Wednesday, March 15, 2017

More Cutting Edge (but With an Amazingly Dull Knife) Research

As I did on my posts of November 30, 2011,  October 2, 2012,September 17, 2013June 3, 2014, February 24, 2015, December 15, 2015, and September 13, 2016, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of the former. My comments are in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

Clinical Psychiatric News article, June, 2016Data from a longitudinal study reported at the World Congress on Osteoarthritis show that weight gain in young women is an independent predictor of future low back pain. Well, maybe their backs would do better if they carried around a sack of bricks slung over their shoulders 24 hours a day.

7/21/16. Apparently these researchers don't watch the evening news. Addiction To Prescription Opioids May Be Tied To Creation Of Market For Cheaper, Potent Heroin, Analysis Suggests. The Washington Post (7/20, Humphreys) “Wonkblog” reports that the relationship between restricting access to prescription opioids and increasing heroin use is more complicated than some critics of the Comprehensive Addiction and Recovery Act believe, according to a systemic analysis of the matter that was published in the New England Journal of Medicine. The analysis was led by the National Institute on Drug Abuse’s Wilson Compton who says that restricting access to prescription opioids does not automatically increase heroin use, but that having many people addicted to prescription opioids may be tied to the creation of a market for cheap, potent heroin that appeals to people addicted to prescription opioids, which may explain the increase in heroin use in recent years.

7/21/16.  And these researchers apparently don't get out much. Alcohol Intoxication Increases Aggression While Cannabis Use Reduces Such Feelings, Study Finds. The Washington Post (7/20) reports research published in the journal Psychopharmacology suggest “alcohol intoxication increased subjective aggression” while those who smoke marijuana “became less aggressive when they were high.” Researchers concluded that the “results in the present study support the hypothesis that acute alcohol intoxication increases feelings of aggression and that acute cannabis intoxication reduces feelings of aggression.” The findings are in line with other research.

7/25/16. People exposed to addictive substances found to have higher chance of getting addicted to them. Greater Pain Found to Increase Risk of Opioid Use Disorder. Researchers have long suspected that the level of pain experienced by a patient may increase his or her risk of developing an opioid use disorder. A study in AJP in Advance has for the first time taken a prospective look at this link, revealing a significant association between pain and prescription opioid use disorder at baseline and three years later. The researchers found that people with moderate or severe pain had a 41 percent higher risk of developing prescription opioid use disorders than those without, independent of demographics or other potential contributing factors. Males, younger adults (of either gender), and those with a family history of antisocial personality disorder were also found to be more likely to develop opioid use disorder.
8/2/16. Being sedentary bad for the heart? Who knew? Watching TV longer increases risk of fatal blood clot, study finds. The New York Times (8/1, Bakalar) reports a new study published in the journal Circulation by Japanese researchers analyzing “86,024 generally healthy people who filled out questionnaires with items about health and lifestyle, including time spent watching television,” found that more time watching television increases the risk for a fatal blood clot. Researchers estimated that, after adjusting for other factors, “watching for two and a half to five hours increased the risk for a fatal clot by 70 percent, and watching more than five hours increased the risk by 250 percent,” compared to watching for less than two and half hours each day.


8/2/16. Less serious disorders found to have better prognosis. Predictors of outcomes in outpatients with anorexia nervosa: Results from the ANTOP study. Psychiatry Research, 08/01/2016  Clinical Article. Wild B, et al. – Researchers explored the factors that may predict outcomes in outpatients with anorexia nervosa (AN). They concluded that better outcome was achieved in those who had a higher baseline BMI [Body Mass Index] and shorter illness duration.

8/24/16.  Traumatic brain injuries seen in many domestic assault survivors. The AP (8/23, Tanner) reports that, according to the Centers for Disease Control and Prevention, “about one-quarter of U.S. women and 14 percent of men have experienced severe physical assaults by a partner in their lifetime, including hitting, punching, being slammed against something hard or pushed down stairs.” Meanwhile, according to a research review published this year in the journal Family & Community Health, “head and neck injuries are among the most common, and data suggest that domestic assaults may cause traumatic brain injuries in at least 60 percent of survivors.” Being assaulted can lead to head trauma! OH NO!

9/6/16. Taking care of someone who can't tell you what's wrong should be a breeze! Relatives Who Care For Patients With Dementia Often Experience Frustration Due To Poor Communication, Study Suggests. The Washington Post (9/4, Bluth) reported relatives who care for patients with advanced dementia often experience difficulty because they can no longer communicate with their loved ones, according to a study published in the American Journal of Alzheimer’s Disease & Other Dementias. Researchers found that many family caretakers were often frustrated with their relatives with dementia because they could no longer communicate what they needed or when they were in pain.

