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Tuesday, November 7, 2017

A Psychiatric Diagnosis: Behavioral Problem or Brain Disease?




When the first edition of the DSM (the manual of psychiatric diagnoses published by the American Psychiatric Association) came out in 1952, it listed about 100 different psychiatric diagnoses. By the time the fifth edition was published in 2013, it listed over 550 separate ones! One has to wonder if early psychiatrists were just missing a bunch of them, or if normal but repetitive everyday problems in living due to trauma, stress, and interpersonal dysfunction have been turned into diseases. I vote for the latter.

At any rate, the DSM uses the word “disorder” to fudge this question somewhat, leaving a “to be determined” answer as to whether any of the diagnoses are brain diseases or just psychological or behavioral problems experienced by normal brains. So how do we go about making an educated guess as to which it is?

The question is complex because the phenomena under discussion are very complex. While our understanding of the brain is increasing by leaps and bounds, it is still very rudimentary. That is because the brain is literally the most complicated and complex object in the entire known universe, with about a trillion constantly changing connections between nerve cells. Remember when computers would go crazy and produce the infamous “blue screen” when two programs would conflict, and you would have to restart it? Imagine what might happen if the computer were not hard wired!

A lot of people, including many in the various mental health professions, seem to be prone to highly simplistic “either-or” thinking. If even one of the 550 DSM diagnoses is a brain disease, then they all must be. Or if one is a behavioral/psychological disorder, then they all must be. That is just stupid. But throughout the history of psychology and psychiatry, the field has often lurched back and forth between brainlessness and mindlessness (as described in Chapter One of my last book), incorporating what turned out to be ridiculous or misguided theories.

Autism is caused by refrigerator mothers. Schizophrenia is just a different way of experiencing the world or due to being placed in a double bind by your family. Sexual promiscuity is a genetically determined trait, and certain races are genetically inferior to others. Acting out by children is caused by underlying bipolar disorder. Obsessive compulsive disorder is caused by harsh toilet training. A central part of women’s psychology is penis envy. The list of nonsensical and grossly mistaken theories like these is nearly endless. I’m surprised that no one ever theorized that the memory deficits in Alzheimer’s disease are really a result of the defense mechanism of repression.

But even without such simplistic thinking, determining which diagnoses are truly diseases and which are primarily behavior problems caused by problematic learning and stress is not easy. You cannot just do an fMRI brain scan, as I described in an earlier post, because that test alone does not distinguish an abnormality from a normal conditioned response to a particular social environment.

And even if something is a brain disease, family stress and dysfunction can make it worse – just like with many physical diseases. Then there’s this: having a parent who gets manic and runs naked through the streets creates huge stresses for a child who observes it. Such children are at risk both genetically and environmentally.

Not only that, but you get into a chicken and egg situation: does having a controlling family create anorexia nervosa, or is having a child who is starving herself to death lead parents to become overly controlling? A child who is more temperamental is often somewhat more difficult to raise than one who is not, leading some parents to engage in problematic parenting practices with one of their children but not others.

The whole question of “what causes” a disorder is further complicated by the fact that with the vast majority of psychiatric diagnoses, there are no necessary or sufficient causes of any sort – only risk factors that increase the odds someone will develop a disorder, and mitigating factors that decrease those odds. And there are usually hundreds of these factors operating over time.

So what standards do I use in forming my opinions about various disorders? To me, by far the most important metric is whether the symptoms of the disorder only appear under certain social conditions, and disappear when the social conditions change. Real brain diseases like schizophrenia do not do that; they are present almost all the time. You see victims “responding to internal stimuli” whether you are talking to them one-on-one or observing out of the corner of your eye on a ward in a state hospital them when they don’t realize they are being observed by staff. They show them no matter who is talking to them, or even if they are put alone in a room in a psychiatric ER with a hidden video camera keeping a watchful eye on them.

Someone with, say, a melancholic depression reacts at a snail’s pace compared to the way they usually react (psychomotor retardation) every waking moment no matter where they are or who they are with, and stay in that state all day every day, sometimes for weeks at a stretch. Luckily, when I trained we could keep patients in the hospital that long so we could see this; today’s trainees do not get to do that any more, so are more easily fooled.

