Thursday, June 20, 2019

Book Review: Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry by Lynn Nanos

This impressive book goes into detail concerning the horrifying deterioration in the psychiatric care of the Severely and Persistently Mentally Ill (SPMI’s - primarily people with schizophrenia) in the United States that I have personally witnessed since I was a resident in psychiatry in the late 1970’s in California.

By the time I had started my residency, the passage in California of the Lanterman Petris Short (LPS) Act in 1972 - followed by the passage of similar laws in many other states - had for the most part cleared up a lot of the abuses in the state hospital system that anti-psychiatry groups still go on and on about as if they were still common. It insured that the cases of patients who had been hospitalized involuntarily would be reviewed by the courts within 17 days or sooner. Psychiatrists in the system could no longer just let patients languish in the hospital forever by merely following what a previous doctor had said without doing their own personal evaluation, or avoid closely following the patients’ condition to see if there were any changes.

No longer would patients linger in hospitals for years because of a misdiagnosis. For example, patients with the very treatable bipolar disorder (in which psychotic episodes are often relatively short-lived) had often been diagnosed with the far less treatable schizophrenia (especially if they were African American) Occasionally someone had been hospitalized for decades because unscrupulous relatives conspired to steal their money by labeling them with a mental illness with the help of a gullible or greedy psychiatrist.

After the laws mandating court review were in place,  people who were hospitalized back then often agreed to stay much longer than 17 days -  because their paranoid delusions and hallucinations had been somewhat controlled with anti-psychotic meds. Up until then they had anosognosia - the lack of awareness that anything might be wrong with them. After they became less delusional, they began to understand that they needed treatment.

Psych meds often take two to three weeks just to kick in, or need to be changed to something else after that period of time because one agent was ineffective while another might not be - which in a sense would restart the whole clock - so often they had to remain hospitalized for several weeks. 

This time frame also allowed psychiatrists in training to see first hand the course of major psychiatric illnesses and monitor longer term responses to it. It also allowed doctors time to make a better determination about whether the patient’s primary issue was drug abuse rather than some other chronic mental illness, and refer drug abusers to appropriate rehab treatment.

Committed psychotic patients at that time could be forced to take anti-psychotic meds even if they refused prior to their court review. That has since changed in most jurisdictions. I cannot for the life of me see the point of committing a patient involuntarily  if the doctors cannot then treat them.

Even though the state hospitals were beginning to discharge their long-term patients under the justification that the meds would allow for effective outpatient treatment, hospital stays were long enough to allow ward social workers to arrange for placement in board and care type living situations, get the patients enrolled in Social Security Disability (SSI) to pay for it, and make follow-up appointments in community mental health centers so that patients could continue to receive their medications. Community mental health centers were also far more numerous and available for this purpose than they are today.

The LPS criteria for hospitalizing someone against their will were very reasonable: mentally ill and a danger to self, a danger to others, or gravely disabled. The latter meant that due to their mental illness they were unable to provide for their own food, clothing, and shelter. A cardboard box on a street did not qualify as the ability to provide for their own shelter as it seems to today. 

A “danger to self” did not just mean suicidal, also as it seems to today; it could refer to dangers to self due to delusions and poor judgment, such as walking naked into someone’s house who might mistake them for a burglar and shoot them. Sometimes doctors considering a “603” 72-hour commitment holds had to pump relatives for information they could use to justify that. I recall one patient’s family finally tell me, after I asked many follow-up questions, that the patient had tried to get out of a moving car.

The author of Breakdown, Lynn Nanos, is a social worker who works for a psychiatric emergency services team, and has seen and documented the monstrous changes in the previously described public mental health treatment of chronically ill SPMI’s. She provides sad, disturbing, and hair-raising case studies of suicides and murders of both family members and strangers due to the premature discharge of dangerous, delusional patients who did not think they were ill and refused treatment.

Due to the mutual biases of the so-called patients’ rights advocates on the left of the political spectrum, and tax-phobic politicians and government agencies on the right of the political spectrum, hospital stays have been whittled down to just a few days, so that anosognostic patients are either not  referred for psychiatric follow-up at all, or do not show up even if they had been. Many are discharged with no prescription medication to take after they leave.