9/16/16. But what about all those codgers I see running out on the streets? Many older US adults are physically inactive, CDC study finds. The CBS News (9/15, Welch) website reports, “More than a quarter of Americans age 50 and older do not move beyond basic everyday activities,” research indicates. TIME (9/15, Oaklander) reports that according to an “analysis of 2014 surveillance data, 28% of Americans ages 50 and over are inactive – meaning that 31 million adults are moving no more than necessary to perform the most basic functions of daily life.” HealthDay (9/15, Dotinga) reports that such inactivity increases the risk for “heart disease, diabetes, and cancer,” researchers from the CDC’s Physical Activity and Health Branch found. What’s more, “the older Americans get, the less exercise they get,” investigators found. “Thirty-five percent of people aged 75 and older were inactive, as were 27 percent of those between 65 and 74, and 25 percent of those aged 50 to 64,” the study revealed. 

12/13/16. Risk For Opioid Relapse May Be Lower After Voluntary Treatment Than After Compulsory Treatment, Small Study Indicates. Healio (12/12, Oldt) reports patients “with opioid dependence who were treated in compulsory drug detention centers were significantly more likely to relapse after release than those treated with methadone in voluntary drug treatment centers,” researchers found after conducting “a parallel, two-arm, prospective observational study of individuals with opioid dependence treated in Malaysia.” The findings of the study, which included 184 participants, were published online Dec. 7 in The Lancet Global Health. The author of an accompanying editorial observed that the study findings “provide solid evidence in support of an urgent need to expand availability of, and access to, evidence-based voluntary drug-dependence treatment approaches to all individuals affected by drug dependence.” Because motivation for treatment is irrelevant to its success.

12/12/16. Pain is associated with poorer grades, reduced emotional well-being, and attention problems in adolescents The Clinical Journal of Pain, 12/12/2016  Clinical Article  - Voerman JS, et al. – Findings imply that the association between pain and Dutch adolescents grades is intervened by reduced emotional well–being and attention problems. The association between pain and math grades is mediated by emotional problems. The outcomes recommend that an intervention targeted at the pain in adolescents could have a positive effect on their emotional well–being, attention, and school performance. What a shock! Being in pain has effects on your emotional and cognitive functioning.

2/21/16. Impact of somatic severity on long-term mortality in anorexia nervosa 
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, 12/21/2016  Clinical Article, Stheneur C, et al. – The present study sought to survey whether time in somatic intensive care unit, justified by a patient’s somatic condition in the course of hospital care, has any association with patient outcome in terms of mortality in the long term. The findings suggest that the clinical seriousness of the somatic condition during hospitalisation for AN is a risk factor for excess mortality in the medium term. In the present study, 195 patients were hospitalised for AN between April 1996 and May 2002, 97 were re-assessed 9 years later on average. Researchers observed that out of 195 patients hospitalised for AN between April 1996 and May 2002, 29 had required transfer to intensive care. Findings revealed that mortality at 9 years was 20 times higher in the group having been transferred to intensive care, irrespective of the duration of follow-up.  You mean, the sickest patients had the worst prognosis? How can that be?

Impaired Social Functioning Appears To Be Most Common In Schizophrenia, Study Indicates.

Healio (1/4, Oldt) reports that among people “with schizophrenia spectrum disorders, major depressive disorder with psychosis and bipolar disorder with psychosis, impaired social functioning was most common in schizophrenia,” researchers found in a study including “individuals with schizophrenia spectrum disorders (n = 269), major depressive disorder with psychosis (n = 77), bipolar disorder with psychosis (n = 139), and a comparison group without psychotic disorders.” Participants were followed for 20 years. The findings were published online Dec. 16 in the American Journal of Psychiatry, a publication of the American Psychiatric Association. Have these people ever even been to a psychiatric ward?

1/11/17. And here we thought booze was a cure all: Using Alcohol To Deal With Unpleasant Memories May Worsen Certain Mental Health Conditions, Mouse Study Indicates. The New York Daily News (1/10, Jagannathan) reports that instead of easing the pain of “distressing memories,” alcohol may “actually make it more difficult to cope with distressing memories,” researchers found.  Medical Daily (1/10, Dovey) reports that using alcohol as a coping mechanism “to deal with unpleasant memories...doesn’t work, and may actually worsen certain mental health conditions, such as” post-traumatic stress disorder (PTSD), researchers found. Working with mice, investigators found that “alcohol consumption did not help to ease fearful emotional memories, and may have strengthened them.”

