Friday, October 23, 2015

Double Standards for Brand Named vs. Generic Drugs in Literature Reviews: Use of Medication in Borderline Personality Disorder

In the free psychiatric "journal" Psychiatric Annals (Psychiatric Anals?) of August 15, 2015 - no doubt financed by PhARMA - one article correctly points out that studies on medications used for symptoms of Borderline Personality Disorder have been very small, extremely infrequent, very short-term, poorly controlled, and of limited usefulness. (And done without ANY consideration for comorbid disorders like panic disorder, which is seen in about 40% of subjects, I might add).

It also points out, again correctly, that there are no medications for the disorder itself, and that psychotherapy is the treatment of choice for that. Nonetheless, most of these patients do take medications for certain symptoms of the disorder: most usually the mood instability, irritability, and impulsivity that lead to such other problems such as self-injurious behaviors like cutting.

The review of the studies that have been done is fairly complete, although I notice that they left out an extremely important article on the use of Prozac for the symptom of "impulsive aggression" by Coccaro and Kavoussi from 1997.

During its rather limited review of studies of the use of antidepressants in the disorder, it says things like, "The authors found a reduction in anger among the fluoxetine (Prozac) recipients," "Fluvoxamine (Luvox) improved rapid mood shifts," "Sertraline (Zoloft) was more effective in decreasing symptoms of depression, hypersensitivity in interpersonal relationships, and obsession," and "superior efficacy for phenelzine (Nardil, and MAO inhibitor) on measures of depression, borderline psychopathologic symptoms, and anxiety."

In the summary of this part of the review, it nonetheless says, "No statistically significant effects were observed for the selective serotonin reuptake inhibitors (SSRIs) or phenelzine." So what on earth were those that they had just listed?

Yet, after discussing similar weak data for mood stabilizers, it makes the following summary: "RCT's (randomized controlled studies) involving the mood stabilizers were limited by low statistical power. Divalproex sodium (Depakote) shows an effect for anger and interpersonal sensitivity. Topiramate (Topamax) and lamotrigine (Lamictal) were found to have an effect on anger."

And for atypical antipsychotics, after reviewing even weaker evidence, the summary says: "Olanzapine (Zyprexa) has the most supporting data of the antipsychotics; studies have shown its use can lead to reductions in anger, paranoia, anxiety, and interpersonal sensitivity. Effects were found for aripiprazole (Abilify) on impulsivity, anger, anxiety, psychosis, and interpersonal problems."

Misleading double standard for summarizing the effect of brand-named versus drugs available as generics, ya think?

Tuesday, October 13, 2015

Antipsychotic Medication Used to Dope Up Unhappy Children.

There were two interesting editorials in the September 2015 issue of JAMA Psychiatry, a journal that used to be called the Archives of General Psychiatry and which is published by the American Medical Association. On the surface, the articles seem to address completely unrelated subjects, but on closer inspection, they both involve a common theme.

The first one is entitled "Antipsychotic Use in Youth Without Psychosis: a Double Edged Sword." I have of course railed in many of my blog posts about the use of antipsychotic medication for patients who do not have psychosis, because these agents can have serious drawbacks, and because better alternatives exist. In many cases, the better alternative is psychotherapy that can help the anxiety and mood symptoms that used to considered to be part and parcel of, and caused by, neurosis - behavioral disorders based both on internal ambivalence about one's life choices as well as interpersonal conflicts.

I have been particularly critical of the use of antipsychotic drugs in children who are almost never actually psychotic, and who are being diagnosed with bipolar disorder when they are in fact just misbehaving because of stress and family discord. As the JAMA Psychiatry editorial points out, the long term effects on the brains of developing children of antipsychotic drugs are unknown, although changes in the density of neurons have been observed.

The editorial mentions recent statistics that really do prove that the medications are being used in children primarily to shut them up. I quote: "All signs suggest that [antipsychotic medication use] among children is chiefly in those with aggression and behavioral dyscontrol, ADHD, and disruptive behavior disorders, but not for those with psychosis, bipolar mania, Tourette's Syndrome, or autism spectrum disorders." They are also being combined more and more with stimulants. 

Repeat after me, "Uppers and downers, and bears, oh my!"

Fewer than 25% of the young people in this study had any recorded psychotherapy of any kind. 

These drugs are effective for aggressive behavior - but not because they are specific for that problem, but because they are sedating and at times mind-numbing - as a side effect. Heroin would probably work just as well! After longer term use, however, the sedation side effect diminishes, so the drugs don't seem to work as well any more, which is when second and even third drugs are added.

