Another Crazy News Article About ADHD

Here's yet  another article that should be perfect for my new journal,  Stupid Studies and Even Stupider Headlines. (This is the companion journal to my other journal, Duh! The Journal of Obvious Results).

An article in Health Day on June 14, 2011 carried the headline,  Too Little Sleep in Preschool Years May Predict ADHD: Study suggests link between behavior in kindergarten and sleep loss earlier in life. 

In this case, the study being described has not yet even made it into a journal, which means no peer review has yet taken place.  It is going to presented at a meeting of the American Academy of Sleep Medicine.  No peer review.  On the other hand, according to fellow blogger the Last Psychiatrist (TLP), peer review these days is about equal to proofreading.  Still, Health Day was jumping the gun a bit, no?  Why? 

The authors of the study reported, "Children who were reported to sleep less in preschool were rated by their parents as more hyperactive and less attentive compared to their peers at kindergarten." However, inattention and hyperactivity in the preschool years was not a predictor of sleep duration in kindergarten, the researchers added.

Their conclusion: "These findings suggest that some children who are not getting adequate sleep may be at risk for developing behavioral problems manifested by hyperactivity, impulsivity, and problems sitting still and paying attention."

So does sleep deprivation lead to a mental disorder?  That seems to be the implication.  But that couldn't be it, could it?  Surely these scientists could not possibly believe that correlation is evidence of causation in this particular instance?
 

How about parents who don't insist on a regular bedtime for their sleep-deprived children. Do such parents suddenly become firm disciplinarians when their kids reach kindergarden? Might they also let their kids get away with murder in other ways?  Do children who get to pick their own hours and therefore are up half the night start to act out? Might they also get a little rambunctious and CRANKY? Ya think?  Just asking.

My conclusion based on the relative likelihood of the author's insinuation versus my own observations:  Most kids labelled with ADHD don't have a disorder at all but are just acting out, just like most of the ones labelled these days with pediatric bipolar disorder.

To quote the Last Psychiatrist again, "If a psychiatrist looked a single parent a joint away from a nap right in the eye and said, 'nope, he's acting out because of X, Y, Z, and medications aren't going to fix this' that doctor will get his head handed to him by parent or by lawyer.'"

It's amazing but predicatable how defensive parents who disagree with this line of thinking can get, which sort of proves TLP's (and my) point.  Such parents don't just argue logically, but indignantly get their panties in a bunch.

Adults act out too.  The latest fad no-such-diagnosis making the rounds of confused lay people to describe them (or themselves) is "Schizophrenic Bipolar."

Lies about Hospital Prices: EOB I Owe

I'm going to get away from mental health issues a bit on this post to let readers in on some characteristics of the current United States health system of which some may not be aware.

Imagine that you were fed up with managed care health insurance, that you were fairly young and healthy, and that you were quite affluent.  Say that you still had the choice to opt out of health insurance altogether and pay for your health care as you go - but before you do, you decide to compare the prices of different medical procedures, labs tests, and radiological procedures like MRI's at different doctors' offices and laboratories. 

How would you go about finding out who was offering the best deals and who would be overcharging like a mad auto mechanic with a young girl who knows nothing about cars?

So you call up a lab and find out what a certain MRI costs (these are real numbers): $2635 at one facility.  However, an insured friend just had the procedure at that very same lab, and, being of a suspicious sort, you ask to see the Explanation of Benefits (EOB) from your friend's insurance company.  You are shocked to see that your friend's procedure only cost $2077!  This includes both what the insurance company paid out and your friend's copayment.

You say to yourself, "What the f*@#$!!!"

So you take another look at the EOB.  When you look closer, you see something on there that says that indeed the MRI "costs" $2635, but your friend and his insurance company only have to paid $2077.  The EOB also brags about something called "Network Savings" of $558. 

Look how insurance companies are working for you to hold down medical costs!  You begin to wonder how come your friend's insurance premiums go up by double digit percentages every year when doctors, hospitals, and labs seem to be getting paid less and less for the most common medical procedures.  Gee, I wonder who's pocketing all that extra money? 

So you call up two more labs, tell them you have no insurance, and find out that they also supposedly charge around $2600 for this MRI.

What is really going on is that $2635 is a sort of list price, but that no one with insurance pays list price.  The people with NO insurance routinely pay a much higher price for the exact same procedures at the exact same locations.

Your blood starts to boil. You think that maybe doctor visits are different, so you call up various medical specialists, ask the cost of an initial evaluation for a specific complaint, and lo and behold, you find exactly the same pricing schemes.

Next, you next try to call some doctor's offices and demand that they give you these procedures at the same discount that the insurer gets, but every single one says no. 

Somehow you get a doctor on the phone and corner him, and ask him why you can't have the evaluation at the discount that the insured patients get.  He won't tell you why, and yet he still refuses.

