Monday, May 22, 2023

Medicating Normal - an Interview

I was interviewed today on the Facebook page for a movie called "Medicating Normal" about the current problematic state of psychiatry - such things as malignant polypharmacy, the over-diagnosis of bipolar disorder and other b.s. diagnoses, doctors spending too little time with patients for a good evaluation, and such.

It can be seen at:

Thursday, May 11, 2023

ACE’s, Brain Changes, and Likelihood of Diseases

As mentioned in my post of January 31, there are many studies showing a correlation between Adverse Childhood Experiences (ACE's) and a wide variety of psychiatric and physical conditions. This is probably also true of the effects on offspring of certain parental behavior problems.

Correlation does not mean causation. Answering the question of whether two characteristics that correlate are also involved in a causative relationship depends on a number of factors. How strong is the correlation? A weak correlation can be a statistical fluke, If there is a lot of natural variation in the characteristics being discussed, the found relationship may just be a coincidence. 

Are there other variables that are not controlled for that create the correlation?  In order to verify any relationship seemingly uncovered in any given study, repeated experiments that lead to the same result become necessary. And even if causation is involved, we may not know which variable was the causative factor and which the result.

The metrics I tend to use also include my answers to the following questions: If A and B are indeed causally related, what else would I have to believe? Can I think of a third, uncontrolled-for variable that could account for both A and B? Can I come up with any logical and known facts or data that might be the explanation for an apparent causative relationship, or does it seem inexplicable or even off the wall?

Last, is this result consistent with what I have seen clinically in my 40 plus years as a psychiatrist, or does it fly in the face of it? Now here it is possible that I might be looking at only confirmatory evidence of my opinions and discounting disconfirming evidence (confirmation bias), although I like to think I have at least a modicum of objectivity. 

So I also ask other psychiatrists and therapists if they’ve seen the same things I have in their clinical experience. When I do that, I have to take into account that I asked my patients a lot of questions that most therapists never even think about asking – for example, “What does your mother-in-law think about this problem your daughter is having?” So they might or might not be able to give me any relevant information.

Many studies showing the same thing makes for a stronger case for causation. When it comes to ACE’s and later illnesses, both psychological and physical, they usually pass most if not all of the tests above with flying colors. And they keep on coming in. Here’s some recent additions:


1.    Childhood Adversity Tied to Race-Related Differences in Brain Development

In this study, exposure to trauma was linked to lower gray matter volume in key brain regions in black kids. Among children ages 9 to 10 years, white kids showed greater gray matter volumes compared with black kids in the amygdala, hippocampus, frontal pole, superior frontal gyrus, rostral anterior cingulate, pars opercularis, pars orbitalis, lateral orbitofrontal cortex, caudal middle frontal gyrus, and caudal anterior cingulate (all p<0.001).

Compared with white children, black children had experienced more traumatic events, material hardship, and family conflict and lived in more disadvantaged neighborhoods, while their parents/caregivers had lower income and educational attainment and were more likely to be unemployed.

This analysis provides evidence that contradicts claims about inherent race-related differences found in the brain.

Dumornay N.M., et. al., "Racial disparities in adversity during childhood and the false appearance of race-related differences in brain structure." Am J Psychiatry 2023


2.    Childhood Adversity Tied to CVD in Early Adulthood

Children who experience adversity including serious family illness or death, poverty, neglect, or dysfunctional and stressful family relationships are at increased risk of developing cardiovascular disease (CVD) in early adulthood, a large Danish study of patients aged 16 – 38 has found. Compared to young adults who experienced little adversity in childhood, peers who experienced high levels of childhood adversity had about a 60% higher risk of developing CVD, the researchers found.


Bengtsson J. et al. Childhood adversity and cardiovascular disease in early adulthood: a Danish cohort study.” Eur Heart J. 2023 Feb 14;44(7).


3.    Adolescents’ positive perceptions of their relationships with both their parents are associated with a wide range of favorable outcomes in young adulthood.

In this study of more than 15,000 adolescents, higher levels of adolescent-reported parental warmth, parent-adolescent communication, time together, academic expectations, relationship and communication satisfaction, and maternal inductive discipline were all associated with favorable outcomes in young adulthood.

