Adult ADHD: Another Dubious Hyped Disorder

Here's a song I wrote for some of my symptom-obsessed fellow psychiatrists who are - what's the word? - oh, yes - incompetent:


Take some of these and you’ll feel better
Forget about those hippies who claimed, “speed kills”
You’ve got ADHD and just a touch of bipolar
Things are always better when you’re taking pills

Your family life’s a mess but that we won’t mention
What’s crucial is your trouble paying attention
You say bad memories make you a sad girl
If your ma drank too much, that’s ‘cause you were a bad girl

[chorus:]
So what if your husband’s out chasing booty?
So what if your brother’s coming on to your kids?
If you find that you’re feeling moody
Your brain’s miswired, that’s all that is!


Those things you remember, they’re all distorted
Your stepfather couldn’t have fondled you
If he had he would have been reported
Others must have been there, not just you two

[repeat chorus]
[repeat first verse]
[repeat chorus]


(Anyone who wants the chords, please feel free to contact me).

The Last Time Biological Psychiatry Over-Reached

There once was another time in recent history when purely genetic explanations for complex human behavior were in vogue just as they are today. You’ve no doubt heard about how two identical twins raised apart were both alcoholics, preferred the color red, and were married to women named Flo.

In reality, most human behavior is learned. For God’s sake, we don’t even instinctually know how to have sex - unless someone tells us or we figure it out by trial and error. (Just the urge is instinctual). Luckily, most of us eventually figure it out.

The following is an excerpt from a chapter called The Brainlessness-Mindlessness Pedulum from my book, How Dysfunctional Families Spur Mental Disorders:

Eugenics

The biological underpinnings of many mental phenomena clearly have their origin in genetics.  Although they are hardly the only determinants of brain functioning, our genes set the parameters by which the structure and abilities of the human brain develop and change over the lifespan.  The subtleties of how the brain functions and what behavioral attributes have genetic components are only now beginning to become clear, but despite the lack of knowledge in earlier times, an interest in the inheritance of mental characteristics was certainly understandable.  

In the 1880’s, a cousin of Charles Darwin named Francis Galton began to think about the relationship between Mendelian genetics and the theory of natural selection in evolution.  The idea that the forces of nature seem to favor the strongest and most adaptive creatures led him to formulate a social philosophy that he called eugenics.  He believed that the human race could be improved through the selection by society of which individuals would be allowed or not be allowed to have children, based on what he believed to be their biologically inherited characteristics. 

The list of presumed inherited characteristics was, even by the loose standards of some of today’s “biological” psychiatrists, absurdly broad. Characteristics thought by many of the followers of eugenics to be genetically transmitted included such traits as sexual promiscuity and even poverty.

Eugenics quickly found many prominent believers, particularly in Germany and in the United States.  Among them were Luther Burbank, Alexander Graham Bell, feminist icon Margaret Sanger, the Carnegie Institute, and the Ford and Rockefeller Foundations.  The philosophy gradually expanded from an emphasis on selective breeding or positive eugenics to the idea that “inferior” members of our species should be forcibly sterilized so that they would never be able to pass down their supposedly bad characteristics.  This was termed negative eugenics.  Some people who believed in the idea that forced sterilization was a moral endeavor eventually jumped to the idea that inferior peoples should be exterminated.

In the United States, the influx of large numbers of European immigrants led to fears that such people might be of inferior stock, and might therefore “pollute” or “contaminate” the gene pool.  Eugenics gave voice and legitimacy to these fears, so it was appealing to a large segment of the American population. In 1910, a man named Harry H. Laughlin established an organization called the Eugenics Record Office (ERO), through which he lobbied politicians to help protect the purity of the human race through restrictions on immigration of peoples from Southern and Eastern Europe.  The peoples from these regions were thought to have “excessive insanity.”   The efforts of the organization led to the passage of the 1924 Johnson-Reed immigration bill which successfully limited the immigration of people from these areas, and completely excluded Asians from entering the States.

Harry Laughlin

The ERO also advocated forced sterilizations of certain segments of society.  It was supported financially by the Carnegie Institute, among others. The idea of forced sterilization of the mentally retarded had already gained acceptance by the time of the founding of the ERO, with the first state law requiring it having been passed in Indiana in 1907.   Eventually, thirty states passed similar laws, resulting in the forced sterilization of over 60,000 Americans.  The practice did not completely stop until approximately 1963.

Laughton was unhappy with the earliest versions of state laws mandating this practice and with their lax enforcement.  He also felt that forced sterilizations should be expanded from just for the “feebleminded” to include the insane, criminals, epileptics, alcoholics, and even the deaf and blind.  He apparently believed all of these characteristics were inherited through genetic mechanisms and that any chance of their being passed on to children had to be eliminated.  He drafted a model law in 1922 that became a template for some later state laws.

He was also influential in a case that came to the United States Supreme Court in which the constitutionality of the forced sterilization of the mentally retarded was upheld: the case of Buck versus Buck in 1927.  Carrie Buck was a woman who was branded as being mentally retarded after she became pregnant following a rape by the nephew of her foster parents.  She was very likely of normal intelligence, as was her daughter Vivian.  Nonetheless, no less a figure than Justice Oliver Wendell Holmes led the way in ruling in favor of the State of Virginia in the case, writing, “Three generations of imbeciles are enough.”

