Tuesday, September 7, 2010

Is Dysfunctional the New Normal?

In my new book, How Dysfunctional Families Spur Mental Disorders (shameless plug), I spend some time describing why the actual prevalence of child abuse and neglect in the United States (and other countries) is sometimes a contentious issue, and how certain advocacy groups have an agenda to exaggerate its prevalence while others have an agenda to minimize it. 

In the strange world of pots calling kettles black and people who are living in glass houses throwing stones, these groups ironically use the obviousness of the exaggerations of the other side as evidence for their own side.

Advocacy groups (and individuals with similar points of view) on a wide range of issues do this sort of thing all the time.  When I speak of the importance of psychotherapy for many psychiatric conditions, for examples, some biological psychiatrists love to point out that psychoanalysts used to mistakenly blame schizophrenia and autism on dysfunctional families.  I like to counter by bringing up eugenics and pointing out that biological psychiatrists used to blame poverty and sexual promiscuity on genetics.  When I say this, the bio folks howl, "But those ideas have nothing to do with contemporary biological psychiatry!"  I answer, "That's right, just like the old mistaken ideas of the analysts have nothing to do with contemporary psychotherapy."

This post is about a new study in the British Journal of Psychiatry (197, 193-9 Yang, Coid and Tyrer) about the prevalance of personality disorders (basically patterns of repetitive self-destructive behaviors).  This ties in with the issue of child abuse because patients who are diagnosed with certain personality disorders like borderline and antisocial have been found to have a very high rate of childhood adversity in their backgrounds. 

The vast majority of studies that have been done that have looked into the childhood adversity issue in those disorders comes to pretty much the same conclusion, although obviously many people who exhibit these disorders were not physically or sexually abused or neglected as a child.  Abuse or neglect are risk factors, and no risk factor for any psychiatric disorder is either necessary or sufficient to cause it, as I have argued elsewhere.

The authors of this new study almost seem to have gone out of their way to come up with an exaggerated prevalence for personality disorders.  They surveyed 8886 people living in private homes in Britain selected at random, and asked the questions found in a psychological testing instrument called the screening questionnaire of the Structured Clinical Interview for DSM-IV Personality Disorders.  This test consists of 119 questions in which subjects are asked to answer either "yes" or "no" in describing themselves.  The authors of the study say they only asked 116 of these questions; I have no idea what happened to the other three.

The study concluded, based on the number of "yes" answers, that 48% of the population has some sort of "personality difficulties," 21% has a full blown "personality disorder," and another 7% has "complex" or "severe" personality disorders.  Only 22.5% had no personality disturbance!

So almost no one is normal??  And if this personality problem prevalence is even loosely correlated with dysfunctional families, that would mean that in all likelihood, the majority of families must be dysfunctional.  I mean, everyone has issues, don't they?

Acutally, it's studies like this that give mental health practitioners a bad name and trivialize people who come from real dysfunctional families and have significant personality problems.

The SCID-II Questionaire is a symptom checklist (checklists are always inadequate to make a psychiatric diagnosis) that was DESIGNED to have a lot of false positives (that is, people who seem to meet criteria on the questionnaire but do not really have the disorder - or the even the traits - in question).

The reason for this is that it is supposed to be followed by a SCID interview that examines the criteria in more detail, and asks important follow up questions.  The preliminary questionnaire is given to save examiners time because they don't have to inquire about the questionnaire items to which the subject gave a "no" answer, since those items are very unlikely to turn out to be positive in actuality.

If the questionnaire was all that was given to the subjects in this study, then the estimate of personality disorder prevalence will of course be astronomically higher than it really is.  The authors briefly acknowledge the false positive issue in the discussion section of the paper, but then go on to argue why that shouldn't matter that much.

So what IS the definition of a dysfunctional family? It's sort of like defining pornography - hard to define in words, but you know it when you see it. Good therapists are not dealing with trivial stuff, but with severe child abuse, neglect, domestic violence, absent or totally inconsistent disciplining of children, extreme invalidation, frequent double message giving, and the like. Ain't subtle!!!

There are good, more independent stats on the high numbers of child abuse/neglect cases that are discovered by the authorities in the US every year.  The numbers are high, but not THAT high.

1 comment:

  1. Thank you for this insightful deconstruction of the BJP study. There are two papers in the September issue of Journal of Health Economics, where it is claimed that between 900 thousand (Elder 2010) and 1.1 million (Evans et al. 2010) of those children under age 18 in the US diagnosed with ADHD (at least 4.5 million) are misdiagnosed. I would be interested to see what you think about these studies!