OK, so here's the real explanation of benefits:  All doctors have a high list price for any given procedure or exam.  The number is nonsense, however, because most of their practice is insured patients, and none of the insurance companies pay list price. 

Although there is some room for negotiating prices between managed care and providers, if you started collecting EOB's from different doctors for the same procedure, you will find that all the different insurance companies get approximately the same discount.  Also, the insured patients and their insurers when combined are all paying about the same price for the same procedures.

So why don't the doctors just lower the list price and give the same deal to all the insurance companies as well as the uninsured?  I'm glad you asked.

When negotiating with an insurance company, doctors who want to be one of the preferred providers for that company are forced to agree to the discounted price.  The insurance companies offer essentially nothing in return other than the doctor being listed as one of their preferred providers, who cost the patient less to see than an "out-of-network provider."  Out-of-network providers cost insured patients more out of pocket than do in-network providers, but often still not the list price offered to the uninsured.

If the insurance company finds out that a physician offered an uninsured patient the same discount, they then start to demand a similar discount off of the price they agreed to pay the doctor when the doctor first signed up for their panel, while completely ignoring the fact that that price had already been discounted.

However, if the doctor offers the same discount to get on another insurance company's preferred provider list, the first company has no trouble with that all.  Perhaps they offer one another professional courtesy.  The fact that they all offer approximately the same remuneration for specific procedures seems to indicate that the different companies get together to fix prices. 

And yet somehow they do not seem to run afowl of anti-trust laws.  However, if doctors get together to insist on a minimum amount of remuneration that they would accept for a given procedure, the Justice Department threatens to charge them with violating anti-trust laws!

It is supposedly illegal for one doctor to merely ask another doctor how much the second doctor charges for services.  And yet somehow doctors are supposed to divine what fee is "reasonable and customary" when they set their "list price" for Medicare and insurance companies.  Of course, it is easy to get the data indirectly.

If the doctor decides to lower his or her list price, the insurance company will demand the same percentage discount off the new price.  Hence, the doctor has an incentive to keep the list price as high as possible, and gets  punished if he or she does not.  So much for beneficial effects of the highly vaunted "competition" in the "free" private insurance market.

To get back to psychiatry for a moment, the insurance companies has used this state of affairs to ratchet down the price of psychotherapy, so that doctors earn a lot more money for just prescribing psychiatric drugs and doing nothing else.

So if you are uninsured and would like to pay up front cash for your medical care, you will be fleeced like a helpless little sheep. And you can thank your politicians for this state of affairs.

You're Asking For It

In a recent advice column by Dear Abby, A 19-year-old woman complained about the way her two younger sisters were treating her mother. When the writer was 4, the mom had gone to prison for eight years, but the experience of jail had somehow turned Mom's life around. At 38, the mother had a college degree, a loving husband, a good job and a new home.

The two sisters said that they did not want to be part of the mother’s life, but they never failed to call her at holiday and birthday time to pick up the gifts they know Mom has bought them. Afterward, they would not contact her or answer her calls and texts until the next holiday. From the letter writer’s perspective, this repetitive dysfunction interpersonal interaction would leave the mother depressed and feeling used. If the writer tried telling them to stop this, they would tell her to get out of their business.

In her answer, Dear Abby opined that the two younger sisters were manipulative, selfish and self-centered, but correctly pointed out that the mother was enabling them to behave in this way. Abby astutely said that the mother might be giving and giving out of guilt, while the sister may be taking and taking in order to punish her.

On the surface, the younger sisters were in fact being manipulative, selfish, and self-centered. But - just maybe - they were really responding to what they believed the mother needed and wanted them to do. Perhaps Mom was feeling so guilty for being in jail during their childhood that she was actually inviting the girls to abuse her in this way. They may have been “helping” her to atone for her sins. The mother's "need" for this was evidenced by the fact that Mom kept giving them stuff in spite of their mistreatment of her.

Under this interpretation, the sisters are giving the Mom the punishment they think she feels she deserves, while taking the heat off the mother by looking like they are the villains in the story. They are the ones who appear to be “acting badly.” For a parallel situation, please see my post, Your Spouse’s Secret Mission.

We have all heard the expression, “You’re asking for it,” as when a child defies a parent’s orders knowing full well that he will be spanked. Now of course, this is said as if it were meant facetiously, as a sort of a joke. After all, why would anyone be “asking” for a spanking?

Not a good tattoo for a criminal



What I propose here is instead that people really do mean this. They really think people are in fact asking for it when they do something knowingly that will surely lead to a negative consequence. Why else would they do that? The individual who says, “You’re asking for it,” however, does not know why the “asker” is doing so. He or she has to come up with some sort hypothesis to explain it. Maybe the other person is mad, bad, crazy, guilty, or just a masochist.

So why is the phrase said as if it were being said facetiously? The answer is that the person uttering the phrase knows he or she will be attacked for offering this theory seriously.

