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Thursday, June 30, 2011

And the Hits Just Keep on Coming


In a previous post, I described how the drug company giant AstraZeneca agreed to pay about $198 million to settle lawsuits alleging that its promotional material neglected to mention the significant risk of getting diabetes from its anti-psychotic drug, Seroquel. In another post, I described how The U.S. Department of Justice fined the company $520 million for off-label marketing of the very same drug.


With stories like this coming with almost nauseating regularity, the company has now agreed to pay the District of Columbia and 37 other states $68.5 million for, once again for off-label marketing of Seroquel (for sleep disorders and anxiety, among other conditions) and failure to warn of potentially serious side effects such as weight gain, elevated blood sugar and diabetes.

In settling this last suit, the company of course once again denied any wrongdoing at all but said it was paying it off to get the complainants off of its collective back.  They did agree, however, to start doing what they claim they were already doing in the first place: having their drug representatives refer only to the FDA-approved indications of the drug and avoid focussing discussions with doctors on disembodied symptoms alone.

The company also said they had already set aside money for settling these sorts of lawsuits, so apparently this expense will not show up on any financial reports that they send to their shareholders.  And for the company, despite the seemingly large sums involved, the fines are chump change compared to what the drug brings in.  Just a minor cost of doing business.

As I have also frequently blogged about, and written about in my book, PhARMA's shady promotion of antispsychotic medication has been a big factor in the explosion of phony bipolar "spectrum" diagnoses.

Monday, June 27, 2011

Why Does the Predominant Treatment Paradigm for Borderline Personality Disorder Neglect Family Dynamics?

Marsha Linehan is the creator of what is currently the most prominent psychotherapy paradigm used to treat Borderline Personality Disorder (BPD). Her "Dialectical Behavior Therapy" (DBT) is often said to be the most "empirically-validated" of all such psychotherapy treatments. Actually, as I pointed out previously, DBT is only "empirically validated" mostly for the treatment of one symptom of BPD called parasuicidality. But I digress.

Dr. Linehan's theory of the cause of BPD, for which she cited no actual scientific evidence when she first described it (although there has been some since), is called the "biosocial model."  BPD, she believes, is created by the patient's genetic tendency toward being highly emotionally reactive and slow to recover from an emotionally "dysregulated" state, combined with what she refers to as an invalidating environment.

Invalidation, as used in psychology, is not merely people disagreeing with something that another person said. It is, as I said previously, a process in which individuals communicate to another that the opinions and emotions of the target are invalid, irrational, selfish, uncaring, stupid, most likely insane, and wrong, wrong, wrong. Invalidators let it be known directly or indirectly that their target’s views and feelings do not count for anything to anybody at any time or in any way. In some families, the invalidation becomes extreme, leading to physical abuse and even murder. However, invalidation can also be accomplished by verbal manipulations that invalidate in ways both subtle and confusing.

Bonus question: Do DBT therapists validate parking?

Dr. Linehan wrote only briefly in her book (Cognitive-Behavioral Treatment of Borderline Personality Disorder) about which environment she is talking about as being invalidating (page 56-59), and she barely mentions it in her talks and videos.  It is the family environment in which the person grew up.  Really, what else could it be?  Of course, your spouse and friends can also invalidate you, but why would you choose to fall in with an unpleasant group like that if you were not already accustomed to this sort of treatment? 

When it comes to DBT, however, most of the energy in the treatment described by Dr. Linehan is directed at helping the patients accept themselves as they are, without much said about how they got that way in the first place, combined with other techniques for reducing emotional reactivity. 

At some point in her treatment as described in her book she does say that she focuses on the patient's interpersonal skills later in the therapy process.  She even mentions that family therapy might be included.  Mentions it once or twice.  The first time on page 420.   She does not say anything about what that therapy might entail.



If an invalidating environment is one of two main causes of the disorder as she theorizes, how come she does not address this very much in her treatment plan?