Nanos makes the case that the commonly-heard idea that chronic psychiatric patients are less likely to commit violence than others is highly misleading. It ignores the significant minority of mentally ill folks who do have violent propensities – and who are often more dangerous than others -  when their violent episodes could have been stopped if they had received proper medication. Not to mention that the violence-prone mentally ill are highly unlikely to participate in the epidemiological studies that are the basis of the misleading argument. Dead family members have lost all of their rights. Many suicides of those who are “dying with their rights on” could also likely have been prevented.

Many of these patients now end up in jail. The patients’ “rights” warriors never seem to inquire as to why this might be the case. Could it be that such patients don’t realize they are mentally ill and are responding to command hallucinations to assault others, or are committing nuisance crimes like disturbing the peace or trespassing because they do not know any better? Even when they kill someone, the not-guilty-by-reason-of-insanity defense seldom succeeds (particularly after John Hinckley tried to kill President Reagan, who himself did not appear to think mental illness was real when his administration attempted in the early 1980’s to kick all the chronic schizophrenics off SSI until the courts stepped in), and they of course are sent to jail rather than to a hospital.

According to the author, private hospitals often tend to favor hospitalizing malingerers who fake mental illness in order to have a place to stay and receive food, over the more highly disturbed and potentially violent SPMI’s who really need the beds. This, along with drastic decreases in the number of available beds, has led to a situation in which patients are stuck in hospital emergency rooms  - manned by staff that are ill-equipped to handle them - for days at a time until a bed is finally found or until they are in frustration discharged by the facility to the streets. There are also financial incentives to treat “easier” patients due to the fact that they have shorter hospital stays and hospitals are financially incentivized to keep stays short.

Government agencies often listen to “peer support groups” comprised of individuals who think the signs and symptoms of schizophrenia and other psychoses are just some variant of normal.

Nanos makes a good case for assisted outpatient programs (AOTs), which help patients stay with treatment despite not being forced to take their medication. Mental health professionals attempt to persuade the recipients to adhere to their prescribed medications and attend their clinical outpatient appointments with psychotherapists, psychiatrists, and case managers. All AOT involves intensive case management services and comprehensive supervision.

In court-ordered AOT, judges order seriously mentally ill patients to adhere to their outpatient regimens. AOT’s seem to be even more effective when judges are involved, probably due to what the author refers to as “black robe syndrome.”

Several studies indicate that AOT’s, particular those that last 180 days, significantly reduce violence, readmissions to hospitals, no-shows at outpatient appointments, arrests, jail time, self-harm, suicide attempts and substance abuse, while significantly improving the self care of SPMI patients. Nonetheless, even AOT’s are opposed by various special interests. In Massachusetts, its opponents even include the National Alliance for the Mentally Ill, which is supposed to be advocating for these patients.

Unfortunately, these patients are downright lousy at advocating for themselves, so it’s going to take a lot of other people speaking up before things go back to the far more functional way they were just a few decades ago.

Wednesday, June 5, 2019

Private Insurance Circumvents the Mental Health Parity Treatment Act

The Mental Health Parity and Addiction Equity Act of 2008 is a federal law that generally was supposed to prevent group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on such treatment than on other medical or surgical treatments. So far, it hasn’t come close to accomplishing its goal, although a recent court decision may possibly change that.

Supposedly, if a group health plan or health insurance coverage includes medical and surgical benefits and mental health benefits, the financial requirements (such as deductibles and co-payments) and treatment limitations (such as number of visits or days of coverage) that apply to the mental health must be no more restrictive than those that apply to the medical/surgical benefits.

However, insurers were easily able to "circumvent" the consumer protections intended in the legislation by imposing maximum numbers of doctor visits and/or caps on the number of days an insurer would cover for inpatient psychiatric hospitalizations. They played with the definition of “medical necessity” in psychiatry.

Insurance companies often make doctors and hospitals jump through hoops to even obtain a decision by the insurance company that their proposed treatment is “medically necessary.” For inpatient treatment, managed care companies adopted what amounts to a  code word: dangerousness. If a patient is not specifically and imminently homicidal or suicidal, the insurance company would mandate that  the patients be thrown out of the hospital and onto the street. Science and the best interest of the patients were really non-factors in this decision, which were basically based solely on greed and profiteering.

Suicide rates for patients soon after discharge from a psychiatric inpatient facility are much higher than suicide rates in the general population. This problem has gone up significantly in recent years due to patients having many fewer days in the hospital than they used to.