For example, let’s take the case of one not-uncommon type of abusive husband. In my most recent book, I describe the case of a woman who was married to a hyper-jealous and hyper-possessive husband with a history of violence.

One day in a fit of pique, she torched his prized vehicle and then had sex with his best friend. She then went home to tell him all about what she had done - in the nastiest way she could think of - and blamed her misbehavior on his inadequacy as a husband. So what happened next? Duh!!!

Before I go on, let me add a caveat. I am not suggesting that this guy’s behavior should be excused. One should not beat someone else up no matter what the provocation, except perhaps in the case of Osama Bin Ladin. So don’t write me a nasty note!

Now, if this husband were to tell, say, a marital therapist, that his wife was “asking for a beating,” what response would he be likely to get in return? The therapist would almost certainly exhibit an angry and disgusted facial expression and accuse him, perhaps in a sugar-coated but still easy to spot way, of trying to justify his vile behavior through rationalizations and deflecting the blame for his own shortcomings onto his victim. The average abuser generally knows better than to subject himself to that - unless he actively wants the therapist to hate him.

Such a reaction would hardly be limited to a therapist. Most people would attack this guy unless they were afraid of him or somehow complicit. Better to use the phrase facetiously, no?

Now, “asking for it” does not have to be this clear and dramatic. Subtle behavior can draw out hostile responses just as well as can gargantuan provocations.

The great Eric Berne, founder of a type of psychotherapy called Transactional Analysis (TA) and author of the best-seller, Games People Play, describes a “game” that he calls Kick Me : This game is played by people whose social manner is equivalent to wearing a sign that reads “Please Don’t Kick Me.” The temptation for everyone is almost irresistible, and when the natural result follows, the person cries piteously, “But the sign says ‘don’t kick me.’” Then he adds incredulously, “Why does this always happen to me?”

The mother in the Dear Abby letter might have been acting in such a manner with they younger daughters, while acting very differently with the eldest daughter. If this were the situation, the eldest daughter would probably not understand what the younger sisters were really reacting to, and blame them. Just as they would want. As I have pointed out in previous posts, people are so thoughtful that way!

How to Disarm a Borderline, Part VIII: Splitsville

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), Part VI (March 2), and Part VII (April 30). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

In today's post, I will discuss how patients with BPD get two or more other people to fight with one another, and how to avoid getting sucked into such fights.

The psychoanalytic concept of splitting has been used by analysts in a few different senses.  The different meanings of the term are clearly connected with each other, but the analysts are somewhat vague in describing in detail what this relationship actually is.  The most common use of the term, as I described in my post A Splitting Headache of 4/24/10, applies to something going on entirely inside the heads of patients with BPD. 

As I described in the earlier post, BPD patients are thought by analysts to be either unable to see both the good and the bad in anything or anyone at the same time, or do not do so because they are using splitting as a defense mechanism.

As is their wont, the analysts seem loathe to look at a mental phenomenon in terms of its interpersonal meanings withing the context of the patient's real relationships.  However, one well-known interpersonal phenomena seen with patients with BPD is often spoken about when analytic therapists converse.  This phenomenon is also called splitting.

When individuals with BPD are hospitalized in psychiatric facility, it is frequently noted that professionals will start arguing among themselves about the patient.  Two doctors, or a doctor and a nurse or social worker, will get into what are at times very heated discussions about the patient's treatment.

Sometimes the entire ward staff becomes divided into two warring camps, with one side thinking that the patient is being treated unfairly with the other side wanting to come down on the troublesome patient with the proverbial hammer.  This situation became known as the infamous staff split.

My first clue as to what was happening in these situations came with the realization that a lot of the aggravating behavior of patients with BPD is a big act that can be turned off and on at will, like a faucet, depending on who they were performing for.  The act can also be greatly altered so that they act one way with one group of people and completely differently with another group.

I was consulted on a hospital patient on a medical (not a psychiatric) floor whose medical condition was clearly being affected adversely by her stress level.  When I first met the woman, she was the sweetest, friendliest, and most pleasant of patients.  We were having a nice chat about her stress level when her phone rang. It was the patient's husband. 

Suddenly I witnessed the most amazing transformation short of a caterpillar turning into a butterfly.  She without warning turned into the nastiest, most shrill harridan one could imagine.  Her comments towards her husband were so unrepentently vicious and venomous that I began to feel sorry for him.  After a short conversation, she practically hung up on him.  As soon as she put down the receiver, however, she turned right back into all sweetness and light in a heartbeat.

Amazing.  Patients who have real mental illnesses cannot do that.  They act pretty much the same way with everyone - and even when they do not realize they are being observed.

The staff split is set up by the patient.  To one group, he or she acts like a damaged, pitiable abuse victim in need of kind understanding. To the other group, like hell on wheels.