Carrie and Emma Buck

Adolph Hitler and his henchman found this ruling by an American court inspiring.  They loosely used Laughlin’s model law in drafting Germany’s own “Law for the Prevention of Genetically Diseased Offspring,” which went into effect in 1934.  In 1936, Laughlin was granted an honorary degree from the University of Heidelberg in Germany for his work on behalf of “racial cleansing.” 

In a sublime irony, Laughlin himself developed epilepsy in his later years.  Sufferers of this disorder were one of the groups of people he thought should be eliminated from the planet.

The mentally retarded, followed in quick succession by the mentally ill, were among the first victims of the Nazi death machine.  Forced sterilizations began in 1935, followed by the T-4 program for “euthanasia” of the mentally ill in 1939.  One of the architects of this death program was a psychiatrist, Ernst Rudin, as were several of the doctors directly involved in it.  The methods he helped devise for killing individuals with mental problems were later adapted for use in the large scale attempted extermination of those ethnic groups that the Nazis considered genetically inferior, such as the Jews and the Gypsies, as well as of certain individuals within their own ethnic group such as homosexuals.

Ernst Rudin

In the early days of the T-4 program, even small children were not spared.  At one point some families of children with mental problems, who were being told that their offspring had died peacefully of natural causes, became suspicious because they learned that so many of their children seemed to have all died on the same days.  In order to keep the program secret, the Nazis stopped killing the children directly in favor of just letting them starve to death so they would all die on different days.

Meanwhile, back in the United States, support for eugenics waned by the end of the 1930’s because of its association with the Nazis and also because the so-called science behind it was proving to be quite poor.  The Carnegie Institute withdrew its funding of the ERO in 1935 and it soon folded.  Some psychiatrists in the United States, however, apparently did not get the message. 

A psychiatrist named Foster Kennedy gave an address to the American Psychiatric Association’s annual meeting in 1941.  In it, he strongly advocated not only for the forcible sterilization of the mentally retarded, but for killing them, especially if they fell below a certain functional level.  Because he assumed that such individuals were in constant suffering and would be better off dead, he referred to this killing as euthanasia or mercy killing.  His address was published in the Journal of the American Psychiatric Association in July of 1942.  In the same issue an opposing viewpoint by another psychiatrist, Leo Kanner, was also published, along with an editorial.

Leo Kanner

While Kanner had no objection to sterilization, he did object to euthanasia.  He also questioned the validity of assuming that people of low IQ would necessarily beget children who were also mentally deficient, but did not spend any time exploring the ramifications that would ensue for his philosophy if this were indeed the case.  He believed that sterilization should be reserved only for those who could not perform useful work.  He feared that stopping more functional people of low intelligence from reproducing might lead to a labor shortage in unskilled occupations which would adversely affect the functioning of society. 

Of note is the fact that by July of 1942, psychiatrists were already aware of what was going on in Germany.  Kanner noted, “If [journalist and historian] William Shirer’s report is true – and there are reasons to believe that it is true – in Nazi Germany the Gestapo is now systematically bumping off the mentally deficient people of the Reich…” (p.21).

Do Panic Attacks Really Come "Out of the Blue?"

 

Panic disorder (PD) can be a severe, highly disabling and debilitating psychiatric condition. Thankfully, it is usually easily treatable with a combination of medication and a cognitive-behavioral technique known as cognitive restructuring, which I will not describe here.

 

Panic attacks are basically attacks of extreme anxiety accompanied by a variety of physical symptoms which I will describe in a moment. People experiencing them for the first time often think they are having a heart attack, because the symptoms of panic attacks mimic those of a myocardial infarction. They often go the emergency room multiple times. When they get there, the doctors do an EKG and blood tests that would be evidence that the patient was indeed having a heart attack, and lo and behold, all the tests would come back completely normal.

 

In the days before ER docs became familiar with the disorder, patients would be basically told that their symptoms were all in their head and sent home. The patient would be flumoxed. The physical symptoms are of such intensity and acuity that patients would come to the correct conclusion that something physical must have happened.

 

Panic attack symptoms include palpitations (pounding heartbeat), increased heart rate, sweating, tremulousness, shortness of breath, choking, chest pain, dizzyness or lightheadedness, nausea and abdominal distress, a sense that everything is unreal, fear of losing control or going crazy, fear of dying, numbness, tingling, chills, and hot flushes. Symptoms can last for a few minutes or for a few hours.

 

Hyperventilation, or breathing too fast, may trigger many of these symptoms, but not all panic attack sufferers hyperventilate. They still get a lot of the same symptoms. Nothing physical going on? What claptrap!!

 

When people have recurring panic attacks, they are said to have panic disorder, and are at high risk of developing a psychological reaction called agorophobia. This byproduct of panics is more common in women with the disorder than men for unknown reasons. In any event, people with agorophobia become fearful of being trapped and avoid crowds (malls, supermarkets, theaters, sporting events and even church), elevators and other tight spaces, lines, and driving, especially distances or over bridges. Sometimes sufferers become fearful of going outside the house alone, and in severe cases they become completely housebound.

The diagnostic criteria for panic disorder is defined in the DSM-IV-TR are:

Recurrent unexpected panic attacks and:

• The attacks are not due to the direct physiological effects of a substance (such as drug of abuse or a medication), or another general medical condition.