Participants rated their depression, stress, optimism, nicotine dependence, substance abuse symptoms (alcohol, cannabis, or other drugs), unintended pregnancy, romantic relationship quality, physical violence, and alcohol-related injury.  

This was done while controlling for age, biological sex, race and ethnicity, parental educational level, family structure, and child maltreatment experiences.

Ford, et. al. “Associations Between Mother-Adolescent and Father-Adolescent Relationships and Young Adult Health.” JAMA Netw Open. 2023;6(3)    

Friday, April 14, 2023

Behavioral Disorders are not "All in Your Head"

The serenity prayer: 

God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.


When I read psychotherapy journals and posts on psychotherapy list-serves, it often sounds to me like the field has lost its collective mind. Some authors seem to think that every behavioral syndrome results entirely from some deficiency within a person, rather than being mostly a reaction to their social environment (the fundamental attribution error). If their patients are upset or anxious, they ask them things such as what is wrong with your thoughts or why don’t you know how to calm yourself down (cognitive behaviorists). Or what might be their deep-seated desires that they won’t face (psychodynamic therapists). 

(To be clear I’m not talking about major psychiatric disorders that are most likely real brain diseases such as schizophrenia).  

While these types of questions can be helpful for people who are not very disturbed about their lives and relationships, sometimes their use has been comical. As a psychiatrist named Jim Dillon put it:

“As a psychiatrist, I cringe upon hearing recommendations for psychotherapeutic methods employed to resolve ongoing social conflicts. It is like suggesting labor unions obtain group counseling when the threat of a strike is the only strategy that will improve their economic circumstances.”

Or teaching clients “mindfulness” when they are being invalidated, criticized or abused by their family and spouses - instead of helping them learn how to put a stop to the dysfunctional interactions.


As I described in a previous post, more systemic or social types of therapy that involve family members (family systems therapy), while still out there and being employed by masters’ level therapists, have fallen out of favor with psychologists. And they were never taught to psychiatry trainees at all (except in a residency program that I ran). This has occurred because of a number of social issues. Examples: Feminists thought systems people were blaming just women, who are still the primary caretakers for children;  some folks believed that there were people using the “abuse excuse” for criminal behavior and to avoid taking any personal responsibility for their problems; unscrupulous therapists were uncovering “false memories” of abuse through suggestions to the highly suggestible, as well as through hypnosis.


That last one also points to another issue that shows the field’s current state is more political than scientific. Just because some of the ideas therapists' used for problematic behavior were being misused in some contexts does not automatically make them invalid. Furthermore, if some of aspects of complex theories are wrong, that hardly means that all of them are wrong.


These phony arguments are also used to further the financial interests of  pharmaceutical companies, who want to sell more pills. If everything is a disease, drugs should be all you need. They are also used by the medical insurance companies. These insurers refuse to pay for any longer-term psychotherapy treatments in order to better cash in. They only cover symptomatic treatment. Bogus “medical necessity” criteria are used to drastically cut down the number of sessions therapists can administer. In other words, the current models help the greedy. The federal parity law that says psychiatric disorders must be paid for by insurers just like physical disorders has been a complete joke.


Science has clearly shown beyond a reasonable doubt that the structure of the “plastic” human brain is in part shaped by interpersonal interactions. Most of what we do in social situations is learned (or intuited as I believe some are),  and is then done automatically in response to environmental clues. The brain has about 6 Billion neurons with up to a thousand connections each, and the circuits change in response to what is learned. And learning also includes how to best react to literally thousands of environmental factors operating at different times, strengths and combinations.


An article published by Harvard University Center for the Developing Child says that 700 new connections per second are made in the brains of newborns within the context of care-giving relationships  Another recent study showed that small differences in a mom's behavior early on in interactions with infants may possibly show up in child's epigenome (epigenetics is the study of how genes are turned off and on in response to such things as social interactions).


It is time for therapists to learn, not how to change their clients’ “internal” family system (another recent therapy fad), but how to help them react better to their external one.

Tuesday, March 21, 2023

Book Review: Why People Believe Weird Things by Michael Shermer


Michael Shermer is the man behind Skeptic and the Skeptic Society. The group talks about all the crazy stuff people believe in and promotes science and critical thinking. This book was originally published in 1997 and a new edition came out in 2002. As someone who thinks that there are a lot of crazy ideas in the mental health fields, I wanted to see if Shermer had any ideas about the nature of weird beliefs that I had not already come across.

