Assuming Facts Not in Evidence: ADHD and Pediatric Bipolar Disorder

As I discuss in my book, How Dysfunctional Families Spur Mental Disorders, one marketing technique used by big Pharma to mislead physicians is the engineering of a journey of ideas that have never been proven into the clinical lore as if they were established facts.  So-called experts who are paid off by drug companies make presentations at continuing medical education conferences or write "review" articles for medical newspapers or throwaway journals in which they mention these so-called "facts."

They do tend to use conditional language, like "[such and such diagnosis] may be made in cases that do not meet the established DSM criteria, or that "[such and such] drug appears to have efficacy."  And they almost always throw in a, "Of course, more research is needed" or something like that.

Conditional phrases are said or written as a quick aside in order to leave the speakers and writers a loophole just in case a member of the audience challenges them about overstating their case. Should this happen, the speakers are then able to point to the conditional language they used and “remind” the audience that their use of this language indicates that they are not making spurious claims.  Most of the time, however, no one in the audience will make such a challenge. The audience is left with a dangling implication (and a superficial sigh?) that the statement is an established fact. 

The non-discerning physician comes away with the “take home lesson” that the assertion is true.  Research has shown that most people only remember one or two salient points from a paper or an oral presentation anyway, and Pharma knows this very well.

A superb example of this was recently seen in the December 2011 edition of the newspaper Psychiatric Times.  The article - for which a doctor could get credit for continuing medical education - was entitled The Clinical and Treatment Implications of Co-Occurring Mania and ADHD in Youths.  It was written by Janet Wozniak, a protege of well-known pediatric bipolar and ADHD enthusiast Joseph Biederman at Harvard Medical School.

Janet Wozniak, M.D.

She writes, "A major component of the debate regarding the diagnosis of bipolar disorder rests with its high overlap with ADHD." (her reference: a paper co-written by Biederman). In truth, the real debate is whether both pediatric bipolar disorder and ADHD are being over-diagnosed in children who have plain old behavioral problems or anxiety due to family dysfunction of various sorts and/or who are just plain acting out.

She admits, "Arguably, all of the symptoms of ADHD, including inattention, impatience, disorganization, and restlessness, could be part of the mania component of bipolar disorder."  And vice versa! Since we have no lab tests, exactly how then are we able to distinguish them? Unmentioned is that all of these symptoms can be due to anxiety or acting out as well.

In her answer to this question, she brings up the fact that, according to the diagnostic manual, the DSM, "episodicity" is a definitional feature of bipolar disease.  Loosely translated, this means that a manic episode has to last for at least a week, non-stop.  She then goes on to say, "However, the documented chronicity and complex/rapid cycling of bipolar disorder in youths often renders the notion of classic episodicity as a distinguishing feature of mania functionally impracticable." So, she is saying that the DSM criterion is at the very least clinically unusable, with the strong implication that it has this idea completely wrong. 

Her view is documented, she opines.  Sounds impressive.  But I don't think she has a leg to stand on.  People who created the diagnosis of pediatric bipolar disorder are the ones who made that up, using circular reasoning in my opinion.  In fact, as I described in a previous post, the available evidence shows that unstable moods (affective instability) in children are not, in fact, related to bipolar disorder. And the whole concept of ultra rapid cycling is also highly dubious in adults, as I described in another recent post.

Of course, Wozniak adds a sentence to the end of the paragraph that implies that the jury is still out on this question, but you can safely wager that the average doc reading this will not pay attention to that caveat.  Besides, it's just not practicable to worry about such issues.

She goes on to point out that of course giving stimulants for ADHD can make mania worse - true, if the child were really manic, a rare occurrence usually involving frank psychosis - and that medications for mania have a lot of potentially toxic side effects (also true).  So if you cannot tell ADHD and bipolar disorder apart by their symptom presentation, then what is a doctor to do?

Simple.  She recommends diagnosing children with BOTH conditions!  If you treat the patient with a downer like depakote, then the stimulant won't make them hyper.  Uppers in the morning, downers in the evening, sugar at suppertime.  File this under pharmacology, insane.

She then states that one study demonstrated that children with the "combined disorder" continued to meet criteria for both mania and ADHD after discounting overlapping symptoms, which to her "suggests" (to most readers, "suggests" means that it's true) that co-morbidity is not an artifact resulting from shared diagnostic criteria.  And who did this study?  Biederman's group!

And then comes the kicker.  She states that 70 to 90 percent of pre-adolescents with bipolar disorder also have ADHD!  Imagine that.  70 -90 per cent.  Her reference for this truly unbelievable figure: another study of which both she and Biederman were co-authors.

Now, I myself often reference my own previous work in my academic papers, but most of my work involves ideas rather than alleged statistics, and I do not want to have to have repeat all of my ideas anew in each paper.  In this case, however, when a whole research group has come under suspicion like Wozniak's has, it might behoove them to quote someone who is completely independent from them and not funded by big Pharma.

Take the Bull by the Horns



In Carolyn Hax's advice column of last November 25, she addressed the problem of people who need to speak up about the way they are being treated by parents, spouses, siblings, in-laws, and other family members and lovers, but do not do so because they "don't like confrontation."