The second editorial is titled, "Why Are Children Who Exhibit Psychopathology at High Risk for Psychopathology and Dysfunction in Adulthood?" Somebody actually did a study about this question, which should be high on my all time list of studies appropriate for the journals Duh! and No Shit, Sherlock. The study wasted time and money actually investigating the question of whether or not the proposition in question was even true. Turns out it was. Surprise!

Gee, childhood conduct disorder predicted antisocial tendencies. Who'd'a thunk? However, behavior problems in childhood predicted a wide range of different mental disorders, and was therefore a non-specific risk factor for a whole host of problems. 

Even less surprising, "a subthreshold or threshold mental disorder at some time from late childhood through adolescence predicts lower levels of adaptive functioning." So poorly functioning children become poorly functioning adults. I wonder why?

Actually, the question of why childhood behavior problems are non specific in being risk factors for various other psychiatric disorders is addressed in the editorial, and this part is where this editorial touches on the issues addressed by the other editorial discussed above. Three possible "causes" of why disturbed children become dysfunctional adults are listed. 

While there is some truth to the possibilities, which are not mutually exclusive by any means, it is simply amazing to me how the editorial author studiously avoids any clear-cut mention of ongoing family dysfunction as the culprit.

Family dysfunction is often chronic and ongoing and is rather widespread in our culture. To name just a few: parental drug abuse, divorces with multiple lovers coming and going and/or with children being passed around to different relatives, child abuse (physical, sexual, psychological), domestic violence, parenting issues (parents leaving children unattended or neglected for long periods, putting childcare entirely on the backs of older siblings, catering to children's every whim, invalidation, screaming and yelling, undermining the disciplinary efforts of one another), parents having multiple affairs, bad mouthing the other parent in front of the children and enlisting them as allies (triangulation), and general chaos at home. Is the author of the editorial really saying that none of these problems might explain the connection between childhood and adult psychiatric problems? Is that their argument?

If you don't believe that these patterns are common, I have two words for you: country music.

The closest the author of the editorial comes to this issue is reason #3. But notice the wording: ongoing instability is mentioned, but mostly things like poverty and living in bad neighborhoods. The nearest thing to family dysfunction that is mentioned is "lack of stable social support." Vague enough for you?

In reason #1, the authors seem to be blaming the child for the problems of the adults, rather than the other way around! They say, "exhibiting the behaviors that define conduct disorder in childhood may alienate peers and family."

Which do you think is more powerful and important: adults' behavior negatively impacting children, or children's behavior negatively impacting adults? This reminds me of a speaker touting Adderall at a grand rounds in our department who said, "If you had kids with ADHD, you might drink too much too!" In other words, he was saying that rambunctious children are a cause of alcoholism.

In reason #2, the authors do refer to environmental factors, but over-emphasize early ones. I guess the authors think either than family dysfunction ceases miraculously by virtue of a child turning 18, or that adults are not affected much any more at all by what their family members are doing to and with them. Sorry, but those assumptions are just plain nuts.

Before I quote what they listed as the three reasons, what is the connection I am implying to the issue of antipsychotic use in kids? It is this: instead of recommending family therapy, the doctors are just drugging the kids who act out in response to these problems.

Anyway, here are the reasons as they described:

1. Child psychopathology and adult psychopathology could have different causes, but experiencing mental health problems in childhood may directly or indirectly increase the risk for adult psychopathology. For example, exhibiting the behaviors that define conduct disorder in childhood may alienate peers and family, lead to curtailed education and incarceration, and increase the risk of brain and spinal cord injuries. In turn, these adverse consequences of childhood conduct disorder may place the individual at increased risk for later psychopathology and compromised adaptive functioning during adulthood.

2. It is possible that some or all of the causes of psychopathology across the life span operate early in life. That is, childhood psychopathology could predict psychopathology and compromised functioning in adulthood because they are both influenced by at least some of the same genetic and early environmental factors. Although there may also be later age specific causal influences, such enduring effects of early causal influences would foster the observed predictive association. At the level of mechanism, child and adult psychopathology would at least partly share atypical functioning in the same neurobiological processes in this case.

3. The predictive association between child psychopathology and adult psychopathology could reflect chronic or intermittent exposures to conditions that give rise to psychopathology when encountered across a life span. For example, psychopathology at all ages may be fostered by chronic economic instability, pollution, living in disorganized and violent neighborhoods, and lack of stable social support. To the extent that these causal environmental factors are stable across a person’s life, childhood psychopathology would reliably predict adult psychopathology even in the absence of a shared causal or mechanistic link between them. 