On the other hand, borderline personality disorder symptoms are not like that at all. I would see patients with the disorder acting out with staff in a psychiatric hospital, but behaving completely appropriately with the other patients when they didn’t know I was observing them. In fact, they are famous for acting one way in the presence of certain staff members and exactly the opposite when in the presence of others, leading the two groups to fight with each other (the staff split)!

I’ve seen people I know who have the disorder out and about at music festivals and theaters acting as normally and appropriately as anyone else. In therapy, certain emotional reactions and provocative behavior would come out of them if the therapist did one thing, but would disappear quickly if the therapist changed to doing something else.


In looking at neuroscience evidence, an important metric in distinguishing disease from mere dysfunction is the sheer number of different types of brain anomalies and other neurological findings. As I said, a single fMRI finding alone tells you nothing. But a whole bunch of different fMRI abnormalities with some of them completely unrelated to the symptoms of the disorder suggests a brain disease. For example, people with schizophrenia tend to have a lot of different abnormalities, many of which have nothing to do with delusions or hallucinations. One cannot be certain, of course, but I would be hard pressed to explain many of these neurological findings in terms of conditioned responses to particular social environmental stimuli.

Wednesday, October 25, 2017

More Stories from the Journal of Obvious Results




As I did on my posts of  November 30, 2011,   October 2, 2012September 17, 2013,  June 3, 2014,  February 24, 2015,  December 15, 2015,  September 13, 2016 and March 15, 2017, 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 later. 

The journals honor the tradition of The Golden Fleece Award, an award given to public officials in the United States for their squandering of public money, its name sardonically derived from the actual Order of the Golden Fleece, a prestigious chivalric award created in the late-15th Century, and a play on the word fleece, as in charging excessively for goods or services. The late United States  Senator William  Proxmire  began to issue the Golden Fleece Award in 1975 in monthly press releases.

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.


3/17/17. Because substance abuse is an indicator of being satisfied with your life. US Veterans With Substance Abuse Problems May Have Higher Risk Of Suicide Than Veterans Without Such Problems, Study Suggests. HealthDay  reported, “US veterans with substance abuse problems have a higher risk of suicide than veterans who don’t,” researchers found after examining data on “more than four million veterans.” The findings were published online March 16 in the journal Addiction.


5/24/17. Because having a potentially fatal illness is so exhilarating. Lung Cancer Diagnosis May Increase Suicide Risk, Study Suggests. HealthDay (5/23, Mille) reports that research suggests individuals “with lung cancer have a strikingly higher-than-normal risk of suicide.” Investigators looked at “data from over 3 million patients during a 40-year period.” The research indicated “that a lung cancer diagnosis raised the odds of suicide by over four times compared to people in the general population.” The findings were presented at the American Thoracic Society meeting.


5/30/17. Because most people adjust instantly when uprooted from their entire way of life by a bloody war. Syrian Refugee Children Living In The US Reported High Levels Of Anxiety, Small Study Suggests. MedPage Today (5/28, Visk) reported, “Syrian refugee children living in the US reported high levels of anxiety,” researchers found. Specifically, “based on self-reported test scores, more than half of children had a probable anxiety diagnosis, and more than 80% had probable separation anxiety,” the 59-child study revealed. The findings were presented during a poster session at the American Psychiatric Association’s annual meeting. Healio (5/26, Oldt) also covered the study.


8/17/17. Cheaters are prone to cheat? Will wonders never cease? Serial Infidelity Across Subsequent Relationships (Arch Sex Behav; ePub 2017 Aug 7; Knopp, et al ).  Prior infidelity emerged as an important risk factor for infidelity in next relationships, according to a recent study. Researchers addressed risk for serial infidelity by following adult participants (n=484) longitudinally through 2 mixed-gender romantic relationships. Participants reported their own extra-dyadic sexual involvement (ESI) (ie, having sexual relations with someone other than their partner) as well as both known and suspected ESI on the part of their partners in each romantic relationship.


9/6/17.  And I thought most elderly people who fall fall out of bed. For nursing home residents, mobility increases risk of fracture. Reuters (9/5, Rapaport) reports a new study published in The Journals of Gerontology: Series A found that for nursing home residents, “risk factors for fracture included the ability to walk independently, wandering the halls, dementia and diabetes.” The study was based on data from “419,668 nursing home residents, including 14,553 who experienced hip fractures.” Lead author Sarah Berry, MD, of the Institute for Aging Research and Harvard Medical School in Boston said, “Frail nursing home residents that are still mobile and independent have opportunity to fall.”