Eric Berne, founder of the school of psychotherapy known as Transactional Analysis and author of the best selling book Games People Play, had a name for this whole pattern. He called it the game of Lets You and Him Fight. In other words, the patient acts in ways that essentially picks a fight between other people.  If this game had a professional league, individuals with BPD would be the superstars.



Eric Berne

The solution to the staff split is actually simple and straightforward.  First, staff members have to be aware of the fact that their arguments are being set up by the patient, not by the unreasonableness or stubborness of the other side.  They can then ask each other on what patient behavior they are basing their opinion, and compare notes.  They can then decide on a mutually acceptable course of action and present a united front to the patient, and voila, the patient stops trying to split them.

The relationship between the senses of the term splitting is that the patient acts all good with one group, and all bad with another group.  If pressed, the analysts would probably say that the staff split is just an incidental byproduct of the patient's tendency to see some of the staff as all good and others as all bad. 

I, in contrast, see is at a well planned, although sometimes automatically and subconsciously played, interpersonal strategy designed to create staff wars.  Once again, however, I believe such patients are ambivalent about this and down deep hope that their efforts to provoke fights will fail.  The power to play mommy off against daddy is actually very frightening for them.

When seen in individual therapy, patients with BPD will often make a damaging or incendiary accusation about an important referral source, about a colleague who is well respected or who is even a friend of the therapist, or about a nurse with whom the therapist will have to work. If therapists defend the other person without having an impartial account of what actually transpired, they are invalidating the patient.
 
However, the patient may be exaggerating what happened, making undue inferences about the motives of the accused, or discounting the role of his or her own provocative behavior in the dispute. Also, the therapist should never forget that there really are a few Nurse Ratcheds on psych wards.
 

Nurse Ratched, "One Flew Over the Cuckoo's Nest"

 
My solution: I state, "I was not there, and I have a different impression of him from my other contacts, so I am not in a position to make a judgment on this." I just refuse to take sides in the dispute, and the patient will often then drop the subject completely.

One major exception I make to this is when a patient alleges that a former therapist had sexual intercourse with the patient. (This caveat does not apply when the patient just had the opinion that the former therapist had inappropriate thoughts).  I take this allegation very seriously because, in my experience, patients rarely make unfounded allegations about this subject, and unscrupulous therapists need to be taken out of the profession.  The willingness of the patient to allow the therapist to take advantage of her in this manner is irrelevant.

The next time your friend with BPD tendencies tells a story about someone else that starts to make your blood boil - at the person being described in the story - keep these suggestions in mind and do not take sides.

The Limits of Cognitive Psychotherapy

The purveyors of the type of psychotherapy known as cognitive-behavior therapy (CBT), which is currently the predominant psychotherapy paradigm being taught in psychology graduate degree programs, like to claim that their type of therapy is the most "evidenced based" of all psychotherapies and is therefore vastly superior to the more humanistic and relationship-oriented types of psychotherapy. 

It is true that they have more studies than anyone else, but that is because they have very limited treatment goals which are very easy to measure, and they do not study complex people who have a lot of different (comorbid) psychological problems.  Even so, their claims of the superiority of their evidence base are highly inflated.  I go into exactly how in detail in How Dysfunctional Behavior Spurs Mental Disorders. 

It is also true that they control the funding for psychotherapy outcome research and deny the followers of other schools a chance to prove their mettle in randomized clinical trials.  Psychotherapy researchers refer to the "cognitive behavioral mafia" at the National Institute of Mental Health.

One of the major components of CBT is cognitive therapy, first pioneered by psychologist Albert Ellis and then refined by psychiatrist Aaron Beck.  Cognitive therapy is based on the idea that human beings are fundamentally irrational creatures in that they make a lot of logical errors whenever they assess the risks and benefits of various situations and courses of behavior.  These irrational ideas then lead to out of control emotions like unreasonable anger and depression.

Albert Ellis

 Ellis speaks of people "depressing themselves" with worst case scenarios (catastrophizing), or by drawing broad conclusions from single examples (e.g., "Since I failed this test, I'll fail all the ones in the future" - overgeneralizing), or by setting up absurdly high standards for themselves with a lot of musts and shoulds.  He liked to call this last one "shoulding all over yourself."

Aaron Beck

Cognitive therapy is designed to employ something called collaborative empiricism.  The patient and therapist get together to discuss the logical fallacies in some of the patient's thinking and to objectively examine the "evidence" for his or her beliefs.  If the individual can become more of an objective, empirical, scientific type, he or she will not experience chronically negative emotional states - or so the reasoning goes.

A current and popular version of cognitive therapy is called Acceptance and Commitment Therapy (ACT).  At slight risk of oversimplifying this therapy, it consists almost entirely of trying to teach people that they do not have to believe everything that they think.

It's interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do.  IMO, one big reason for this is the existence of certain types of beliefs that human beings tend to hang on to as if their lives depended on it, notwithstanding even the most obvious evidence to the contrary. 