Friday, October 2, 2015

How to Fail at Family Problem Solving

In prior posts, I have discussed what I call the principle of opposite behaviors as it applies to repetitive behavior in personality disorders as well as in recurring dysfunctional family behavior. It is related to an idea that I call the net effect of behavior: that if someone always gets the same results from their actions, and they keep doing it anyway, then the result they get is the result they are trying to get.

The principle of opposite behaviors applies in those cases in which someone repeatedly does the exact opposite of what another person is doing, yet repeatedly gets the same results anyway. Or those cases in which a person goes from one extreme to the other, and still always ends up in the same place.  Prior examples discussed in this blog: Parents who let their kids do anything they want versus those who try to control their every move; those who never ask anyone for anything versus those who ask people for the moon.

This post is about how the principle of opposites applies to metacommunication — family members discussing both their mutual interactions and the family dynamics over several generations. As readers of this blog know, I believe that doing so is the most effective way to solve problems and put a stop to ongoing dysfunctional interactions which trigger psychological symptoms and troublesome behavior. It is the "curative" part of my psychotherapy, which I call Unified Therapy.

When I discuss this idea on either this blog or on my blog on Psychology Today, I am usually besieged with comments saying that readers have tried this and it just doesn't work, or that I cannot appreciate that their family members are totally incapable of stopping abusive, distancing, or other provocative behavior.

I always reply that I do not blame anyone for not believing what I say about how metacommunication is both possible and effective in any family in which members are not fragrantly psychotic or a victim of brain damage or Alzheimer's disease. In fact, when I first broach this ideas with my own psychotherapy patients, I frequently get this response. Patients tell me that I couldn't possibly know how impossible their particular family can be.

Oh, but I do. In fact, I've almost always seen families that are far worse. And it is true, I add, that metacommunication done poorly can make a family problem even worse. Then I go on to say that doing it well is extremely difficult and that if it were easy, the patients would have already done it. 

In order to do it well, they have to become aware of things about their family and its members that they could not possibly have known before. Last, every family is different, so I can't just tell them right off how to proceed. Therapy is a complex process by which the right interventions are devised prior to any actual attempts at implementing them.

So why do folks who have tried to talk about family issues get into trouble? Well, again, every family is different, but we can discuss some general issues. It is much easier to talk about what does not work than trying to predict what will work in a given family or with a given relative. 

For this post, I invoke the principle of opposite behaviors: talking too much about something— especially if one always goes about it in the same way—is as futile as not talking about it at all. In either event, nothing gets resolved.

Obviously, trying to ignore an issue might work for a short time, but the issue will continue to hang over the heads of the participants like the proverbial Sword of Damocles, and things will eventually blow up. Or there will be an emotional cutoff in which family members try to divorce one another. But even that does not prevent the issues from continuing to contaminate the participants' other relationships, particularly between them and their lovers and children.

So what "doesn't work?" Here is a short list: blaming, accusing, and saying some variant of "You're bad (or evil, or stupid)," "You hate me," or "You did this to me." Getting angry rather than trying to hear the other person out, and/or becoming defensive rather than being thoughtful about what might be the kernal of truth in what the other person is saying. Not giving the other person the benefit of the doubt no matter what they say.

Another big one is invalidation. There are several variants of this. One of the most obvious is denial of events such as child abuse when both parties to the conversation know very well what happened. 

Telling the other person what they are feeling rather than asking them what they are feeling is another well known example.

A less well-known pattern is when each party is so keen on making their own points that they do not address the points that the other person is making at all. They steamroll any exchange by talking over each other, by completely ignoring what the other person has said in response to something they said, or through other ways of refusing to acknowledge the other person's point of view at all as they continue to make their own additional points.

Interestingly, people talking about a family problem can move on to discuss a related issue without ever having come to any agreement on the initial issue that was broached - so that neither of the issues is addressed fully. Sometimes people make a big circle, bringing up one related or tangential issue after another without achieving any resolution of any one of them, and then at long last returning to the initial issue. And then starting the whole circle all over again from the beginning!

Last is the best illustration of how talking too much leads to the same results as talking too little. After achieving some resolution of an issue, the parties continue to bicker incessantly about it, refusing to drop it even though, if they followed up on their initial plans, the problem would have been solved. In a commonly discussed example, some members of couples are well known for repeatedly bringing up an old grievance even decades after the problematic event took place.

There are a lot of ways to fail.