Tuesday, July 9, 2019

NAMI, Big PHarma, and Family Therapy

Back in the beginning of June 2019 I received an e-mail from a manager in marketing and communications in NAMI inviting me to write a blog post for them, as they were planning on featuring articles in August about personality disorders. I replied that I would be happy to do so. However, I wrote, since I discuss the relationship between family dynamics and personality disorders, what I write might be offensive to some of NAMI readers. The manager then suggested to me that I could avoid that and write about what it means to have a personality disorder and how they are diagnosed. 

I agreed to do it, but had a strong suspicion that they would not like what I would write. I believe that personality disorders are different from other diagnoses in the DSM diagnostic manual and that the now-eliminated separate classification (Axis II) should have been retained. A copy of said blog post follows this introduction.

I was right. Soon after I turned in the post, I received an e-mail from higher up on the NAMI food chain, the Director of Marketing Communications.

She wrote: “…it appears there may be a misunderstanding about the agreed upon blog topic about what it means to have a personality disorder and how they are diagnosed. There are elements in your submission that do not align with NAMI’s position and educational materials about personality disorders. We align with the DSM-5 categorization of personality disorders as mental illness.”

I wrote back thanking them for the opportunity, but basically saying that I was not going to write a post as if the definition of "mental illnesses" in the DSM diagnosis list was not broad, and that it obviously covered some behavioral syndromes that are not brain diseases. Furthermore, by design,the DSM says nothing about etiology (causes of the disorders).

So why did I sort of know this would happen?

NAMI started out in life as advocates for the severely and chronically mentally ill – mostly people with schizophrenia. In the past, they had done some great work in this regard. I know that members were rightfully furious with both psychoanalysts and especially family systems therapists for blaming what is essentially a biological brain disease on family dysfunction. Of course, stressful family environments can make the presentation of any psychiatric or physical illness worse, but most readers probably know by now that I do not believe that schizophrenia is caused by family double binds or schizophrenogenic mothers.

Unfortunately, the NAMI membership morphed into those who dislike anyone who would dare suggest that ANY diagnosis in the DSM just might be created by severe family dysfunction. This position was attractive to the guilty parents I mention in the masthead of this blog, who do not want to look at their own family dysfunction, and therefore put a lot of store on phony “biological” psych disorders like pediatric bipolar disorder and adult ADHD. They joined the parents of people with actual brain disorders in the advocacy group.

In the post I submitted, I purposely did not mention adverse childhood experiences or family dysfunction in making the case that personality disorders (not including Cluster A – see the post) were behavioral syndromes and not brain diseases. Still, some members of NAMI might suspect that that was the implication of the piece. Unfortunately, there was also a second thing going on at NAMI that, although I cannot absolutely prove that the two factors led to the rejection of my post. They clearly seem to point in that direction.

This second process happened around the time that there was a major change in how NAMI derived the bulk of its funding. In October of 2009, the New York Times reported that Senator Charles Grassley had been looking into how patient advocacy groups like NAMI were getting a good portion of their funding from big PHarma. He found that drug makers from 2006 to 2008 contributed nearly $23 million to the alliance, about 75% of its donations. NAMI has long been criticized for coordinating some of its lobbying efforts with drug makers and for pushing legislation that also benefits industry.

Although I was unable to find more recent reports, there is little reason to think that this has changed significantly. Of course, if all DSM diagnoses were brain disorders, then they should be treated with pills, not psychotherapy. This increases drug sales. NAMI has clearly fallen under their spell.

Here’s the rejected post:

Is a Personality Disorder a Brain Disease?

Personality disorders (PD’s) are mental disorders defined as problematic, lasting patterns of behavior, thinking, and inner experience, exhibited across many social contexts – but, importantly, not all contexts. This latter point is seldom appreciated. The patterns are in fact often dependant on specific types of interactions and situations with certain other people, and may completely disappear at other times. People who exhibit symptoms of one of the more severe disorders, borderline personality disorder (BPD), are well known for creating arguments between doctors and nurses on hospital wards by acting sweet around one set of them, while acting horribly around the other set (the infamous staff split).