This type of belief was first identified by psychoanalytic pioneer Karen Horney.  She referred to them as positive value blockages, for reasons I will describe shortly.  They are held by individuals.  Later on, family systems therapists noted a similar phenomenon at the level of the kin or family group.  They called these collectively held notions family myths.  Of course, dogmatic myths are also seen at the level of the subculture, where one might refer to them as theology.

Karen Horney

Try to challenge these beliefs, and in response you get a version of," My mind is made up; don't confuse me with the facts." Trying to challenge the rationality of positive value blocks or family myths using cognitive therapy is like trying to convince a Birther that President Obama was born in Hawaii.

Horney's idea of positive value blocks, which she conceptualized as defense mechanisms, is tied to the idea of a false self, which also called a persona.  Children growing up in dysfunctional families who are subjected to rejection, brutality, withering criticism, ridicule, and/or hostile control will feel safer when they act in certain ways which are rewarded by the family environment, but which may run counter to the way they really feel deep down inside of them.  The different sorts of behavior that fill this bill leads them to develop certain character types. 

According to Horney, when such children - and later when they become adults - act in these ways, they often pretend to be proud of their behavior, but deep down they feel alienated from themselves and full of self-hatred.  This neurotic or conflictual pride is a glorification of a phony self.  This false pride is usually supported with a number of ideas which justify the character type.  These ideas often take the form of proverbs or slogans such as, "Nice guys finish last."  Such ideas act as blocks to the expression of a person's true self (which might wish to be nice), and this is what is meant by the term positive value blockages.

An individual's family often not only shares these beliefs, but lives by them.  Some beliefs can be specific to certain individuals within the family (for example, what one family member is "really" like and who within the family he or she is closest to), while others apply to everyone.  The ideas in this context are what is referred to as family myths.  They justify and support a set of rules which dictate how each family member should behave, and what family roles each must fully and compulsively play, in order for the family to function in a predictable way (family homeostasis). 

The myths function as a belief system which the family uses, often defensively, to explain its experience to itself.  They are sometimes not verbalized explicitly so as to avoid any challenges to them. They can be taught implicitly through various forms of acting out and family rituals.  However, they may also take the form of oft-verbalized adages just like positive value blockages do in individuals. 

I had one patient who justified never trying to change a bad situation with three different proverbs:  "the grass is always greener on the other side," "the devil you know is better than the devil you don't know," and "you've made your bed so now you have to lie in it."  All three slogans had been repeated to her ad nauseam by her parents when she was growing up.

Therapists, challenge these ideas without understanding how central they are to a person's psychology at your own risk.  Your patient will fight you tooth and nail, and you will get absolutely nowhere. Cognitive therapists, put that in your pipe and smoke it.  Or is that just another family myth?

Pro-Death Florida Legislators Run Amok

A physician determines that a patient, while not an imminent suicide risk, is a longer-term risk.  The patient has a history of impulsiveness, and under an acute stress might make a sudden and thoughtless decision to take his life.  The doctor inquires if the patient owns a firearm, and the patient answers in the affirmative.  The doctor advises the patient to get rid of the guns in the house so as to prevent any quick, irreversible decisions that might be made by the patient in an agitated state.

Someone in law enforcement finds about this and reports the doctor.  The physician is then arrested and convicted of violating Florida Bill 432.  He is then sentenced to five years in prison, and fined five million dollars.

I bet you think I am making this up, but believe it or not, this bill was actually proposed by members of the Florida state legislator, and similar proposals are planned by the NRA in several other states:
http://jacksonville.com/news/metro/2011-01-31/story/florida-physicians-take-nra-gun-privacy-issue.

The bill would make it a felony for a physician or any medical worker to ask a patient or the patient's family whether they own a gun.  This might include prohibiting pediatricians from advising parents on gun safety issues when there are children in the house.

After a large protest from physicians, the bill was finally amended to offer an exception to the legislation that would shield doctors from prosecution in cases that involve mental health issues, such as the patient who is suicidal.  It then passed both Florida houses and is expected to be signed by the governor.

Now contrary to what you might think, I tend to be rather right wing on the subject of guns and gun control.  I want firearms to remain legal and available.  I worry far more about collective violence than random crime, since many more people have been killed by groups and by governments over the years than by criminals. 

The governments of Syria and Iran would have a lot more trouble convincing their troops to mow down political demonstrators if their troops were afraid that they might be fired upon by snipers on rooftops all over the city.  Think something like that could not happen here?  Probably not, but then again, there was this little incident at Kent State in the sixties that came pretty close.  And then there were all those lynchings in the South.

On the matter of doctors advising patients, however, I think the proposed legislation is completely insane.  Besides being a gross violation of free speech, accepted community standards of practice, and professional ethics, it has absolutely nothing to do with the Second Amendment. 

A therapist cannot force a patient to get rid of their guns, although I personally would refuse to treat any potentially suicidal patient who did not agree to do this. 

