance abuse (dual diagnosis)?

Answer:

NPD (Narcissistic Personality Disorder) is often diagnosed with other mental health disorders (such as the Borderline, Histrionic, or Antisocial personality disorder). This is called "co-morbidity". It is also often accompanied by substance abuse and other reckless and impulsive behaviors and this is called "dual diagnosis".

The Schizoid and Paranoid Personality Disorders

But there is one curious match, one logic-defying co-appearance of mental health disorders: narcissism and the Schizoid Personality Disorder (see FAQ 67).

The basic dynamic of this particular brand of co-morbidity goes like this:

  1. The Narcissist feels superior, unique, entitled and better than his fellow men. He thus tends to despise them, to hold them in contempt and to regard them as lowly and subservient beings.
  1. The narcissist feels that his time is invaluable, his mission of  cosmic importance, his contributions to humanity priceless. He, therefore, demands total obedience and catering to his ever-changing needs. Any demands on his time and resources is deemed to be both humiliating and wasteful.
  1. But the narcissist is dependent on input from other people for the performance of certain ego functions (such as the regulation of his sense of self worth). Without narcissistic supply (adulation, adoration, attention), the narcissist shrivels and withers and is dysphoric (=depressed).
  1. The narcissist resents this dependence (described in point 3). He is furious at himself for his neediness and - in a typical narcissistic maneuver (called "alloplastic defense") - he blames others for his anger. He displaces his rage and its roots.
  1. Many narcissists are paranoids. This means that they are afraid of people and of what people might do to them. Wouldn't you be scared and paranoid if your very life depended continually on the goodwill of others? The narcissist's very life depends on others providing him with narcissistic supply. He becomes suicidal if they stop doing so.
  1. To counter this overwhelming feeling of helplessness (=dependence on narcissistic supply), the narcissist becomes a control freak. He sadistically manipulates others to satisfy his needs. He derives pleasure from the utter subjugation of his human environment.
  1. Finally, the narcissist is a latent masochist. He seeks punishment, castigation and ex-communication. This self-destruction is the only way to validate powerful voices he internalized as a child ("you are a bad, rotten, hopeless child").

The narcissistic landscape is fraught with contradictions. The Narcissist depends on people - but hates and despises them. He wants to control them unconditionally - but is also looking to punish himself savagely. He is terrified of persecution ("persecutory delusions") - but seeks the company of his own "persecutors" compulsively. The narcissist is the victim of incompatible inner dynamics, ruled by numerous vicious circles, pushed and pulled simultaneously by irresistible forces. A minority of narcissists choose the schizoid solution. They choose, in effect, to disengage, both emotionally and socially (see below and in FAQ 67).

Read more about the Narcissist's reactions to deficient narcissistic supply:

The Delusional Way Out

The Roots of Paranoia

HPD (Histrionic Personality Disorder) and Somatic NPD

"Somatic narcissists" acquire their narcissistic supply by making use of their bodies, of sex, of physical of physiological achievements, traits, health, exercise, or relationships. They possess many histrionic features.

Here is how the DSM-IV-R defines the Histrionic Personality Disorder:

"A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:

  • Is uncomfortable in situations in which he or she is not the center of attention;
  • Interaction with others is often characterized by INAPPROPRIATE SEXUALLY SEDUCTIVE or provocative behavior (very rare with a narcissist – SV);
  • Displays rapidly shifting and shallow expression of emotions;
  • Consistently uses physical appearance to draw attention to self;
  • Has a style of speech that is excessively impressionistic and lacking in detail;
  • Shows self dramatization, theatricality, and exaggerated expression of emotion;
  • Is suggestible, i.e. easily influenced by others or circumstances;
  • Considers relationships to be more intimate than they actually are."

Narcissists and Depression

If by "depression" we also mean "numbness" then narcissists are often depressed. Most narcissists are numb, emotionally absent and unavailable. They inhabit an emotional and cognitive twilight zone. The world appears to them false, fake, invented, contrived, or in wrong hues. But they do not have a sense of being imprisoned. The inmate remembers the world and sees a way out. Not so in narcissism. The outside has long faded into oblivion. And there's no way out.