Yet another trick was companies deciding which psychiatric conditions were severe enough to warrant hospitalization, and which ones were not, irregardless of the severity of a patient’s symptoms and functional capacity. For example, doctors in a hospital near where I work appeared to have been pressured by the facility to make diagnoses that were more likely to be covered by insurance even if their patients did not meet criteria for those disorders. The result was that the patients were often put on medications that were ineffective, not indicated, and/or potentially toxic.

Within my own patient population of people with borderline personality disorder, “bipolar disorder” was the go-to option.

In the recent court decision mentioned above, on February 28, 2019 the US District Court for the Northern District of California found that United Behavioral Health (UBH), the country’s largest managed behavioral health care organization, illegally denied coverage for mental and substance use disorders based on flawed medical necessity criteria (David Wit, et. al. v. United Behavioral Health).

UBH was noted to have internally developed medical necessity guidelines that comprehensively fell short of accepted standards of care to deny outpatient, intensive outpatient, and residential treatment to UBH beneficiaries. They only paid for the alleviation of a patient’s acute symptoms, but not of any underlying condition – particularly chronic conditions.

The court said that the fact that a lower level of care is less restrictive or intensive does not justify selecting that level if it is also expected to be less effective. Placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions.

Effective treatment of mental disorders includes services needed to maintain functioning or prevent deterioration. Appropriate duration of such treatment should be based on the individual needs of the patient and not on some arbitrary guidelines regarding the duration of treatment for a given disorder.

Even though the plaintiffs in Wit v. UBH were enrolled in plans that are exempt from the federal parity law, the court recognized that mental disorders are chronic illnesses and rejected the insurers’ practice of treating only the acute symptoms. This may establish a precedent for plans covered by the parity law.

Will the recent court decision make any difference? I have my doubts. Insurance companies can be experts in not paying for the adequate care of their subscribers.

In an upcoming post, I will be reviewing a book about the even more disgusting horrors currently being inflicted on the severely and persistently mentally ill by the public mental health system.

Tuesday, May 7, 2019

Personality Disorders: Researchers Continue to Make Misleading Assumptions

In this blog I have discussed several instances of researchers making unwarranted assumptions about both their study populations and in interpreting their results in a variety of ways. In this post, I’d like to focus on three recent articles about personality disorder research. The first is a possible refutation of a common presumption, while the second two assume facts not in evidence.

The difference between “cannot” and “do not:” Confusion based on lack of attention to subject motivation, and ignorance of the concept of “false self.”

Shane MS; Groat LL. “Capacity for upregulation of emotional processing in psychopathy: all you have to do is ask.” Social Cognitive & Affective Neuroscience. 13(11):1163-1176, 2018 11 08.

Could it be that a psychopath’s apparent lack of ability to be empathic stem from differences in motivation rather than ability? This article is certainly possible evidence that this is the case. Perhaps people who routinely engage in anti-social acts suppress empathic responses because that is their role in their family. That what has been observed results from subjects’ false selves

This study of course does not address that latter issue, but thinking about it certainly suggests something which could explain the results. (Of course, it would help in that endeavor if we could read minds, because the thing about a false self is that it is based on someone lying to themselves in order to fulfill a social function, so they are highly unlikely to tell experimenters the truth during a short interview).

In any event, in this study, high-psychopathy participants showed typical, significantly reduced neural responses in the brain on an fMRI to negatively-toned pictures under passive viewing conditions. However, this effect seemed to disappear when the subjects were instructed to try to maximize their naturally occurring emotional reactions to these same pictures!

The locations of these increased neural responses included several brain regions involved in the generation of basic emotional responses and which have often been shown to be reduced in psychopathic populations. Thus, despite baseline differences from non-psychopaths,  high-psychopathy participants appeared capable of deliberately manifesting emotional responses to the negatively toned pictures within several brain regions believed to underlie emotional processing. 

Of note was that the magnitude of these deliberately evoked emotional responses was comparable to levels exhibited by low-psychopathy participants’ during passive processing.

A high index of suspicion versus an “inability” to correctly read the mental states of others

Quek et. al., “Mentalization in Adolescents with Borderline Personality Disorder.: a Comparison with Health Controls.” Journal of Personality Disorders, 33 (2):145-165, April 2018.

