Tuesday, May 15, 2018

60 Minutes on Grandparents Raising Grandchildren: Reading Between the Lines

On Sunday, 5/13/18, the news magazine show Sixty Minutes aired a new story about grandparents raising grandchildren which focused entirely on the epidemic of opioid addiction as the primary cause of the middle generation taking such poor care of their kids that the grandparents had to “take over.” 

The show reported that there are now over one million grandparents raising grandchildren because of their own kids’ failings

This hearkens back to my very first post on my Psychology Today blog, back on June 22, 2011, in which I discussed the already skyrocketing incidence of grandparents raising their grandchildren because of their dysfunctional children’s abdication of the parental role (rather than in those cases of temporary needs like a military deployment). Note that this post was written well before the current brouhaha about the opioid epidemic.

I discussed the idea that the children were, in a sense, being “gifted” to the grandparents, who seemed to the children to have a pathological need to raise children despite continually complaining about it.

I wrote that the major apparent (pardon the pun) reasons were because the children:

1. Carry the psychiatric diagnosis of borderline personality disorder (BPD) and neglect, abuse or otherwise endanger their children. 

2. Have antisocial traits and end up in jail (antisocial personality disorder is also a Cluster B personality disorder just like BPD). 

3. Are addicts or alcoholics. Many of those folks may also exhibit significant Cluster B personality traits at one time or another, although in addicts the traits may disappear if and when the addict cleans up.

As most of my readers will know, I believe that the parents’ intrapsychic conflicts over the role of raising children is by far the most important cause of cluster B symptoms and acting out by their children and adult children. 

Furthermore, the grandchildren in these cases are also being subjected to its manifestations and might later develop the same disorders themselves.

In a previous newsmagazine show from around the time of the earlier post, grandparents raising their grand kids were heard to say how much they loved taking care of the grand kids, but how chasing after them made them soooooo tired! And clearly if we heard that, so did the grand kids. So the grandparents end up doing to the grandchildren the same problematic things that they did to their own children.

Some of these grandparents were interviewed on the Sixty Minutes segment, and the reporter discussed how they were plowing through their retirement savings, having to downsize and not go on previously planned vacation trips, arguing more between themselves, and even worrying about how they would find the money to treat their own illnesses like, in one case, cancer.  Again, if we heard this, so do the grand kids. In fact, one child was asked what the grandparents were giving up in order to take care of them, and replied, “Grandma had to give up dating. She says it all the time.”

Two grandparents protested, “We can’t not do it [take care of the grand kids]; they’re our family!”

When it described what went on before the grand kids were “rescued” by their grandparents, the story did a good job of describing how older siblings would have to become so-called “parentified children” for their younger siblings, and how they felt they had to grow up too fast. I described what can happen in that situation in a previous post.

So was there any evidence that these grandparents may have engaged in problematic relationships with the absent parents that affected the middle generation’s irresponsible behavior with their own kids? Well, no direct evidence, but a couple of things were mentioned in passing that might suggest that this was the case.

In two of the described cases, the grandparents spoke of keeping track of what was going on with their kids and grand kids as the parents became homeless and crashed at various shady dives and crack houses along with their children. Rather than simply calling protective services to investigate, one set of parents bought their child a van and put a tracking device on it, while another set said they camped out across the street from one of said crash pads to make sure that their grandchildren were not being abused. Apparently all night long!

We don’t know for certain how long this sort of “tracking” was going on, but my guess is: a long, long time. As readers recall from my previous posts, the parents’ conflicts over their parental role in many (but not all) of these cases leads them to vacillate between severe over-involvement and severe under-involvement with their kids. One of these two poles often predominates much (but not all) of the time. This creates the double message to the children, “I need you-I hate you.” Constant tracking is one manifestation of the over-involved polarity.

So am I dismissing all of the so-called evidence that opioid addiction is a biogenetic disease over which these parents have no control, and that it has nothing at all to do with family dynamics? Well, yes. If you believe these people have absolutely no control over their drug use, you would also have to believe that:

1.     12 Step Programs like AA and NA could never work. Especially when the addict has "hit bottom" (that is, when the addiction is at its worst).   

