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Tuesday, September 13, 2016

More Studies Reveal Widely Known Facts to be Actually True




As I did on my posts of November 30, 2011,  October 2, 2012,September 17, 2013June 3, 2014, February 24, 2015, and December 15, 2015, 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 latter. 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.

This last few months has been such a treasure trove of studies of the obvious, my descriptions of the individual studies listed will be a little briefer than usual.

At the end of today's issue of No Sh*t Sherlock is a special section on some new shocking and counterintuitive findings about things we used to think were good for your mental health and well-being - but turned out not to be.


12/15/15. Adolescents Who Abuse Prescription Pain Medicines May Be More Likely To Have Sex, Participate In Risky Sexual Behaviors

HealthDay (12/15, Haelle) reports that adolescents who abuse prescription pain medications may be “more likely to have sex or to participate in risky sexual behaviors,” a study published online Dec. 14 in Pediatrics suggests
Impulsive, self destructive people were, I guess, previously thought to be highly selective in which impulses to indulge.

12/15/15. Study Shows Reduced Patient Satisfaction When Computers Are Used Excessively In Exam Rooms

On the front of its Personal Journal section, the Wall Street Journal (12/15, D1, Reddy, Subscription Publication) reports on a study published the previous month in JAMA Internal Medicine, which found that patients whose doctors spent a lot of time looking at a computer screen during examinations rated their care lower. 
And here we thought that patients just hate doctors who pay close attention and listen to them carefully.

12/23/15. College Students Who Smoke Marijuana Appear More Likely Than Their Peers To Skip Classes

HealthDay (12/23, Norton) reports, “College students who smoke marijuana appear more likely than their peers to skip classes – which eventually leads to poorer grades and later graduation,” a study published in the September issue of the journal Psychology of Addictive Behaviors suggests. 
This finding is just so difficult to explain.

1/6/16. Many Single Mothers with Minor Children are Sleep-deprived, CDC finds

The Los Angeles Times (1/6, Kaplan) reports in Science Now that a data brief from the Centers for Disease Control and Prevention’s National Center for Health Statistics reveals that “44% of single moms living with children under the age of 18 fall short of recommendations to get at least seven hours of shut-eye each night.” Thirty-eight percent of single fathers who live with their children “sleep less than seven hours per night,” the report found. 
I just don't understand why these parents can't make their days last more than the usual 24 hours.

1/22/16. Prevention Programs for Youth Most Effective When At-Risk Families Are Clinically Stable

Programs that teach stress management and cognitive-restructuring skills may help to prevent the onset of depression in teens at high risk for depression, but how effective they are appears to depend largely on the mental health of youth and their parents when the intervention begins, according to a study published online this week in the Journal of the American Academy of Child and Adolescent Psychiatry
At last the long-sought proof that the more severe a disorder, the worse the prognosis tends to be.

3/2/16. Study Suggests Factors Predictive of Violent Behavior in People With Mental Illness

Results from a meta-analysis in Psychiatric Services in Advance shows that three factors may be associated with an increased risk for adults with mental illnesses to commit community violence in the near future. They are alcohol use, exhibiting violent behaviors, and being a victim of violence within the past six months. 
Booze fuels violence? Past behavior a predictor of future behavior? Who'd'a thunk??

3/16/16. Disruptive Patients may Get Worse Care from Physicians

HealthDay (3/15, Dotinga) reports, “‘Disruptive’ patients may get worse care from physicians,” studies suggest. 
Can't be. Doctors have been trained to be completely unaffected by annoying people. (Well, psychoanalysts anyway).

4/21/16. Eating Disorders May Be More Prevalent At Schools With A Greater Proportion Of Female Students

HealthDay (4/20, Preidt) reports, “Eating disorders may be more prevalent at schools where a greater portion of the student body is female,” research suggests. 
I just never noticed the higher prevalence of women among patients with anorexia and bulemia.

5/25/16. Severely Obese Children Picked On, Bullied More Than Normal-Weight Kids

HealthDay (5/25, Reinberg) reports, “As early as first grade, severely obese children are getting teased, picked on and bullied more than normal-weight kids,” research published online May 25 in Child Development indicates. Researchers arrived at this conclusion after gathering “data on nearly 1,200 first graders from 29 rural schools in Oklahoma.”  
Did these researchers ever go to grade school?