9/6/17. People prone to diseases get them more often than those who are not? Genetic variants linked to health problems appear less frequently in people who live longer, study indicates. Newsweek (9/5, Osborne) reports genetic research published in PLOS Biology used data from over 200,000 people to show humans “appear to be evolving to hit puberty later and those who start at an older age live longer.” Researchers also discovered that “genetic variants linked to heart disease, obesity and high cholesterol appear less frequently in people who live longer.”


9/8/17. Because major depression has a genetic component, and depressed mothers may have attachment issues or altered parental behavior, ya think? Children Whose Mothers Took Antidepressants During Pregnancy May Be At Increased Risk For Psychiatric Illnesses Themselves, Research Indicates. HealthDay (9/7, Preidt) reports, “Children whose mothers took antidepressants during pregnancy may be at increased risk for psychiatric disorders themselves,” researchers concluded after reviewing “data from more than 905,000 children born in Denmark between 1998 and 2012,” whose “health was followed for up to 16.5 years.” The findings were published online Sept. 6 in the BMJ. According to Medscape (9/7, Brooks), the authors of an accompanying editorial “say that reporting absolute risks, as the researchers do in this study, is important to facilitate communication between clinicians and pregnant women.”


9/8/17. Maybe cuz they’re the ones who are eating again? Young Women With Anorexia Nervosa Who Resume Menstruation By End Of Treatment May Experience Greater Improvement In Psychological, Physiological Well-Being Than Those Who Do Not, Small Study Suggests.

Medscape (9/7, Davenport) reports, “Young women with anorexia nervosa (AN) who resume menstruation by the end of treatment experience greater improvement in both psychological and physiologic well-being than those who do not,” researchers found after studying 39 women with AN and 40 women with bulimia nervosa. The findings were presented at the European College of Neuropsychopharmacology Congress.

9/8/17.  Why would you need doctors for people to have healthcare? I just don’t understand. ACA Plans With Narrow Networks May Provide Less Access To Mental Healthcare, Study Indicates. Reuters (9/7, Rapaport) reports that according to a new study conducted by researchers at the University of Pennsylvania Perelman School of Medicine in Philadelphia, “narrow-network insurance plans created by the Affordable Care Act (ACA) offer only limited access to mental health care.” The article says these plans seem to have substituted lower costs for less access to mental healthcare.


9/11/17. Self destructive kids study less? High school students with poor grades more likely to have unhealthy behaviors, CDC study indicates. The Atlanta Journal-Constitution (9/8, Hart) reported, “There’s a link between unhealthy behavior and bad grades, according to a new study of high school students by the US Centers for Disease Control and Prevention.”  HealthDay (9/8, Preidt) reported the study suggests US high school students with poor grades are “much more likely to have unhealthy behaviors – including illegal drug use – than teens at the top of the class,” researchers concluded after “analyzing data from a 2015 government survey.” The findings were published in the CDC’s Morbidity and Mortality Weekly Report.

9/15/17. Because as we all know the incidence of health problems decreases with age. Risk For Health Anxiety May Be Increased In Older Adults, Study Suggests. MD Magazine (9/14, Warren) reports, “The risk for health anxiety...a disorder characterized by a preoccupation with physical health and/or somatic/body symptoms, is increased in older adults,” researchers found after assessing “538 primary care patients” ranging in age from 18 to 90. The findings were published online June 24 in the Journal of Anxiety Disorders.


9/29/17. They thought infectious disease occur spontaneously, I guess. Babies with older siblings may be at higher risk of hospitalization for influenza, researchers say. In “Well,” the New York Times (9/28, Bakalar, Subscription Publication) reports, “Having older brothers and sisters puts infants at higher risk for being hospitalized” for influenza, researchers concluded after studying “1,115 hospital admissions of children under two born in Scotland from 2007 to 2015.” The findings were published in the European Respiratory Journal.

10/2/17. Because listening to people talk about the voices in their heads is so relaxing. Caregivers of Individuals With Schizophrenia Experience High Levels of Distress, Study Finds. Psychological distress among family or friends who provide unpaid support to people with schizophrenia or schizoaffective disorder is much higher than the general population, reports a study published today in Psychiatric Services in Advance

 

10/4/17. I didn’t know PTSD had anything to do with being traumatized. PTSD Particularly Common Among People Exposed To Mass Shootings, Studies Indicate. The AP (10/3, Tanner) reports that people who survived this week’s shootings in Las Vegas may be at risk for post-traumatic stress disorder (PTSD). Also at risk for “psychological fallout” are first responders, medical staff, eyewitnesses, and bystanders. Studies indicate “PTSD is particularly common among people exposed to mass shootings versus other types of trauma, with rates as high as 90 percent reported” by some researchers.