Dissociative Identity Disorder and NPD

Is the False Self an alter? In other words: is the True Self of a narcissist the equivalent of a host personality in a DID (Dissociative Identity Disorder) – and the False Self - one of the fragmented personalities, also known as "alters"?

The False Self is a mere construct rather than a full-fledged self. It is the locus of the narcissist's fantasies of grandiosity, his feelings of entitlement, omnipotence, magical thinking, omniscience and magical immunity. But it lacks many other functional and structural elements.

Moreover, it has no "cut-off" date. DID alters have a date of inception, as a reaction to trauma or abuse (they have an “age”). The False Self is a process, not an entity, it is a reactive pattern and a reactive formation. The False Self is not a self, nor is it false. It is very real, more real to the narcissist than his True Self.

Narcissists actually vanish and are replaced by a False Self (Kernberg). There is no True Self inside the narcissist. The Narcissist is a hall of mirrors – but the hall itself is an optical illusion created by the mirrors. It is akin to a painting by Escher.

In DID, the emotions that are segregated. The notion of "unique separate multiple whole personalities" is primitive and untrue. DID is a continuum. The inner language breaks down into polyglottal chaos. Emotions cannot communicate with each other for fear of pain (and its fatal results). So, they are being kept apart by various mechanisms (a host or birth personality, a facilitator, a moderator and so on).

All personality disorders involve a modicum of dissociation. But the narcissistic solution is to emotionally disappear. Hence, the tremendous, insatiable need of the narcissist for external approval. He exists only as a reflection. Since he is forbidden to love his self – he chooses to have no self at all. It is not dissociation – it is a vanishing act.

The total, "pure" solution is NPD: self-extinguishing, self-abolishing, entirely fake. Other personality disorders are diluted variations on the themes of self-hate and perpetuated self-abuse. HPD is NPD with sex and body as the source of the narcissistic supply. The Borderline Personality Disorder involves lability, the movement between poles of life wish and death wish and so on.

Read more about Pathological Narcissism as the Root of all Personality disorders:

The Use and Abuse of differential Diagnoses

NPD and Attention Deficit Hyperactivity Disorder

NPD has been associated with Attention Deficit / Hyperactivity Disorder (ADHD, or ADD) and with RAD (attachment Disorder). The rationale is that children suffering from ADHD are unlikely to develop the attachment necessary to prevent a narcissistic regression (Freud) or adaptation (Jung). Bonding and object relations ought to be affected by ADHD. Research, which supports this has yet to be made available. Still, many psychotherapists and psychiatrists use it as a working hypothesis. Another proposed linkage is between autistic disorders (such as Asperger's Syndrome) and Narcissism.

Narcissism and Bipolar Disorder

Bipolar patients in the manic phase exhibit most of the signs and symptoms of pathological narcissism - hyperactivity, self-centeredness, and control freakery.

More about this connection here:

Stormberg, D., Roningstam, E., Gunderson, J., & Tohen, M. (1998) Pathological Narcissism in Bipolar Disorder Patients. Journal of Personality Disorders, 12, 179-185

Roningstam, E. (1996) Pathological Narcissism and Narcissistic Personality Disorder in Axis I Disorders. Harvard Review of Psychiatry, 3, 326-340

BPD, NPD and other Cluster B PDs

All personality disorders are interrelated, in my view, at least phenomenologically. We have no Grand Unifying Theory of Psychopathology. We do not know whether there are – and what are – the mechanisms underlying mental disorders. At best, mental health professionals register symptoms (as reported by the patient) and signs (as observed). Then, they group them into syndromes and, more specifically, into disorders. This is descriptive, not explanatory science. Sure, there are a few theories around (psychoanalysis, to mention the most famous) but they all failed miserably at providing a coherent, consistent theoretical framework with predictive powers.