1/23/17. Because no one ever drinks to forget. Spousal Loss Found to Increase Risk of Alcohol Use Disorder.  Spousal loss due to divorce or death appears to be associated with an enduring risk of alcohol use disorder (AUD), but remarriage may help to reduce this risk, according to a study published today in AJP in Advance. “The pronounced elevation in AUD risk following divorce or widowhood, and the protective effect of both first marriage and remarriage against subsequent AUD, speaks to the profound impact of marriage on problematic alcohol use and the importance of clinical surveillance for AUD among divorced or widowed individuals,” lead author Kenneth Kendler, M.D., of Virginia Commonwealth University and colleagues wrote.  And on a related note: Getting A Divorce May Increase The Risk Of Developing An Alcohol Use Disorder For Both Genders, Study Indicates. Medscape (1/26, Anderson) reports, “Getting a divorce increases the risk of developing an alcohol use disorder (AUD) by more than sevenfold for women and almost sixfold for men,” researchers found after identifying and then following “942,366 individuals born in Sweden between 1960 and 1990 who were married and residing with their spouse in or after 1990 and who had no AUD prior to marriage.” The findings were published online Jan. 20 in the American Journal of Psychiatry, a publication of the American Psychiatric Association.

1/24/17. Stress and anxiety were always thought to be totally unrelated. Stress Of Managing Breast Cancer Care May Provoke Symptoms Of Anxiety In Partners, Caregivers, Study Suggests. HealthDay (1/23, Thompson) reports that research suggests “the stress of managing breast cancer care provokes symptoms of anxiety in more than 42 percent of partners and caregivers.” Investigators found that “this stress-induced anxiety can last years after their loved one’s illness.” Investigators came to these conclusions after surveying “289 partners of patients diagnosed with breast cancer at age 40 or younger.” The findings are scheduled to be presented at a meeting of the American Society for Clinical Oncology. 

A Lancet study reports that deprivation and neglect in early childhood can have a lasting psychological effect into adulthood. Using findings from a study that assessed children adopted from Romanian institutions into families in the United Kingdom, The Lancet reports that deprivation and neglect in early childhood can have a lasting psychological effect into adulthood.

Tuesday, February 28, 2017

Not Taking the Bait in Family Discussions

When adult children complain to their parents about how the parents are repetitively engaging in invalidating, hateful, critical, demanding, and or abusive behavior towards them, the elder family members have almost always developed a number of ways to get them to shut the hell up. Often these ways include dismissing the adult children's complaints by accusing their progeny of being:

A) Little snowflakes (to use the current trendy term) who are overly-sensitive, weak, selfish, unable to take a little good natured teasing, or "high maintenance."


B) Stupid - reading things into what the parents are saying that are not really there.


C) Pathological -making things up that did not even happen or twisting the meaning of everything the parents says to unfairly shift the blame for the child's problem onto the poor, put-upon parents.

Unfortunately, in many of today's psychotherapy models, many therapists seems to agree with the parents that the adult child's problems are all in their heads and are not, in fact, due to their having being traumatized or understandably upset by dysfunctional or abusive family relationships.  

And of course, as readers of my blogs know, if parents act as if they expect  their children to act in weak, stupid, or pathological ways, in response the children often do indeed start to act out exactly what they are being accused of doing. When dysfunctional family patterns include that phenomenon in addition to the problematic parental behavior mentioned at the top of the post, the situation is a bit more complicated to talk about and will not be discussed further here.

To solve the problems, the adult children have to find a way to not shut the hell up, but to constructively push the conversation forward in order to put a stop to the problematic patterns. (I'm currently under contract for and working on a self-help book for New Harbinger publishers that discusses in great detail a large number of different strategies for achieving this goal).

This post will discuss one countermove to use when you are being accused of A, B, and/or C above that is often successful in disarming the parents and pushing the conversation onward. Of course, no strategy works with all families, or even all the time within any one family. But this one increases the odds of productive conversations when adult children bring up the complaints mentioned in the first paragraph of the post.

The strategy is based on a premise that was described beautifully and concisely by my colleague Dr. Jim Woods. He said, "You can't be pulled into a game of tug-of-war if you don't pick up the rope."

In this case, the accusations by the parents are bait. They want you to take it. You are being baited into becoming angry or defensive. Once that happens, constructive conversations immediately end in fight, flight, or freeze responses. No problems get solved then. Do not take the bait!

So how to avoid doing so?

Let's say you tell your parents that their demands are getting on your nerves because no matter how much you do, it never seems to be enough for them, and that that they seem to ignore the fact that you have other things to do and cannot just drop everything at a moment's notice to do things for them. Say they respond by telling that you are grossly exaggerating how much they ask of you, and that you ought to be happy to take the time to help them out. They add that you are being ungrateful. Just think of all the sacrifices they had to make for you when you were growing up!

How not to respond:

A) Argue with them about the frequency or reasonableness of their requests, or how much they sacrificed for you as a child.

B) Attack them and tell them they are insensitive, overly-critical clods.

C) Defend yourself by pointing out that your life is busy and of course you cannot always just drop everything to come over and do something for them.

D) Explain in detail your feelings and go on and on about how those feelings are justified.

E). Scold them or lecture them about etiquette and the proper relationship between adult children and their parents.