Mentalization refers to an individual’s capacity to understand and interpret the meaning of one’s own and others’ behavior by considering underlying thoughts, feelings, intentions, and desire. As in other studies, this was “measured” in adolescent subjects with borderline personality disorder (BPD) and normal controls while interpreting the mental states of others shown in pictures, videos, and narrative vignettes of people in various social situations.

The authors of this paper mention almost in passing that the ability to mentalize  is thought to develop within the context of, and is dependent on, the quality of infant- parent interactions. In the experiment, the differences between the performance of the BPD subjects compared to the control group on the various tests became much greater when the material they interpreted suggested attachment-related stress or arousal. 

Additionally, the major differences between BPD subjects and controls seemed to primarily involve what the authors describe as hypermentalization (that is, making much more complex inferences than expected about social cues, signs, and mental states) by the BPD subjects, rather than through a loss of detail.

Despite all this, the authors don’t seem to consider the obvious possibility that attachment figures’ influence on their children’s ideas about the social behaviors of others continues unabated long after they are no longer infants.

So let’s do a mental experiment. How might you evaluate the motives of other people if you were to grow up in an family environment characterized by your being constantly invalidated and given highly confusing double messages about how you are supposed to think and behave, and even being verbally abused— if not physically or sexually abused—if you seem to have guessed wrong about that? Do you think you might have a higher index of suspicion about other people’s intentions than someone who did not grow up in that environment? Do you think you might have more difficulty making sense of other people's behavior? Ya think??

So, do kids with BPD grow up in that environment? Well, in addition to Linehan’s theory of an invalidating environment being part of the etiology of BPD, and my own paper from 2005 (Comprehensive Psychiatry, 46[5] pp. 340-352) which showed that adults with BPD reported about three times the number of double messages from their parents than non-BPD controls, consider the following paper.

Changing parent’s behavior towards BPD children can make those with BPD better—but their behavior apparently had nothing to do with their kids having developed the disorder in the first place

Grenyer et. al., “A Randomized Controlled Trial of Group Psychoeducation for Carers of Persons with Borderline Personality Disorder.” Journal of Personality Disorders 33 (2):214-228, April 2018.

As mentioned in a post on my blog on Psychology Today, researchers into BPD have of late developed an interest in the “burdens” on parents and other caretakers (almost always other relatives) of having a child or adult child with the disorder. Such “carers” are the subject of this particular study, and were recruited through flyers distributed to mental health services, local media, patient advocacy groups, and patient family and support networks. The recruits were put into groups and given a lot of “psychoeducation” about their charges.

The first thing that jumped out at me in this paper was the fact that, even though the carers were evaluated for being critical and over-involved with their BPD children, there was nothing mentioned about seeing if the parents had been guilty of physically or sexually abusing their charges when the fledgling BPD patients were children. This, despite the fact that every empirical study done on this subject in BPD patients finds a high level of significant abuse history. Of course, parents who respond to flyers and volunteer to be research subjects in this sort of study are highly unlikely to have been seriously abusive. So right away, the experiments are selecting for a somewhat atypical sample of parents of children with BPD.

The second thing that jumped out at me was that the psychoeducation provided for the subjects was supposedly based on Bowen family therapy theory, when the researchers mentioned and seem to know absolutely nothing about one of the major tenets of that theory. You know, those that involve intergenerational transfer of dysfunctional family patterns. The researchers mention nothing about the parents being somewhat responsible for the development of the disorder in their kids in the first place!

That they seem to make this assumption is even more awe-inspiring when you look at what was being taught to the parents and which apparently led to improvement in the BPD child’s behavior as well as in the parent-child relationship. They were taught to:

1.      Be non-judgmental, validating, attentive and appropriate.
2.      Reduce their reactivity and try to remain calm and “mindful.”
3.      Attend to their own needs through staying connected with friends and family, attending to their own physical and mental health, and taking breaks.
4.      Model appropriate assertiveness and setting appropriate boundaries and ground rules for the relationship.
5.      Get outside help when crises arise and having a crisis plan.

So, if they had to be taught these things, and if doing those things leads to improvements in their children, maybe the fact that they were doing the opposite of those things all the time previous to the experiment was what was creating their child’s problems in the first place. Exactly what you would expect considering the family dynamics of BPD.

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.