Patients suffering from personality disorders have many things in common:

1. Most of them are insistent (except those suffering from the Schizoid or the Avoidant Personality Disorders). They demand treatment on a preferential and privileged basis. They complain about numerous symptoms. They never obey the physician or his treatment recommendations and instructions.

2. They regard themselves as unique, display a streak of grandiosity and a diminished capacity for empathy (the ability to appreciate and respect the needs and wishes of other people). They regard the physician as inferior to them, alienate him using umpteen techniques and bore him with their never-ending self-preoccupation.

3. They are manipulative and exploitative because they trust no one and usually cannot love or share. They are socially maladaptive and emotionally unstable.

4. Most personality disorders start out as problems in personal development which peak during adolescence and then become personality disorders. They stay on as enduring qualities of the individual. Personality disorders are stable and all-pervasive – not episodic. They affect most of the areas of functioning of the patient: his career, his interpersonal relationships, his social functioning.

5. The patient is not happy, to use an understatement. He is depressed, suffers from auxiliary mood and anxiety disorders. He does not like himself, his character, his (deficient) functioning, or his (crippling) influence on others. But his defenses are so strong, that he is aware only of the distress – and not of the reasons to it.

6. The patient with a personality disorder is vulnerable to and prone to suffer from a host of other psychiatric disturbances. It is as though his psychological immunological system has been disabled by the personality disorder and he falls prey to other variants of mental sickness. So much energy is consumed by the disorder and by its corollaries (example: by obsessions-compulsions), that the patient is rendered defenseless.

7. Patients with personality disorders are alloplastic in their defenses. In other words: they tend to blame the external world for their mishaps. In stressful situations, they try to pre-empt a (real or imaginary) threat, change the rules of the game, introduce new variables, or otherwise influence the external world to conform to their needs. This is as opposed to autoplastic defenses exhibited, for instance, by neurotics (who change their internal psychological processes in stressful situations).

8. The character problems, behavioral deficits and emotional deficiencies and instability encountered by the patient with personality disorder are, mostly, ego-syntonic. This means that the patient does not, on the whole, find his personality traits or behavior objectionable, unacceptable, disagreeable, or alien to his self. As opposed to that, neurotics are ego-dystonic: they do not like who they are and how they behave on a constant basis.

9. The personality-disordered are not psychotic. They have no hallucinations, delusions or thought disorders (except those who suffer from a Borderline Personality Disorder and who experience brief psychotic "microepisodes", mostly during treatment). They are also fully oriented, with clear senses (sensorium), good memory and general fund of knowledge.

The Diagnostics and Statistics Manual (DSM) – IV (1994) defines "personality" as: "...enduring patterns of perceiving, relating to, and thinking about the environment and oneself... exhibited in a wide range of important social and personal contexts."

It defines personality disorders as:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:

a. Cognition (i.e., ways of perceiving and interpreting self, other people, and events);
b. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response);
c. Interpersonal functioning;
d. Impulse control.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma).

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition (DSM IV). Washington, DC: American Psychiatric Association.

Each personality disorder has its own form of narcissistic supply:

  • HPD (Histrionic PD) – Sex, seduction, flirtation, romance, body
  • NPD (Narcissistic PD) – Adulation, admiration
  • BPD (Borderline PD) – Presence (they are terrified of abandonment)
  • AsPD (Antisocial PD) – Money, power, control, fun

Borderlines, for instance, can be construed as NPDs with an overwhelming fear of abandonment. They are careful not to abuse people. They do care deeply about not hurting others – but for the selfish motivation of avoiding rejection. Borderlines depend on other people for emotional sustenance. A drug addict is unlikely to pick up a fight with his pusher. But Borderlines also have deficient impulse control, as do Antisocials. Hence their emotional lability, erratic behavior, and the abuse they do heap on their nearest and dearest.