The basic form of the recommended response:

"Well, maybe so, Dad, but I am finding this situation to be a big problem. Do you think you could help me out by checking with me first about when it would be convenient for me to come over to help you?"

This sort of response is basically a refusal to argue about the merits of your personality characteristics, but trying instead to make a relationship better. In doing this, you are neither agreeing nor disagreeing with their characterization of you. It might be accurate, partially accurate, or complete wrong. Who's to say, really? That isn't the point. The point is how you are reacting to them when they do something, not whether your reactions are justified or not. They should want to know that so that everyone can, to quote Rodney King, just get along.

Surely they'd prefer a pleasant relationships to an unpleasant one. I know that it often looks as if this is not the case, but nonetheless, I advise that you give them the benefit of the doubt. 

Tuesday, February 14, 2017

The Concept of Resilience - Another Way to Marginalize the Effects of Family Dysfunction on Children?

Some people are just born hardier and tougher than others. Such individuals are better able to process, handle, and bounce back from stress and can handle more of it - on the average - than other people. They are said to be more resilient. No denying it. 

However, it is also true that at least some of any apparent resilience does not come from having been born with a better innate temperament, but results from having had at least one supportive and nurturing adult family member who buoyed up the person's coping skills as a child. Dysfunctional families may contain some of these folks in addition to other adult members who are more, shall we say, problematic. This helps to reduce the adverse consequences created by the latter.

Adverse Childhood Experiences, or ACE's, are clearly shown by a variety of research methodologies to be, overall, the most important risk factors for the development of personality dysfunction (as well as being major risk factors for a wide variety of other health problems). Somehow, however, in reading the personality disorders literature, you might think that defective brains were instead the biggest factor. 

In many previous posts I have discussed several different ways in which this latter idea is falsely argued - such as by looking at how a normal brain processes trauma physiologically and declaring, ex cathedrathat those processes represent some sort of abnormality. I have also discussed one of the major reasons this sleight-of-hand is employed: to avoid holding parents responsible for their problematic parenting and chaotic family interactions. 

It's just not popular to discuss the role of dysfunctional parenting in creating psychological problems in their offspring. The poor dears just cannot take it! Better to blame the victim.

Of course, it is also true that bashing parents and making them feel guiltier, more defensive or angrier than they already do is counterproductive, as doing so often causes them to double down on whatever dysfunctional interactions they had been routinely engaging in previously. Nonetheless, pretending that their behavior has nothing at all to do with their child's problems is just a big fat, ugly lie.

The blog Aces Too High is devoted to discussing the effects of childhood trauma. It usually puts the family environment in the proper perspective in discussing the relative effects of children's inherent, genetic capabilities, the problems their child's innate tendencies present to parents, and the effects on children of ongoing interpersonal trauma and dysfunction.

A recent posting in the ACES blog by Christine Cissy White contains a highly informative and wide-ranging discussion about how vague a concept resilience actually is, as well as about how difficult it is to measure. I recommend reading it. 

She also points out how the concept of resilience can be used as another device for the purpose of blaming the child victims of severe family dysfunction for their predicament and pretending that the parents' behavior is hardly important at all, if not completely irrelevant:

"Many trauma survivors, with experiences that are often minimized, marginalized or medicalized, are often frustrated by what seems like excessive funding for or fascination with resilience. It can seem as though resilience and protective factors can get overemphasized while the prevention and treatment of ACEs ends up sidelined – as though human suffering might be optional if it’s served up with enough resilience." 

Well said.

Tuesday, January 31, 2017

Genetic Programming Makes Nurture the Most Important Factor in our Behavior: Another Paradox

Claudia Gold, on a post on her Child in Mind blog, mentioned in passing that 700 new connections per second are made in the brains of newborns within the context of caregiving relationships700 per second! 

One of the basic theories behind my psychotherapy treatment method (unified therapy) for repetitive self destructive or self-defeating behavior patterns is that the behavior of primary attachment figures - in most cases, the parents - are, from a cognitive-behavioral standpoint, simply the most important environmental factor in triggering and reinforcing the problematic patterns. And not only when we our children, but throughout life. Certainly more powerful than a therapist could ever be.

I argue that babies come into the world completely helpless and with absolutely no knowledge about how the universe operates. We remain helpless far longer than the young of most species. Therefore, evolution likely proceeded in a way that resulted in our being biologically programmed to wire our automatic and repetitive  behavioral responses in most environmental contests - in particular social contexts - in accordance with what we learn from our interactions with those attachment figures. 

There is much evidence from neuroscience that the brain wiring that develops in this context and remains in the brain is particularly resistant to change through the normal process of neural plasticity. While it is true that later in childhood and adolescence the number of these connections is greatly reduced through a process called pruning, I suspect the ones that are lost are those that are not continually reinforced by the attachment figures.