5/27/16. Depressed Patients Who Attempt Suicide Four Or More Times May Have Higher Risk Of Eventually Dying By Suicide, Research Suggests

Medscape (5/26, Brooks) reports, “Depressed patients who attempt suicide four or more times have a higher risk of eventually dying by suicide compared with their depressed peers who have never attempted suicide or who have done so fewer times,” research suggests. 
The fifth time is the charm.

6/2/16. Higher Out-of-pocket Costs Lead to Reduced Adherence

A literature review of 160 articles and abstracts identified a clear relationship between cost sharing, adherence, and outcomes. Of the articles that evaluated the relationship between changes in out-of-pocket costs and adherence, 85% showed that increasing patient out-of-pocket medication costs leads to reduced adherence. 
Did these researcher ever hear of the law of supply and demand? Guess not.

6/16/16. Hospital Deaths more Costly and Involve More Tests and Procedures than Deaths at Home

On its website, NPR (6/15, Kodjak) reports people who die in hospitals “undergo more intense tests and procedures than those who die anywhere else” and that more is spent on people dying in hospitals compared to people who die at home, according to an analysis by Arcadia Healthcare Solutions. 
I was wondering about that (not!)

7/1/16. Problem Of Missed Medication May Increase With Age, Failing Memory

HealthDay (6/30, Preidt) reports that a study published in the Journal of the American Geriatrics Society “suggests that the problem of missed” medication “rises with age and failing memory, especially for men.” The investigators found that other factors linked to “medication lapses” were “memory deficits” and having “trouble with the tasks of everyday living.” 
Gee, people with memory problems forget things.

And now for the special section that details how we have recently discovered that many things in the environment that were once thought to be sources of tremendous joy and uplift turn out to actually be downers that create various negative feeling states and are risk factors for depression and anxiety.

These include childhood abuse and neglect, poverty, post-partum depression, traumatic experiences, cancer, kids having parents with chronic severe migraine headaches, having your livelihood threatened by a disciplinary action from a licensing board, diabetic retinopathy, having a premature infant, and combat experiences.

I bet you think I'm making this up. Sorry, but you just can't make this stuff up.

3/1/16. Study finds children who face adversity before age 5 struggle in school

Kaiser Health News (2/29, Gillespie) reports a study published in the journal Pediatrics found that “adverse childhood experiences [ACEs] before age 5,” including “neglect, abuse and dysfunctional home lives,” were associated “with poor academic and behavioral performance in kindergarten.” 
These researchers just don't understand that these kids just have ADHD.

3/17/16.  Low-Income People Exposed To Rats In Urban Environment May Be More Likely To Have Depressive Symptoms

According to the NBC News (3/16, Fox) website, a study conducted by the Johns Hopkins Bloomberg School of Public Health and published online Feb. 10 in the Journal of Community Psychology reveals that “people living in Baltimore’s low-income neighborhoods who see rats as a big problem are significantly more likely to have depressive symptoms such as sadness and anxiety.” 

3/21/16. Women Who Have Had Postpartum Depression May Not Have More than Two Children, Study Indicates

HealthDay (3/18, Preidt) reported, “Women who’ve had postpartum depression may not have more than two children,” the findings of a study published in the January issue of Evolution, Medicine and Public Health suggest. 
Depression was previously thought to be so much fun that everyone wanted to go through it as many times as possible.

4/25/16.  Exposure To Traumatic Events May Be Associated With A Host Of Potential Negative Behavioral And Physical Effects

Medscape (4/25, Melville) reports, “Exposure to one or more potentially traumatic events in a lifetime is associated with a host of potential negative behavioral and physical effects, ranging from mental illness and depression to substance abuse, asthma, and” hypertension, the findings of a new report from the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality indicate. 

4/28/16. Cancer Diagnosis may be Associated with Increased Risk for Anxiety, depression

HealthDay (4/28, Preidt) reports that research published in JAMA Oncology “details the psychological damage” a cancer diagnosis “often leaves in its wake for patients.” Investigators “found much higher rates of anxiety, depression and even drug and alcohol abuse for those who’ve been told ‘you have cancer,’ compared to healthier people.”  Healio (4/28) reports that the study indicated “the risk for mental disorders appeared stronger among patients whose cancers had poorer prognoses.” 
       