The letter writer had complained that the family of her long-term boyfriend, unlike her own family, seemed to go out of their way to exclude her from their family events.  Holidays had become a bone of contention.  The boyfriend refused to say anything about this to his family, despite her entreaties, because (cue cliche), he "doesn't like confrontations."

Ms. Hax's answer contained one of my recent favorite quotes: "People who like confrontations are outliers; the rest of us simply put up with them when the alternative is to tiptoe through life, never articulating where you stand or what you need, and accruing the dissatisfaction of never setting the terms. A suspicion of drama can be healthy, but the moment something needs to be avoided at all costs, then healthy no longer applies."

She added, "...if the only way to avoid drama is for you to absorb all areas of disagreement, then pretty soon there won’t be any you left, either.  The way to avoid that fate — the only way — is to figure out which battles matter to you, and to fight those battles.

I recognize that in many families, speaking up is a lot easier said than done.  In some families, it can lead to verbal abuse, vicious arguments, emotional cut-offs or excommunication, and in some cases, physical violence.  Sometimes family members in response start a guilt-tripping chorus of mea culpa's or figuratively or literally stick their heads in the oven.

Still, just sitting there and allowing a big problem to fester is not the solution.  Nor is divorcing oneself from the family - although that is better than allowing oneself to be abused or mistreated.  The problem with the "just divorce them" school of thought about toxic parents is that we carry our parents around with us in our heads. Unresolved family issues can lead one to have marital problems, as well as negatively affecting our relationships with our own children.

Luckily, there is a third choice besides taking abuse or divorce.

I recommend trying to find some way get around one's family's natural defensiveness in order to discuss the family dynamics and to alter dysfunctional relationship patterns (metacommunication). If you change your approach to them, it can force the others to change their approach to you. Family systems theorists liken the family to a mobile - if you tug at one hanging part, it reverberates throughout the whole piece.  (This does not mean that it is your job to "fix" your family.  Your job is to fix your relationships with the various family members).

But it's a bit more complicated than that. Family members have numerous tricks to counteract changes that you try to make. The target of your metacommunication may counterattack with their own complaints about you, some of which may be quite valid, without ever addressing your complaints about them. Seldom-seen family members may even come out of the woodwork to express the sentiment, "You're wrong, change back!"

Unfortunately there is no one-size-fits-all strategy for discussing family interactions, since each family has there own unique dynamics and sensitivities. [Marketing alert, but only in a good way:] Fortunately, there are therapists around trained in family systems issues who help with this sort of thing (particularly followers of Murray Bowen). Finding one, however, may take a bit of work.

Take the bull by the horns and do it.  It's definitely worth the effort and the expense.

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).

Ve Have Vays of Making You Talk, Part VI: Post Hoc Reasoning

Reproduced from http://xkcd.com/552/

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 the problems that usually ensue whenever they try. 

I discussed the most common avoidance strategy - merely changing the subject (#1) - and suggested effective countermoves to keep a constructive conversation on track. In Part II, I discussed strategies #2 and #3, nitpicking and accusations of overgeneralizing respectively. In Part III, I discussed strategy #4, blame shifting. In Part IV, strategy #5, fatalism.

This post is the second in a series about strategy #6, the use of irrational arguments.  Descriptions of this strategy have been subdivided into several posts because, in order to counter irrational arguments, one first has to recognize them.  I will hold off describing strategies to counter the irrational arguments until after I have describe some of the most common types.

Irrational arguments are used in metacommunication to throw other people. The other individuals either becomes confused about, or unsure of the validity of, any point they are trying to make or question they are trying to ask.  Fallacious arguments are also frequently used to avoid divulging an individual's real motives for taking or having taken certain actions. 

The fallacy I would like to discuss in this post is post hoc ergo propter hoc, which literally translated means "after this, therefore because of this." Under this fallacy, two events that occur in sequence are merely assumed to be causally related. That is, if event B follows event A, then an assumption is made that A caused B, even though many other environmental events were also going on during the time between A and B that could have caused B, either individually or in some combination.

This sort of fallacy can be funny when it is obvious but difficult to detect when subtle. No one would believe a doctor who claims that headaches are caused by a deficiency in the body of aspirin, but the debate rages on over whether the effects on assailants of por­nographic movies caused them to become rapists.

I frequently see this fallacy used in arguments made by the anti-psychiatry crowd.  If some psychiatric symptom developed by a patient occurred after he or she either started or discontinued a drug, they argue that it simply must have been caused by the medication.  Well, sometimes it is, but often it is not.  The further removed in time from when the medication was started or discontinued, the less likely it becomes that the drug had anything to do with the symptom. 

There are a very limited number of drug-induced symptoms that, once started, never go away, and those usually involve a situation in which a drug actually grossly damaged an organ.  Some dyes used in X-ray procedures, for example, may physically damage the kidneys. Tardive dyskinesia, a long-term neurological problem in the central nervous system caused by antipsychotic medication, is one obvious exception.

Withdrawal symptoms from addictive drugs almost always go away after a relatively short period of time.

With patients in psychotherapy, the post hoc fallacy is most frequently seen with during conjoint marital or family sessions. When spotted, such a fallacy may reveal the presence of a family myth.  A family myth is a false belief that assists family members in suppressing those thoughts, feelings, preferences, or behavior deemed to be unacceptable and in allowing one or more family members to continue playing a spe­cific role. The myth may be believed by an individual, a sub­system of the family, or the entire family.