•The attacks are not better accounted for by another mental disorder, such as social phobia (such as occurring on exposure to feared social situations), specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder or separation anxiety disorder.

I italicized the "unexpected" criteria because that is the main subject of this post. But first, I would like to point out that all of the listed physical panic symptoms can also be experienced as part of a rage reaction. Rage attacks are most often seen in patients with borderline personality disorder, a high percentage of whom also have panic attacks.

In fact, the physiology and symptoms of a rage attack are identical to those of a panic attack. The individual's cognitive processes (thoughts and evaluation of the symptoms and what may have triggered them) during an attack may be the only phenomena which distinguish them.

That this should be the case is not surprising. Both panic and rage attacks are a manifestation of the primitive fight, flight, or freeze response in all animals. A fight response would lead to rage, and a flight or freeze response might result from panic. Indeed, it seems that people who have panic disorder have a disturbance of this fight, flight or freeze mechanism that causes it to go off and keep going off even after any threatening stimulus is no longer present. An important, self-protective physiological phenomenon may have gone haywire.

In humans, the ability to think might help an individual to decide whether to run or to fight in the presence of a potentially dangerous or threatening stimulus.

To make a diagnosis of panic disorder, the DSM requires that the individual with panic attacks experience them as unexpected, spontaneous, and uncued. That is, there does not seem to be an environmental event that triggers the attacks.

Rage attacks, on the other hand, are usually thought to be triggered by specific environmental events. If an individual has recurrent rage attacks which seem to be unexpected, spontaneous, and uncued, then a completely different diagnostic label is usually applied to them by psychiatrists: intermittent explosive disorder. I have never seen a case in over 30 years that could not be better explained by another diagnosis.

To summarize, for panic disorder, as opposed to the occasional panic attack, the conventional psychiatric wisdom is that they occur “out of the blue” rather than as responses to environmental threats. If they only occur in the presence of one or more specific environmental threats, say snakes, then the person is diagnosed with a specific phobia instead of panic disorder - a snake phobia in this case.

One caveat is that the idea of panic attacks being "unexpected" refers to the absence of a specific stimulus, not to whether or not the presence of a feared stimulus is expected to be present. If, for example, a snake phobic "unexpectedly" comes across a snake on a hike and has an attack, this would not qualify under the "unexpected" rubric of panic disorder.

Panic disorder might be considered a prime example of something that would pit "biological" psychiatrists against psychotherapists. In people who suffer from panic disorder, the attacks do seem to come out of nowhere. They can be sitting quietly in their house doing almost nothing when one comes on. They can even be jolted awake from them in the middle of the night, without having had a nightmare. A tendency to have panic attacks tends to run in families, so clearly some people are more genetically prone to get them than others.

So does this mean that panic disorder is purely and entirely a brain disease? Is its classification as an anxiety disorder incorrect? Does it have nothing to do with chronic stressors?

In my opinion, the answer to all three questions is a resounding no. People who are prone to the disorder do indeed seem to have to have a problem with the internal regulation of their flight or flight mechanism, to be sure, but environmental factors do, in my clinical experience, determine whether such a person has an occasional attack or has a lot of them.

But if attacks happen without a fearful stimulus being present, how is this possible? My theory is thatpeople who are genetically prone to them will start to have them when they are chronically anxious. Whenever they are on guard, on edge, walking on eggshells, or disturbed about something, they then can have a panic at any time during the whole period they feel that way. Why they happen at any particular time remains a mystery.

Now comes a study which adds a lot of credence to the opinion I have formed over the years (Ethan Moitra et al, Journal of Affective Disorders, in press). The study results show that, instead of an immediate reaction, stressful life events (SLEs) in patients with PD can cause a gradual, but steady, increase in panic symptoms over time.

The investigators note they expected to find that panic symptoms would spike immediately after a stressful event and then taper off, but this was not the case. In analysis of more than 400 patients with PD from the Harvard/Brown Anxiety Research Program (HARP) study, panic symptoms worsened progressively over 3 months after participants experienced specific SLEs, including serious family discord or being fired.

What this study tells clinicians is that they need to be aware that, although people may have an immediate reaction, be vigilant in keeping track of how patients are doing over the next few months after the event, and perhaps even longer," according to lead author Dr. Moitra quoted in a Medscape article.

So most patients with panic disorder, even if the symptoms are extremely well controlled with medications as they often are, should also be offered psychotherapy to learn better coping skills to handle the stressors they are experiencing. Otherwise, they will most likely never be able to get off the medication. Not offering or referring for therapy in these cases is disgraceful.

I almost always find that anyone who seems to be experiencing any long term, ongoing anxiety symptoms and/or unhappiness is usually in the middle of ongoing repetitive dysfunctional family interactions. If the doctor does not specifically ask about them, the patients is unlikely to bring them up.

Do Antidepressants Cause Suicide?

Readers of comments to this blog may have noticed that I have had frequent discussions with readers who question all use of psychiatric medications. They know that I believe (actually I know) that medications can be extremely useful in some properly diagnosed patients with disorders known to respond to the medications who are also monitored for the emergence of side effects.

I have had some interesting conversations on the back channel with people who are absolutely convinced that loved ones committed suicide directly because of having taken an antidepressant. Psychiatrists counter that antidepressants prevent suicide because they treat depression, which is itself - obviously - a cause of suicide.