5/31/15. Childhood Trauma May Increase Risk of Adolescent Drug Use, Study Shows

Children who experience traumatic events prior to the age of 11 may be more likely to use marijuana, cocaine, nonmedical prescription drugs, or other drugs as teens, according to a report online in the Journal of the American Academy of Child and Adolescent Psychiatry

6/27/16. For Teens, Living With Parents Who Have Chronic Migraine May Negatively Affect Activities Of Daily Life, School Performance.

Medscape (6/24, Davenport) reported, “For adolescents, living with parents who have chronic migraine has a negative effect on activities of daily life and on school performance and is associated with increased rates of anxiety,” research suggests. 
Parental misery and pain were previously thought to have no effect on their children whatsoever.

7/15/16. Patient Complaints Against Physicians and the Ensuing Complaint Review Process Seriously Affect Physicians' Long-term Psychological Well-being 

and can lead to their practicing defensive medicine, results of a large qualitative survey show. Led by Tom Bourne, MD, PhD, from the Department of Surgery and Cancer, Imperial College London, United Kingdom, the study is an analysis of responses to qualitative questions as part of a larger anonymous survey completed by almost 8000 physicians. 
7/8/16.  Severe Diabetic Retinopathy May Be Associated With Depression, Study Suggests

MedPage Today (7/7, Minerd) reports, “Severe diabetic retinopathy...was linked to depression, and its presence should prompt clinicians to inquire about a patient’s mental health,” research suggested. The findings of the 519-patient study were published online July 7 in JAMA Ophthalmology.  

7/21/16Parents Of Extremely Premature Infants May Be More Likely To Become Depressed Than Parents Of Full-Term, Healthy Infants

Reuters (7/20, Rapaport) reports, “When babies are extremely premature, parents are about 10 times more likely to become depressed than mothers and fathers of full-term, healthy infants,” research suggests. Included in the study were “113 mothers and 101 fathers of preemies, as well as 117 mothers and 151 fathers of healthy, full-term infants.” The findings were published online July 18 in JAMA Pediatrics.

8/12/16Female Service Members who Experience Combat may have Much Higher Risk of PTSD than Those Who do Not

Reuters (8/10, Rapaport) reports, “Women in the military who experience combat have a much greater risk than those who don’t of developing post-traumatic stress disorder (PTSD) and other mental health issues,” researchers found after examining “data from post-deployment mental health screenings for more than 42,000 women enlisted in the US Army and deployed in Iraq and Afghanistan from 2008 to 2011.” The findings were published online Aug. 1 in the Journal of Traumatic Stress. 

I wonder how many other things that were once thought to joyful actually are not.

Tuesday, August 30, 2016

Adult Sibling Rivalry and Family Dysfunction


Ahmet and Dweezil Zappa with their Mom, Gail, in happier times?

When adult siblings are continually at one another's throats, the conflicts have often been set up, either openly or covertly, by the behavior of one or both of the parents over an extended period of time - usually dating back to the siblings' childhood. Such parental behaviors are particularly effective for this purpose if started when the children were very young and have been continued, with minor variations, throughout their lives. 

There are a number of relatively straightforward techniques for parents to accomplish this goal. 

Here are a few common ones; there are undoubtedly a whole lot more.

1. The parent gossips and complains about each sibling behind that sibling's back to the all the rest of the other siblings.

2. The parents make constant negative comparisons of one sibling with another. For example, they might repeatedly scream, "Why can't you be more like your brother?!?"

3. The parent consistantly focuses only on those siblings who are creating repetitive, ongoing problems for themselves - and for everyone else in the family - and pays no or minimal attention to the siblings who are doing well and who are functioning independently.

4. Parents may leave the bulk of their estate to one or two siblings after they pass away, and much less - or even a pittance - to the rest. This is especially effective if they give almost all the money to the biggest screw up, or to the ones that did not come over and help take care of them when they were sick or indisposed in some way.