Family myths may take the form of a causal explanation of a family member's be­havior that is not the true explanation. In order to be believ­able, the myth often makes use of the post hoc ergo propter hoc fallacy. In such a myth, the belief in a causal connection is based solely on a sequence of events that takes place in a certain period of of time. If the behavior to be explained begins after a certain event, the behavior is blamed on the event. As with other mechanisms used by people who are attempting to hide their true feelings and beliefs, the proposed cause often re­veals clues to the real cause, even though the proposed cause is meant to be a smokescreen.

One example occurred in a family being seen under duress from a probation officer. A young teenager was caught shoplifting. He lived with his father and his siblings. The mother ­had not only divorced the father but abandoned the family, entirely abdicating any family responsibility in order to pursue a career. The father could rarely spend time with the boy because the firm that he worked for was demanding more and more overtime. The father ­routinely worked fourteen-hour days; he expressed disappointment· that the boy could not take better care of himself without supervision.

The post hoc fallacy was expressed in the session following an incident in which the son picked a fight with another boy who was twice his size. The father theorized that the son had engaged in this rather dangerous activity because he had not had a good night's sleep the night before the inci­dent - and was therefore overly irritable.

This seemed to me a rather odd explanation. When provoked, overly irritable people will sometimes unthinkingly do or say things that they other­wise might keep to themselves, but they seldom go out looking for trouble.

The father appeared to be attempting to veer away from any explanation of the boy's odd behavior that might involve family dynamics, but he unwittingly revealed something about himself. It was he, the father, not the son, who was irritable from lack of sleep.

I later guessed that the boy's acting-out behavior was a feeble attempt to force the father, who was utterly ex­hausted from working so much, to work less. The probation officer had in fact required the father to be at home more in order to supervise the misbehav­ing youngster. The boy was also bidding for more attention, as many therapists would theorize, but I believed that he was genuinely concerned about his father’s mental health.

When I suggested to the father that the boy was, at great per­sonal sacrifice, attempting to indirectly demonstrate his concern by forcing the father to insist on more time off, the father never really bought it. However, soon Dad was spending more time home, and the patient stopped acting out. No causal connection between my intervention and the boy’s subsequent im­provement was ever established. 

Physicians as Unwitting Research Subjects

"We'd like to invite you to join your colleagues and thought leaders in the field for a discussion concerning a new treatment for major depression."

This sounds like something that a busy physician, trying to keep up with the latest developments in the field, might really benefit from.  I continue to get invitations that sound just like this one.  The group sponsoring such discussion groups is not usually identified clearly in the invitation, but if it is mentioned the name usually contains words like "medical education."  Of course, the sponsor does not formally offer the kind of Continuing Medical Education most physicians require for keeping their medical licenses.

When I was a young and somewhat naive psychiatrist back in the early 1980's, I responded to one of these invitations to learn about a new antidepressant called Desyrel (generic name: trazodone).  This medicine is used today primarily in low doses (25 -  150 mg.) as a non-addictive sleep medication because many people find it extremely sedating.  The anti-depressant dose, rarely prescribed because many people taking it have trouble staying awake, is 400 to 600 mg per day.  Consequently, many doctors don't think it is an effective antidepressant because they never prescribe anywhere near that much.

Desyrel came out in the years before the SSRI antidepressants like Prozac and Paxil were on the market, and many docs were looking for alternatives to tricyclics like Elavil or imipramine, and MAO inhibitors like Nardil, since those medications often cause a lot of side effects and are also fatal if taken in overdose.  The real sponsor of the discussion group - the pharmaceutical company making Desyrel - was well aware of this and was looking for the best ways to take advantage of this situation in order to increase the number of prescriptions being written for its new drug. 

And not just by having doctors learn about the drug.

In fact, the real and covert reason for sponsering such discussion groups in the first place is to study physician behavior.  Of course, I did not know that at the time.  The drug companies were putting doctors under the microscope to determine the best ways of marketing their products.  They still do this, and they are very good at it.

Looking back, I remember the "leader" of the discussion asking the panel, "If I told you that Desyrel works much faster than tricyclics, would that be something that would be important to you?"  Since anti-depressants, when they work for Major Depressive Disorder, do not begin to kick in for about two weeks, and do not provide their full benefits until five to six weeks have elapsed, this would indeed be a fine selling point.

"Of course," most of the members of the now quite excited discussion group replied.

Since then, almost every new antidepressant, up to and including the latest one called Viibyrd, has made the claim that it has an earlier onset of action than all the others. 

For the record, none of them actually does.

The pharmaceutical industry shows particular interest in discussion group members who seem reluctant to endorse their new product.  These folks become objects of more intense study.  The group leaders probe these persons to find out exactly what might convince them to prescribe the new pill.  How can they best appeal to them?  Feed their ego in some way?  Preach patient convenience?  Which side effects are they most concerned about? 

The answers to these questions are not only used to develop overall strategies for pharmaceutical sales reps to use with reluctant prescribers, but are also used to compile information on individual physicians in the area, so sales reps can prepare themselves with a plan that is highly tailored to each physician. The plan is then used on the unsuspecting practitioner to help increase the number of prescriptions for their drug that that doctor writes.