Even if patients agree, they could lie to the doctor, or go out some time later and purchase another gun.  One patient I know who killed herself checked "yes" on the application to purchase a handgun on the question that asked if she suffered from a mental illness.  They sold her the gun anyway.

Well, you might protest, you do not need a gun to kill yourself.  You could go to a bridge and jump off, or obtain some pills and overdose, or hang yourself in the closet.  What is so important about getting rid of guns?

The answer is that using a gun is quicker and easier than any other method, and usually more deadly.  Other methods take some minimal advance planning, so are unlikely to be employed impulsively.

I'll bet these legislators call themselves pro-life, too.

The False Theory That Refuses to Die

"The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact."  ~ Thomas Huxley

The presence in the brain of a "chemical imbalance" is one theory about the cause of certain mental illnesses. Specifically, the basic concept is that neurotransmitters -  the different chemicals that are released from the ends of brain cells into the space between two neurons (synapses) and are the means by which two neurons communicate - are out of balance within the brains of patients suffering with clinical depression or schizophrenia. Therefore, medication which helps these conditions must surely correct these "imbalances."

In the case of clinical depression, two neurotransmitters are thought to be the primary culprits. Because antidepressants increase the amount of serotonin and norepinephrine in synapses, these monoamines or catecholamines - different name for the class of chemicals in which they are classified - this was presumed to be the mechanism of action through which the drugs helped depressive symptoms.


Zoloft Ad



Research into other mental illnesses such as schizophrenia also found that too much activity of certain neurotransmitters such as dopamine was correlated with these disorders.  The basic problem with this theory is that it is wrong. There is no evidence that a "chemical imbalance" is behind serious clinical depression. 

A few problems with this idea: 

First, the effect of antidepressants on serotonin and norepinephrine in the brain is immediate, but the therapeutic effects do not begin to appear until after about a week and a half pass by, and the full effect takes 3-6 weeks.

Second, all of the drugs affect the monoamine neurotransmitters, but some people respond to one but not another, while others do not respond to the first but do to the second.

For a third point, I quote neuroscientist John J. Medina, author of the wonderful Molecules of the Mind column in the Psychiatric Times.   From his April column: 

"When we consider the molecular mechanisms of SSRI interactions, it is easy to resort to commonly taught ideas about interactions that involve a single synapse.  Nothing could be further from the truth. 

The most comprehensive neurological view of SSRI actions must take into account the participation of thousands of individual neurons strung together in coordinated, complex neural networks.

And not just serotonergic neurons.  The cells are in contact with many other central nervous denizens, from adjacent glial cells to the extracelular matarix into which the cells are embedded."

And yet, the monoamine theory refuses to die!  "Biological" psychiatrists have become obsessed with monoamine neurotranmitters and the parts of the neurons which snap them up and react to them - the neurotransmitter receptors. I think that horse has been beaten to death.  Studying receptor physiology will, I predict, not lead to any new drugs with a different mechanism of action from the ones we have now.



The propaganda coming from Big Pharma continues to push the importance of the neurotransmitters and their receptors, even when the significance of many findings of receptor differences is completely unknown.  A recent ad that does this is discussed in Dan Carlat's blog.

For one thing, these monoamines make up only about 5% of all neurotransmitters in the brain.  For another, all the other ones, most notably glutamate and GABA, all regulate each other in a cascade of two-directional influences among thousands or even millions of cells. Last, all neurotransmitters are widespread throughout the entire brain.

Now do not get me wrong.  Just because one theory about how antidepressants work is wrong, this does not mean that the drugs do not work.  Clinically, in properly diagnosed patients, they work fabulously.  I have personally witnessed their dramatic positive effects in literally thousands of patients.

There are other reasons why recent studies seem to show that antidepressants do not work in moderate to mild depression (NO honest study says they do not work in severe depression). Not the least of these reasons is that the drugs have mostly gone generic and Big PhARMA has a vested interest in seeing other, less effective drugs being used.  See my 8/31/10 post, SSRI Tales.  The drug company marketing departments are so sophisticated that they use the anti-psychiatry zealots to help them sell more (and more dangerous) brand named drugs!

To those that think antidepressants never work, I have one word for you:  Bullsh*t!

For ages, we did not know how aspirin works.  I am not sure that we really do now.  But it relieves an awful lot of headaches for sure.

Ve Have Vays of Making You Talk, Part II: Nitpicking and Accusations of Overgeneralizing

In Part I of this post, I discussed why family members hate to discuss their chronic repetitive ongoing interpersonal difficulties with each other (metacommunication), and what usually happens when they try.

I discussed the most common avoidance strategy - merely changing the subject (#1) - as well as suggested effective countermoves to keep a constructive conversation on track.

