Monday, April 15, 2019

How Good Psychiatrists Evaluate New Patients

If you think you might need psychiatric medications, here's the minimum of what the doctors should cover in a GOOD evaluation. If they do not, FIND ANOTHER PSYCHIATRIST:

1. They should spend at least 45 minutes to an hour in the initial interview.

2. When asking about your symptoms, they should pin you down as to exactly when and in which psychosocial circumstances you experience them. To be relevant to any diagnosis, all symptoms should be present at the same time and significantly affect you over more than just short periods.

Major mood disorders such as true major depression and mania are grossly over-diagnosed nowadays. The symptoms of these disorders are pervasive: you have to have them nearly all day nearly every day no matter what else is going on in your environment. Major depressive episodes need to last for at least two weeks straight, while mania requires a whole week. While these “duration” criteria are arbitrary, they are in the diagnostic criteria to distinguish major mood disorders from emotional reactions to purely environmental changes or relationship problems.

During a major mood disorder episode, your reactions to everyday stress should also be completely different from your usual, baseline reactions (how you react to your environment when you are not in a mood episode). They should also be out of character for you - Jeckyl and Hyde territory.

Mood and anxiety disorder diagnoses can NOT be made definitively if you are actively using psychoactive substances. Intoxication with drugs like cocaine can, for instance, mimic mania.

Stressors can trigger a new mood episode, but once episodes happen, they take on a life of their own.

3. The doctor should do a psychiatric "review of systems" to ask questions to rule out (at the minimum) a history of mania, substance abuse, panic attacks, OCD, and self-injurious behavior. 

They should ask you about whether there is a family history (among blood relatives, not adoptive relatives) of psychiatric problems or substance abuse. They should also ask you for your medical history and medications you take to try to rule out medical reasons for your symptoms.

In particular, panic attack symptoms are often ignored or falsely classified as symptoms of a mood disorder.

4. They should take a COMPLETE psychosocial history covering your family constellation, parental behavior, any parental divorces and subsequent marriages, any history of abuse or neglect, how far you went in school, and a complete history of your employment and relationships.
This part of the history has almost disappeared from psychiatry, blurring the distinction between psychological reactions and major mental illnesses.

A history of adverse childhood experiences such as abuse, neglect, violence, substance abuse or infidelity by parents can put you at risk for personality problems, low moods, anxiety problems or many other psychological symptoms. Again, a traumatic environment can trigger chronic problems that medication can help, but psychotherapy is the more important treatment. Even if your psychiatrist only prescribes medication, he or she should still refer you to a therapist in these instances. A good psychiatrist will focus on ALL the relevant variables amenable to different treatments and not focus myopically on just your symptoms.

5. If you are having trouble focusing or concentrating, this alone does not mean you have “ADHD.” You can have this symptom due to stress, sleep deprivation, boredom, preoccupation with something, or a wide variety of other reasons. A good doctor will ask questions to rule out these causes rather than just throw dangerous stimulants like Adderall (a methamphetamine clone) at you. 

6. If medications are prescribed, they should tell you what the most common side effects are, and if there are any dangerous ones even if they are rare, and also tell you that if you think you are having an adverse effect, that you should call the doctor's office.

Wednesday, March 27, 2019

Guest Post: Borderline Family Dynamics Up Close

Today's guest post is by Lin. The writer recounts her own experience growing up in a family with issues that lead to Borderline Personality Disorder 

I was born into a highly dysfunctional family, consisting of my parents, my very domineering and generally narcissistic grandmother, and my alcoholic uncle. My parents both had physical and mental health issues and, in hindsight, I can clearly see that my mother had untreated Borderline Personality Disorder.

After my mother had 7 miscarriages and one stillbirth, they had been told that they couldn't have children. Therefore, they had planned their future without children. When I came along it was a shock; they both overjoyed to have me and also shaken that they suddenly had a new responsibility that they never thought they would have. Because I was an at risk pregnancy, I was born 8 weeks early by cesarean and, due to my mother's unstable mental health, she was unable to see me for 6 weeks. Instead I was kept in hospital while they stabilized me and I only had contact with the staff and, on his occasional visits, with my father.