There is some data that indicates that antidepressants can increase suicidal ideation (but not necessarily completed suicides) in teens and young adults who take antidepressants. So what gives?

Before I answer that, I would like to point out that anti-depressants take two to six weeks to work, and often we have to increase the dose or change drugs which makes this period of time much longer, so people are at risk for suicide because of the underlying depression before the drugs have kicked in. Frequent follow up and a good suicide evaluation usually can prevent tragedy. Also, as I have posted before, there are different types of depression. The less severe type, dysthymia, will often not respond to meds at all, while significant major depression usually does.

But yes, antidepressants per se can indeed cause increased suicidal ideation, suicidal behavior, and completed suicides. However, I believe this only happens in three very specific situations, all of which can be managed by a competent psychiatrist.

The first situation is when a patient develops a side effect known as akisthesia, which is extreme agitation in which a patient can barely sit still. Milder agitation can also be a side effect. Studies clearly show that a mix of depression and anxiety greatly increases the risk for suicide. The psychiatrist can warn patients about this side effect and tell them to call the doctor if it develops. Tranquilizers usually take care of this problem, but some patients must be switched to a different antidepressant, which may or may not cause that particular side effect.

Second, if a patient has bipolar disorder but has not yet had a manic episode or has been misdiagnosed, an antidepressant can unpredictably cause them to switch into mania. Some mania is not characterized by euphoria as it is in most typical mania, but can instead be "dysphoric mania" in which the patients are miserable rather than elated. Suicide risk is high in this condition. Again, family members can be warned to look for signs of this and stop the patient from taking any more antidepressant until the doctor is reached.

Third, in a severe form of depression called melancholia, patients have a lot of clear-cut biological symptoms like thinking in slow motion and having no energy for anything. When treated with an antidepressant, their energy tends to come back well before they felt better subjectively. They suddenly develop the energy to kill themselves whereas before they did not. This is well known to psychiatrists - or should be well known - as a very dangerous time for suicide attempts.

We warn patients and families about this, and tell them to get guns and other possible means of suicide out of the house during this crucial time, as well as to keep an eye on their depressed family members. We are not seeing as much melancholia these days as we used to probably because patients usually get an antidepressant before their illness develops to the point where it is that severe - indirect evidence that the drugs are effective, by the way.

Readers of this blog also know I am highly critical of both pharmaceutical company marketing tactics and "biological" psychiatrists who think that pills can cure every human foible, that psychotherapy is a bunch of bull that has never been validated in randomized controlled studies (totally not true), and who tend to exaggerate the benefits of drugs in those conditions in which they are indicated.

I have not had many comments from these latter type of folk on the blog. So, in the spirit of being an equal opportunity critic, I thought I would post a debate I had on another blog called Medscape with other psychiatrists. Parts of the debate are somewhat technical, so I will put explanatory material in brackets and italics. I am not including every post on this particular thread, but only the ones that I respond to or that respond to me, and I've edited out some comments that are not relevant to the points I am trying to make.

The debate was started by a posting by the blogger, Nassir Ghaemi, MD about the finding that antidepressants may increase suicidal ideation in teens and young adults.

Dr. Ghaemi, MD: ...In reviewing the published FDA meta-analysis [combining the results of several different studies, often using different methodology, and running statistics on the combination] of the randomized clinical trials (RCTs) of antidepressants, [a researcher] summarized the rather clear finding that antidepressants seemed to have an age-dependent effect on suicide risk: In children and young adults below age 25, they increased the risk ...in later adult years they were neutral ...and in middle age and in the elderly they were protective... When all these age groups are summarized, antidepressants have a small protective benefit for suicide ...In all these analyses, suicidality (defined as actual suicide, suicide attempts, or notable increase in suicidal ideation) is being assessed, one should say, rather than completed suicide. There were only 8 suicides in 77382 subjects, though 2 were on placebo and 6 on antidepressant.

Predictors of antidepressant-related suicidality with antidepressants were interesting: Suicide attempts (i.e., actual behavior) were more associated with antidepressants rather than increase in suicidal ideation (thoughts without behavior). Also, non-depressed persons (e.g., studies of antidepressants in other conditions such as anxiety disorders or PTSD) were more likely to be suicidal with antidepressants than those diagnosed with clinical depression (major depressive disorder).

[The researcher] also addressed the common critique that adolescent suicides increased after the FDA warning, which led to a decrease in antidepressant prescriptions in children. He reviewed data showing that suicides per 100,000 population for adolescents occurred at rate of 7.3 in 2003, 8.2 in 2004, 7.6 in 2005, and 7.2 in 2006. The FDA warning came out in 2004, but that increase in suicide rates occurred before the decline in antidepressant prescription rates for adolescents, which happened more in 2005 and 2006, corresponding to a decrease in adolescent suicide rates.

It is a not entirely appealing aspect of our profession that we wish to criticize, but not be criticized: Many of us are critical of the pharmaceutical industry, or of diagnosing mental illnesses like bipolar disorder in children, and yet we react angrily when asked to restrain our use of drugs. Instead, we should think seriously about the clear question arising from these data: Why are antidepressants preventive of suicide in later adulthood, and causative of it in younger age?