Now comes a story in the New York Times (http://www.nytimes.com/2011/06/23/health/23lives.html?_r=2&pagewanted=all) which may shed light on this question.  Dr. Linehan admits that when she was younger, she "attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on." She added, “I felt totally empty, like the Tin Man."  Self injurious behavior and feeling empty are two of the hallmark symptoms of BPD.  Did she have the disorder?  According to the article at least, BPD is a diagnosis "that she would have given her young self."

I have only met Dr. Linehan once very briefly, and she was perfectly appropriate and personable.  However, I had heard the occasional rumor from other researchers that she has a little bit of the BPD in her.

So why has she so studiously avoided family dynamics in her treatment paradigm when an "invalidating environment" is fully half of her theory about the cause of borderline personality disorder?   And why would she include an invalidating environment in her theory if she, as someone who has struggled with the disorder, had not been invalidated herself?  If her theory is true, she of all people would have experienced that.

The Times article does describe her family a bit, but there does not seem to be a whole lot of dysfunction in the description:

          "Her childhood, in Tulsa, Okla., provided few clues. An excellent student from early on, a natural on the piano, she was the third of six children of an oilman and his wife, an outgoing woman who juggled child care with the Junior League and Tulsa social events. People who knew the Linehans at that time remember that their precocious third child was often in trouble at home, and Dr. Linehan recalls feeling deeply inadequate compared with her attractive and accomplished siblings. But whatever currents of distress ran under the surface, no one took much notice until she was bedridden with headaches in her senior year of high school.  Her younger sister, Aline Haynes, said: “This was Tulsa in the 1960s, and I don’t think my parents had any idea what to do with Marsha. No one really knew what mental illness was.”

Sounds like she was just mentally ill, and that that is the whole explanation for her behavior, does it not?  Just a somehow messed up brain.  But that would only be half of her DBT theory, and a problematic part of the theory at that. 

In one study by researcher extraordinaire Andrew Chanen and others, adolescents who presented for the very first time with BPD did not show the hippocampal and amygdala (parts of the brain's limbic system) volume reductions previously observed in many adult BPD samples - two of the MRI findings of adult BPD considered to be the most significant. They did, however, show small changes in one other part of the brain compared to controls.  (Psychiatry Research: Neuroimaging 163 [2008] 116125).

This finding could mean that some of the brain phenomena that may create high emotional reactivity come primarily as the effect of some other factor or factors.  An effect, not a first cause. What factors might they be?  An environmental factor?  I would suspect so.  Perhaps the invalidating environment?

So, again, why does Dr. Linehan relegate changing family behavior to what is basically a footnote in her treatment text?  Of course I have no way of knowing. 

With my patients who do not want to look too closely at their family dynamics, however, the reason why is crystal clear.  They are very protective of their families, even if they complain unceasingly about them.  They really do not want anyone to think badly of their family, so they tend to keep the skeletons in the family closet to themselves, at least at first.

Maybe if you just ignore a problem, it will go away.  Not.

Tuesday, June 21, 2011

Another Crazy News Article About ADHD

Here's yet  another article that should be perfect for my new journal Stupid Studies and Even Stupider Headlines. (This is the companion journal to my other journal, Duh! The Journal of Obvious Results).

An article in Health Day on June 14, 2011 carried the headline,  Too Little Sleep in Preschool Years May Predict ADHD: Study suggests link between behavior in kindergarten and sleep loss earlier in life. 



In this case, the study being described has not yet even made it into a journal, which means no peer review has yet taken place.  It is going to presented at a meeting of the American Academy of Sleep Medicine.  No peer review.  On the other hand, according to fellow blogger the Last Psychiatrist (TLP), peer review these days is about equal to proofreading.  Still, Health Day was jumping the gun a bit, no?  Why? 

The authors of the study reported, "Children who were reported to sleep less in preschool were rated by their parents as more hyperactive and less attentive compared to their peers at kindergarten." However, inattention and hyperactivity in the preschool years was not a predictor of sleep duration in kindergarten, the researchers added.

Their conclusion: "These findings suggest that some children who are not getting adequate sleep may be at risk for developing behavioral problems manifested by hyperactivity, impulsivity, and problems sitting still and paying attention."