The goal of metacommunication is effective and empathic problem solving. In this post, I will discuss two other avoidance strategies, nit-picking examples of problematic interactions, and it's opposite, accusations that the person initiating metacommunication is over-generalizing about how pervasive the problematic reaction really is.

I will also discuss counterstrategies that are often effective in getting past these avoidance maneuvers. As with all counter-strategies, maintaining empathy for the Other and persistence are key.

Strategy #2: Nitpicking

In attempting to metacommunicate about behavior patterns within the family system, family members will at some point be forced to discuss particular examples of the behavior pattern that they have in mind in order to make their point. A problem with the use of any example is that, no matter how clear-cut it may appear to be, there will always be aspects of it that are open to nuances of interpretation.

The targeted family member can often sidetrack an attempt at metacommunicating by quibbling with some minor aspect of the metacommunicator's example. Metacommunicators need to be alert to this so that they can refuse to become embroiled in nitpicking discussions about trivial issues. For example, in order for an adult daughter to discuss the effects on her of her mother's unreasonable requests for immediate assistance at all hours of the day and night, she would undoubtedly have to bring up an example of such a request.

The mother could easily sidetrack the issue by quibbling over the reasonableness of any instance that the daughter might bring up. The urgency of a need for assistance is always open to question. The daughter's talk with her mother might turn from an attempt at metacommunication into an argument over how badly the mother needed help three months ago. The issue of the effect of the mother's behavior on the daughter would be entirely lost.

To counter nitpicking, I recommend making statements such as, "Perhaps that wasn't a perfect example, but there are many instances where this sort of thing seems to happen. I think you know what I'm talking about."

A metacommunicator can often bring up a series of sequential interactions that, while all different to some degree, seem to follow a similar overall pattern. The metacommunicator can then talk about the overall pattern while refusing to argue about whether any specific example is truly representative.

Strategy #3: Accusations of Overgeneralizing

Instead of nitpicking, the target may attempt to quibble with the patient's examples of family behavior by accusing the metacommunicator of over-generalizing. No matter how often individuals behave in a similar fashion, there are always times when they do the opposite. A hateful person is at times loving, an incompetent one competent, and so on.

The other person can attempt to contradict a family member’s assertions about anyone by bringing up a counterexample. Just as with someone designing a true-false test, one should be careful to avoid the use of words such as always and never in discussing the behavior of any family member.

If they are caught over-generalizing, metacommunicators can agree that the other person’s counterexample is valid but maintain that most of the time, the person being discussed behaves as they have described. Additionally, metacommunicators can often use the counterexample in the service of strengthening the point that they are trying to make. The counterexample might indicate the presence of a hidden conflict in the person being discussed or might be evidence of some hidden quality that he or she possesses.

An example is a patient who was in the process of metacommunicating with her mother about the family attitude toward men. Although the females in the family seemed to be overly dependent on men, their verbal behavior indicated a marked disdain for them. The patient's mother had, in fact, cleaned up after her fair share of alcoholics. So had the patient.

The mother constantly spoke of how irresponsible the male of the species was and about all the sacrifices a woman must make for her husbands and lovers. These kinds of statements, made in front of both her daughters and sons, had striking effects on the family. The patient and her sisters felt obliged to go along with their mother's opinion; they instinctively rejected any potential suitor who might exhibit strength. Her brothers and nephews, on the other hand, acted as if they were non compos mentis, as if to live up to the mother's expectations.

In the course of the discussion of the family problem, the mother protested that the patient was over-generalizing. While the mother had had several irresponsible partners, her current lover was very dependable. She knew that there were men on whom a woman could count. The patient quickly admitted that her mother's current relationship did seem to be an exception – and a significant improvement.

She added that she realized that her mother wasn't always critical of men. "Nonetheless, in light of your horrible experiences with your own father and your husbands, I can see why you might be concerned about the inadequacies of men. I know your statements are just meant to warn me, but they are still very disheartening."

This example also illustrates a very important principle of effective metacommunication: always give the other person the benefit of the doubt regarding his or her motives, and even praise these motives whenever possible, before describing the negative effects of the other’s behavior on you and asking them to be aware of it. This principle is basically the same one described in my post of April 9, Putting an End to the Game Without End.

Let Go and Let God

Al-Anon is a well known 12-Step program that branched off from Alcoholics Anonymous.  It, along with Alateen for adolescents, is a self-help group for the relatives and spouses of alcoholics.  It considers the people who often live with Alcoholics and who either try to "fix" them or cover for and protect them to be "enablers" or "codependents."

Wikipedia defines co-dependency thusly: "It is a tendency to behave in overly passive or excessively caretaking ways that negatively impact one's relationships and quality of life. It also often involves putting one's needs at a lower priority than others while being excessively preoccupied with the needs of others."  In a sense, the co-dependent is addicted to dealing with relatives and romantic partners who are themselves addicted to alcohol.