From the outset I was the perfect baby. I seldom cried or asked for attention and was usually compliant. I talked and walked at an early age and was reading by the time I was 3. My earliest memory is of being that age and in my pushchair. I had a pacifier in my mouth and saw my mother walking towards my father and myself.

I remember the fear and shame of her possibly seeing me using it and I quickly hid it under a blanket. I already had learned not to upset her and felt that I was bad. I learned to hide what I did and felt.

My mother sexually abused me from the earliest age I can remember until I was 16 years old. I am sure my father was aware of it because he had a separate bed in the same room that my mother and I shared. She made me pray to God afterwards and ask for forgiveness for making her do it. She told me if I told anyone she would leave me. The abuse was the only form of physical touch I had—she never hugged me or told me she loved me or was affectionate in any way. Instead, she would buy me anything I wanted. Toys every Sunday, sugary foods in a large quantity every Thursday. I just had to ask and I would get it. All the while the abuse continued every night. I learned sexual abuse meant my mother would stay with me and I learned to equate material possessions and food with love.

I was told we were family and didn't need strangers. Strangers were the enemy. This meant I was not allowed to have friends. I was never allowed out without a parent; I was dropped off at school and picked up every lunchtime and at the end of the day in order to minimize my interaction with others. My father did have a sister but my mother forbade him from seeing her. During the times my mother was in hospital, he would take me to visit her always, saying "Don't tell anyone."

My father would often do bizarre things, such as once telling me we were going to play a game with my mother and pretend that he had been mugged on the way home from work. I thought this was a great game and having secrets with my father made me feel close to him. I learned to lie for attention.

My mother would either be very weak or overbearingly strong—sometimes both at the same time. She ruled me with a rod of iron—I always had to be perfect or I would be told I was nothing to her and then physically beaten. At the same time she appeared incredibly weak. I remember a 4 year old child once swore at her and she cried like a baby. I despised her weakness and sensed she did too, so I learned to make her angry instead at these times so we would both feel better. I learned how to manipulate her as she had manipulated me.

My mother would have frequent psychotic episodes [She was diagnosed with episodes of psychotic depression]. Either me or my father would force anti-psychotics into her mouth. She would hear voices stating we were trying to kill her and fight back. The first time I witnessed that was late at night when I was 6 years old. I ran to the corner of the bedroom in terror while my father held her down as she lashed out at him. Once she was calm my father told me I could join her in bed again. I shook my head, terrified to go near her. My father turned out the lights and went to bed himself, leaving me sitting in the corner of our bedroom all night, alone. I learned that I could be abandoned without comfort from those closest to me at any time.

By the time I was 12 I had learned to give back what they gave to me. They had taught me well. I became better at constant manipulation and control than they were. My father developed congestive heart failure and became physically weak. I would fight with him constantly to make him fight back and be strong again. My mother's mental health was worsening and she blamed my father’s lack of care now that he was ill. I learned to agree with her about how bad he was and thus make her feel stronger.

My father eventually took his own life on my 13th birthday, leaving me alone with my mother. My mother became totally dependent on me. The same spoiling behaviors I had learned would continue for the next 5 years. I would attempt to strengthen her when she was weak and weaken her when she was strong. I did not understand why I was doing this, behaving in a purely instinctual way in order to provide what we both needed. Even though we fought constantly, I was still being sexually abused by her and given whatever material things I wanted. During psychotic episodes, my mother would sob and state that her baby had been replaced at birth by a changeling of the Devil. As a Devil's spawn, I was going to murder her just as I had murdered my father. I believed I was evil and hated myself.

By the time I was 18, I had been in psychotherapy for several years. It had been arranged for me after I had told other children at school that my father had died a year before he actually had. I hated him for not stopping my mother and wanted him dead—the worst punishment I could think of. I became more aware of my motivations and becoming aware that I had a choice as to how I reacted. I moved away from home, only visiting my mother sporadically. She never ever forgave me for choosing strangers over her. Our relationship continued to be very difficult, with me despising her weakness and trying to make her strong, and her despising my new found strength and trying to make me weak. I cut her off entirely when I was 20 and she took her own life a month later. I still struggle with the guilt and self-blame for both my parents suicides.

This is all that I learned and why I have Borderline Personality Disorder.