So does sleep deprivation lead to a mental disorder?  That seems to be the implication.  But that couldn't be it, could it?  Surely these scientists could not possibly believe that correlation is evidence of causation in this particular instance?
 


How about parents who don't insist on a regular bedtime for their sleep-deprived children. Do such parents suddenly become firm disciplinarians when their kids reach kindergarden? Might they also let their kids get away with murder in other ways?  Do children who get to pick their own hours and therefore are up half the night start to act out? Might they also get a little rambunctious and CRANKY? Ya think?  Just asking.

My conclusion based on the relative likelihood of the author's insinuation versus my own observations:  Most kids labelled with ADHD don't have a disorder at all but are just acting out, just like most of the ones labelled these days with pediatric bipolar disorder.

To quote the Last Psychiatrist again, "If a psychiatrist looked a single parent a joint away from a nap right in the eye and said, 'nope, he's acting out because of X, Y, Z, and medications aren't going to fix this' that doctor will get his head handed to him by parent or by lawyer.'"

It's amazing but predicatable how defensive parents who disagree with this line of thinking can get, which sort of proves TLP's (and my) point.  Such parents don't just argue logically, but indignantly get their panties in a bunch.

Adults act out too.  The latest fad no-such-diagnosis making the rounds of confused lay people to describe them (or themselves) is "Schizophrenic Bipolar."

Thursday, June 16, 2011

EOB I Owe

I'm going to get away from mental health issues a bit on this post to let readers in on some characteristics of the current United States health system of which some may not be aware.

Imagine that you were fed up with managed care health insurance, that you were fairly young and healthy, and that you were quite affluent.  Say that you still had the choice to opt out of health insurance altogether and pay for your health care as you go - but before you do, you decide to compare the prices of different medical procedures, labs tests, and radiological procedures like MRI's at different doctors' offices and laboratories. 

How would you go about finding out who was offering the best deals and who would be overcharging like a mad auto mechanic with a young girl who knows nothing about cars?

So you call up a lab and find out what a certain MRI costs (these are real numbers): $2635 at one facility.  However, an insured friend just had the procedure at that very same lab, and, being of a suspicious sort, you ask to see the Explanation of Benefits (EOB) from your friend's insurance company.  You are shocked to see that your friend's procedure only cost $2077!  This includes both what the insurance company paid out and your friend's copayment.


You say to yourself, "What the f*@#$!!!"

So you take another look at the EOB.  When you look closer, you see something on there that says that indeed the MRI "costs" $2635, but your friend and his insurance company only have to paid $2077.  The EOB also brags about something called "Network Savings" of $558. 

Look how insurance companies are working for you to hold down medical costs!  You begin to wonder how come your friend's insurance premiums go up by double digit percentages every year when doctors, hospitals, and labs seem to be getting paid less and less for the most common medical procedures.  Gee, I wonder who's pocketing all that extra money? 

So you call up two more labs, tell them you have no insurance, and find out that they also supposedly charge around $2600 for this MRI.

What is really going on is that $2635 is a sort of list price, but that no one with insurance pays list price.  The people with NO insurance routinely pay a much higher price for the exact same procedures at the exact same locations.

Your blood starts to boil. You think that maybe doctor visits are different, so you call up various medical specialists, ask the cost of an initial evaluation for a specific complaint, and lo and behold, you find exactly the same pricing schemes.

Next, you next try to call some doctor's offices and demand that they give you these procedures at the same discount that the insurer gets, but every single one says no. 

Somehow you get a doctor on the phone and corner him, and ask him why you can't have the evaluation at the discount that the insured patients get.  He won't tell you why, and yet he still refuses.

OK, so here's the real explanation of benefits:  All doctors have a high list price for any given procedure or exam.  The number is nonsense, however, because most of their practice is insured patients, and none of the insurance companies pay list price. 