The alcoholic hides the bottle; the co-dependent finds it and tries to hide it somewhere else.  In almost all cases, the bottle is somehow found anyway.  (This is one of the limitations to studies that try to employ animal models of alcohol addiction.  No one has ever been able to find rats who hide bottles).

Alanon's basic message can be summed up in one phrase, "Let go and let God."  What this is supposed to mean is that co-dependents, like their alcoholics, are too willful.  They wrongfully think that they should, and are powerful enough to, take  responsibilty for the problem drinker.  Hence, they need to "let go" of this need to be powerful, and surrender their will to a higher power.  They need to "let go" and leave their alcoholic's problems for God to take care of, one way or another.

This is actually helpful advice, but not for the reasons advanced by 12 step programs.  12 step programs are based on Protestant techniques that are used to convert others to that religion.  While there is psychology involved, it is a phenomenon that would be most appropriately studied by social psychologists, and sociologists, since it involves group dynamics.

On the surface, "Let go and let God" seems to be advice to not do anything about the alcoholic's self destructive behavior, but to leave it in other hands.  The paradox, however, is that by not enabling, they are in fact doing something - something, in fact, that is completely different.  As I described in my post, The Mother Teresa Paradox, if you constantly try to protect people from themselves, you interfere with their motivation for taking responsibility for themselves.

But it goes deeper than that.  If you compulsively rescue alcoholics, then they and everyone around you will start to think that rescuing them is something you need to do.  Why, if you did not have an alcoholic around, they tend to think, you would not know what to do with yourself.  The alcoholic will not deprive you of this role, so he or she will continue to drink - just so you can keep performing it!

So, if you buy into the Alanon philosophy, and you quit trying to rescue the alcoholic, you take away his or her motivation to keep you "satisfied" in this peculiar way.  Now of course this does not guarantee that the affected alcoholics will for sure stop drinking.  They may decide to leave the relationship and find another enabler, or start destroying themselves without any help at all.

However, by changing their approach in this manner, the "co-dependent" is increasing the odds that his or her drinker will change for the better.  By not doing something, they are doing something: employing one of the most effective interpersonal strategies that exist. 

Keeping the Customer Satisfied



Recently, a Dr. S. Brown wrote in Medscape:

"A while ago, a patient called me to say he couldn't believe I charged him $50 to tell him he didn’t need a chest X-ray. He was a was a 30-something male patient who had had a cough for a few weeks. He had a short visit, wherein I took a brief history of his illness, did his vital signs, listened to his lungs and told him he probably had a viral bronchitis but didn’t need antibiotics or a chest X-ray; his condition would improve with time. He felt he had been overcharged.

I find it increasingly frustrating to do the right things for patients who feel they are being shortchanged if they don’t leave with either a prescription or a requisition. I attempted to explain to him that I make my living mainly by giving professional advice, not by pushing drugs or ordering tests "

The fact that patients seem to demand a prescription when they go to the doctor has led to such things as the overuse of antibiotics. Viruses, which cause a significant percentage of infections, do not respond to them; only bacteria do. Doctors want to keep patients happy, so often will prescribe them even when they know the patient has a viral infection which will clear up all by itself.  The over-prescription of antibiotics, in turn, has led to the emergence of highly antibiotic-resistant bacteria.

Psychiatrists have taken a lot of heat in some quarters for being overly quick with a prescription pad.  If you go to a psychiatrist, you are in fact very likely to leave with a prescription whether you need one or not.  However, some of this situation is accounted for by patients who demand a medication to solve every problem.  It is not due just to psychiatrists being overly enthusiastic about the wonders of modern medicine.

Not that wilting in the face of a patients' demandingness is a legitimate excuse for the doctor to prescribe drugs for everyday problems in living.  Doctors should be prepared to give patients their honest opinion, whether the patient likes it or not.  If the patient gets upset because the doctor says they need individual or family therapy - or perhaps even no treatment at all - then so be it.  If the patients go away angry and see someone else to get a different opinion, that is their perogative.  There is enough legitimate business to keep psychiatrists busy.

Nontheless, what happens if such a patient goes on some website and gives the doctor a bad review, or creates some other kind of negative publicity?  The government has even discussed the use of patient satisfaction surveys for evaluating a physician's "performance."

What if an insurance company demands a diagnosis or refuses to pay for the doctor's negative evaluation?  I do not know for sure if any managed care company has tried to pull that trick, but I have heard tell about it. 

If that happened to me, I would call the insurance company and demand payment, and immediately resign from that insurance company's provider panel if turned down, because I have to spend time doing an evaluation to find out whether or not a patient needs treatment.  I deserve to be paid for my time.

I can nonetheless appreciate how some doctors can succumb to the temptation to take the easy way out and give patients and insurance companies what they seem to want.  Medicine is a business, and alienating potential "customers" can be a poor way to stay in business.

The medicalization of behavior problems has may causes, and the demands of patients for quick and easy solutions to every problem has to be counted among them.