MD #1: "Why are antidepressants preventive of suicide in later adulthood, and causative of it in younger age?"
The qualifier there is in RCTs for FDA drug approval. There are many reasons these days why clinical populations are different.

My only criticism of the pharmaceutical industry is that they have not found many safe and effective drugs. I would like to be able to prescribe a mood stabilizer to a bipolar patients where I did not have to warn them that in 20 years there is a small but substantial risk of kidney failure. I would be quite happy to provide psychotherapy alone to bipolar patients if it prevented them from killing themselves or otherwise destroying their lives. In fact, it would be much easier to provide therapy than obsessing about lithium toxicity.

MD #2: It's a peculiar to read criticism of pharmaceutical industry for "not found[ing] many safe and effective drugs" along with favorable (at least the way I read it) mentioning of psychotherapy which failed to provide anything substantial and replicable for suicide prevention whatsoever. While pharmaceutical limitations are measurable and evident, psychotherapeutic shortcomings are hidden behind self-congratulatory process. It's de rigueur in psychiatric narrative nowadays to insert reverences toward "psychotherapy" together with BigPharma admonitions (a form of psychiatric PC, I suppose) without any critique of the former or balanced view about the latter.

The response to the criticism 'why the pharmaceutical industry have not found many safe and effective drugs' is unprecedented, enduring assault on the industry from angry psychoanalysts, greedy selfish government, opportunistic politicians, and many busybodies. I am surprised BigPharma stayed in business this long - there are less vexing ways to make a buck.

Me: What a bizarre conversation! Talking about "drugs" or "psychotherapy" or even "depression" as if they were monolithic entities is insane.

Treating a melancholic depression with any type of psychotherapy is indeed a waste of time, as is treating most cases of dysthymia with just drugs alone.

As to suicide with antidepressants, [I list the clinical situations mentioned earlier in this post].

And of course we need better drugs. With all current antipsychotics, for instance, you get to pick between a significant risk for metabolic syndrome and a significant risk of tardive dyskinesia [a long-term neurological side effect]. What a wonderful choice. And of all the things one can choose to criticize big pharma for, I don't think that problem is one of them.

MD #2: It would be nice if one could comfortably tell one type of depression from another and expect at least half of his colleagues to agree. But your dysphoric mania is another man's agitated depression and the third one's depression with ADHD. And someone else's frontotemporal dementia. Before we start claiming superiority of one treatment over another shouldn't we first sort out the nomenclature?

The irony about "wonderful choice" is misdirected. Consider oncological drugs and their side effects. I don't see oncologists mocking BigPharma. Psychoanalytic/dynamic psychiatrists, OTOH, do. They are still convinced that the world is flat and if you keep moving ahead you can fall from the edge of the earth.

Me: I agree there is a lot of diagnonsense around, but if a psychiatrist can't tell a severely melancholic depression from a typical dysthymia, he or she needs to go back to medical school. While the DSM contains a lot of b.s., much of it is also highly consistent with both clinical presentation and treatment response.

About the "wonderful choice," what I said was that should NOT be blamed on big Pharma. However, if you think big PhARMA science is so honest, perhaps you should read The Truth About the Drug Companies by Marsha Angell, former editor of the New England Journal of Medicine, and see if you still think so. Or check out the Zyprexa marketing documents on FuriousSeasons.com, or the US Justice Department settlements with FIVE different big Pharma companies, available on the DOJ website, for a description of highly misleading and pervasive marketing of psychotropic drugs - including ghostwriting journal articles and paying big name "experts" to sign on as authors. Get your head out of the sand!

By the way, I'm not a psychoanalyst in the least. I agree that old line psychoanalysis was wrong about a lot of stuff, but not everything, and hardly any therapists practice it anymore anyway. I mean, biological psychiatrists have stopped doing insulin shock, so I don't continue to hold that against them now.

MD#2: I see the fine line separating constructive criticism from vilification is permanently erased by critics. Even if we dispense with objectivity, slamming BPharma is plain impractical. We see several leading manufacturers exiting the stage. Another Pyrric victory?

It was refreshing to see your trust in the US DOJ as a pillar of fairness. When thugs put on suits and badges, does it make shake-down palatable? One can grudgingly accept governmental thuggery but applauding would be a bit exuberant, wouldn't it? Any other gov organization in line for blind love and trust? BTW, the data on Zyprexa side effects were available from the get go for anyone who cared to check, but laziness and ignorance of our colleagues found excuses in pharma bashing.

And why shouldn't pharm co's aggressively advertise and market? Are there laws against it?

After descending from planet Utopia to our sinful Earth, maybe misdeed of E Lilly & Co won't look so evil and the US government so white and fluffy.

PS I am curious what entails "not everything" that "old line psychoanalysis were wrong about"? In regard to psychiatry, I mean.

Me: I am not out to vilify the drug companies. We need them. I'm a capitalist myself. I have no objection to marketing if it's even relatively honest. Make your best case. Buy me lunch, even. I don't care. However, the horrendous tactics described in the DOJ agreements go far far beyond that, and they can readily be observed every day at sponsored promotional talks, in regular and throw-away journals, and in DTC advertising. I don't have to make it up. The so-called science behind sponsored clinical trials has become almost comically biased.

You think the government has been too hard on big business? I'd say they're more often partners in crime. We all know that unrestrained big business never does bad things - just look at those paragons of virtue, Enron and BP. And don't big insurance companies always give both patients and us physicians a fair shake?