Although there is some room for negotiating prices between managed care and providers, if you started collecting EOB's from different doctors for the same procedure, you will find that all the different insurance companies get approximately the same discount.  Also, the insured patients and their insurers when combined are all paying about the same price for the same procedures.

So why don't the doctors just lower the list price and give the same deal to all the insurance companies as well as the uninsured?  I'm glad you asked.

When negotiating with an insurance company, doctors who want to be one of the preferred providers for that company are forced to agree to the discounted price.  The insurance companies offer essentially nothing in return other than the doctor being listed as one of their preferred providers, who cost the patient less to see than an "out-of-network provider."  Out-of-network providers cost insured patients more out of pocket than do in-network providers, but often still not the list price offered to the uninsured.

If the insurance company finds out that a physician offered an uninsured patient the same discount, they then start to demand a similar discount off of the price they agreed to pay the doctor when the doctor first signed up for their panel, while completely ignoring the fact that that price had already been discounted.

However, if the doctor offers the same discount to get on another insurance company's preferred provider list, the first company has no trouble with that all.  Perhaps they offer one another professional courtesy.  The fact that they all offer approximately the same remuneration for specific procedures seems to indicate that the different companies get together to fix prices. 

And yet somehow they do not seem to run afowl of anti-trust laws.  However, if doctors get together to insist on a minimum amount of remuneration that they would accept for a given procedure, the Justice Department threatens to charge them with violating anti-trust laws!

It is supposedly illegal for one doctor to merely ask another doctor how much the second doctor charges for services.  And yet somehow doctors are supposed to divine what fee is "reasonable and customary" when they set their "list price" for Medicare and insurance companies.  Of course, it is easy to get the data indirectly.

If the doctor decides to lower his or her list price, the insurance company will demand the same percentage discount off the new price.  Hence, the doctor has an incentive to keep the list price as high as possible, and gets  punished if he or she does not.  So much for beneficial effects of the highly vaunted "competition" in the "free" private insurance market.

To get back to psychiatry for a moment, the insurance companies has used this state of affairs to ratchet down the price of psychotherapy, so that doctors earn a lot more money for just prescribing psychiatric drugs and doing nothing else.

So if you are uninsured and would like to pay up front cash for your medical care, you will be fleeced like a helpless little sheep. And you can thank your politicians for this state of affairs.

Saturday, June 11, 2011

You're Asking For It

In a recent advice column by Dear Abby, A 19-year-old woman complained about the way her two younger sisters were treating her mother. When the writer was 4, the mom had gone to prison for eight years, but the experience of jail had somehow turned Mom's life around. At 38, the mother had a college degree, a loving husband, a good job and a new home.

The two sisters said that they did not want to be part of the mother’s life, but they never failed to call her at holiday and birthday time to pick up the gifts they know Mom has bought them. Afterward, they would not contact her or answer her calls and texts until the next holiday. From the letter writer’s perspective, this repetitive dysfunction interpersonal interaction would leave the mother depressed and feeling used. If the writer tried telling them to stop this, they would tell her to get out of their business.

In her answer, Dear Abby opined that the two younger sisters were manipulative, selfish and self-centered, but correctly pointed out that the mother was enabling them to behave in this way. Abby astutely said that the mother might be giving and giving out of guilt, while the sister may be taking and taking in order to punish her.

On the surface, the younger sisters were in fact being manipulative, selfish, and self-centered. But - just maybe - they were really responding to what they believed the mother needed and wanted them to do. Perhaps Mom was feeling so guilty for being in jail during their childhood that she was actually inviting the girls to abuse her in this way. They may have been “helping” her to atone for her sins. The mother's "need" for this was evidenced by the fact that Mom kept giving them stuff in spite of their mistreatment of her.

Under this interpretation, the sisters are giving the Mom the punishment they think she feels she deserves, while taking the heat off the mother by looking like they are the villains in the story. They are the ones who appear to be “acting badly.” For a parallel situation, please see my post, Your Spouse’s Secret Mission.