Wednesday, February 20, 2019

Book Review: The Misinformation Age by Cailin O’Conner and James Owen Weatherall

This interesting and highly recommended book about the spread and persistence of false beliefs covers a subject that is both near and dear to my heart and something I write about extensively. Most of the book does not go into the types of false beliefs with political overtones that seem to infest our Facebook feeds, although the authors allude to it, but focuses instead on how false beliefs about science come about and then spread among scientists and the general public alike. 

Of particular interest to me is Chapter 3, The Evangelization of People, which focuses on the way large commercial interests have studied the behavior of scientists and have learned how to manipulate them effectively for profit.

In recent years I have developed a strong interest in “Groupthink” – the type of thinking in which people ignore the evidence of their own eyes, ears, and logic in order to argue for something that either justifies group norms or leads to an enhancement of a group’s political, ideological, or financial interests or the interests of group leaders. 

My curiosity originally stems from my observations that self-destructive people cannot possibly be hurting themselves out of “selfish” motives if they are not mad, bad, or stupid. Instead, they are finding ways to sacrifice themselves for the seeming good of their families.

The latter idea is not accepted by the vast majority of practitioners and academics in the mental health and biological evolution fields, where a wide variety of only partly-logical theories have often taken root. My frustration in promoting my own idea led to my becoming interested in the phenomenon of groupthink in science, which turned out to be a far greater problem than I had originally thought. In fact, I am currently co-editing a multi-authored book about groupthink in science, in which practitioners from widely diverse academic disciplines focus on quite a few different manifestations of it.

While groupthink in families and in professional groups share a lot in common, there is one fundamental difference. Scientists, while they may belong to some sort of profession fraternity, are usually not related biologically. Nor are the scientists usually all members of the same ethnic group or even the same nation. It is the biological connection which makes the family system so powerful over its members that they are willing to sacrifice themselves. Scientists are not under that sort of pressure.

The book basically starts with a discussion of how ideas generally spread among those scientists who are trying to find truths but who are most often complete strangers to one another. Most scientists communicate directly with just a few colleagues and find out what the others are thinking by reading their articles in professional journals. They only occasionally actually hear these others in person, usually at professional conventions. 

Although scientists can often be more easily swayed by colleagues they know personally than by those they do not, a scientist’s overall reputation in a particular field plays a big part. The behavior of people in “communication networks” like these is examined, and it is this understanding that is being used by commercial interests, sometimes for clearly nefarious purposes.

What’s amazing is that, although companies can hire fraudulent scientists to consciously do studies that skew the data in industry’s favor, they do not have to mess with the science that way at all. In fact, they can skew the data without any direct input into any scientist’s work. One of the big ways is through selective reporting of real data – they push the science that works in their favor with politicians and the public while not mentioning the contradictory studies, even when the contradictory studies vastly outnumber the ones in their favor.

An ingenious way to accomplish this is through grant funding. Science is such that there will in most cases be a variety of studies with different conclusions. Industry can pick those scientists whose work is in their favor and provide them with grants and other funding. Independent grant funding, as from governments, is relatively more rare and hard to come by. Science can be very expensive to do. Therefore, industry-funded studies become more likely to be completed and then published than those funded elsewhere, making them appear more generalized than they actually are. 

Then there is a snowball effect where success breeds success. The more studies they publish, the more likely the scientists will be to attract students who then follow in their biased footsteps.

Scientists who later learn they have been duped may be too embarrassed to publicly admit it.

An interesting side issue the authors bring up concerns what does and does not get published. Different fields have different thresholds for how much data a given study must contain in order to meet their prevailing standard for publication. It is disconcerting but hardly surprising that the authors single out neuroscience and psychology for having much lower standards than other fields. Readers who follow my blog will have many examples of this from which to choose.

Tuesday, January 29, 2019

Guest Post: My Experiences with Family Dysfunction and Therapists - Anonymous

Editor’s note: This guest post came in response to my request for stories from those on my Facebook  fan page who had a bad experience with therapists who seemed to think that all of their problems were in their heads (for example, poor distress tolerance, irrational thoughts, or anger issues) and had little to do with other people who were stressing them out or pissing them off.

When I was 6 or 7, a neighbor (age 17 or 18), took me into his house "to play a game." He blindfolded me, made me kneel, and took his penis out for me to suck. The blindfold wasn't properly attached so I was able to figure out what he was doing. Afterwards - and after the mandatory "don't tell anyone" - I told my grandma, who then informed my parents.