The success of the reps is then monitored by the company by studying the prescribing practices of the given physician.  This information is readily available from local pharmacies unless the physician knows that he or she can opt out of allowing pharmacies to sell their information, as I described in a previous post.

Ultra Rapid Cycling Bipolar Disorder

OMG! Watch out for flying pigs!  DUCK!

Pigs in Spaaace

Something I have been harping about for years was finally correctly set straight in - of all places - a throwaway, drug-company supported, pharmaceutical-advertisement infested psychiatry journal - Current Psychiatry. Frozen hell!

In an article by Joseph F. Goldberg M.D., a clinical associate professor of psychiatry at the Mount Sinai School of Medicine in New York, the following summary was highlighted as a "bottom line: "Ultra rapid cycling [bipolar disorder] has not been validated as a distinct clinical entitiy, and frequent mood swings should not be used as a criterion for diagnosing bipolar disorder."

In the diagnostic Bible, the DSM, a rapid cycling bipolar disorder is defined as an individual who has four episodes of depression or mania per year, not per hour.  Yet the "bipolar disorder is everywhere" crowd has insisted for decades that there was such a beast as an "ultra-rapid cycler."  Thus anyone who was moody, had a sudden mood change no matter how brief, or had  the unstable emotions characteristic of individuals with borderline personality disorder, was suddenly "bipolar" and in need of medication for his "bipolar spectrum disorder." 

"Psychotherapy? What's that?" they seem to say.

The supposed existence of rapid cycling was advanced as an argument against using anti-depressant medication in bipolar patients having a depressive episode, because the drugs allegedly induced it.  This argument was even picked up by Robert Whitaker, author of Anatomy of an Epidemic, as a possible reason to be cautious about using antidepressants in general.  An argument based on a phenomenon invented by some psychiatrists that does not even exist!

Funny how after having practiced for 35 years in two states, with a wide variety of clinical populations, and specializing in the treatment of borderline personality disorder, I have never seen rapid cycling, with the possible exception of one case in which sudden episodes of psychosis (not mood changes) would come and go without warning.  Maybe I've just been lucky.  Or rapid cycling could be so rare as to be nearly non-existant.

When I first saw the cover of Current Psychiatry under discussion, I must admit was prepared for the worst.  "Oh no, not again,"  I thought. At least, I figured, I would have more material for a new post with another scathing attack on the whole bipolar spectrum craze.

Then I read the article.  What a pleasant surprise.

Meanwhile, in other myths-about-bipolar-disorder news, a new small study seems to contradict a bit of current conventional wisdom about the disorder: A study published in the January issue of the Journal of Affective Disorders (Baldessarini et. al.,136, 2012 pp. 149–154) reported: "Patients with bipolar I disorder show disease progression that is random or even 'chaotic.'"

After following 128 patients with bipolar I disorder for about six years to assess "inter-episode intervals (cycle length)," researchers found that "most current bipolar I disorder patients are unlikely to show progressive shortening of recurrence cycles."

In the past, the impression that bipolar patients had episodes more frequently as they got older, the authors believed, was a statistical artifact caused by a minority of patients with frequent recurrences!

As most of these subjects were being treated with medications, and were probably going on and off of them every so often as patients are wont to do, this is evidence that the treatments do not make bipolar disorder worse over time.

An Update of Some Earlier Blog Posts

There have been some new developments recently concerning some of the issues and stories I have discussed previously on this blog, so I thought I would write a new post that updates some of my previous ones.

First, apropos my post of May 25, Pro-death Florida Legislators Run Amok, about a recently-enacted Florida law prohibiting health care practitioners from even discussing health care concerns about gun ownership with their patents: it was temporarily blocked by Federal U.S. District Court Judge Marcia Cooke. The state plans to appeal the injunction blocking enforcement of the law.

Second, concerning the debate about SSRI antidepressants and whether they are better than placebos:  A Commentary in the December 2011 edition of the American Journal of Psychiatry pointed out that placebo response rates to antidepressants in studies have increased as much as 7% per decade since 1980. 

Not coincidentally, this bizarre inflation of placebo response rates correlates very well with the timing of the rise of the so-called contract research organization, or CRO (http://opp.morningstar.com/PDFs/MOI-EvoCRO.pdf).  These organizations are usually doctors in private practice who are hired by drug companies to do their randomized controlled studies of medications.  These doctors get paid - quite handsomely - for each subject that they successfully recruit for the study. 

The subjects are, in turn, recruited through offers to pay them for their participation. ABC News recently did a story about stay-at-home moms who turn themselves into guinea pigs to earn extra cash. The use of paid subjects has led to the phenomenon of the "professional research subject" who participates in multiple drug trials.

Under these circumstances, both the doctors and the patients are being given cash incentives for exaggerating their symptoms in the initial evaluation so they can qualify for the study!  Once they are picked, no one then has a financial incentive to exaggerate symptoms on follow-up exams.

No wonder placebo response rates have skyrocketed.

CRO Newspaper ad clues in potential research subjects who wish to get paid as to what symptoms to complain about



Last, there are two developments concerning schizophrenia and its treatment with antipsychotic drugs. 