Because being abused as a child is good for your mental health. Young Adults Who Recall Being Maltreated May Have A Particularly Elevated Risk For Psychopathology, Researchers Say.   A study to be published in the January issue of the Journal of Psychiatric Research (10/24, Newbury, Arseneault, Moffitt, Caspi, Danese, Baldwin, Fisher) “explores the validity and utility of retrospective self-reports versus prospective informant-reports of childhood maltreatment.” Study data “were obtained from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative birth cohort of 2,232 children followed to 18 years of age (with 93% retention).” Researchers evaluated “childhood maltreatment” through “prospective informant-reports from caregivers, researchers, and clinicians when children were aged 5, 7, 10 and 12,” and via “retrospective self-reports of maltreatment experiences occurring up to age 12, obtained at age 18 using the Childhood Trauma Questionnaire.” The study revealed that “young adults who recall being maltreated have a particularly elevated risk for psychopathology.”

Sunday, September 24, 2017

Cognitve Behavioral Therapy "Evidence-Base" Grossly Exaggerated




In my post on my Psychology Today blog on November 21, 2011, I discussed how the purveyors of today’s most predominant psychotherapy methodology, cognitive behavioral therapy, grossly exaggerate the strength of their research evidence base in the psychotherapy outcome literature.

My opinion was recently confirmed in a review of meta-analyses of the CBT literature in the Journal of the American Medical Association, published online September 21, 2017 (“Cognitive Behavioral Therapy the Gold Standard for Psychotherapy:  The Need for Plurality in Treatment and Research” by Falk Leichsenring and Christiane Steinert).
 

They reported that a recent meta-analysis using criteria of the Cochrane risk of bias tool reported that only 17% (24 of 144) of randomized clinical trials of CBT for anxiety and depressive disorders were of high quality. The “allegiance factor”—study authors were CBT therapists themselves and often designed the studies to make their treatment look better than it was, and opposing treatments look worse that they were—was rarely controlled for.

Compared with "treatment as usual" —letting subjects get whatever other treatments outside of the study treatment that they chose to have, allowing good therapists and bad therapists, and good therapies and bad therapies, to essentially cancel each other out—the sizes of treatment effects were only small to moderate and might eventually even be found to be due to the allegiance effects.

In panic disorder, CBT was not more effective than treatment as usual but only to being on a waiting list.

Even with these amazing biases, for depressive disorders, response rates of about 50% were reported. This was true for anxiety disorders as well. “Response” just meant there was some significant improvement in symptoms, not that the symptoms of the disorders actually went away. Rates for actual remission from the disorders were even smaller. Conclusion: a considerable proportion of patients do not sufficiently benefit from CBT.

Last but certainly not least, there was no clear evidence that CBT was more effective than other psychotherapies, either for depressive disorders, anxiety disorders, personality disorders or specific eating disorders.

Personally, my biggest beef with CBT and other psychotherapy outcome studies has less to do with symptom relief than with actually changing maladaptive interpersonal behavior. The latter is almost never even looked at, let alone measured in these studies.

CBT’ers seem to think anxiety, depression, and self-destructive behavior are all due to screwed up thinking by individuals rather than being normal reactions to stress-inducing environments. In experimental psychology circles, this is known as the fundamental attribution error. Telling people with these particular symptoms that their problems are basically “all in their heads” in this manner is very invalidating for them.  Ironically, an ‘invalidating environment” is one of the two primary factors these very same therapists cite as the main causes for borderline personality disorder.

Tuesday, July 18, 2017

Book Review: "Behave" by Robert M. Sapolsky




For anyone who wants to understand all of the huge number of factors that influence human behavior, as well as counter overly pat, simple, or downright mythological explanations for it, I cannot recommend a book more highly than this one. Every page – and there are almost 700 of them - is just packed with enlightening information on the role of almost everything you can think of. 