NPDs and Other PDs

  • Both NPDs and BPDs are afraid of abandonment. Only their coping strategies differ. Narcissists do everything they can to bring rejection about (and thus "control" it and "get it over with"). Borderlines do everything they can either to avoid relationships in the first place – or to prevent abandonment once in a relationship by clinging to the partner or emotionally blackmailing him.
  • Seductive behavior alone is not necessarily indicative of HPD. Somatic narcissists behave this way as well.
  • The diagnostic distinctions between the various personality disorders are pretty artificial. It is true that some traits are much more pronounced (or even qualitatively different) in given disorders. For example: delusional, expansive, and all-pervasive grandiose fantasies are typical of the narcissist. But, in a milder form, they also appear in many other personality disorders, such as the Paranoid, the Schizotypal, and the Borderline.
  • It would seem that personality disorders occupy a continuum.

NPD and BPD

A sense of entitlement is common to all Cluster B disorders.

Narcissists almost never act on their suicidal ideation – BPDs do so incessantly (by cutting, Self Injury, or mutilation). But both tend to become suicidal under severe and prolonged stress.

NPDs can suffer from brief reactive psychoses in the same way that BPDs suffer from psychotic microepisodes.

There are some differences between NPD and BPD, though:

  1. The narcissist is way less impulsive;
  2. The narcissist is less self-destructive, rarely self-mutilates, and practically never attempts suicide;
  3. The narcissist is more stable (displays reduced emotional lability, maintains stability in interpersonal relationships and so on).

NPD and Antisocial PD

Psychopaths or Sociopaths are the old names for antisocial PD. The line between NPD and AsPD is very thin. AsPD may simply be a less inhibited and less grandiose form of NPD.

The important differences between narcissism and the antisocial personality disorder are:

  • Inability or unwillingness to control impulses (AsPD);
  • Enhanced lack of empathy on the part of the AsPD;
  • Inability to form relationships, not even narcissistically twisted relationships, with other humans;
  • Total disregard for society, its conventions, social cues and social treaties.

As opposed to what Scott Peck says, narcissists are not evil – they lack the intention to cause harm. As Millon notes, certain narcissists "incorporate moral values into their exaggerated sense of superiority. Here, moral laxity is seen (by the narcissist) as evidence of inferiority, and it is those who are unable to remain morally pure who are looked upon with contempt." (Millon, Th., Davis, R. - Personality Disorders in Modern Life - John Wiley and Sons, 2000)

Narcissists are simply indifferent, callous and careless in their conduct and in their treatment of their fellow humans. Their abuse of others is off-handed and absent-minded, not calculated and premeditated like the psychopath's.

NPD and Neuroses

The personality disordered maintain alloplastic defenses (react to stress by attempting to change the external environment or by shifting the blame to it). Neurotics have autoplastic defenses (react to stress by attempting to change their internal processes, or assuming blame). Personality disorders also tend to be ego-syntonic (i.e., to be perceived by the patient as acceptable, unobjectionable and part of the self) while neurotics tend to be ego-dystonic (the opposite).

The Hated-Hating Personality Disordered

One needs only to read professional texts to learn how despised, derided, hated and avoided the personality disordered are even by mental health practitioners. Many people don't even realize that they suffer from a personality disorder and they feel victimized, wronged, discriminated against and hopeless. They don't understand why they are so detested, shunned and abandoned.

They cast themselves in the role of victims and attribute mental disorders to others ("pathologizing"). They employ the primitive defense mechanisms of splitting and projection augmented by the more sophisticated mechanism of projective identification.

In other words:

They "split off" from their personality the bad feelings of hating and being hated – because they cannot cope with negative feelings. They project these feelings unto others ("He hates me, I don't hate anyone", "I am a good soul, but he is a psychopath", "He is stalking me, I just want to stay away from him", "He is a con-artist, I am the innocent victim").

Then they force others to behave in a way that justifies their expectations and their view of the world (projective identification followed by counter projective identification).

Some narcissists, for instance, firmly "believe" that women are evil predators, out to suck their lifeblood and then abandon them. So, they try and make them fulfill this prophecy. They try and make sure that women behave exactly in this manner, that they do not abnegate and ruin the model that the narcissist so craftily, so elaborately, and so studiously designed.