First, as the states have been cutting back on funding for community mental health centers due to the economic downturn, we are seeing a lot of what is described in the following news article:

http://www.freep.com/article/20111127/OPINION02/111270434/After-closing-psychiatric-hospitals-Michigan-incarcerates-mentally-ill-?odyssey=tab%7Ctopnews%7Ctext%7COpinion

After closing psychiatric hospitals, Michigan incarcerates mentally ill

"Wayne County Sheriff Benny Napoleon spoke for most sheriffs when he said, during a community meeting earlier this year, that his jail had become his county's largest mental health care institution.
Over the last two decades, changes in state policy and big cuts in funding for community mental health care have pushed hundreds of thousands of mentally ill people into county jails and state prisons...

"'We closed too many (hospitals), too quickly,' Mark Reinstein, president of the Mental Health Association in Michigan, told me this month. "It wasn't done in a planned, rational way."
Community mental health agencies -- which were supposed to take up the slack but never received the resources to do so -- face continuing budget cuts. The state has resumed warehousing its mentally ill -- this time behind bars...

 "In 1999, a Department of Community Health study -- conducted by Wayne State University -- of jails in Wayne, Kent and Clinton Counties found that more than half their populations were mentally ill and one-third were seriously afflicted, suffering from schizophrenia, bipolar and other psychotic disorders... Since 2008, the state has slashed $50 million from community mental health agencies, with Wayne County absorbing more than half of the cuts.

"Treating one client in a community program costs about $10,000 a year, compared with $35,000 a year to house one prisoner.  Statewide, more than 200,000 people a year use community mental health services, but experts say at least twice that many need them."

To really understand what happens when funding to community mental health centers is cut significantly, one has to realize that fewer patients with schizophrenia will get treated with anti-psychotic medication. Such medication is all the treatment that community mental health centers are providing nowadays.  In addition, those patient with schizophrenia who are seen will be seen much less frequently.  We know from multiple sources that lack of close follow-up highly exacerbates the issue of people not taking prescribed medications (non-compliance).

Off their meds, psychotic patients still end up being incarcerated, but as this story indicates, in jail, not in a hospital. Paradoxically, psychotic inmates are usually then prescribed anti-psychotic medications in prison - at a much higher cost.

One wonders how author Robert Whitaker (Anatomy of an Epidemic), who believes that antipsychotic medications make psychotic people worse, explains away how people with schizophrenia somehow become far more likely to end up in jail when they do not take antipsychotic medication.  Or perhaps he thinks that this development is the result of a malicious government plot .

The question of whether schizophrenia is in fact a real brain disease, and why it has been so hard to pin down the actual pathology, was recently addressed in a newspaper column by neuroscientist  par excellence John J. Medina. 

John J. Medina

An excerpt:

"... a biological explanation for the disease seems heartbreakingly just out of reach. Schizophrenia has a powerful genetic component (heritability percentage is in the low 80s), something I’ve known for years, something that could make it low-hanging research fruit. There is also a large clinical base on which to do studies: schizophrenia afflicts millions of people (the estimated prevalence rate is about 1% of the global population). Despite these seeming advantages, a molecular mechanism capable of describing all aspects of schizophrenia has almost completely eluded researchers.

"There’s a simple reason for this. A deep understanding of schizophrenia at such an intimate level has been hampered by a single technical bottleneck: the lack of a robust in vitro [in the lab as opposed to in the body] disease model.

"That may all be about to change. The results from a study that used cells derived from a deceased patient’s skin tissue has recently been published. Findings from the study may provide just such a model. It is not yet full-fledged schizophrenia-in-a-dish, but the findings portend a powerful future for the field."

Medina then goes on to explain a new technology - a way to produce something called Pluripotent stem cells (iPSC's) which I will not go into here.  Basically, they are re-programmed stem cells.  He then goes on to say:

"With these technologies in mind, I now have the tools needed to understand how to create a dish-bound model of schizophrenia. It involves answering some simple questions: What if you took the skin cells from patients who had schizophrenia and turned them into neurons? Would they exhibit behaviors of typical, healthy cells? Or would they exhibit behaviors reminiscent of previously determined properties of neurons in patients with schizophrenia? If the latter were observed, would you have a robust cellular model of schizophrenia, the missing link in this line of work? A consortium of researchers decided to to find out."

Skin cells from diseased patients made iPSCs that were similar to cells that were obtained from unaffected people.

"The most interesting result came from what happened next. Even though the reprogrammed cells were clearly neural tissue, they did not behave like typically functioning neurons. Several observed differences were eerily similar to previous findings other researchers had seen in tissue samples from patients with schizophrenia."

Despite what you may hear from mental illness deniers, neurons (brain cells) derived from patients with previously diagnosed schizophrenia "exhibit specific, aberrant properties."  I do not wish to get into highly technical neuroscience on this blog, but anyone interested might want to look up definitions for the following terms, and learn about how brain cells from people with schizophrenia differ from those who do not show symptoms of the disorder:

Dendritic arborization,  neuregulin expression, and Global gene expression changes.

After pointing out that this technology does have some problematic aspects to be resolved, Medina concludes: "Having a dish filled with cells that carry many characteristics of a human disease is a lot like having a flashlight in a dark cave. The greatest utility is in the ability to illuminate molecular mechanisms that might go undetected without such a model. It can go a long way toward relieving the frustration often associated with this line of work. Give it enough time and it might even—someday—illuminate a cure."