The book looks at some commonly seen unscientific ideas including abduction by aliens, recovered memories, anti-evolution notions, and Holocaust denial. It tears apart the tricks that leading “thinkers” in these movements use whenever they are seen in the media. Shermer has debated many of them, and seems somewhat surprised by how likeable and intelligent these people can be even when they are pushing very hateful myths.

Their methods include focusing solely on opponents’ weak points while avoiding saying anything definitive about their own position. They use quotations by reasonable experts but use them out of context. They take honest debates about one aspect of some phenomenon within a field to dispute the entire field. They focus on what is not known while ignoring things that are, and they emphasize data that does not fit the prevailing wisdom while discounting data that does.

One of their tactics I am familiar with is the use of the fallacy that if scientists were wrong about one part of a complicated theory like evolution, then the whole theory must be wrong. This reminds me of attacks on psychoanalysis. Just because Freud was wrong about the pervasiveness of the Oedipus Complex or penis envy does not mean he was wrong about the existence of intrapsychic conflicts and defense mechanisms. All-or-none thinking is a hallmark of groupthink.

Another tactic is one which I have written about. It occurs when a theory has been misused for foul purposes by a political or social group. If fact, any idea can be misused like that. Such misuse does not negate the validity of the theory. The big one for me is rejection by a majority of evolutionary biologists of the concept of kin selection because it might be used to justify social Darwinism. One of the people that is responsible for this turn of events is noted evolutionary biologist Stephen Jay Gould, who is someone frequently quoted in a positive manner by Shermer throughout the book.

And speaking of groupthink, that is something the author alludes to somewhat briefly but does not seem to completely understand. In fact, groupthink maintenance is the best answer to the question posed in the book’s title in a lot of cases. I recall when it hit me that oft-used logical fallacies like begging the question and non sequiturs were not just random weaknesses in critical thinking but had a purpose: enforcing group norms, which are often, in turn, enforced by the use of illogical thoughts. In other words, they have a biological purpose.

Instead, Shermer focuses on somewhat more selfish reasons for why folks push a weird point of view. The thoughts are comforting (like believing in a specific type of afterlife), or the idea helps advance some political agenda like racist policies, or to sell books and become famous. He also discusses our ubiquitous tendency to look for data that fits our beliefs while discounting data that does not (confirmation bias). People are very good at “seeing what they are looking for.” People of high intelligence may even be better at that than those lower on that Totem Pole because they can devise reasonable-sounding justifications for their beliefs.

Another issue I had is that the author seems to think that in many of these cases the people who spout nonsense really believe what they are saying, rather than saying them because of an ulterior motive of some sort. He opines, for example, that some of these people believe in, say, alien abduction because they also mistakenly believed that hypnagogic or hypnopompic hallucinations they experienced in which they saw an alien in their room. These hallucinations are actually a normal phenomenon that occasionally occur as people are drifting off to sleep or awakening from a deep sleep. Most of them only last a couple of minutes and, despite what the author says, feel somewhat dreamlike when the person comes to – at least those I’ve experienced did. 

To think that very smart people who don’t know about this phenomenon wouldn’t question their own sanity rather than believe that what they saw was real seems to me to be a bit of a stretch. As he points out, a lot of these people are quite bright, so they have to know that a lot of what they are advancing is b.s.

Despite these limitations, the book is a fun and interesting read. The history of fad-like belief systems is informative. He has a lot of amusing stories about arguing about these nutty ideas with their champions on talk shows like Phil Donahue.

Thursday, February 23, 2023

Family Dysfunction and BPD Behavior: A Chicken And Egg Situation


A new article in a nursing journal discusses the experience of Swedish families of people with members who have borderline personality disorder (BPD), and who have access to something they call “Brief Admission” to the hospital because of recent self-injurious behavior (SIB). In their study, 12 patients, whose age range is not specified in the article, have picked out one of their family-of-origin relatives or spouses for the researchers to interview. The relative is then interviewed by phone by two of the authors and asked to describe their experiences as the parents or spouse of someone with disorder. The two authors basically coordinate with each other so they are basically covering the same types of questions.