In the nature-nurture debate about psychological behavior problems, for most of them I come down on the side of nurture being far more important than nature. Nature just provides us with a range of possible behaviors and reactions, while both nurture (and thinking - don't forget about that) allow us to choose where in that range we would prefer to reside.

But our nature as determined by our genes apparently does have one all-important function. Interestingly, it is the same influence no matter what the rest of our individual genome (assuming we have intact neural functioning) contains: it dictates that we are highly likely to respond to our nurture in accordance with the feedback provided to us by our parents. Paradoxically, it is nature that makes nurture so damned important in determining our behavior.

So learning about those 700 connections per second seemed to me to be good evidence for this point of view. So I looked up the source and found an article published by  Harvard's Center on the Developing Child. It said that those neural connections "...are formed through the interaction of genes and a baby’s environment and experiences, especially “serve and return” interaction with adults, or what developmental researchers call contingent reciprocity. These are the connections that build brain architecture – the foundation upon which all later learning, behavior, and health depend."

Serve and return was further explained as interactions that shape brain architecture: "When an infant or young child babbles, gestures, or cries, and an adult responds appropriately with eye contact, words, or a hug, neural connections are built and strengthened in the child’s brain that support the development of communication and social skills. Much like a lively game of tennis, volleyball, or Ping-Pong, this back-and-forth is both fun and capacity-building. When caregivers are sensitive and responsive to a young child’s signals and needs, they provide an environment rich in serve and return experiences."

Tuesday, January 17, 2017

Motivation and Standardized Testing

In the Viewpoint section on Sunday, January 8, 2016, in the Memphis newspaper the Commercial Appeal (the opinion section with op ed pieces), a white teacher named Carly Fricano wrote a column in which she described a conversation with one of her students. Ms. Fricano works for the heavily African American school district in Shelby County, and the student was named Marquavan, so I am assuming he was African American.

The student came up to her and said, "Ms Fricano, I know you think I'm dumb or something, but I'm not."

"What makes you say that I think you're dumb?" She replied.

"You keep giving me these tests that say I don't know this stuff, but I do. I just don't really care about these tests."

I italicized the last statement because it makes a point I have sometimes made. Even though this story is just anecdotal, I believe it is a valid representation of the folly of using standardized tests alone to evaluate teacher competency, the intelligence of the test taker, their academic achievement, or much of anything else actually. The problem is that there is no way to control for a student's motivation to do well on the test, and without that, you may be getting more of a measure of how little or how much the student is trying to answer correctly on the test than of how much he or she actually knows or is capable of learning.

And teachers do not have a lot of weapons they can employ to help students get motivated to perform well if the student's parents do not care about that either. The parents' attitude is the far bigger problem than that of less-than-competent teachers.

Of course, in saying this I will no doubt be accused of "parent bashing" and/or discounting the sad legacy of racism in determining the attitudes of both the parents and the students. To that I call, "Bullshit!"

Of course the parents play a huge role in determining their children's attitude towards learning. Do you really think that the relatively higher average achievements of Asian and Jewish students are just a result of their having higher average IQ's? That's nonsense. It's the family attitudes of Asians and Jews that is the primary determining factor.

And what about the other nonsense about my discounting the effects of racism in discussing African American student achievement? One can only accuse me of that if they think that I believe that these families reside in some sort of cultural vacuum. Or if they themselves are ignoring the wider context! It isn't only scientists who can be reductionistic.

Actually, it IS the racism that is the larger cause of the attitudes of many African American parents (and of course not all of them have troublesome attitudes - not by a long shot. I just said that, so please do not say I did not).

I will oversimplify the process in order to make it clear, but not really by much: Under slavery and Jim Crow, the latter of which existed for quite some time during my own lifetime, Whites' mistreatment of Blacks was justified on the basis of Blacks being thought of as stupid and lazy and therefore somehow less than human. 

Any black person who tried to disprove that mythology by sticking his neck out and showing how intelligent he really was was ritually and routinely humiliated, beaten, or even lynched and killed. Entire neighborhoods of successful black businesses were attacked and burned to the ground.

Culturally, this understandably led to a lot of fear within Black communities of looking too smart in front of white people, or even among themselves. This fear was then transmitted to the children by the parents - for the kids' own protection from the very real negative consequences, not because the parents had some innate defect or deficit. When these children grew up and had children themselves, they may not have completely understood where the fear had came from originally, but the damage to their attitude about education, success, and intelligence was already done. 

And the ongoing racism of Whites that is still evident all around them reinforces their fears. And so their kids "catch" it.

And thus we have the Marquavans of the inner city. 

I am afraid it is up to African American parents themselves to solve this problem, despite the continuing racism by Whites all around them, by taking the bull by the horns and learning how they have been affected, and by starting to start push their children to succeed academically. 