The picture at the top of the post are musician Frank Zappa's wife Gail and his two sons, Ahmet and Dweezil. Although there is no way to be certain from news stories orTwitter wars, a recent public feud in the family might possibly be an example of what I'm talking about. 
According the the Los Angeles Times:

 "Frank Zappa’s rich musical and cultural legacy, and which children have a right to profit off it, have recently become the subject of a public and contentious family battle. The children of Frank and Gail Zappa – Moon Unit, Dweezil, Ahmet and Diva – were left unequal shares of the Zappa Family Trust, which owns the rights to a massive trove of music and other creative output by the songwriter, filmmaker and producer — more than 60 albums were released during Zappa’s lifetime and 40 posthumously. Thanks to a decision by their mother, who died in 2015, Ahmet, 42, and his younger sister, Diva, 36, share control of the trust — to the dismay and anger of their two older siblings, Dweezil, 46, and Moon, 48, who received smaller portions."

For more on this interesting family, see:  http://www.rollingstone.com/music/features/inside-the-zappa-family-feud-w431684

Tuesday, August 16, 2016

Bipolar versus Borderline: Disease Mongering Pill Pushers Stack the Deck




In my Psychology Today blogpost of 12/11/11, Bipolar or Borderline, I described how disease mongering, pill-pushing psychiatrists have done their utmost best to blur the distinction between the mood (affective) instability seen in borderline personality disorder (BPD) with the mood episodes characteristic of true bipolar disorder. 

This distinction is important because BPD is clearly a disorder of interpersonal relationships and behavior mixed in with a history of trauma and family dysfunction, while true bipolar disorder is a serious biogenic brain disease. BPD, while some of its symptoms do respond quite well to the right medications, should be treated primarily with psychotherapy, while bipolar disorder should be treated primarily with medication.

In the prior post I discussed the use of invalid symptom checklists in studies to exaggerate the incidence of bipolar disorder. They are also used by some incompetent psychiatrists to make diagnoses that justify snowing every patient who walks in the door with potentially toxic antipsychotic medication. In the June 2016 issue of the Journal of Personality Disorders, researcher Mark Zimmerman goes into some detail about exactly how corrupt researchers use slight of hand to distort their data (Improving the Recognition of Borderline Personality Disorder in a Bipolar World, pp. 320-335).

They are very good at it. And it matters. Zimmerman states: "Although BPD is as frequent as (if not more frequent than) bipolar disorder, as impairing as (if not more impairing than), and as lethal as (if not more lethal than) bipolar disorder, it has received less than one tenth [emphasis mine] the level of funding from the NIH [the National Institutes of Health] and has been the focus of many fewer publications in the most prestigious psychiatric journals."

And, Zimmerman points out, the difference is not due to just the fact that there were more drug studies for bipolar disorder. In fact, the amount of funding for the drug treatment of bipolar disorder was just a little more than 10% of the total.

As I have mentioned several times in this blog, self-report symptom checklists are meant to be screening devises. This means that if you are positive for bipolar disorder on the screen, it does not mean you have bipolar disorder. It means you should be evaluated further! Screening tests are designed to have a lot of false positives - people who come out as positive on the test but who do not actually have the disorder. In fact, the majority of people who screen positively do not have bipolar disorder.

Zimmerman specifically brings up the Mood Disorders Questionnaire (MDQ) that I discussed in the previous post. Get this: in one study by Frye and others in the journal Psychiatric Services in 2005, the authors found that one half of the patients who were positive for bipolar disorder on the MDQ were not diagnosed with bipolar disorder by the treating clinician.  

Their conclusion? They said the clinicians "failed to detect" or "misdiagnosed" bipolar disorder in these patients! Actually, the exact opposite is far more likely: it sounds like the clinicians' judgments tended to be correct.

Frye and others then went on to state that these patients were "inappropriately treated because they were given antidepressants instead of mood stabilizers." Again, exactly the wrong conclusion to draw from the authors' own data. Yet they went on to say that this completely false conclusion was "worrisome." Some of us would call this real chutzpah.

Bipolar, my ass researchers love to talk about the bipolar "spectrum," based on the crazy logic that if a given symptom appears slightly similarly in two people, they must both have a version of the same syndromic psychiatric disorder. Zimmerman asks why no one talks of a borderline spectrum, when clinically, many patients are diagnosed as having borderline traits. This means that out of the nine criteria, of which you are required to meet any 5,6,7, 8, or all nine to qualify for the diagnosis, the patients may only have three or four. 