The authors mention almost in passing that the interviewers had to remind the relatives repeatedly not to focus their discussion on the patient, but rather talk about their own experiences. Not only that, but they also make the claim that “the burden experienced by families of someone diagnosed with BPD involves greater suffering than those with other mental disorders."

Now of course, if a loved one is acting in ways like SIB that reminds everyone that suicide is an issue, they are going to worry more about that person than they may have before. But how are we to know whether the obsession with the patient that is described by the family members over and over again was not what triggered the self-injurious behavior in the first place? After all, some people with BPD hide the self injury from their families (or at least the families are ignoring the evidence for it), while these research subjects obviously did not.

What distinguishes one from the other? Well, in my clinical experience, there are two reasons for this. When SIB is hidden, it’s sole purpose is to stop the panic attacks that occur when a patient feels helpless to alleviate a family problem. When it is not, the behavior does that and also feeds into the parent’s preoccupation with the patient’s mental health.

Of course, the parents will all claim that it was the patient’s behavior that created their preoccupation. This is the basic reasoning espoused by two support groups for parents of offspring that have BPD (TARA4BPD and NEA-BPD). They say such parents are sick and tired of being blamed by the psychiatric profession for their child’s condition. 

As my readers know, I agree that blaming parents is counterproductive because it sidetracks any and all attempts at actually solving problems that are shared by all members of the family and which were caused by events that took place over at least three generations.

So how do we know which came first: the parents’ preoccupation with the patient, or the patient’s self injurious behavior? A true chicken-and-egg type question. My readers already know my answer: the parents’ anxious and guilty preoccupation comes first, which then leads to their child developing the role of spoiler designed to somewhat control both the guilt and anger they see in their parents. The family members then all continue to simultaneously feed into and make worse one another’s problem behavior, especially over the long run.

The parents’ overblown preoccupation, albeit after the SIB has started, can be seen in comments the authors make throughout the study, starting with the above-mentioned statement comparing it to the parents of people with other psychiatric disorders. 

Other examples: the family members’ fear about the children makes “it difficult for them to prioritize their own well being.” The family members have “a hard time allowing themselves to have fun” – due to their feelings of “guilt and shame,” – not fear for their child’s life. “Constantly prioritizing their loved one and ignoring their own well being meant that many of the families suffered from their own mental illness and fatigue diagnoses…” “In this study, feelings of helplessness and anger and a constant need to monitoring their loved ones...”

It seems doubtful that the interviewers asked certain questions about the parent’s pre-occupation having perhaps pre-existed before their child’s SIB began. At least in their article, there is no mention by the authors about the possibility that this was the case, despite their making the following points: “…children can see if someone is unwell and can withdraw and try to make themselves invisible” (that’s only one of many other possible “helpful” responses). “When a parent suffers from mental illness, the children can become carriers of their anxiety.” “Children of parents with mental illness can take a great responsibility for their ill parents.” “…the families and their loved ones’ lived experiences are considered to be linked and interaction with each other.”

The other big problem with this study was that this was a highly biased set of subjects. As mentioned, the SIB of the subjects was known to their families. Also, recall that the patients had to pick a relative for the authors to interview, and the relative had to agree to it. Parents that were sexually or physically abusive would probably not be suggested by the patients, who often go to great lengths to hide the family’s secrets because of dire consequences. 

They know what will happen if they spill the beans. In the family, such revelations are responded to with denial, or alternatively, with an accusation that the patient was at fault for, say, being molested because of being seductive. Usually, everyone in the family including the victim just pretends it never happened – as illustrated by mothers who had been sexually abused by their father letting that man baby sit their own small children when rest of the family suggests it.

And even if the subjects picked the abusive parent, and the abusive parent agreed to be interviewed, it would be highly unlikely that such abuse would be divulged. After all, if it were indulged, the interviewers might have to turn them in!

Tuesday, January 31, 2023

Adverse Childhood Experiences and Psychiatric Disorders


In my last post, I mentioned that the American Psychiatric Association rejected the diagnosis of Developmental Trauma Disorder in 2011, and refused to acknowledge that “…childhood adverse experiences lead to substantial developmental disruptions” and added that this idea is “more clinical intuition than research-based fact.”