Such narcissists tease women and betray them and bad mouth them and taunt them and torment them and stalk them and haunt them and pursue them and subjugate them and frustrate them until these women do, indeed, abandon them. At this stage the narcissist feels vindicated and validated – totally ignoring his contribution to this recurrent pattern.

The personality disordered are full of negative emotions. They are filled to the brim with aggression and its transmutations, hatred and pathological envy. They are constantly seething with rage, jealousy, and other corroding sentiments. Unable to release these emotions (personality disorders are defense mechanisms against "forbidden" emotions) – they split them, project them and force others to behave in a way which legitimizes and rationalizes these negative emotions. "No wonder I hate everyone – look what people do to me." The personality disordered are doomed to inhabit the land of self inflicted injuries. They generate the very hate that legitimizes their hate, which generated the hate in the first place.

The Borderline Narcissist – A Psychotic?

Kernberg suggested the "Borderline" diagnosis. It is somewhere between psychotic and neurotic (actually between psychotic and the personality disordered):

  • Neurotic – autoplastic defenses (something's wrong with me).
  • Personality disordered – alloplastic defenses (something's wrong with the world).
  • Psychotics – something's wrong with those who say that something's wrong with me.

All personality disorders have a clear psychotic streak. Borderlines have psychotic episodes. Narcissists react with psychosis to life crises and in treatment ("psychotic microepisodes" which can last for days).

Masochism and Narcissism

Isn't seeking punishment a form of assertiveness and self-affirmation?

Author Cheryl Glickauf-Hughes, in American Journal of Psychoanalysis, June 97, 57:2, pp 141-148:

"Masochists tend to defiantly assert themselves to the narcissistic parent in the face of criticism and even abuse. For example, one masochistic patient's narcissistic father told him as a child that if he said 'one more word' that he would hit him with a belt and the patient defiantly responded to his father by saying 'One more word!' Thus, what may appear, at times, to be masochistic or self-defeating behavior may also be viewed as self-affirming behavior on the part of the child toward the narcissistic parent."

The Inverted Narcissist – A Masochist?

The Inverted Narcissist (IN) is described in great detail in FAQ 66.

The IN is much closer to being a co-dependent than a masochist.

Strictly speaking masochism is only of a sexual nature (as in sado-masochism). But the colloquial term means "seeking gratification through pain". This is not the case with co-dependents or IN. The latter is a specific variant of codependent that derives gratification from a relationship with a narcissist or an anti-social personality disordered partner. But the gratification has nothing to do with the (very real) emotional (and, at times, physical) pain inflicted upon the IN.

Rather the IN is gratified by the shadows of a past re-awakened. In the narcissist, the IN feels that he has found a lost parent. The IN seeks to re-enact old unresolved conflicts through the agency of the narcissist. There is a latent hope that this time, the IN will get it "right", that this emotional liaison or interaction will not end in bitter disappointment and lasting agony.

Yet, by choosing a narcissist, the IN ensures an identical outcome time and again. Why should one elect to fail in his or her relationships is an intriguing  question. Partly, it has to do with the comfort of familiarity. The IN is used – since childhood – to failing relationships. It seems that the IN prefers predictability to emotional gratification and to personal development. There are also strong elements of self-punishment and self-destruction added to the combustible mix that is the dyad narcissist-inverted narcissist.

Narcissists and Sexual Perversions

Narcissism has long been thought to be a form of paraphilia (sexual deviation or perversion). It has been closely associated with incest (research supports this) and pedophilia (which research does not, as yet, support).

Incest is an auto-erotic act and, therefore, narcissistic. When a father makes love to his daughter – he is making love to himself because she is 50% himself. It is a form of masturbation and reassertion of control over oneself.

Homosexuality is NOT a sexual perversion. I analyzed the relationship between narcissism and homosexuality in FAQ 19.

A Dialog regarding Hysteroid Dysphoria

A short dialogue regarding FAQ28.

XXX:

Sam, you're describing here what the empirical-descriptive folks have called "hysteroid dysphoria" (among other things).

Sam:

I am describing the narcissist's pattern of reaction to deficient narcissistic supply.