You're right about the side effects of Zyprexa being (or should have been) common knowledge a long time ago. I actually wasn't concerned about that. What I was concerned about was that, according to the company own memos (which were not even supposed to be released according to the agreement with the "thugish" DOJ, but a journalist got a hold of them), there was a conscious marketing decision to deceive doctors into expanding the definition of bipolar disorder to include any patient who was both anxious and depressed, without regard to any duration criteria, in order to sell more atypicals [expensive brand named anti-psychotic medications].

I have to admit I'm shocked by how many doctors fell for this, but if all you have is medication to offer, everything looks like a brain disease. There's an excellent study by Zimmerman and others that showed that in his sample, 40% of patients who had seen a previous psychiatrist and who clearly met DSM criteria for borderline personality disorder, and who did not even come close to meeting DSM criteria for bipolar disorder, had been diagnosed as bipolar by the previous doctor. Argue with the DSM definitions if you will, and I often do, but I think they got a lot things right.

There's plenty of b.s. in the psychotherapy literature as well. Your question about what is right and wrong about analytic theory would take a book to answer, so I won't even try. What I will say is that any neuroscientist can tell you that the brain is plastic and is literally shaped by interactions with primary attachment figures and other social influences on an ongoing basis. There's a ton of hard science available to back up that assertion.

MD #3: What a profoundly dispiriting exercise reading these comments has been. With one or two exceptions the desire to make a point has created only a painful experience of heat and smoke with precious little light.
Let's face a few facts:

What we don't know is enormous, for all of us. What we don't know we don't know is even greater. Therefore it behoves us all, myself included, to have humility in the face of our ignorance....

I am saddened to see that the arguments which rage for and against Big Pharma, necessary but venal, and psychoanalysis, unpalateable and frequently misused, are just infantile. They each have a place and each have contributed to where we are today. The exciting findings of today in neurophysiology in relation to infant attachment and trauma confirm the prescience of early psychoanalysts, their other failings not withstanding.

The absence of healthy doubt is dangerous. Let's have more doubt.

MD #2: It's unusual to see anyone to be so emotionally perturbed with tepid professional discourse and experience pains while reading opinions different from his/her own. "Let's have more doubts" appeal might work for dogmas (psychoanalytical and others), not for emerging, vibrant, and already highly controversial field like biological psychiatry..

"The exciting findings of today in neurophysiology in relation to infant attachment and trauma", IMO, are not exciting, specific, replicable, practical, and measurable. They serve a purpose, though, - resurrection of fading psychoanalytical orthodoxy. Good luck with that.

Suicide is too serious problem to trifle with psychoanalytic nonsense. There was steady, linear increase in teenage suicide rates for more than half a century during heydays of psychoanalysis in absence of other viable treatments until 1990, when (as some might remember) SSRI’s was introduced. Then, there was a 15 years of suicide decline (first time in recorded history). The decline reversed when first reports of suicidal thoughts related to SSRI treatment initiation emerged in the literature accompanied by sharp decrease in prescriptions

http://www.emaxhealth.com/1/22/24448.html
http://www.sciencedaily.com/releases/2007/09/070907221530.htm
http://www.infoplease.com/ipa/A0779940.html
http://teenadvice.about.com/b/2008/09/05/teen-suicide-rates-growing-in-us.htm
http://www.afsp.org/index.cfm?fuseaction=home.viewpage&page_id=050fea9f-b064-4092-b1135c3a70de1fda

We ought to talk about suicidality (i.e. suicidal thoughts) only in conjunction with discussion about protective role of medications contrasted with measurable (!) impact of other treatment modalities on suicide. Otherwise the discussion turns into fear mongering and emotional plea for "healthy doubt".

Me: No dogmas in biological psychiatry? How about every difference found between diagnostic groups and normals on an fMRI [a brain scan] being automatically labeled as an abnormality when it might instead be a conditioned response or even an adaptation? London taxi drivers have more grey matter in their posterior hypothalamus [part of the more primitive section of the brain] than controls. I suppose that driving a taxi is a disease?

How about the complete ignorance by biological psychiatrists of the vast literature in social psychology, which shows that, given the right environmental context, most people can be induced to do almost anything?

The effect of trauma on the hypothalamic-pituitary axis [the part of the brain that is responsible for regulating the release of stress hormone in the body] not specific or replicable? That's factually incorrect.

I agree that antidepressants, properly prescribed and in patients who are closely followed for the emergence of side effects, do reduce the suicide rate in some patients. Unfortunately they don't work for a significant number of suicidal patients.

Following epidemiological trends is suggestive but proves nothing, however. There are unfortunately almost no drug OR psychotherapy outcome studies that directly involve suicidal patients (for obvious ethical and practical reasons), so I think making overly broad statements about which treatments are most effective in preventing suicide (without regard to the evaluation of the individual patient) is both naive and extremely premature.

MD #2: Let's sort out confusions and contradictions. First paragraph is critical of "every difference found ... on an fMRI being automatically labeled as an abnormality when it might instead be a conditioned response or even an adaptation."

Third paragraph categorically refutes any suggestion that "the effect of trauma on the hippothalamic-pituitary axis" is not specific and replicable.

When a biopsychiatrist finds correlation then it is fatuous, unless it's convenient finding. Then it's alright.