Undoubtedly, mental illness deniers will find something wrong with any evidence that schizophrenia is a brain disease.  It's in their nature.

The Cognitive Behavioral Mafia

I recently posted on my Psychology Today blog what I had written in a previous post from this blog, The Limits of Cognitive Therapy.  In it, I had the audacity to criticize one very prominent technique used in Cognitive Behavioral Psychotherapy (CBT), and discussed how it neglects a type of cognition that is central in personality pathology (the family myth). I also complained that CBT therapists grossly exaggerate the strength of their evidence base from randomized controlled psychotherapy outcome studies while simultaneously blocking funding research into other forms of treatment.

Researchers who look at other psychotherapy techniques and are members of the Society for Psychotherapy Research (a group I used to hang with for several years), refer to the "cognitive behavioral mafia" at the NIMH, which systematically blocks grants for research into other therapy schools.  Leading trauma researcher Bessel van der Kolk couldn't get a psychotherapy research grant at one point because of it!

They also blocked me from getting a small grant to study my therapy paradigm, unified therapy.  The grant I had applied for was supposed to be for researchers to get preliminary data – called pilot data – for new ideas.  Although the rejection I got did point out some very valid things I needed to change with the proposed study design (and would have been readily agreeable to doing so and then resubmitting the grant proposal), their biggest criticism of my proposal was that I did not have any pilot data! 

Writing two books on psychotherapy and having 20 years of clinical experience (at that time) did not count at all.  I did not get a low score, I got no score. Roughly translated: faggetaboutit.

In response to my Psychology Today post, not surprisingly The CBT folks went on the attack.  In fact, another blogger on Psychology Today named Robert L. Leahy posted a rebuttal on his blog. I was accused of being a – horror of horrors – psychoanalytic psychotherapist, which I of course am not in the least.

While I can see how many people might have mistaken my post, because of my broad style, for an attack against the entire CBT treatment model - which if you read the post carefully it decidedly is not - I was accused of mischaracterizing the entire field because I was talking about one specific although very central intervention they use.

Cognitive therapy pioneer Albert Ellis called it active disputation and the other cognitive therapy pioneer Aaron Beck called it collaborative empiricism. Interestingly, some other commenters implied that the technique I focused on  is no longer being used at all by the other main innovator of CBT, Aaron Beck.   This is patently untrue.  He just changed the name to cognitive restructuring  or guided discovery.

In the post, I had given an example of a family myth in action in a psychotherapy case.  In the early 1980’s, I was trying out a technique from paradoxical psychotherapy called reframing, in which a family member labels something as bad and the therapist changes the valence to good.  For instance, an acting out child is described as the savior of the parents marriage because he or she is distracting them from their arguments.  (Technique used best by family systems therapy pioneer Salvador Minuchin). 

I was accused by the critics of “arguing with my patient” and that I was both doing and oversimplifying the cognitive therapy technique. Some of them also seemed to dismiss Albert Ellis in favor of Beck, as Ellis definitely did argue with patients until he died, although in a very empathic way. 

Salvador Minuchin

This contention might be true if one’s definition of argument is limited to the type of argument seen in Monty Python’s argument clinic:

 “Yes it is.”

“No it isn’t!” 

“Yes it is!”

 “No it isn’t!” 
 

What Beck does instead is examine the “empirical evidence” for the patient’s “irrational” thoughts to see if it is consistent with the facts.  That, my friends, is a form of argument (as is reframing –also not merely contradicting the patient).

From a discussion of cognitive therapy on Psych Central: “Cognitive-behavioral therapy, in a nutshell, seeks to change a person's irrational or faulty thinking and behaviors by educating the person…”  They won’t get an argument from me.

Another thing I was accused of was that I did not acknowledge that CBT has changed from the early days and has become a much more complete treatment, even though my original post clearly stated:

It is interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in severe personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do.  

This criticism was actually one I considered to be fair, and I quickly acknowledged that CBT has evolved considerable from its early days.  However, I pointed out that the evolution mostly consisted of stealing, slightly reinterpreting, and renaming concepts and techniques from other psychotherapy schools.  Even the central psychoanalytic concept of transference, vehemently denied by both behavior therapy and cognitive therapy since their inception, is merely redesignated as “the client's underlying schema about themselves and others.”

Speaking of schemas, the critics particularly complained that I wasn’t acknowledging them because I said that both Beck and Ellis (not CBT in general) have both said repeatedly that they believe that human beings are fundamentally irrational.  The concept of schemas, or mental models of how relationships and other things in the world are supposed to work, did not originate completely within CBT circles. 

Mardi Horowitz was one of the first widely read psychotherapists to talk about it - and he was psychoanalytically-oriented.  The concept of life scripts, which are basically several schemas linked together to form a plan for one’s life, was originated by another therapy school called transactional analysis.

I also happen to know Jeff Young, who is the main champion of using cognitive schemas in therapy.  He had in fact been a protégé of Aaron Beck, and was one of the cognitive therapists in the big NIMH collaborative study on depression in the 80’s (which incidentally also found interpersonal therapy equally effective to CBT in "depression"). Jeff personally told me that many of his former colleagues in cognitive therapy circles turned on him when he started to talk more about issues such as the effects of child abuse.