With the exception of the Cluster A disorders, described below, they are likely not brain diseases but problems with functioning, especially in relationships with others, and in my opinion the behavior patterns are learned responses. Because the behavior can be quite extreme, some people and clinicians think they simply must be brain diseases, but the neuroscience does not support that. The fact that the behaviors appear and disappear depending on social context shows this; real brain diseases like Alzheimers are not like that. Furthermore, findings on fMRI studies and heritability studies, often cited to “prove” that PD’s are brain diseases, are misleading or fraudulent. Readers can follow the links here to understand how.

Another odd characteristic of PD’s is that there can be over a hundred different combinations of traits that all lead to the same diagnosis. Some traits may even seem contradictory. Narcissistic personality disorder requires at least 5 of 9 different characteristics— Any 5— or any 6, 7, 8, or all 9. One trait is an excessive need for admiration, but another is “takes advantage of others.” It is hard to think of a worse way to gain people’s admiration that to make them feel used!

A patient can also simultaneously show symptoms of several different PD’s in any possible combination. One study showed that once someone is diagnosed with BPD, they also qualify, on average, for 1.6 other PD’s. Any others.

The traits that make up PD’s are said to be maladaptive. This means they cause problems for the intimates of the involved individuals, but also in the long run are self-destructive or self-defeating for the person with the disorder. Over the short run, these traits may be used to solve certain types of interpersonal problems, but the “solution” does not last and prevents the use of better ways to resolve ongoing problems.

PD’s were at one time thought by psychiatry to be different from all other psychiatric disorders. They were placed on a separate “axis” from other disorders - Axis II. Of course, all human behavior involves the brain, but as I have argued, PD’s are likely “functional” or behavioral disorders. For this reason, I was in favor of keeping Axis II. However, because insurance companies often refused to authorize treatment for them— despite the fact that they can be highly disabling and require extensive therapy—Axis II was eliminated. (Psychiatry does not consider causation in describing its diagnoses, because the true “causes” of almost all of them are not known for certain).

As mentioned, the personality disorders are subdivided into “clusters” that have common themes. The first, Cluster A, consists of disorders that are usually a prelude to more serious brain conditions such as schizophrenia, and probably have little in common with the PD’s in the other two “clusters.” For this reason, I believe that they should not have been classified as personality disorders in the first place, and they will not be discussed further here.

The most serious personality disorders are seen in Cluster B, the “dramatic” disorders. Antisocial p.d., the most difficult to treat, is characterized by disrespect and disregards for the rights of others, often leading to criminal behavior. They rarely come to therapy voluntarily.

BPD is currently the most common. I have noticed a marked increase in its prevalence since I was in training back in the mid 1970’s, which makes me think it is related to ongoing developments and changes in our culture. It is also seen much less commonly in traditional cultures. People with BPD often react with strong anger or panic to seemingly minor slights. This has led some psychiatrists to believe that BPD is a variation of bipolar disorder, but good evidence says otherwise. People with BPD are impulsive, self-destructive, and may cut themselves or engage in other self injurious behaviors. They often worry about being abandoned by loved ones. A history of overt physical or sexual child abuse is a feature in the backgrounds of many of them, although certainly not all of them.

Cluster C personality disorders exhibit highly prevalent anxiety or fearfulness. Those with avoidant PD, for example, are socially inhibited, feel inadequate, and are hypersensitive to negative evaluations by others. They constantly worry about what other people think about them,

Because of their now-you-see-it, now-you don’t nature, a variety of information must be taken into account to make an accurate PD diagnosis. Good clinicians specifically ask about some of the more severe symptoms and behavior in a good psychiatric diagnostic interview, which includes a complete history of the patient’s upbringing and relationships over the course of their lives – things asked about less and less recently. Often it takes more than one session for the clinician to see the patterns. A patient’s behavior with the doctor and with the staff also provides clues. Interviews with the patient’s significant others may reveal important information, although they may at times be just as misleading as patients sometimes are.

1 comment:

  1. I can recognize the institutional obstacles in your field and am persuaded by your POV on this issue. I am shocked to hear that money drives professional opinion in the world of psychiatry. As an investigative journalist who sees similar institutional bias driven by the profit motive in institutional journalism, I am led to "share your pain." Great article David.