The studies, BTW, found certain degree of ASSOCIATION - not cause-effect relationship, as implied, - between trauma and "dysregulation" (!) of HPA (blunted HPA-axis reactivity ) which was neither indicative nor specific for the type of trauma or associated diagnoses. Similar "dysregulations" were found in physical trauma, chronic disease, maternal undernutrition, substance abuse, and every mental disorder in DSM). It is a nonspecific finding in medicine, akin elevated sed rate, that don't demonstrate, less so proof, anything. There might be confusion btwn HPA studies and hippocampal volume decrease (cell death and cell atrophy )and corresponding increase in amygdala size and activation associated with chronic abbuse (http://www.isps-us.org/koehler/trauma_brain.html)

These studies indeed demonstrated that CHRONIC repetitive trauma in certain (not all) vulnerable individuals might produce anatomical and physiological changes. But these do not explain psychiatric disorders in children who were never abused and lack of mental disorders in many chronically abused.

Some biopsychiatrists my not be familiar, as was suggested, with "vast literature in social psychology" (this particular biopsychiatrist is an exception) but why should they if this literature, as interesting as it might be, has little to do with diagnosis and treatment of debilitating mental disorders. From social psychology viewpoint, hypothalamus and hippocampus are just two Greek words. Biopsychiatrists would disagree.

Another quote: "...given the right environmental context, most people can be induced to do almost anything". Not to develop a psychiatric disorder, they don't.

Now, back to our suicidal patients. It is irresponsible, IMO, not to consider the role of medications in suicide prevention. We may not know to what extent if any medications protect from suicide, but we can convincingly assume that psychoanalysis is as good as useless in these cases.

Me: Good point about my inconsistency on the hypothalamic-pituitary axis example. What I should have said was that this finding was found frequently in, as you say, chronic repetitive trauma, and of course not everyone is genetically susceptible. My bad. This finding has been replicated, however.

There are NO necessary or sufficient "causes" for almost any psychiatric diagnoses, only risk factors. No matter what biological, psychological, or social risk factor you look at, there will always be a lot of people who have a lot of it but don't develop any disorder, and a lot of people who have very little of it that do develop a disorder. And almost all risk factors like child abuse or the short allele of the MAOI [An enzyme that degrades chemicals in the brain] gene are risk factors for any number of different disorders. Totally non-specific.

Looking for necessary or sufficient causes in psychiatry is for the most part a fool's errand, and as statisticians (e.g. Cook & Campbell) will tell you, any study results that suggest otherwise are in most cases presenting a statistical artifact generated by where continuous variables were dichotomized [coded as present or absent].

I would also fault social psychologists who are not aware of biology. If one is going to truly understand human psychology, one needs to include ALL sources of information. Yes, there were horrendous historical mistakes made by the analysts with schizophrenia and autism. There were also horrendous historical mistakes made by the biological psychiatrists - i.e., eugenics [the theory that weaker members of society should be prevented from reproducing or even eliminated to improve the human gene pool]. Brainlessness versus mindlessness, as Eisenberg pointed out.

Not all psychiatric diagnoses are created equal - and many of them are probably not brain diseases in the way schizophrenia is. (and yes, even that dichotomy is simplistic).

I agreed with you, by the way, that NOT considering the role of medication in suicide IS irresponsible.

And please, everyone, quit conflating all psychotherapy with orthodox psychoanalysis. I personally think DBT [dialectical behavior therapy, a type of psychotherapy that does not directly involve psychoanalytic theory or technique] is an incomplete treatment for borderline personality disorder, but replicated randomized controlled studies do show it is quite effective for reducing suicidal and parasuicidal behavior in that population, at least for the first year after therapy. That's more than I can say for almost any drug study you care to look at.

[I did not mean to give myself the last word on purpose; MD #2 never responded to my last post, and it's been over a week].

Attachment: the Latest Dirty Word in Biological Psychiatry

The crowd that wants to substitute the “bio-bio-bio” model for the bio-psycho-social model in psychiatry apparently freaks out if anyone brings up the wealth of studies that look at the effects of attachment behavior and attachment trauma on human behavior.

Attachment phenomena are those interactional variables that are present in the relationship between babies or children with their primary caretakers. These patterns affect the child’s psychological development as well as his or her adult intimate relationships.

Attachment patterns are loosely classified as “secure” or “insecure.” Insecure attachments are further subcategorized as “avoidant/dismissive,” “ambivalent/preoccupied,” or “disorganized.”

Clear evidence ties parental behavior problems and parenting styles with subsequent behavioral and interpersonal relationship problems in their children. Those children with disorganized attachments, for example, become overcome with anxiety, confusion, and paralysis whenever they are involved in intimate relationships. The literature shows that the best predictor of how a mother will bond with her child is the nature of the attachment bond the mother had with her own mother.

At the recent meeting of the American Academy for Child and Adolescent Psychiatry in Hawaii, some of the so-called researchers who have been diagnosing bipolar disorder in young children were presenting their material. Peter Parry, an Australian academic psychiatrist who is, to say the least, highly skeptical about pediatric bipolar, relates the following:

“They had no answer to attachment and trauma. Melissa DelBello, when I asked her about her presentation on neuroimaging in Pediatric Bipolar Disorder (PBD) - which was incredibly detailed and actually quite well put together and I complimented her on that – I said that the findings presented seem to have considerable overlap (a phrase she'd kept using about findings with PBD and ADHD) to the neuroimaging findings presented by Alan Schore etc re attachment trauma.