2.  The way the drugs makes them feel is so all-encompassing that they lose all ability to reason and the ability to appreciate the harm they are doing to themselves and their own children, or lose the ability to care about that at all.     

3.  If you pointed a gun at them and told them that if they picked up the drug or drink in front of them you would shoot them the moment they did, assuming they believed you and were not overtly suicidal at the time, then they would have to go ahead and let themselves die.

Do you really believe those things?

Monday, April 16, 2018

11 Laws of Systems Thinking

Systems thinking is one of the main themes of Peter M. Senge's best-selling book, The Fifth Discipline, which I reviewed back on November 22, 2016. Family systems therapy - which is at the heart of my form of psychotherapy for personality disorders - is based on systems thinking, and looks at the role of the interactions of all family members over at least three generations in the genesis, triggering, and reinforcement of self-destructive behavior in individual members. 

Senge's book discusses eleven “laws” that apply to the behavior of individuals within groups who are engaged in trying to solve a variety of difficulties that affect the achievments of the group’s goals. The laws look at how a wide variety of different variables interact over the long term, and discuss the folly of efforts to try to reduce problems down to just simple relationships between only two or three variables over the short term.

In this post, I list the eleven laws from the book, with a few minor changes or additions I made to make them more relevant to problem solving specifically in dysfunctional families—as opposed to just any organization.

11 Laws of Systems Thinking.

#1: Today's problems come from yesterday's "solutions." In our desire to avoid conflict, we solve problems by avoiding them. Inevitably, the problem comes right back more intensely and in an even more frightening aspect. Solution: Learning to negotiate and solve problems cooperatively in a win/win manner.

#2. The law of reversed effort: the harder you push, the harder the system pushes back. Attacking the people in the system creates resistance. For example, the more you lecture children about something, the more likely they will be to keep doing whatever you are complaining about.

#3. Dysfunctional family and other problematic interpersonal group behavior gets better before it grows worse, and conversely, it grows worse before it gets better.

When we sacrifice our own needs in order to give the family or group what it seems to need, this stabilizes it over the short run, but since structural problems and ongoing shared intrapsychic conflicts are never dealt with or even addressed, this soon starts causing more problems over and over again.

Conversely, when problems are finally addressed, people often escalate their previous dysfunctional behavior in order to test whether everyone else really wants change - but if everyone sticks to their guns, the problematic behavior eventually subsides and then starts to go away altogether (except for occasional relapses which must then also be openly addressed).

#4. The easy way out usually leads back in. Quick and easy solutions often lead to weak and poorly thought out approaches that backfire. Solutions that come from a desire to avoid conflict or difficulty overlook the deep listening required to reveal the emotional core of family issues.

#5. The cure can be worse than the disease. Without thinking about ALL of the interacting variables, we often fix the wrong problem or approach the right problem inappropriately. Reactions and counter-reactions often leave us in a worse place than we where we started.

#6. Go slow to go fast. Rushing to completion leads to a lack of thoughtfulness and reversals of direction to go back and pick up missing pieces.

#7. Cause and effect are not necessarily closely related in time and space. We often assume the solution to be close to the problem, but most often, today's problems were caused by decisions made long ago but forgotten.

#8. Small changes can produce big results -- but the areas of highest leverage are often the least obvious. Taking the widest possible systemic view allows us to see the small changes that will have long term and beneficial outcomes.

#9. You can have your cake and eat it too -- but not at the same time. Patience is its own reward. Rushing produces compromise such as "I'll cut off my leg if you cut off yours." Taking the long view allows you to accomplish more and reap the benefits of the work.

#10. Dividing an elephant in half does not produce two small elephants. One must look at groups as a whole. Simply dividing people in a family or organization into separate, smaller groups will not produce the same dynamics, nor double the value. The right hand has to know what the left hand is doing.