In fact, there have been numerous studies showing a correlation between ACEs and a wide variety of clinical conditions. Below are brief descriptions of the results of four studies, recently published, addressing this contention. One is a review and meta-analysis, which is a research process used to systematically synthesize or merge the findings of, in this case, 39 (!) single, independent studies, using statistical methods to calculate an overall or 'absolute' effect.

Of course, the studies do only show correlations, which means that they do not “prove” that ACE’s actually cause psychiatric disorders or even symptoms. But the correlations are as good as any in the psychiatric research literature, which is pretty much minimal in findings that prove actual causation for almost every psychiatric disorder.


Adverse Childhood Experiences Among Adults With Eating Disorders: Comparison To A Nationally Representative Sample And Identification Of Trauma

The primary objectives of the current study were: (1) to examine and compare ACEs between two samples: treatment-seeking adults, and a nationally representative sample of adults, (2) to characterize ACEs items and total scores across demographic and diagnostic information in adults seeking treatment for an ED, (3) to statistically classify ACEs profiles using latent class analysis, and (4) to examine associations between ACEs profiles and diagnosis.  Results: Patients with EDs had significantly higher ACEs scores than the nationally representative sample. Within patients with EDs, four latent classes of ACEs item endorsement were identified. Patients with other specified feeding or eating disorder (OSFED) and binge eating disorder (BED) were more likely to fall into the "Household ACEs" and "Abuse ACEs" groups, respectively, compared to anorexia nervosa-restricting subtype (AN-R). Conclusion: Patients with EDs reported more ACEs than the nationally representative sample, across all ED diagnoses.

“Adverse childhood experiences among adults with eating disorders: comparison to a nationally representative sample and identification of trauma profiles.” Rienecke, Johnson Journal of Eating Disorders , volume 10, Article number: 72 (2022). 


Considerable Mental Health Burden Associated With Childhood Trauma

Trauma is associated with increased odds of anxiety disorders and any psychiatric disorder at age 6 years. There is a considerable mental health burden in association with childhood trauma. 

 “The association between childhood trauma and psychiatric disorders in low-income and middle-income Countries." Alckmin-Carvalho et. al., The Lancet Psychiatry, Oct. 31, 2022.

Association of Neural Connectome With Early Experiences of Abuse in Adults

In this cohort study of 768 participants, individuals with abuse experienced during childhood (but not adolescence) demonstrated an altered connectome [connections between brain neurons] of greater functional connectivity [changes in usual and not pathological connections in various brain areas] associated with somatomotor and dorsal-ventral attention brain networks, irrespective of current diagnosis or symptom state. These findings suggest that a history of child abuse is associated with altered functioning of systems responsible for perceptual processing and attention, and these findings were found in the presence of many different psychiatric conditions.

"Association of Neural Connectome With Early Experiences of Abuse in Adults." Korgaonkar et. al., JAMA Network Open. 2023;6.


A  Systematic Review and Meta-Analysis of the Relationship Between Childhood Adversity and Adult Psychiatric Disorder.

A review and analysis of 39 different studies suggests that childhood and adolescence is an important time for risk for later mental illness, and an important period in which to focus intervention strategies for those known to have been exposed to adversity, particularly multiple adversities. There was some evidence of a dose-response relationship with those exposed to multiple forms of maltreatment having more two and a half times odds of developing a mental disorder. 

“A revised and extended systematic review and meta-analysis of the relationship between childhood adversity and adult psychiatric disorder  [Review]." McKay et. al., Journal of Psychiatric Research, 156 (2022).



Thursday, January 5, 2023

Book Review: The Body Keeps the Score by Bissel Van Der Kolk

As I stated in my Review of Nadine Harris’s The Deepest Well, every mental health professional should know that adverse (traumatic) childhood experiences (ACE’s) - especially with parents who are abusive, neglectful, are perpetrators or victims of domestic violence, have multiple partners, or have substance abuse issues - are a major risk factor for children developing many different psychiatric disorders, as well as being a risk factor for a variety of physical illnesses. Yet therapists and psychiatrists often ignore this issue in favor of theories about some sort of genetically-caused, pre-existing brain disorder.