Now, my mom certainly has her own issues. She hates being touched, always tends to think only about herself, is obsessed with TV shows, tends to be depressed and spends most of her free time in her room, and has a very high fear of going to the doctor - even though she is one! My Dad was certainly narcissistic (as you'll see it in a minute), so they both decided it was best to sweep it under the rug.

Years later, when I was 12, I had my dad's brother pull me close while dancing in order to rub his large stomach against my budding breasts.  Thinking back, I later realized that my Dad never ever let me stay with my cousins. My mom then confirmed that his brother is a pedophile. His poor, poor stepdaughter from my aunt's previous relationship! My dad must've known this, yet when I was raped, his answer become my rapist's godfather!!!

My dad - and mom - made me go to my rapist's Confirmation (a Catholic ritual for teens) a year after my rape. We remained neighbors, and my Dad had weekly breakfasts with that family. No, I am not kidding. When I was 8 or 9, my mom bought a house two doors down from my grandparents...but only she and my dad moved out. I was told to stay with my grandparents "because I would be more comfortable there, and we need money to build a second floor." They never did.

My Dad was never steadily employed. I caught him kissing the maid when I was almost 13. So my mom, who at that time was working in a different region, came back home and told him to get out. He then blamed me for the "breakup of our family." I was also sexually harassed several times as a teen, but I never told my mom or grandma because my grandma told me I was "dirty" because I was still talking and playing with that neighbor. Why would I stop? NO ONE bothered to explain that what had happened to me was sexual abuse.

My uncle on my mom’s side slapped me when I was 13 for defending his teen housekeeper, and my aunt and mom (after I had come back home) wept but said nothing. Again, no one talked to me about what had happened. My dad got cancer when I was 17 and I asked him to come home. His siblings were robbing him and not taking care of him. He initially rejected our offer. Only when he knew for certain that his siblings were taking important property deeds (he owned a house in the mountains. I am Peruvian), did he finally agreed to come back to be looked after by us. He was bitter and scared, but was still a bad parent. I had barely seen him during the 5 years that he was not living with me - his choice, of course. I again saw him flirting with the maid during his remission. He died when I was 22.

Although I've barely ever been beaten, and no one in the family did drugs or alcohol, I nonetheless had a highly traumatic childhood. I'm a Psychology student. I am a 4-time college dropout from 3 universities. I am married now and living in Europe. I have been subjected to verbal abuse at home, but he's getting treatment. I’ve been diagnosed with ADHD, but I’m wondering if it's the right diagnosis. I do acknowledge that a trial of Concerta did show me I can do more, although I stopped after 14 days because the side effects on my mood were too much for me.

With all of this, I have also been subjected to racism and homophobia in society. I'm not a lesbian, but I "look like one,” apparently because of my very short hair and baggy pants. Once,  when I had messy hair and not-fancy clothes, I had to leave a store because of a screaming security guard who was asking me what the hell was I doing at that store (I lived in a "well-to-do" neighborhood). Where I am, racism is expressed with frowning faces and rude attitudes from clerks. But when they see me with my White husband, I am "graciously welcomed" anywhere. I guess those two (racism and sexism) can never be escaped, but I am DAMNED sure happy I am far away from my family's dysfunction now.

At 22 I started psychoanalysis, and my therapist wanted me to focus on forgiving my parents.

Later, I did CBT, and that psychologist wanted me to focus on my goals, when all I could think of was how damaging the sexual abuse had been, and how troubled I felt about being neighbors with the rapist.

I don't know what kind of treatment I received from a third therapist I took on, but he said I should focus on why I went into the neighbor's house in the first place. That was said to mean that I was starving for male attention, and I was told I should work on that.

There was that psychiatrist too, when I was 26, who I told about my anxiety and possible ADHD, He said I should just take it easy, that no one is supposed to demand too much of themselves and that is okay not to accomplish everything I want. He added that it's all about "finding contentment." I felt that that one was sexist AND racist.

My parents and I went to ONE session of family therapy when I was 16, but as soon as the therapist pointed out to my parents their troublesome, inattentive behavior towards me, we stopped going.