#11. There is no blame. Perhaps the most critical of the laws of systems thinking, stopping blame eliminates the fear that turns employees or family members against you. Don't try to change people, change systems. Discover the systems problems and you can change the entire direction of a work group or family.

Thursday, March 29, 2018

Drug Abuse and Drug Companies

As most readers will know, opiate abuse and overdoses have increased dramatically in recent years, and it’s all over the news. Some of the public may even be aware of the role of drug companies and drug distributors in the process – the latter being recently profiled on an episode of Sixty Minutes. Let’s look at the role of the drug companies.

A Pharma executive, a billionaire, was arrested in October on charges of bribing doctors to prescribe opioid painkillers. ( The Department of Justice arrested Insys Therapeutics founder John Kapoor, 74, in Phoenix. Kapoor was charged with using bribes and fraud to prop up sales of a pain medication called Subsys, a fentanyl spray typically used to treat cancer patients suffering excruciating pain. Fentanyl is 50 to 100 stronger than morphine, and contributed to the overdose deaths of pop stars Prince and Tom Petty.

When it comes to drugs of abuse, the lunatics seem to have taken over the asylum in medicine these days. In their push towards huge profits, dangerous drugs are being hawked when cheaper, less toxic, and less addictive alternatives are available for treating some conditions. And as discussed in this blog, whole diseases such as “adult adhd” have been invented out of whole cloth.

For those readers who may not know, potentially addictive drugs are referred to by the Drug Enforcement Agency (DEA)  as “scheduled” drugs. Schedule I drugs are the illegal ones. Schedule II drugs are those with the highest abuse potential: narcotics and stimulants. Schedule  IV drugs are those considered to be of low potential for abuse. If you didn’t know how the drugs were scheduled, you certainly would never know it from listening to presentations by doctors working with Pharma.

Pharma hires doctors to do research on as well as give talks to other doctors about their products, totally with the goal of increasing sales – if patients do happen to benefit in some way, all the better – but that is hardly a requirement. The slides that are presented during the talks are furnished entirely by the drug company after being approved internally; the doctors giving the talks are not allowed in most instances to use their own slides.

Pharma is particularly known for employing what they call “Key Opinion Leaders” (KOLs) to give promotional talks to doctors around the country. The more academic credibility they seem to have the better – that is one source of determining who might be a KOL. But it is not the only one.

Pharma can actually get any given doctor’s prescribing records from the pharmacy industry (unless the doctor “opts out” of allowing his or her data to be mined in this way. Most docs are not even aware of this option—and having the information publically available is the default position). Pharma then uses this data to see if prescriptions for their products increase after one of their KOLs makes a presentation. 

Those doctors that make the best salesmen are hired again and again, while those who do not measure up are dropped.

A colleague of mine has taken a course required in Tennessee for licensure that discusses the “proper way” to  prescribe drugs of abuse. The course was sponsored by our malpractice carrier. According to him, one year the leader of the course scolded the doctors present for not prescribing enough opiates to people with chronic pain. 

The doctors were told how much suffering they were causing these patients by withholding these medications. Just one year later, after the “opioid crisis” hit the news, the same course was given. Only this time, the doctors were scolded because they were prescribing these “suddenly” dangerous and highly addictive substances to their patients with chronic pain!
In my post of 3/29/17, Those Big Bad Benzodiazepines, I discussed how the risks of that class of medication (Schedule IV) have been wildly overblown in the medical literature and in public news stories. As well as being classified as “low abuse potential” by the DEA, they do not cause intoxication, and have next to no side effects compared to just about any other class of meds in most patients. I am not saying they are never abused, but usually only by people that mix them with opiates and alcohol. 
And of course any individual can have a bad reaction to any drug. It seems benzo’s are never discussed without the admonition that the “are addictive,” or have a few side effects in (some) patients – while drugs like amphetamines (Schedule II) that are abused far more often, and have more potential adverse or toxic side effects, are enthusiastically pushed.
And I do mean pushed, as in supplied by pushers masquerading as drug companies. I recall a “grand rounds” (a major lecture at an academic department in a medical school) from maybe 18-20 years ago in which the KOL was saying that about 18% of all adults should be on high doses of speed, that the reason that many of the parents of kids diagnosed with ADHD were substance abusers was because, "If you had a kid with ADHD, you'd drink too," and that kids who had ADHD could concentrate intensely on video games in an arcade despite multiple and pervasive loud distractions all about because that is "not concentrating." (I always wondered what the heck it supposedly was). I kid you not.
As another amazing example of drug pushing, one news service for psychiatry called MDLinx devotes a whole e-mail newsletter to articles extolling the use and virtues of drugs like Adderall and Concerta. Some recent examples:
MDLinx Psychiatry 3/13/18 - Ranked, sorted, and summarized by MDLinx editors from the latest literature.
SHP465 mixed amphetamine salts effective, safe for ADHD in adults
Liz Meszaros, MDLinx, 03/08/2018