These factors include genes, gene regulation, epigenetics, neurotransmitters, hormones, brain structures, neural networks, unconscious cuing and sensory triggers, stress responses and protective factors, neural plasticity, peers and social acceptance, attachment figures, brain development in childhood and adolescence, socioeconomic and hierarchical status, collectivist vs. individualistic cultures, gender, reactions to “them” vs. “us,” heritibility  vs. inheritance of traits, gene/environmental interactions,  population density, evolution (individual, kin, and group selection), reciprocal and pathological altruism, obedience vs. resistance, cooperation vs. competition, and empathy. And a whole lot more.

Can one book really be that encyclopedic?? Yes! I have no idea how he accomplished writing this. 

If you do not understand some of the scientific concepts that are under discussion, he conveniently includes three appendices in the book to help explain them. Not that the main body of the book is dry and overly technical. It is laced throughout with witty jokes, stories, and ironic observations that kept me thoroughly entertained.

Does he leave anything out? Well, yes, he does not seem to know about the effects of rapid cultural change on families which may create shared intrapsychic conflicts leading to parents giving mixed messages to their children which then trigger and reinforce their repetitive self destructive behavior. But I haven’t yet seen anyone else write about that besides me – at least not in the way I have conceptualized the process - so I wouldn’t expect that. He also doesn’t discuss the effects of chaos theory on the amazingly multi-factorial “causes” of behavior he goes into - a minor quibble.

Sapolsky shoots down behavioral and neuroscientific myths believed by health care professionals, some scientists, and the lay public alike (what mirror neurons actually do, for example) with the abandon of someone armed with an Uzi facing off against people armed with swords. Amazing.

Some of his important points: 

1.       Brains and cultures co-evolve.

2.       We haven’t evolved to be selfish or altruistic, but to behave in particular ways in particular settings. Context is everything.

3.       Genes are not about inevitabilities, but about potentials and vulnerabilities, and they do not determine any behavior on their own.

4.       Evolution has been most consequential when altering regulation of genes, not the genes themselves.

5.       Saying a biological system works well is not a value judgment – it can function equally well for those who do something wonderful or in those who do something horrific.

6.       Nothing seems to cause anything - everything just modulates something else within a specific environmental context. And changing one thing often changes ten other things as a byproduct.

7.       Any causative factor within any specified population of individuals within any specific environmental context has an average effect on behavior that may or may not apply to any given individual. There are always exceptions.

What an accomplishment.

Thursday, July 6, 2017

Themes of This Blog Seen In Newspaper Advice Columns: The Game without End, Gender Role Division




In Amy Dickinson’s advice columns of 5/29, 6/14 and 6/18/17, and in Carolyn Hax’s column of 6/23/17, the Agony aunts published letters which serve as a good, simple and straightforward illustrations of something that family therapists have called the game without end, described in several previous posts.

Whenever one member of a couple or a family makes a good case for changing the rules by which people in the family operate, other members of the family (or the other member of the couple) get suspicious. The person making the request has always followed the old rules. I mean, they say they want things to be different, but do they really?

So the person making the request gets “tested” to see how sincere their request really is. The others make the requested changes, but do so in an obnoxious or annoying manner. My favorite illustration of this is a situation widely created by rapidly evolving changes in gender role functioning, which the letters that are the subject of the current post clearly illustrate.

Both members of a couple work, but somehow everyone - including the females - has always expected the female to do all or most of the housework due to the rules followed by earlier generations of men and women.  The woman often has treated the kitchen, for example, as her own personal fiefdom in which she is the undisputed boss of how things are supposed to be done.

If she suddenly asks her husband or boyfriend to help clean up and do his share of the cooking, he wonders if she really wants that - because of her prior attitude and the accompanying behavior, which had been readily and repeatedly observable up to this point.

So, when it’s his turn to clean the kitchen, he does a half-baked job and puts the dishes and pots and pans in all new places, so that his partner cannot find them when it’s her turn to do, say the cooking. Or he does any of numerous other passive-aggressive things that annoy the heck out of her. So she criticizes him unmercifully for his poor performance.

In a sense, she starts criticizing him for doing the very thing she had asked him to do in the first place.

His conclusion: "See, she really didn’t want me to help out after all." I can never understand why he discounts his own behavior in drawing this conclusion, but that is highly typical.

An effective way to handle a game without end so that the rules really can change is described here.