It is also true that Jeff Young had to go to Holland to get funding for a psychotherapy outcome study of schema therapy.

Another person commenting accused me of "whining" about the CBT mafia because I mentioned that I was blocked by them from getting research funding.

Still another thing that I was accused of doing was denigrating psychotherapy research in general, which is also something I did not do.  I had merely opined that the CBT people were over-selling the strength of their research results. 

Critics immediately jumped into my favorite form of sophistry: circular reasoning.  They basically made the point that because cognitive therapy was scientifically proven (not!), money should not be wasted on studying other paradigms!  In other words, why do we need more studies when we're already convinced.

Many of the critics also seemed to be saying that CBT was some sort of monolithic entity and did not acknowledge that there are several sub-schools of CBT which all approach patients differently  and which argue among themselves about who is right.  There is ACT, REBT, DBT, and schema therapy, to name but a few.  Schema therapy in particular is quite unlike the original form of cognitive therapy, as it not only looks at the developmental origins of so-called irrational ideas but sees the origins as central to the actual therapy. 

At least one critic went on to accuse me of being unscientific because I was not using CBT therapy exclusively with my patients, as well as being possibly unethical because I used "unscientific" treatments:  “It is also clear you practice a therapy with no established evidence base. An eclectic mix that where you've picked and chosen what you like from different schools without the package being subject to evaluation. Overall this sounds like deeply unethical (and potentially dangerous) clinical practice.”

Oh, like that isn't what all therapists do - including CBT therapists who pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them without having their "whole package" subject to evaluation. Of course, by the critic's reasoning, the originators of all the CBT techniques were all unethical because they undoubtedly tried them out on patients before packaging them for outcome studies.

This critic illustrates another point of confusion: a basic misunderstanding of psychotherapy research. As I said, CBT therapists in treatment studies pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them and then subjecting the "whole package" subject to evaluation. Since every therapist in the study is doing something somewhat different with each patient, a truly scientific evaluation of “the “package” would be quite a feat!

In fact, outcome research does not focus on specific techniques but on some overall strategies. Finding out which techniques were valuable and which superfluous on their menu of interventions would require something called dismantling studies, which are few and far between. Psychotherapy process research, on the other hand (of which there is a huge literature that dwarfs the outcome research) does focus on specific techniques, and often shows that techniques used by more humanistic and relational therapies are highly effective for certain therapeutic goals.

Adherence to the therapy model by the different therapists participating in an outcome study is another big issue. If it is measured at all, it almost always shows wide variation. There is usually no "red line" by which, if a therapist's adherence to the model goes below a certain point, his or results are not included in the study! So what really worked?  We don't know. 

The critics on both Psychology Today blogs seem to be proving my point that CBT grossly exaggerates its science base. When I and another commenter pointed out specific and highly significant weaknesses in their literature, the silence was deafening.

Also noteworthy that not a single critic had anything to say about the issue that was the main point of my blogpost – the existence and importance of family myths. I asked them for references where this issue or where any social psychological concept that was similar had been discussed by CBT therapists. Not a word.

To my knowledge, cognitive therapists have never written about how many allegedly irrational ideas are held collectively by kin groups.  Ignoring collective phenomena is actually a problem with almost all forms of individual psychotherapy, because therapists are entirely wrapped up only with what goes on inside people's heads.

The sole complaint of the only critic that even mentioned family myths was that I had not brought it up until the tenth paragraph of my original post. (That was because I had to explain some concepts from cognitive therapy before my criticism would make sense). So sue me.

I was too lazy to quote a bunch of studies to demonstrate the weaknesses in their science, and I figured they would merely cherry pick some counter-examples and then summarily declare victory.  However, another reader came to my rescue.

****Submitted by Philip on November 26, 2011 - 6:34am.

I have been reading a number of outcome studies recently because I am seriously worried by claims that 6 to 20 sessions of cognitive behavioural therapy are sufficient to cure such disorders as major depression and anorexia nervosa.

Allow me to summarize, briefly, the findings of a meta-analysis of CBT for bulimia nervosa. The rate of recovery for patients who completed treatment was found to be around 45%. This is quite substantial - a substantial minority of patients recover after and average of 12 sessions of CBT or behaviour therapy (they are equivalent in effect). It should be noted that there is very little follow-up data by which to judge whether or not these patients remained well.

However, consider the following:

20% of patients dropped out of treatment. 40% of patients who were initially considered for inclusion in the studies were excluded from treatment. This is because, as Dr Allen correctly noted, such studies exclude co-morbid patients (those with multiple diagnoses). Thus, the treatment samples are composed of less complex cases.

As an aside, most outcome studies of CBT for depression exclude around 60-70% of patients - again, because these cases are considered too complex to treat with CBT.

Back to bulimia. On average, after completing treatment, patients continued to binge/purge twice per week. So, although the treatment resulted in a statistically significant reduction in symptoms, many - perhaps most - patients remained symptomatic.

Thus, 45% of a restricted sample (which excluded severely disturbed patients bulimia, patients with bulimia and drug or alcohol addictions, suicidal patients with bulimia and patients with 'borderline personality' disorder and bulimia) reportedly recovered (with little follow up data to support this conjecture).