In fact, as reported in the July issue of the American Journal of Psychiatry (Vol. 173, pp. 688-694), Zanarini and others followed 290 patients with BPD closely over 2 years. They found that "...the symptoms of borderline personality disorder are quite fluid..." This means that they come and go over time. This was particularly true for acute symptoms like self-mutilation. Therefore, people with the disorder may frequently go from 5 symptoms to 4, and suddenly they don't "have" it anymore - unless and until the 5th symptom recurs!

In actual reality, he said redundantly, those people who exhibit three or four of the nine symptoms look a lot more like those folks who have five or more than they do like those folks who have none of them. Now that sounds like a "spectrum" to me.

Tuesday, August 2, 2016

Guest Post: What Happens When Mental Health Care Is Unavailable?


Adam Lanza, Sandy Hook Elementary School Shooter

Today’s guest post is by Audrey Willis.

It's a sad fact that mental health care in the United States is becoming increasingly unattainable.

From 2009 to 2012 the mental health care industry saw a $5 billion drop in funds across the country, primarily stemming from national budget cuts. While one in four adults---nearly 62 million individuals--experiences some type of mental illness in a given year, a staggering 4,500 public psychiatric hospital beds were eliminated during the same period. New York, Kentucky, California, and Illinois were among the top cutting states. Additionally, 13 states closed at least 25 percent of their state hospital beds. Unsurprisingly, this has resulted in a steep increase in patients visiting emergency rooms across the country in search of mental health care assistance. States that closed the highest number of mental health care beds also experienced an increase in violent crime over the same time period.

Aside from these budget cuts, there is another concerning issue, as the global mental health care industry is experiencing a shortage in working professionals. Globally, nearly one in ten people has a mental health issue. Who will take care of these people if only one percent of the universal health care workforce is dedicated to mental health?

Some real life examples may help to illustrate the serious nature of this ongoing issue:

-A 19 year old from New Hampshire recently spent 10 days in the common area of a Maine emergency room waiting for a bed to open in the mental health facility.

-A man who allegedly stole the equivalent of $5 in snacks died in jail as he waited for space to open up in a mental health center.

-A woman visited an Illinois emergency room 750 times over the course of 10 years searching for mental health assistance. The cost was a sobering $2.5 million.

These are problems that could be easily eliminated by integrating mental health care professionals into the emergency room staff of every major hospital.

With examples like this, it is easy to see why deep budget cuts have negatively impacted the quality of treatment for those who suffer from chronic mental illness. A recent heartbreaking report from the Treatment Advocacy Center found that at least one in four fatal police encounters involved the death of an individual suffering from a severe mental illness.

Individuals suffering from various mental illnesses who do not receive proper treatment often find themselves in the country's criminal justice system. Aside from the very real concern that these people will fail to recover without treatment, this also results in a significantly higher cost to taxpayers and makes for a more dangerous landscape, both for patients and law enforcement professionals.

While a tragic event can often increase public attention to mental health needs, the passion is rarely sustained after the news media cameras stop rolling.

A solution to this healthcare problem is to staff hospitals with mental health professionals, and find a way to open additional beds in treatment facilities---places that are specially trained on how to handle the vast spectrum of mental illness. Until that occurs, tragedies, much like the gut wrenching 2012 Sandy Hook Elementary School shooting---that claimed the lives of 20 children and six adults---may continue to happen. The perpetrator of this specific incident is known to have suffered from various mental illnesses, and was not able to obtain successful help.

Here is an infographic from the Cummings Institute (http://cummingsinstitute.com) that goes into more detail. Please Zoom in to see:







Tuesday, July 19, 2016

Ambiguous Language and Recognizing Emotional Conflicts in Others - Part II




The literary critic William Empson took Freud's idea of intrapsychic conflict as a springboard for appreciating the art of the poet, which in turn is a way of understanding the poet. Empson conceptualized intrapsychic conflict along psychoanalytic lines, but his ideas can just as well be relevant to a conflict between the individual's self and the family system to which that self belongs. In the book, Seven Types of Ambiguity, he listed different types of literary ambiguities which indicate increasing levels of confusion in the minds of the reader, the characters, and perhaps the author.