So for those readers to are skeptical, here are some abbreviated letters from the advice columnists:

5/29/17. Dear Amy: I am really tired of my husband asking: “How can I help you?” “What can I do for you?” or “What do you need?”Here’s why this upsets me: If I am cooking dinner for the both of us and he asks, “What can I do for you?” I think, well, you are eating this dinner too, so why not just ask, “What can I do?” Why is he offering to do something “for me”? I get so frustrated that my response is: “…nothing.” When I suggest that he just pitch in, he tells me that I do these household things so much better than he does. 

He seems to want me to need him. I don’t need him. I just want him to initiate the household work on his own. He watches TV while I run around picking up the house or making dinner, and his only response is, “Am I in your way?”...When he finally does something like putting a load in the washer, he needs to announce it like it’s the second coming. What can I do? - — Frustrated!

A response from a man to the above letter: 6/14/17. Dear Amy: I am a man who has been in the same position as “Frustrated’s” husband, who would ask, “What can I do for you?” instead of just taking responsibility for his half of the household chores. I used to be like this. I just didn’t know how to be helpful and I didn’t want to get in the way. Honestly, my wife basically trained me how to take on more responsibility and now we work together. — Reformed (This guy is still letting her be the boss!)

Dear Reformed: I have received a huge response to this letter, and many men echo your statement — they needed some guidance and when they got it, they stepped up.

6/18/17. Above letter, continued. Dear Amy: I understand a lot of men are responding to the letter from “Frustrated!” about her husband’s lack of initiative regarding household chores. In my case, I jump in and do my best, but my efforts are criticized and belittled. It is hardly inspiring me to do more. — Also Frustrated

6/23/17.  Dear Carolyn: I love my partner. He recently moved in... I’m so tired of people who won’t clean up after themselves and leave it until I do it. I made it very clear to my partner before he moved in that it was important to me...But I’m already tired of asking and I’ve been reading about “the mental load.” Like last night: I was stressed and headed to my second job and he asked what he could do to make me feel better (sweet!) so I said, get wrapping paper and a card and wrap your sister’s wedding present. And when I got home later, he had! But. The box was left out instead of recycled, the couple of dishes I used to feed us before I went to work weren’t done, the living room was a mess ... he just doesn’t see it…— I’m Already Tired




Saturday, June 10, 2017

Themes of This Blog Seen In Newspaper Advice Columns: The Principal of Opposite Behaviors





In Amy Dickinson’s advice column of 4/5/17, she published a letter which serves as a good, simple and straightforward illustration of something I call the principle of opposite behaviors, described in several previous posts, as well as illustrating how seemingly opposite behaviors are actually just two sides of the same ambivalent coin.

The principle states that completely opposite behavior patterns can lead to the exact same result. If you’re afraid of being dependent on others, you can refuse to let anyone help you with anything. Or you can ask for way too much, annoying and eventually driving off people who might want to help you. In either case, you will end up with no help!

This principle comes into play when someone is ambivalent about certain rules of behavior in specific social situations. If this ambivalence is pervasive and frequently seen as a problem, said people who exhibited it were once called neurotics. The psychoanalysts who were the first to describe intrapsychic conflicts as a phenomenon missed the fact that these conflicts were usually shared by all the members of their patients’ entire family. 

In some cases, the conflict is expressed by compulsive or polarized behavior at one end of the spectrum - or at the exact opposite end. Some highly ambivalent people go back and forth between the two extremes, while in other cases, one generation goes to one extreme, the next to the other, and the third back to the first one.

In the letter, the father in the family was ambivalent how involved he should be with his son, and his conflictual behavior became apparent at his son’s little league games. His behavior was polarized and seemingly the exact opposite of that of his fatherAmy’s answer points out that trying not to be like your own parents in some way that you didn’t like can lead to a situation in which you try to do the exact opposite – and get the exact same result. Here, in abbreviated form, is the letter and the relevant response.

Dear Amy:  ...when we go to our son’s Little League games…my husband is the loud one on the sidelines — pacing, swearing and turning red; he micromanages our son, and shouts belittling comments at him and other kids on our team. He argues with the umpires, and complains about the coaches… he has been ejected from games during those seasons. I’ve tried asking him to be calmer...He says that he’s a lot better than his own dad, who never showed up for anything…


Dear Exhausted: Your husband claims that he is “better” than his own father was, but how is getting ejected from a game better than not showing up for the game? Either way, Dad is not at the game!