So from my experience, what I learned is that even people with the best intentions (or at least who are supposed to have them) will try to redirect you to what they think it's best for you, instead of actually listening to you. Validate your own feelings, and after that, inform yourself  both about what psychology says about your own experiences AND about how to pick a good therapist. Work from there. Too many uninformed people will spout their opinions, whether they are family or professionals.

Wednesday, January 2, 2019

Book Review: The Kevin Show by Mary Pilon

In this impressively well written book – I may have to steal a few of her cool phrases, like when she discusses situations in which people walking on eggshells start to feel more like they are walking on landmines – Mary Pilon tells the story of Kevin Hall and his family. Kevin Hall was a championship sailor who on one occasion made the Olympic Team, although he did not win a medal. At the same time, he struggled with Bipolar Disorder. The real illness, not what passes for bipolar disorder these days.

The author’s discussions of what went on inside of Hall’s head during a manic episode are some of the best I’ve ever seen. After reading them, readers will know that this has absolutely nothing in common with normal human thinking. After coming down off of a manic high, a sufferer knows that. Although they may question themselves about the “reality” of what they had experienced during an episode, it still seems to them to be bizarre and alien.

The book also does a great job of describing the traumatic effects on parents, spouses, and siblings in having to deal with a family member with a major mental illness – especially one who is not always cooperative with treatment but doesn’t let them know when he goes off his meds.

Hall’s delusion when manic was that he was some part of a larger “Show,” run by some all-knowing “Director”  - sort of like the movie “Truman Show,’ which indeed is mentioned several times in the book -  in which he is meant to save the world by interpreting various “signs” in the environment. The signs could be things he happened to see in the environment, unusual coincidences like his having been a college classmate of one of the doctors who treated him, song lyrics, or passages in various books he liked to read.

Unfortunately the author, who seems only to have a limited  familiarity with mental illness and, in particular, the treatment of manic-depressive illness, falls a bit into the trap of starting to wonder if it may just be some variation of normal. After all, with the rise of Instagram, selfies, and social media, everyone is seemingly thinking of themselves as in some sort of show and as having an almost national presence in the minds of others.

Mary Pilon

Not only that, but the author adds that certain delusions are more common in certain cultures than others, and some only seem to exist in a single culture.

In fact, the difference between psychotic delusions and false beliefs that are due to groupthink, everyday human foibles, wishful thinking, and just plain kidding oneself is colossal and not in the least bit subtle. Of note is that the author spends almost no time describing Hall’s thinking during periods of bipolar depression. She only mentions one episode in which he maintained that he was depressed but not delusional - but we do not know if he ever experienced a psychotic depression.

Either way, when depressed, it is mentioned almost in passing, he believed the exact opposite of what he felt while manic – that he was a born loser, loony-bin screw-up who was worth absolutely nothing despite his fairly spectacular accomplishments in love and work while euthymic (neither manic or depressed – in other words, normal).

Hall kept going off his medication because he felt that it was drugging the real him, which is why he kept having recurrences. While I obviously can’t say for certain anything about his reasons for stopping his treatment, the frequent reason bipolar patients discontinue their meds is that mania feels so good in so many ways that normal feels like down to many sufferers, and they want the high back.

Another possibility is that he was taken off lithium -  which generally does not make people taking it feel drugged – not because it was ineffective but because the doctors thought it was ineffective when in actuality he had stopped taking it or his blood level was too low. Good doctors monitor lithium blood levels.

He was apparently put on the antipsychotic Haldol at one point, which definitely does make people feel drugged. Antipsychotics, while they do prevent mania, should only be give in acute mania (because it takes time for lithium or depakote to kick in) – and then discontinued after the other drugs start working. Or used indefinitely only if all other options fail or are not tolerated. The author does not really tell us any details about Hall's treatment.

And what about the cultural aspects of delusions? Well of course delusions concern things that people with the disorder are familiar with. You can’t think the CIA is following you around with ray guns if you have never heard of the CIA or ray guns. And just like with Alzheimer’s disease, in which underlying personality traits affect the expression of impaired memory issues and cognitive confusion, they affect the content of delusions as well. 

Pointing out the cultural differences as a possible reason that bipolar is not a real brain disease is a bit like doing the same by pointing out that the delusions of Japanese people are expressed and thought about in the Japanese language, while the delusions of Spanish people are expressed and thought about in Spanish.