The fact that the odds may be stacked against their children is no excuse. That makes their success more difficult; it does not make it impossible. And the risks of Black success are now greatly reduced from what they had been. Not nearly as many lynchings these days. And please do not tell me that the last statements mean I am discounting current ongoing racist attitudes among Whites, or the fact that law enforcement still reacts with more violence and worse punishments against black suspects than white ones, because the statements simply do not do that.

Tuesday, January 3, 2017

Who's in Charge in Families, Parents or Children? A Paradox

In a recent column, my favorite parenting columnist John Rosemond asked a mother and father, “Who are the most important people in your family?” They replied, as many of today's parents are wont to do, “Our kids!”

Rosemond essentially read them the riot act:  “There is no reasonable thing that gives your children that status... many if not most of the problems they’re having with their kids—typical stuff, these days—are the result of treating their children as if they, their marriage, and their family exist because of the kids when it is, in fact, the other way around... without the parents, their kids wouldn’t eat well, have the nice clothing they wear, live in the nice home in which they live, enjoy the great vacations they enjoy, and so on.

He added: "This issue is really the heart of the matter. People my age know it’s the heart of the matter because when we were kids it was clear to us that our parents were the most important people in our families. And that, right there, is why we respected our parents and that, right there, is why we looked up to adults in general."

I absolutely agree with Rosemond that the parents' marriage should be the most important relationship in the house—not the relationship between the parents and the kids—and that the parents should be the authority figures in charge. The idea that this is the proper hierarchy within the house is in fact the basis of one of the more effective forms of family therapy, Salvador Minuchin's structural family therapy

On the other hand, I do have a slightly skewed take about the phenomenon of parents thinking their kids should be the most important people in the house that differs slightly from Rosemond.

The part I disagree with him about is when he say that, because of the parents' behavior, it is no longer clear to children these days that the parents are in charge. In fact, our brains are biogenetically programmed to put our primary adult attachment figures in charge. Our very survival depends on it.

When the children seem to be in charge, I believe they are just acting like it is not clear to them who is in charge, and are acting as if it is they, and not the parents. So how to explain the paradox? It may seem confusing, but it is actually quite simple. 

If children do in fact know that parents make the important decisions in the home, and the parents in their wisdom have decided that the children are more important and that the children's choices should be paramount, then who are they to question the parents' judgment? They will go along with it: They will act like they should make all the decisions, because doing so is in line with precisely the important decision the parents seem to them to have made.

Tuesday, December 20, 2016

Yet Another Drug Company Fined for Off-Label Marketing of Psych Medication

Since I started this blog way back in March of 2010, I have posted several times about big Pharma companies being fined for the off-label marketing of various psychiatric medications. Well, the hits just keep on coming.

The Consumerist was one of several news sources to recently report that: 

"New York Attorney General Eric Schneiderman announced the settlement Thursday resolving allegations that Bristol-Myers Squibb improperly marketed and promoted the drug Abilify.
Abilify — the brand name for the prescription drug aripiprazole – is a second-generation antipsychotic prescription drug, commonly, commonly referred to as “atypical antipsychotics,” that were originally used to treat schizophrenia.
According to the states’ complaint, which was also filed today, BMS engaged in off-label marketing, which is the promotion of drugs for uses that are not FDA-approved.
For example, the complaint claims that BMS improperly promoted Ability for pediatric use and for use in elderly patients with symptoms consistent with dementia and Alzheimer’s disease.
This, despite the fact that in 2006, Abilify received a “black box” warning stating that elderly patients with dementia-related psychosis who are treated with antipsychotic drugs have an increased risk of death.
Additionally, the complaint alleges that BMS violated state consumer protection laws by misrepresenting and minimizing the risks of the drug including metabolic and weight gain side effects and by misrepresenting the findings of scientific studies.
Under the proposed agreement, BMS is prohibited from promoting Ability from off-label uses; making false or misleading claims about the drug; compensating health care providers for attended promotional activities; using grant funds to promote Ability; and providing samples of the medication to health care providers who do not intend to use it for labeled purposes."
Bristol-Myers Squibb settled the claims with 43 states for a total of 19.5 million dollars. That sounds like a lot of money, but for big drug companies, it is actually a paltry sum. Fines like that are considered a cost of doing business

As readers know, I am rabidly against the use of antipsychotic medications in non-psychotic children, which is unfortunately becoming more and more common. However, I must admit I have negative feelings about that black box warning regarding the use of any (not just Abilify) antipsychotic medication in patients in nursing homes with advanced dementia due to Alzheimer's disease or other severe brain conditions. 