One of the authors of a study reporting these results concluded that CBT is the "treatment of choice" for Bulimia Nervosa. It is the only treatment that has been adequately studied. This is what Dr. Allen is referring to when he notes that the credentials of CBT are exagerated.

If we actually think about Bulimia in the real world - where most patients have severe co-morbid disorders, and 50% also have a borderline pattern of symptomalogy - these studies tell us little about the efficicy of CBT. In the lingo of researchers, outcome studies have little 'external validity'.

Why is it that researchers are unwilling to apply CBT to complex or co-morbid cases? They claim it is because they want to exercise experimental control - they want their studies to have internal validity. That is, they want to know which treatment works for which disorder.

It is also very likely that, were researchers to attempt to treat severely disturbed patients with CBT, they would fail to obtain results which reflect well on CBT. They also would have a hard time getting their work published, for journals do not like to publish null [negative]-findings.

If one is willing to read the research carefully, and has a basic education in statistics and research methods, the evidence supporting the effectiveness of CBT is very modest. Indeed, CBT contains a smaller and less diverse 'evidence base' than does cotemporary psychoanalytic psychotherapy.

What CBT has more of than other psychotherapies is outcome research. However essential outcome studies are, they "prove" nothing about the validity CBT. For all they show, the patient might be cured because of a placebo effect or because of cognitive restructuring. Same same but different.

This is called, by the way, the dodo bird effect: the finding that all treatments are equivalent (whether they be behavioural therapy, CBT, 'psychodynamic' therapy, interpersonal therapy and so on). That's what outcome studies tell us. And we don't know why. It seems that the debate is only just starting, and some have already declared CBT the winner.

Thanks, Philip.

When it comes to getting people to change their behavior, thoughts and feelings, there is always a multitude of ways to skin the proverbial cat.  And every patient responds to interventions differently. This is where social sciences differ from hard sciences like physics.

"CBT therapists are superior to therapists from all other schools of thought, so come see us." This exaggeration of the research results by CBT folks looks a lot like the same phenomenon seen in drug studies these days: it isn’t so much science as marketing.

Mainstream Media Finally Covers a Scandal

Kudos to ABC news for finally reporting on the scandal in which disturbed children in foster care are being drugged to shut them up - rather than being treated for the trauma of coming from abusive or neglectful homes and then being passed around from foster family to foster family. 

Bizarre and pharmacologically absurd cocktails of powerful central nervous system drugs are prescribed after five minute visits with doctors.  Foster parents are often pressured to go along with the practice.



You can find the story at  http://abcnews.go.com/US/study-shows-foster-children-high-rates-prescription-psychiatric/story?id=15058380

The government report that ABC describes is the only thing that's "new" about this story.  I have seen  this discussed for several years in the professional media.

Only problem is, while foster kids get treated like this more often than other children, they are hardly the only ones getting this sort of "treatment."

Were They Awarded Tenure for These Studies?

It’s once again time to discuss some brand new psychiatric studies that would be just perfect for my two favorite journals, “Duh!” and “No Sh*t, Sherlock.”

As we all know, our collective experiences are nothing more than anecdotal evidence for anything, and what appears obvious to almost everyone cannot be considered true unless subjected to a randomized controlled or epidemiological study. 

Research dollars are very limited and therefore precious.  Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already thought to be true but have yet to be "proven"?  Such an approach increases the success rate of studies almost astronomically.

And studies with positive results are always far more likely to get published than negative ones, so why should an academic take that risk?

Here are some of my favorite recent headlines reported by psychiatric news gathering organizations:

“Body dissatisfaction appears to be the major factor propelling young people on the road to eating disorders.”  Really? I though most people do not complain about being too fat or too thin.  I mean, especially women.

“Sleep disorders are prevalent with mental illnesses.”  And here I was under the impression that depressed, anxious, and paranoid patients slept more soundly than anyone.

“Youngsters with depressed fathers are more likely than other kids to have emotional and behavioral problems, according to a new study of more than 20,000 U.S. families.”  This is so good to know.  I had no idea that having unhappy, miserable adult family members might affect a child’s mood.

"A new analysis released by the Kaiser Family Foundation shows that tough economic times have led to a downturn in doctor visits."  That can’t be true in the United States, where as we all know, everyone gets free healthcare.

"Receiving a diagnosis of dementia increases a person's risk for suicide, particularly if symptoms of depression and anxiety are present," according to a studyresearch published in the November issue of the journal Alzheimer's & Dementia.”  Now come on!  The prospect of becoming senile and a financial and emotional burden on one’s family might cause an already depressed or anxious person to despair?  No way!

“Long-Term US Unemployment Taking Psychological Toll." Now this is really surprising, since we all know money cannot buy happiness.  I was just positive that not having enough food to eat and a roof over your head would hardly matter.

“A history of maltreatment during childhood increases the risk for depression in adulthood and poor treatment outcomes, new research suggests.” Another amazing discovery.  This had never been noticed by either psychiatrists or psychotherapists before now.

And finally, "Violence against women is significantly associated with mood, anxiety, and substance use disorders throughout the victim's lifetime."  Since we already know these psychiatric disorders all have purely genetic causes, we now know that these very same genes also cause women to get beaten up.