Researchers investigate the link between ADHD and risk of self-harm
Paul Basilio, MDLinx, 02/23/2018

Study of 23,000 people links ADHD with genetic signature for delay discounting. Paul Basilio, MDLinx, 12/11/2017
They also have a section of their more general psychiatric newsletters also devoted to this goal that is called the ADHD Resource Center: A collection of articles and features related to ADHD with articles like:

            National Conference & Exhib Conference

Of course, none of these Pharma sales mechanisms would matter that much if there were not already a ready market for abusable medications. That market is growing, and adverse childhood experiences and family dysfunction are a huge part of that problem.

Still, as Steppenwolf used to sing, “G-d damn the pusher man.”

Sunday, March 25, 2018

Sunday, March 11, 2018

My 10 Part Interview on Borderline Personality Disorder on Internet Radio Available Again

The audio of my 10 hour discussion of 

borderline personality disorder on 

"Free Thinking Voice - The Earth Needs Rebels" 

internet radio show on 

Orion Talk Radio (which became unavailable 

after the interviewer passed 

away), has now been uploaded to my YouTube 


Saturday, March 10, 2018

When Commonly Believed Ideas Turn out to be False

When I list a whole lot of stupid, money-wasting studies "proving" things we already know on my periodic blog posts from my favorite journals, "Duh!" and "No Sh*t, Sherlock," I often hear the argument that we still need to do these studies because at times things thought to be obvious turn out to be wrong.

While that does indeed happen very rarely, most of the time when a commonly-believed proposition turns out to be false, it's because 1 or the other of 2 conditions was operating:

1. Evidence that calls the proposition into question had been systematically ignored or devalued ("Kids with ADHD are able to appear to be able to concentrate while engaged in video games, but that isn't really concentration"), or

2. The proposition was just an old wives' tale that someone pulled out of their ass and that was never based on widespread observations in the first place ("You should drink eight glasses of water per day").  

This issue relates to the widespread use of certain charges made by those in the fields of psychology and psychiatry with various oxen to gore. They pooh-pooh ideas by saying that the conclusions that some of us base primarily on our clinical experience and multiple observations are automatically invalid because they are based on so-called “anecdotal evidence.” I dissected “anecdotal evidence” in my post of March 11, 2014.

I still maintain that you don’t need a scientific study to prove that the sky looks blue to non-colorblind people at the equator at noon on a cloudless day.

Tuesday, January 23, 2018

The Role of the Family Black Sheep – The Hidden Aspects

Are you a black sheep in your family? You know, the one that doesn’t seem to go along with the program and acts in ways that seemingly run counter to the values of the rest of the family? Guess what: you are not nearly as rebellious as you think you are.

A frequent topic on this blog and on my blog on Psychology Today is dysfunctional family roles. Because of the biological phenomenon known as kin selection, individuals are often willing to sacrifice their own needs and desires in order to act in ways which stabilize unstable parents and maintain what family systems therapists refer to as family homeostasis

The latter is a process by which the family operates by rules, strongly enforced by all family members, in which every family member plays a predictable, designated part. Family rules are originally derived from the culture or ethnic group in which the family has operated as well as by family experiences that necessitated certain behavior. In dysfunctional families, the family rules have become obsolete due to rapid changes in the ambient culture (cultural lag).