We have all heard the expression, “You’re asking for it,” as when a child defies a parent’s orders knowing full well that he will be spanked. Now of course, this is said as if it were meant facetiously, as a sort of a joke. After all, why would anyone be “asking” for a spanking?


Not a good tattoo for a criminal

What I propose here is instead that people really do mean this. They really think people are in fact asking for it when they do something knowingly that will surely lead to a negative consequence. Why else would they do that? The individual who says, “You’re asking for it,” however, does not know why the “asker” is doing so. He or she has to come up with some sort hypothesis to explain it. Maybe the other person is mad, bad, crazy, guilty, or just a masochist.

So why is the phrase said as if it were being said facetiously? The answer is that the person uttering the phrase knows he or she will be attacked for offering this theory seriously.

For example, let’s take the case of one not-uncommon type of abusive husband. In my most recent book, I describe the case of a woman who was married to a hyper-jealous and hyper-possessive husband with a history of violence.

One day in a fit of pique, she torched his prized vehicle and then had sex with his best friend. She then went home to tell him all about what she had done - in the nastiest way she could think of - and blamed her misbehavior on his inadequacy as a husband. So what happened next? Duh!!!

Before I go on, let me add a caveat. I am not suggesting that this guy’s behavior should be excused. One should not beat someone else up no matter what the provocation, except perhaps in the case of Osama Bin Ladin. So don’t write me a nasty note!

Now, if this husband were to tell, say, a marital therapist, that his wife was “asking for a beating,” what response would he be likely to get in return? The therapist would almost certainly exhibit an angry and disgusted facial expression and accuse him, perhaps in a sugar-coated but still easy to spot way, of trying to justify his vile behavior through rationalizations and deflecting the blame for his own shortcomings onto his victim. The average abuser generally knows better than to subject himself to that - unless he actively wants the therapist to hate him.

Such a reaction would hardly be limited to a therapist. Most people would attack this guy unless they were afraid of him or somehow complicit. Better to use the phrase facetiously, no?

Now, “asking for it” does not have to be this clear and dramatic. Subtle behavior can draw out hostile responses just as well as can gargantuan provocations.

The great Eric Berne, founder of a type of psychotherapy called Transactional Analysis (TA) and author of the best-seller, Games People Play, describes a “game” that he calls Kick Me : This game is played by people whose social manner is equivalent to wearing a sign that reads “Please Don’t Kick Me.” The temptation for everyone is almost irresistible, and when the natural result follows, the person cries piteously, “But the sign says ‘don’t kick me.’” Then he adds incredulously, “Why does this always happen to me?”

The mother in the Dear Abby letter might have been acting in such a manner with they younger daughters, while acting very differently with the eldest daughter. If this were the situation, the eldest daughter would probably not understand what the younger sisters were really reacting to, and blame them. Just as they would want. As I have pointed out in previous posts, people are so thoughtful that way!

Sunday, June 5, 2011

How to Disarm a Borderline, Part VIII: Splitsville

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), Part VI (March 2), and Part VII (April 30). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

In today's post, I will discuss how patients with BPD get two or more other people to fight with one another, and how to avoid getting sucked into such fights.

The psychoanalytic concept of splitting has been used by analysts in a few different senses.  The different meanings of the term are clearly connected with each other, but the analysts are somewhat vague in describing in detail what this relationship actually is.  The most common use of the term, as I described in my post A Splitting Headache of 4/24/10, applies to something going on entirely inside the heads of patients with BPD. 

As I described in the earlier post, BPD patients are thought by analysts to be either unable to see both the good and the bad in anything or anyone at the same time, or do not do so because they are using splitting as a defense mechanism.

As is their wont, the analysts seem loathe to look at a mental phenomenon in terms of its interpersonal meanings withing the context of the patient's real relationships.  However, one well-known interpersonal phenomena seen with patients with BPD is often spoken about when analytic therapists converse.  This phenomenon is also called splitting.

When individuals with BPD are hospitalized in psychiatric facility, it is frequently noted that professionals will start arguing among themselves about the patient.  Two doctors, or a doctor and a nurse or social worker, will get into what are at times very heated discussions about the patient's treatment.