In this fascinating book, the author also makes the case for the importance of ACE’s, especially in the case of pediatric psychiatric conditions, by examining the physiological effects of trauma on brain development. There is an extensive literature on this, although most of it neglects the fact that a continued relationship with an abusive or formerly abusive parent is usually continuing in some form throughout much of these patients’ adult life. 

In any event, the author points out that organized psychiatry in 2011 refused to acknowledge that “…childhood adverse experiences lead to substantial developmental disruptions” and added that the idea that it is is “more clinical intuition than research-based fact.” They then added, “There is no known evidence of developmental disruptions that were preceded in time in a causal fashion by any type of trauma syndrome.” (From the American Psychiatric Association rejection of a Developmental Trauma Disorder diagnosis, as quoted in the book).


That last part is misleading if not an outright lie. We don’t have high caliber causal evidence on the causes of just about any diagnosis in the DSM. Van Der Kolk has a list of references from an extensive literature on the enduring negative effects of early maltreatment. ACE’s are a major contributor to a variety of psychiatric symptoms that are part and parcel of the genesis of many different psychiatric disorders. Especially the childhood ones like ADHD, conduct disorder, and oppositional defiant disorder, as well as many of the mood and anxiety disorders.


This blindness by the psychiatric community has led to what is called “malignant polypharmacy”  – the tendency of some psychiatrists and psychiatric nurse practitioners to confuse symptoms that appear in different forms within a variety of different psychiatric diagnosis as instead being co-morbid (co-occurring) conditions. When I was in practice, I would find new patients who were on several different psych medications – sometimes including both uppers and downers simultaneously – because new drugs were added whenever the practitioner noticed additional, seemingly untreated symptoms. 

Clinicians had misinterpreted these symptoms as being due to their being indicative of other psychiatric disorders that were not being addressed by the existing drug regimen. As the author points out, what was really not being addressed is the underlying issue – the history of abuse.


As mentioned, and as with the Deepest Well, this book unfortunately ignores the question of whether brain changes caused by ACE’s are at least partially reversible - were it not for continuing reinforcement of the trauma throughout the lives of the subjects of this literature. This question lurks in many of the book’s case examples and within the literature that the author quotes. 

For example, he talks about a case where a woman continued to blame herself for her father molesting her despite her rational mind knowing full well that this was nonsense. He describes traumatized firefighters who were “desperately trying to protect the system.” As part of a suggestion for criteria for a proposed diagnosis of developmental trauma disorder, he included,  “Intense preoccupation with the safety of the caretaker or other loved ones.” He even describes himself as mistakenly thinking that his own parents no longer had a major influence on him!


In the numerous, highly interesting case examples, Van Der Kolk omits mention of whether or not the patient still maintained contact with abusive parents. The closest he comes is a statement on page 210 about a perpetrator "hopefully" not still being around to hurt a traumatized individual.


Nonetheless, this well-written and almost entertaining book is a good introduction to the consequences of ACE’s on psychological and brain development, as well as introducing some possible therapeutic ways to treat traumatized patients. Van der Kolk is a master story teller.

Tuesday, December 13, 2022

Accidental Overdose - or Suicide?


There has been a lot of news recently about the significant increase lately in the number of drug overdoses resulting in fatalities. Most of these overdoses are labeled “accidental,” and surely many of them are. Of course, if drugs have been secretly laced by dealers with something dangerous like fentanyl, and the addict is unaware of that, the overdose can indeed be accidental. Although not necessarily even in that case, because news about the fact that dealers are lacing other drugs with this one has been widely reported in the press, and many addicts know other addicts.


I suspect that a considerable portion of these “accidental” overdoses are actually suicides, either through specific intent at that particular moment, or through strong chronic suicidal intent leading to carelessness that will certainly cause death, but at some unpredictable time.


There is no way to know for certain, obviously, but I would like to discuss the deaths of two celebrities to illustrate my thesis here: actor Phillip Seymour Hoffman and Americana singer-songwriter Townes van Zant.


Van Zandt wrote numerous songs, such as "Pancho and Lefty", "For the Sake of the Song", "Tecumseh Valley", "Rex's Blues", and "To Live Is to Fly", that are widely considered masterpieces of American songwriting.  