Many cultural changes have lead to situations in which individuals are much freer to express their own wants and needs separate from those of the family (self-actualization). If the family is stuck in the past, members (especially the older ones) may be threatened by certain aspects of individual freedom. They may be enticing and seductive, but were strongly forbidden to them by the people that raised them in earlier times.

This desire versus fear dynamic is what the Freudians were talking about with their notion of intrapsychic conflict. What they missed, however, was that the conflict is not entirely intrapsychic, but is triggered and reinforced by an entire family. In fact, the “intrapsychic conflict” is actually shared by all of them! It leads to family members giving off mixed and contradictory messages to one another about what is expected of them.

A big source of shared intrapsychic conflict in families that I have not discussed extensively is changing attitudes toward individual satisfaction involving things such as the proverbial sex, drugs, and rock and roll. There has been a marked cultural shift in the propriety of pleasuring oneself with these pursuits. Because of cultural lag, people will often give lip service to such issues as sexual abstinence or reserving sex for procreation only, while at the same time covertly availing themselves of opportunities seemingly at odds with their expressed values.

This is the situation that leads to one member of the family – often but not always a younger child—to volunteer to be the rule breaker, enjoying that which is attractive to but forbidden to all the others. The others, particularly the parents, get vicarious satisfaction of their own secret desires through watching their children indulge themselves. However, the situation is far more complicated. While black sheep may seem to be having a good time so the parents can do this, that unfortunately is not their only job.

If they have too good a time, and end up being happy and content, a parent who was secretly and subtly pushing them to break the family rules starts to become unstable. Vicarious experience, while mildly satisfying, is just not the same thing as actual experience. The conflicted parents start to wonder about their own choices in life and then become depressed, have marital problems with the spouse that has helped them go along with family rules, or engage in self-destructive behavior.

To prevent this and keep the parents stable, the black sheep must also demonstrate the folly of engaging in the “rebellious” behavior. They do so by, in a sense, finding ways to make themselves miserable because of it. In a sense, they fail at it, so the parents can become once again secure in the knowledge that they made the right decision in sticking to the old prohibitions.

In the process of indulging themselves in sex, drugs, and rock’n’roll, black sheep may develop an addiction, contract a sexually transmitted disease, have an affair and destroy their marriage and their relationships with their own children, have multiple divorces, or become deadbeat dads. The rest of the family can then hold them up as examples that “prove” that the forbidden impulses are forbidden for good reason. The old family rules against self indulgence simply must continue to be followed. 

If they want to redeem themselves, black sheep may have to join a 12 step program and denounce their own willfulness. They need to go back to that old time religion – and the group that they join, in order to maintain itself, also needs someone to do just that. Just like their families need them to do.

Wednesday, December 27, 2017

Family Dysfunction and Gene Expression: Effects on Personality and Behavior

Jenny Macfie, Ph.D., Department of Psychology, University of Tennessee Knoxville

It’s amazing what you can discover if you actually look

When it comes to the “scientific” literature about what causes borderline personality disorder (BPD) and other forms of self-destructive and self-defeating behavior, readers of my blogs know that I think genetic influences are way overemphasized and the effects of dysfunctional family dynamics and child abuse ignored as much as possible.

In my clinical practice, I see dramatic evidence that the effects of the family dysfunction on behavior are often passed down from one generation to the next.  A few studies have also looked at this, and in every case supported this viewpoint.

Two more recent studies support my views in general about what creates the disorder.

Jenny Macfie and others, following the work of Karlen Lyons-Ruth described in a previous post, actually watched the interactions between children aged 4-7 and their mothers with BPD (“A Mother’s Borderline Personality Disorder and Her Sensitivity, Autonomy Support, Hostility, Fearful/disoriented Behavior, and Role Reversal with her Young Child,” Journal of Personality Disorders 31(6):  pp. 721-737, 2017).  