Sunday, May 21, 2017

Climate Change and Severe Mental Illness Deniers Use a Common Strategy




One topic I discuss on this blog is the tactics used by various advocacy groups to make misleading arguments in their efforts to advance their interests.

There is, of course, a large anti-psychiatry contingent that argues that severe and chronic mental illnesses like schizophrenia and (real) bipolar disorder are not real brain diseases.  They also argue that, since their brains are normal, the abilities of affected individuals to think rationally enough to properly take care of themselves are not highly impaired, so that involuntary commitment and treatment are never indicated under any circumstances. Of course, they seem to make a big exception for people who suffer from the brain disease of Alzheimer’s disease, but that’s another issue.

It recently occurred to me that the argument I have been hearing from those who deny that climate change exists, or that people are contributing to it, is very similar to one that is used by the mental illness deniers. They knowingly set a bar for “proving” the nature of these phenomena that is totally unachievable by science, and then use this ridiculously high bar to assert that, since the science is not "proven," then it is invalid.

In complex phenomena like weather or brain structure and function, the number of involved factors contributing to the final result is enormous, and their interactions unpredictable to a significant degree. Schizophrenia, for instance, is clearly not a disease of the gross pathology of the brain, which is what the deniers insist is necessary for “proof,” but is probably a disease of the interconnections between literally billions of nerve cell synapses that connect one neuron to others. We have no way currently to map out these connections in precise detail, and they change constantly over very short periods of time, so we cannot prove that they are pathological. There is, however, an astronomical amount of indirect evidence that they are.

Similarly, climate change deniers use the fact that the various computer models which predict how the process will unfold differ from one another in their predictions about the exact timing and locations of various expected weather events as evidence that the science is completely flawed. What they completely omit to mention, of course, is that no one is arguing that we have or probably ever will have the ability to predict weather patterns with that degree of precision. They also conveniently forget to mention that all the models point in the same direction, and that the patterns are already happening in ways that are consistent with the more general predictions.

Well, there are a lot of things that science cannot predict with absolute certainty, so we have to go with the preponderance of the evidence. In cases in which the consequences of inaction are enormous, we still have to act without this ridiculously high level of “proof.”

I would argue that allowing the mentally ill to languish in jails or in cardboard boxes on the streets of cities like San Francisco is such an instance. So is climate change that can lead to mass population dislocations with resultant wars, severe pollution, starvation, and the spread of tropical diseases that might kill us all.

I do not know if there is a name for this logical fallacy so glibly employed by science deniers. But there should be!

Friday, April 28, 2017

Measuring the Nature of Parenting Practices in Studies




A "scientific" journal article entitled, “Which dimension of parenting predicts the change of callous unemotional traits in children with disruptive behavior disorder?” By Muratori and others in the August 2016 issue of Comprehensive Psychiatry attempted to determine whether parenting practices influenced the development of so called callous and unemotional (CU) character traits in children. Alternatively, are those traits – which are common in children with disruptive behavior –more genetic in origin? 

In the study, no significant relationship was found between "negative" parenting and CU traits; these two variables were also unrelated when "positive" parenting was considered in the same model. However, using a slightly different model, higher levels of positive parenting predicted lower levels of CU traits.

Although I would like to believe and tend to agree that “positivity” in parent-child relationships helps decrease acting out behavior in children, a huge problem with this type of study is how the hell can you precisely measure the nature of the relationship between parents and children? The biggest problems with that include the fact that these relationships are not constants but vary across time and situational contexts. Parents might be good disciplinarians when it comes to providing children with adequate curfews, for example, but terrible at allowing them to stay up all hours of the night. Furthermore, the disciplinary practices certainly change over time as the children get older.

Second, how does a study even attempt to measure the tone of parenting practices? This study used a measure called The Alabama Parenting Questionnaire (APQ) [40] mother report. This parent report measure has five subscales: parental involvement, positive parenting, poor monitoring/supervision, inconsistent discipline, and corporal punishment. Items are rated on a 5-point Likert scale, ranging from 1 (never) to 5 (always).

They used the mother’s own report of her own disciplinary practices! If a mother were abusive or inconsistent, how likely do these authors think she would admit to it, even if she were very self-aware, which obviously many people are not. There is no way to be sure, of course, but the odds are very good that the amount of “negative” parenting is  higher than their study results would indicate, while the amount of “positive” parenting could be overestimated. 