Things have gotten to the point where docs are afraid to prescribe these medications even in such patients who are actively psychotic with hallucinations and/or paranoid delusions, for which there are no other effective treatments.
Even in non-psychotic demented patients, antipsychotic meds are often the best agents for controlling assaultive behavior in this population. Unlike other sedatives, they do so while only minimally exacerbating memory and cognitive deficits in these people. Our society seems to want to pay nursing assistants only the minimum wage to take care of our impaired family members as they age. Long-term facilities are very expensive as it is. Not only that, but we under-staff them as well. While there may be psychosocial interventions which would reduce assaultive patients with dementia, we do not want to pay people to provide them.

Given those conditions, what is left? Medications, that's what. Do we really want to expose underpaid and overworked caretakers to dangerous aggressive behavior from patients who basically have no life anyway - just to prevent a tiny percentage of them from dying a little sooner due to the medications' cardiovascular side effects? Time to either pay up or shut up.

Tuesday, December 6, 2016

Parents and Adult Children React to My Descriptions of Borderline Family Dynamics

Parents and Adult Children React to My Descriptions of Borderline Family Dynamics

In my post about the family dynamics of Borderline Personality Disorder (BPD), I describe the role of the spoiler. A child or adult child of a family that exhibits the family patterns described in my posts on this subject begins to behave in ways which turns things around. The child invalidates the parents' efforts to "help" or "take care of them" in nasty ways. He or she essentially responds to invalidation by making comments that invalidate the parent right back. 
The reason the children do this is because they believe the parents need a child to be a target for their anger, and volunteer for the gig. They give the parents just cause by behaving in unreasonable and infuriating ways.
When it comes to the people who make comments on my posts on this and similar subjects, it always fascinates me how parents usually think I am putting all the blame on them for the family problems, while the adult children with the disorder react to the exact same post by thinking I am putting all the blame on them! 
Family systems therapists used the term punctuation to describe these types of reactions. People take something that is an ongoing problem created by continual reactions to feedback from two people with each other, and look at just one isolated segment of it - thereby breaking up a process artificially into misleading cause and effect relationships. They then react accordingly.
Of course, there are readers who do see the whole of the patterns in their lives but still do not know how to put a stop to them. In many cases the problems continue in spite of honest declarations of personal responsibility and even apologies -because there continue to be underlying issues that remain unaddressed.
I have reproduced two comments and my replies which illustrate these phenomena quite well. The first comment doubles as a description of spoiling behavior which illustrates it far better than I ever have.

The Blame Game
Submitted by A Mother of a Possibly BPD Child on November 6, 2016 - 11:39am
Regarding blaming the parents for "invalidating" feelings: I think it's a dangerous idea that all feelings are valid. Does anyone truly believe this?
When you are dealing with someone whose thinking is so distorted that they misperceive all your motives and react to your natural withdrawal as abandonment after they have been screaming abuse at you for an hour, you will just distort your own thoughts if you try to get into their head. If I say to my daughter "When you told me X it hurt my feelings," she often perceives that as an attack and starts to mock me: "Oh did that hurt your feelings? POOR YOU!" This can often escalate, and soon she is telling me what a horrible parent I am. That she is in so much pain that she'd lash out at me like this (again) does *not* mean I was abusive to her. She did not learn how to talk that way from us. We would never say something like that, even though she tells other people that's how we talk to her, and she probably believes we do. We did not cause that pain. Her mind did.
And this is the crux of the matter: just because someone perceives something as hurtful does not necessarily mean it's time to blame someone for hurting them. If someone trips and falls on you, and you scream, and they get mad at you for hurting their ears and making them feel ashamed with your tears of pain, should you feel sorry for them, since they honestly feel hurt by what you did? Should you feel mortified at yourself for inflicting such a nasty guilt trip on them with your tears? Some feelings *are* invalid! We invalidate our own feelings all the time. We *have to* if we don't want to be complete narcissists. A non-BPD person might feel a flash of anger at the ear-pain, but they would quell it, and then feel sorry they fell on you, sorry they hurt you accidentally. And if the screamer is non-BPD, they will probably be furious for a second at being fallen on, but then accept the apology and understand that it was an accident, perhaps even apologize for the loud sound they made - and everything will be fine afterward.
But if it isn't like this, the non-BPD screamer might reflect that they shouldn't have screamed and they certainly shouldn't have cried, since that just escalated things with the BPD person. But they were just behaving the way they would to anyone who fell on them. The reason they might think they shouldn't have screamed though, was because it made things into a conflict they didn't want, and they knew they could have avoided it.
And here's something else that's important: if (in the scenario with the falling person being BPD) the screamer pretends nothing bad happened afterward and tries to be loving again as if the falling person had been apologetic and understanding, are they *enabling* this bad behavior? Spoiling a tantrum-thrower? And if the falling person is the screamer's child, is the screamer not providing a terrible role model for the child? Should the *child* learn to tolerate this kind of behavior in other people? Should they not stand up for themselves and have high standards for their own behavior and that of other people?
Parents want to teach natural consequences, encourage empathy, and model the way one should behave in certain situations. BPD totally warps this. You start to think it's impossible to teach anything useful. You start to think that *ANY* response you have is doing irreparable harm to the BPD person. Walking on eggs to reduce conflict, or refusing to tolerate bad behavior - it's all bad. So what would be *good* for a BPD person? How would we recognize it?
As parents, we are not mind-readers. However we respond to behavior, it should teach something (how to respond, how not to respond, natural consequences, etc.) If the behavior is terrible and entirely lacking in empathy and remorse (just self-loathing, which doesn't do a darned thing to enact change), and if normal parenting only makes it worse, that cannot be - and is not - our fault for not knowing what would set the kid off this time. Of course we guess, of course we suspect - but we don't *know*. If we knew, we would necessarily be mentally ill too!
If we as parents caused this escalation by "invalidating" some feelings that originated in a distorted version of reality, or if we offended the child by refusing to be her punching-bag, that means LIFE itself would have provoked the same outburst. We just happen to be here trying to get her to have some self-knowledge and resilience. We are trying to help her learn how to deal with the real world. The real world will never be as careful as we are trying to be. The real world will never ask itself "Should I try not to take this personally, since she's clearly in so much pain she doesn't know what she's saying, or should I just react the way I normally react, since those are the natural consequences??"
The real world will react to BEHAVIOR. Often wrongly, often nonsensically, often (sad to say) maliciously. We are supposed to prepare kids for this! And as parents, we are supposed to train our kids to control their behavior and take responsibility for their actions. But what if, despite our best efforts, they don't learn this?
Many of the families that seem to shun someone who stops behaving so abusively were probably put through hell and just can't take any more. It's like they were holding up the car out of sheer adrenaline, and now the car is gone, they are burned out and need a break. Castigating them for shunning the person is asking way too much of them. Those were the natural consequences. Natural consequences usually teach non-BPD people how to control themselves and take responsibility for their actions. But what works with BPD people?
Parents of BPD kids need support and skills, not blame. They need tools to cope with a situation that is literally crazy - and quite possibly crazy-making.
blame game - my response