A personality disorder is a complex of hundreds of separate behaviors. Each behavior pattern taken separately can have a different label. Moreover, the same behavior pattern can (and often does) occur in a few mental health disorders.

For instance, "hysteroid dysphoria" is also a part of the cyclothimic disorder. But, in the context of the narcissistic personality disorder what I describe in FAQ 28 is one of a group of recurrent dysphorias identified as early as 1960. The Narcissistic PD has finally crystallized as a mental health diagnostic category in 1980. "Discoveries" from 1969 – preceding Kohut, Kernberg and even early Millon – are absolutely irrelevant in view of today's understanding of narcissism.

XXX:

It's atypical depression (a specific subtype of nonmelancholic depression) with narcissistic/histrionic/borderline "personality" features. A characterization (from "Atypical Depression" – Quitkin et al – in "Clinical Advances in Monoamine Oxidase Inhibitor Therapies", Kennedy ed.):

"In 1969, Klein and Davis described a group of patients referred to as `hysteroid dysphorics'. These patients were characterized by strong desire for attention and applause, positive response to amphetamines, and a marked rejection sensitivity (especially in romantic contexts)."

Sam:

Narcissists do not react only to rejection. They react to any input – verbal, nonverbal, social, implied, real or imagined – which is deemed by them to be incommensurate with their inflated self-image. Often, narcissists react badly to acceptance and love rather than to rejection because they have a self-image as mean, vicious, frightening, etc. - or because being accepted threatens their sense of uniqueness and their grandiose fantasies as "above the crowd".

XXX (still quoting):

"Leading to frequent depressive episodes."

Sam:

The narcissist is mostly ego-syntonic (this is why treatment fails in most cases). His dysphorias are rare and "reactive". He is more likely to react with narcissistic rage to rejection of the type described above.

XXX:

"Features of these depressive episodes frequently included loss of ability to anticipate but not experience pleasure."

Sam:

One of the major differentiating factors: Narcissists do not experience serious, prolonged anhedonia. They immediately distort cognitive input to fit their self-image. It was discovered that they enhance positive inputs rather than reject negative ones.

XXX:

"Hyperphagia or craving for sweets."

Sam:

Never noted in narcissists – but research is rather lacking.

XXX:

"Hypersomnolence, lethargy or inertia, and marked reactivity of mood."

Sam:

These are classic depressive signs. They describe well a major depressive episode, cyclothimia, dysthimia and other types of depression.

XXX:

“Onset frequently occurred in adolescence without a history of adequate premorbid functioning.”

Sam:

The onset of narcissism and its dyphorias is at age 2-4. Klein talks about age 6 months and she has a depressive construct (see FAQ 67). The PD itself sets on in early adolescence.

XXX:

Another interesting feature is, in addition to the general hyperphagia, specific cravings for chocolate (and amphetamines). There is a link to family history of alcoholism (not necessarily in the family of origin). It's thought to be related to a dysregulation in the systems governing reward.

Sam:

No such linkages have been discovered in research. Narcissists are often prone to substance abuse, though (dual diagnosis).

XXX:

Personally I don't think it's useful to label these folks as personality-disordered ("especially" narcissistic), as it tends to stigmatize them, as well as depriving them of potentially useful medical interventions (response rates to MAOIs, for example, are comparable to those of melancholic depressives). I'm sure that a lot of them do have chaotic childhoods, but then again, a lot of people with chaotic childhoods DON'T grow up to become hysteroid dysphorics, so there has to be more to it than just that, even if it does play some role. The use of the word "hysteroid" emphasizes this – it LOOKS like what we assume is a "personality" disorder, but it isn't safe to assume that it IS a PD.

Sam:

No one diagnoses someone as a narcissist just because he is sad. FAQ 28 that you are referring to is one of many FAQs. Narcissism is a hypercomplex phenomenon. I didn't suggest that anyone who matches FAQ 28 is a narcissist. All I did was suggest that many narcissists match the behaviours described in FAQ 28.

 


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