One of the reasons that literature excites us is because we identify with or contrast our feelings with the feelings of the characters as they encounter various predicaments. Those feelings are frequently not fixed, but mixed. Both we and they are plagued with doubts and contradictions. In much the same way, we can enter the internal world of others within our social system. In both cases, we are confronted with various degrees of ambivalence and confusion.

Empson's seven ways in which levels of "two-mindedness" are manifested in language are the subject of this post. Their presence can be used to alert a listener to the possibility that a motivational conflict is present in the speaker. Being able to spot this is key to understanding and then constructively discussing (metacommuncating about) repetitive dysfunctional family interactions. In general, the degree or level of the speaker's awareness of his or her ambivalence increases as we proceed down the list.

1. A statement's makes possible comparisons to several points of likeness or difference. This type of ambiguity turns on the fact that any idea or emotion causes a multitude of associations within the mind of the listener, and also because different people have different associations. A choir, for instance, can lead one person to recall positive images such as grand churches and angelic singing, while for another it summons negative images such as overbearing nuns in Catholic school or guilt-inducing sermons. This is precisely why people use metaphors and why metaphors make language so rich; a single word can stand for so much. A statement is ambiguous when the listener finds himself or herself wondering which of these many potential references and feeling states is in the mind of the author or speaker.

2. Two or more alternate meanings are fully resolved into one because to what a metaphor is really referring seems fairly clear. This device may or may not be ambiguous, depending on whether or not a question exists as to the actual meaning of the author.

 3. Two apparently unconnected ideas are suddenly connected. A good example of this type of ambiguity is the pun. An ambiguity arises whenever a question exists as to whether or not to connect the meanings, or about how to connect them. I remember an instance in high school in which I made a remark to a friend about another fellow student whom I disliked - which that guy overheard - about how he belonged to an anti-nuclear weapons organization. I mentioned that the fellow "was in SANE."
  
4. The speaker indirectly expresses mixed feelings or ambivalence without admitting to them, through the use of exaggeration. Confusion can be communicated, for instance, by provoking in the listener a sense of "methinks he doth protest too much." In other words, when individuals overstate their feelings, a listener may get the idea that they are covering up opposite feelings. The process involved can also be understood as a manifestation of a the defense mechanism known as reaction formation. Individuals may defend against an unacceptable idea by becoming obsessed with the opposite idea, or defend against an unacceptable impulse by compulsively acting in ways contrary to the impulse. A good example was the scandal that surrounded the television evangelist, Jimmy Swaggert. He had vociferously condemned from the pulpit all those who gave in to the "sins of the flesh." As it turned out, and as many of his critics had suspected all along, he had been giving in to the same temptations himself.

5. An individual communicates two ideas which may contradict one another in passing from one of them to the other, but does not address the question of their apparent inconsistency. The speaker either does not seem to be holding both ideas in mind simultaneously or never juxtaposes them, so that the issue of their possible mutual exclusiveness can arise for discussion and clarification. For example, a man may expound on his belief that the only road to satisfaction is hard work, and then go on to complain about how bummed out he feels at his own job. As a therapist, I often notice such possibly contradictory statements made literally weeks or even months apart. A therapist really has to pay attention and write good notes about sessions to pick up on this.

 6. The speaker says something in a way that actively signals to the listener that there should be some doubt as to what has been said. The speaker appears to have avoided making a commitment to an idea or expressing his or her true feelings. In this situation the speaker cannot be held accountable for holding any particular opinion. Damning with faint praise would be one example. When a basketball coach describes a player as "tenacious on defense, and always gives one hundred and ten percent," he is generally not describing one of his starters. A second example is the use of words like "strictly," "exactly," or "totally," as in, "she was not, strictly speaking, very intelligent!” A third way is through the use of nonverbal communication. A grin or a raised eyebrow will often negate the content of what is being said at the lexical level. In all of these cases, the listener is forced to guess what the speaker really means.


7. The last type of ambiguity is a full contradiction, in which the author or speaker obviously seeks to "have it both ways." In type seven, speakers make statements which indicate neuroticism or indecisiveness. They may go on and on ad nauseam describing the pros and cons of particular viewpoint or course of action without ever making a decision. They may obsessively waver back and forth on an issue. They may without warning plunge from the heights of ecstasy to the depths of despair, or from the idealization to the denigration of a person, thing, or concept.