Submitted by David M. Allen M.D. on November 6, 2016 - 4:21pm
Hi A Mother of a Possibly BPD Child,
"Blaming" and finger pointing are counterproductive, but all adults - both parents and adult children alike - have to take responsibility for their part in the family dynamics if these dysfunctional patterns are ever going to stop.
What you have written is a beautiful description of spoiling behavior by a child (or an adult child) with borderline personality disorder. It is designed on purpose to invalidate YOU. The child thinks for various reasons that you need them to do that, believe it or not.
For an explanation of how this seemingly crazy situation may arise in families even if there is no obvious abuse, see the posts

Communication to Estranged Children
Submitted by Ria on November 12, 2016 - 2:10pm

I am so grateful for the comments of adult children on this page. It gave me insight in the feelings and minds of adult children who cut off parents. My daughter has cut me off a year ago - it happened a few times before she had children, I always reached out and tried to mend the relationship, but now the grandchildren are used as pawns. Although I am broken with the loss of my daughter as well as grand children, I have decided it is final this time. I was not the perfect mother, not even a good one. At 64, after many years of therapy, after two marriages, I understand that. 

I know my daughter is angry and anxious and use this cut-off defense after irrational anger outbursts - this time in front of the kids, which was the final straw for me. But you cannot cut off love and wipe out precious memories. I wonder all the time if she is happier without me in her life. Perhaps she has a better chance of growth, sorting out her own anger and pain without me. I want her to be happy and content within herself. It saddens me even more when I read of the bitterness and pain adult children express here and I cannot help to think: is there anything more I can do for her? Can I help her? Or is letting go the better option? I know no one can really answer, but let's talk about this. I know there are really evil people, but many parents were simply damaged as children. When they have children, usually when they are very young, they have no skills or boundaries or knowledge of parenting to care emotionally for their young, especially 38 years ago when information and education was not a given. The result is emotional abuse, neglect, and / or physical abuse. The horrible old cycle - how do we break it?

Communication my response

Submitted by David M. Allen M.D. on November 12, 2016 - 2:42pm

Hi Ria,
Of course I can't say anything about your situation in particular, but in general, of course it is best for parents to acknowledge their problematic behavior in the past, explain what they had experienced with their own parents, and apologize.
However, if the parent then goes on to continue to feel too guilty and beat themselves up for their past flaws, that may backfire. The adult child may then start to think that the parent is better off without them - just as you say you wonder about your kids being better off without you - because the child sees that his or her presence makes the parent feel really bad. In response, they may continue to avoid the parent so as not to add to the parent's burden. 
Additional point not in my original reply: Alternatively, they may act nasty to feed the parent's guilt because they think the parent wants to be punished for various sins - or they may go back and forth between the two depending on whether the parent seems to need to be punished or then starts to feel too guilty.