And which particular types of those parental behaviors listed in the instrument were the most relevant to the question at hand? There is no way to know!

When it comes to assessing the effects of family interactions, details make a huge difference. And as I have maintained over and over again, in order to get these details, you would need a camera on both the parents and the children 24 hours a day over a significant time period. This type of study using absolutely no direct observation of what is purportedly being measured is a complete waste of time.

Wednesday, April 5, 2017

My Second Book Finally Available at a Reasonable Price




My second book, "Deciphering Motivation in Psychotherapy" was reissued a while back after going out of print, but was priced in the stratosphere. It's now available on Amazon for a more reasonable price at https://www.amazon.com/Deciphering-Motivation-Psychotherapy-Critical-Psychiatry/dp/0306437902/ref=mt_hardcover?_encoding=UTF8&me=

The book covers the often covert nature of interpersonal communications within dysfunctional families, and helps both therapists and lay readers learn how to dig out hidden meanings in their verbal interactions. The hidden meanings, in turn, reveal the ulterior motives and underlying internal conflicts of the involved family members. 

The book also clarifies the concept of dialectics in a way that I think is way more accurate that the way the concept is used in Dialectical Behavior Therapy (DBT).

Wednesday, March 29, 2017

Those Big Bad Benzodiazepines





Rare events in the midst of really large numbers of people are still quite common

I often get into debates with Pharma-brainwashed doctors and addiction specialists about the relative dangers and abuse potential of benzodiazepines like Klonopin, Valium, and Ativan. Even the DEA recognizes that they have low abuse potential by classifying them as Schedule IV, which literally means "low abuse potential." Adderall and opiates, in contrast, are Schedule II, which means high abuse potential.
Well, low abuse potential still means that some people will abuse them, but with any drug, risks must be weighed against benefits.
As to the risks, unless you are mixing them with other central nervous system depressants like opiates or alcohol,  the worst thing about being addicted to a benzo is that you are addicted to a benzo. For the vast majority of people, they don't cause any inebriation, and they have almost no side effects. For the few who do get troublesome side effects, the doctor can in those cases discontinue prescribing them. Just like with any other drug!
Benzodiazepines are worth their weight in gold in the treatment of panic disorder with agorophobia. Antidepressants can also help, but often not as much. And they have many more side effects, including destroying a patient's sex life.
At the VA, where benzo's are discouraged, I literally saw veterans who were housebound since Vietnam because of comorbid PTSD and panic disorder (the two conditions are co-morbid in 50-70% of veterans with PTSD according to the only two studies). If antidepressants did not stop their panic attacks, doctors would not prescribe benzo's! If you had choose between having no life and being addicted to a benzo, which would YOU choose? I know what I would do.
For patients with borderline personality disorder who self mutilate - the "cutters" and "burners" for example - benzodiazepines can be combined with SSRI (or MAOI) antidepressants. This combination often results in either complete elimination of or a significant decrease in the frequency of this behavior. Much better and far more quickly than dialectical behavior therapy does, by the way.
There are no clinical trials that support that last statement because the pharmaceutical companies will not do them. Benzo's and antidepressants are generic and cheap, and they'd rather that docs prescribe drugs like antipsychotics that have far more risks. But I've been treating this population for forty years in two states, and in a variety of different clinical settings (private practice, academia, public mental health centers and inpatient units, and the VA), with tremendous results. And other doctors who do this get the same results that I do. So tell me it's anecdotal. So is the belief that parachutes reduce the number of deaths and injuries after falls from airplanes.
A common retort to my position has to do with emergency room admissions caused by misuse of benzodiazepines, as well as the fact that methadone and suboxone clinic patient love to mix those drugs with benzos. On the latter point the solution is simple: be careful prescribing the drugs in that population. And the former?
According to JAMA Psychiatry, there are an estimated 271,000 visits to emergency rooms annually for non-medical uses of benzodiazepines (and how many of these involve simultaneous use of other substances of abuse such as alcohol or opiates is not quantified, but it is probably very highly significant).

That sounds like (and is) quite a few - until you also learn that about 5% of adults between 18 and 80 are taking the medications, which is roughly 12.25 million people. So only about two percent of users end up with severe medical issues per year. Not zero, but a relatively small percentage, and btw, there were also an average of about 78,000 annual ER trips for problems during the same period related to...Tylenol. Maybe we should we ban it.