She initially said she didn't understand my question; after repeating it she twice said that there are some differences with ADHD. I eventually had to again repeat that I wasn’t talking about ADHD - I was talking about the amygdala and right frontal changes she was showing with PBD which they also find in the attachment/developmental trauma literature - at which point she conceded they hadn't looked at that population.”

This interchange is typical of the way some researchers who are overly tied to a pet theory attempt to avoid looking at or talking about any data that would call their theories into question. Usually they just avoid answering any questions that would do this, and subtly change the subject. I admire Dr. Parry’s persistence in not letting her get away with that.

Neural Plasticity

As I discuss in detail in my upcoming book, one way that some "biological" psychiatrists twist the truth in order to justify their belief that certain behavioral problems are due to brain disorders has to do with the neuroscientists' new toy, the Functional MRI (fMRI). fMRI machines, because they measure magnetic fields, can map both brain structure and brain function because the iron in blood that passes through the brain creates a magnetic field.

What researchers do is to use fMRI to compare certain brain structures and brain activity, particularly in the primitive part of the brain called the limbic system, in some diagnostic group with matched controls or "normals." For instance, an important brain structure called the left amygdala is smaller, on average, in patients who exhibit the signs of borderline personality disorder (BPD) than in "normals."

Of course, they are comparing averages, so the left amydala in some BPD patients is larger than those of the average "normal." Notice also that the scientists only occasionally compare different diagnostic with each other. Differences in amygdalar size and activity are found in any number of different diagnostic groups in psychiatry.

The more annoying source of misleading conclusions is that when a difference is found between a diagnostic group and "normals," that difference is automatically labeled an abnormality. If a patient has an abnormality, then of course they must have a brain disease. Actually, these scientists do not know if what they have found is an abnormality or not. What makes the use of the term abnormality totally misleading is that the brain, particularly in terms of limbic system structures, is plastic. This means that, in the normal brain, these structures can change in size to reflect activities that become important to a given individual. The changes can be very quick and substantial.

For example, in the February 2010 issue of the Archives of General Psychiatry (Volume 67 [2] pp. 133-143), Pajonk, Wobrock, Gruber et. al. found that after just three months of a vigorous exercize program, the size of a brain structure called the hippocampus increased an average of 16% in normals! It is also true that the part of the brain that controls finger movements is, on average, much larger in concert violinists than in non-musicians. The conclusions that the so-called biological psychiatrists would be, I guess, that both being a concert violinist and engaging in vigorous exercize are diseases!

Well-known personality disorder researcher and schema therapist Arnoud Arntz has told me that he has some unpublished preliminary evidence that the amygdala changes seen in BPD are reversible with three years of Schema Psychotherapy (a therapy method developed by Jeffrey Young). Thus, these so called "abnormalities" may in fact be conditioned responses from living in a chaotic and invalidating family environment. Not only may they be quite normal, they may be adaptations to the enviroment.

Psychiatry's Latest Manual Goes Too Far

Allen Francis was chairman of the task force that created the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which came out in 1994. Although this essay does not talk about the disease mongering of the pharmaceutical companies as a factor in the expansion of psychiatric diagnoses to "encompass every eccentricity," it does discuss the absurdity of some of the newly proposed diagnoses. Written by someone who should know. Click on the title of this post to link to the essay.

Temper dysregulation disorder with dysphoria

The DSM-V Committee has decided to float a trial balloon about this new "diagnosis." Supposedly their hope is that doctors will quit labeling kids as bipolar, since there is no evidence that the behavior of a typical temperamental kid is in any way caused by or linked to true bipolar disorder. I think the new term will just provide another, even more outrageous label that will provide justification for drug dealing docs to use sedating, brand named, potentially toxic atypical antipsychotic medication on kids

My comments to the DSM-V Committee about this new proposed diagnosis:

Temper Dysregulation Disorder with Dysphoria

This diagnostic category is crazy, and would only help those parents who want to avoid looking at their own behavior and its effect on their children and to avoid taking responsibility for it. There is not one shred of respectable scientific evidence that having frequent temper tantrums is a psychiatric disorder (let alone having three per week), and a world of evidence that shows that in a neurologically intact child with a normal IQ it is triggered by parental inconsistency in discipline. If any psychiatrist is so sheltered he has never personally witnessed a family behave this way, he can watch a very accurate portrayal of it on the TV show "Supernanny." You can also read about it in John Rosemond's nationally syndicated parenting advice newspaper column.

The idea that this "diagnosis" will help doctors avoid labeling acting-out children as bipolar is not a good reason for such deception. The people pushing the idea of manic children do not believe that a manic episode requires ANY duration. A few minutes for them is enough. The children and the families in their studies are never observed in their homes during troublesome interactions. The "experts" make diagnoses using symptom checklists that do not take in to account the context, pervasiveness, and exact time course of the symptoms. They recruit subjects from a website called bpkids.org that has a message boards in which parents advise each other on what to say and what not to say to doctors to get their kids diagnosed as bipolar. Some have been paid large sums by pharmaceutical companies which were not disclosed to their university.