Van Zandt died on New Year's Day 1997 from cardiac arrythmia caused by health problems stemming from years of substance abuse.  In 1994, he was admitted to the hospital to detox, when a doctor told Jeanene Van Zandt that trying to detox Townes again could potentially kill him. He grew increasingly frail during the mid-1990s, with friends noting that he seemed to have "withered.”


The evidence for my viewpoint comes in the shape of the lyrics of a song he wrote called “Waiting Around to Die.” I suspect that this is exactly what he was doing.


The lyrics:

Now I'm out of prison
I got me a friend at last
He don't drink or steal or cheat or lie
His name's Codine
He's the nicest thing I've seen
Together we're gonna wait around and die
Together we're gonna wait around and die


 Hoffman told friends he feared he would die of a heroin overdose weeks before his body was found on the floor of his Manhattan bathroom with a needle sticking out of his left arm. The star, who was found with 70 bags of heroin and 20 used needles in his home, returned to AA in December after relapsing into three-day binges. When asked how serious his addiction was, he replied: “If I don't stop now, I know I'm going to die.” And die he did. On 2/2/14, he was found dead in his New York apartment with a needle in his arm. The New York City Chief Medical Examiner said that he died of an accidental overdose of drugs, but one has to wonder how an “accident” can be predicted with such precision.

Thursday, November 17, 2022

Time to Get a Second Opinion?


If a mental health provider has you on a whole lot of different psych meds on the basis of a cursory diagnostic interview without much follow up and almost no attention to what is going on in your life currently, it is time to see somebody else.

In the July issue of Clinical Psychiatry News, Nicolas Badre and David Lehman discuss what is known as “malignant polypharmacy” –  the tendency of some psychiatrists and psychiatric nurse practitioners to confuse symptoms that appear in different forms with a variety of different psychiatric diagnosis. 

They then make multiple diagnoses – many of which are not really separate conditions co-occurring with a primary diagnoses – and prescribe a variety of medications. Many of these are not only not indicated but may interfere with each other or produce unnecessary side effects. This diagnostic and treatment stew also creates a great deal of confusion for the patient about exactly what they are being treated for.

An example they give is a patient who comes to a new doc having been diagnosed with bipolar II (a b.s. diagnosis to begin with), high anxiety, split personality, post-traumatic stress, insomnia, attention deficit and depression.” The medication list of such a patient may include a stimulant and a tranquilizer (uppers and downers and bears, oh my!), a mood stabilizer, two antidepressants, and a low dose antipsychotic!

Overprescribing of dangerous meds is another problem. The Wall Street Journal exposed abuse of Adderall prescriptions by telehealth organizations. One story (8/19/22) was about a man with substance abuse who was given an Adderall prescription after a “30 minute consult” with a Nurse Practitioner who’s specialty was family medicine with no psych training. 

Reports show the company sometimes prescribed after just a 10 min consults, giving 90 day scripts with limited or no follow up. The NP was making 20k per month. Patients were charged $79 to subscribe. Some of these “providers” were given $10 per script per month with some having over 2,000 of them filled per month.


In adolescents, overprescribing has become pandemic. The New York Times (8/27/22) reported on the common medical practice of “the simultaneous use of multiple heavy-duty psychiatric” medications among adolescents. “Such medications are too readily doled out, often as an easy alternative to therapy that families cannot afford or find, or aren’t interested in.” 

The medicines, “generally intended for short-term use, are sometimes prescribed for years, even though they can have severe side effects,” and a number of psychiatric medications “commonly prescribed to adolescents are not approved for people under 18.”


While of course, as the authors of the Clinical Psych article point out, there is in psychiatry a high rate of co-occurring conditions, a lack of treatment specificity, and poor understanding of causes. However, a complete work up includes the doctor looking at all of the patients’ symptoms, biological factors, psychological factors, and social factors, as well as the course of the patient’s illness. 

Are the symptoms present all the time, or do they come and go depending on environmental factors? If the latter, what factors are we speaking of? Does one diagnosis preclude another, like bipolar and unipolar depression? Is there a family history of certain disorders?


Did your clinician even ask about any of this? Like I said, if not, time to find a new one.

Thursday, November 10, 2022