Sometimes the entire ward staff becomes divided into two warring camps, with one side thinking that the patient is being treated unfairly with the other side wanting to come down on the troublesome patient with the proverbial hammer.  This situation became known as the infamous staff split.



My first clue as to what was happening in these situations came with the realization that a lot of the aggravating behavior of patients with BPD is a big act that can be turned off and on at will, like a faucet, depending on who they were performing for.  The act can also be greatly altered so that they act one way with one group of people and completely differently with another group.

I was consulted on a hospital patient on a medical (not a psychiatric) floor whose medical condition was clearly being affected adversely by her stress level.  When I first met the woman, she was the sweetest, friendliest, and most pleasant of patients.  We were having a nice chat about her stress level when her phone rang. It was the patient's husband. 

Suddenly I witnessed the most amazing transformation short of a caterpillar turning into a butterfly.  She without warning turned into the nastiest, most shrill harridan one could imagine.  Her comments towards her husband were so unrepentently vicious and venomous that I began to feel sorry for him.  After a short conversation, she practically hung up on him.  As soon as she put down the receiver, however, she turned right back into all sweetness and light in a heartbeat.

Amazing.  Patients who have real mental illnesses cannot do that.  They act pretty much the same way with everyone - and even when they do not realize they are being observed.

The staff split is set up by the patient.  To one group, he or she acts like a damaged, pitiable abuse victim in need of kind understanding. To the other group, like hell on wheels.

Eric Berne, founder of the school of psychotherapy known as Transactional Analysis and author of the best selling book Games People Play, had a name for this whole pattern. He called it the game of Lets You and Him Fight. In other words, the patient acts in ways that essentially picks a fight between other people.  If this game had a professional league, individuals with BPD would be the superstars.


Eric Berne
The solution to the staff split is actually simple and straightforward.  First, staff members have to be aware of the fact that their arguments are being set up by the patient, not by the unreasonableness or stubborness of the other side.  They can then ask each other on what patient behavior they are basing their opinion, and compare notes.  They can then decide on a mutually acceptable course of action and present a united front to the patient, and voila, the patient stops trying to split them.

The relationship between the senses of the term splitting is that the patient acts all good with one group, and all bad with another group.  If pressed, the analysts would probably say that the staff split is just an incidental byproduct of the patient's tendency to see some of the staff as all good and others as all bad. 

I, in contrast, see is at a well planned, although sometimes automatically and subconsciously played, interpersonal strategy designed to create staff wars.  Once again, however, I believe such patients are ambivalent about this and down deep hope that their efforts to provoke fights will fail.  The power to play mommy off against daddy is actually very frightening for them.

When seen in individual therapy, patients with BPD will often make a damaging or incendiary accusation about an important referral source, about a colleague who is well respected or who is even a friend of the therapist, or about a nurse with whom the therapist will have to work. If therapists defend the other person without having an impartial account of what actually transpired, they are invalidating the patient.
 
However, the patient may be exaggerating what happened, making undue inferences about the motives of the accused, or discounting the role of his or her own provocative behavior in the dispute. Also, the therapist should never forget that there really are a few Nurse Ratcheds on psych wards.
 

Nurse Ratched, "One Flew Over the Cuckoo's Nest"
 
My solution: I state, "I was not there, and I have a different impression of him from my other contacts, so I am not in a position to make a judgment on this." I just refuse to take sides in the dispute, and the patient will often then drop the subject completely.

One major exception I make to this is when a patient alleges that a former therapist had sexual intercourse with the patient. (This caveat does not apply when the patient just had the opinion that the former therapist had inappropriate thoughts).  I take this allegation very seriously because, in my experience, patients rarely make unfounded allegations about this subject, and unscrupulous therapists need to be taken out of the profession.  The willingness of the patient to allow the therapist to take advantage of her in this manner is irrelevant.

The next time your friend with BPD tendencies tells a story about someone else that starts to make your blood boil - at the person being described in the story - keep these suggestions in mind and do not take sides.