The pairs were given a task with the following instructions: “This puzzle is for your child to complete, but feel free to give any help your child might need.” A researcher presented one puzzle at a time in order of increasing difficulty.  Mothers who did not have the disorder and their child were also given the task. All interactions were observed and scored.

Mothers who had BPD “demonstrated significantly less sensitivity and autonomy support [supporting the child’s efforts to solve the puzzles without the assistance of the parent], more hostility, more role reversal, and more fearful/disoriented behavior in interactions with their children than did comparison mothers.

“Role reversal” is the child taking care of the mother instead of the other way around. In this study they specifically looked at mothers deferring to their child’s demands, the pair acting like playmates (for example, child abandons task and the two run around the room rather than the mother setting limits), and mothers taking the child’s attention away from the task by demanding signs of affection from the child.

There was no group of mothers with other personality disorders so we do not know if the researchers results are specific to mothers with BPD.

In a second, unrelated study, Pierre Eric-Lutz and his colleagues looked at the effects of child abuse on the expression of genes that control the development of the brain (“Association of a History of Child Abuse with Impaired Myelination in the Anterior Cingulate Cortex: Convergent Epigenetic, Transcriptional, and Morphological Evidence,” American Journal of Psychiatry 174 (12), pp.1185-1194, 2017).

Epigenetics refers to the process by which environmental influences turn genes on and off. Most genes in a cell are not operating at all at any given time. Epigenetics ties environmental and genetic influences together in ways that a lot of people in the various mental health field either seem to be unaware of, or consciously ignore. The anterior cingulate cortex is a part of the brain heavily involved in making decisions regarding what to do in various social situations.

Without going into the authors’ methodology, which was quite sophisticated, the study found that individuals abused during childhood showed significantly decreased expression of a large collection of genes involved in myelination of cells in that part of the brain. Myelination is process which markedly changes the level of functioning of brain cells that are part of so-called white matter.

Once again, we find that one of the main purposes of the genes that create the brain in human beings is to make humans exquisitely sensitive to the social environment.

Tuesday, December 5, 2017

Sleep, Discipline and Childhood Behavioral Disorders

A couple of news stories about some new “studies” recently caught my eye. They illustrate the downright ungodly lengths certain segments of the mental health industry, as well as dope-dealing drug companies like Shire Pharmaceuticals, will go to distract both the field and the public from the real cause of many childhood behavioral problems: family interactions. They do so in order to justify their mostly ineffective and potentially toxic treatments. 

The stories were:

1    1. Poor Childhood Sleep May Lead to Behavior Woes in Adolescence by Molly Walker, Staff Writer, MedPage Today, December 04, 2017: Study suggests bidirectional association for some problems

“Young children who had greater sleep problems were more likely to have certain types of behavioral problems years later, Australian researchers found…There was a bidirectional association between sleep problems and externalizing difficulties, such as attention deficit-hyperactivity disorder, oppositional defiant disorder, and conduct disorder, in children when measured at particular time points through early adolescence, reported Jon L. Quach, PhD, of the University of Melbourne in Australia…Quach's group said that the directionality of the associations between sleep problems in children and later behavioral problems are "poorly understood," but argued that "addressing this knowledge gap will provide valuable information to inform the focus and timing of interventions aiming to improve children's sleep and behavior during the elementary school years...Sleep problems were defined by parent report. 

Of course they relied on parental reporting - to make use of parental denial to the maximum extent possible. 

The directionality of the associations between sleep problems in children and later behavioral problems are ‘poorly understood?’” Poorly understood, my ass. See below.

       2.  ADHD and insomnia appear intertwined By: Bruce Jancin, Clinical Psychiatry News, November 30, 2017  (

“Converging evidence suggests that attention-deficit/hyperactivity disorder and sleep difficulties share a common underlying etiology involving circadian rhythm disturbance, J.J. Sandra Kooij, MD, PhD, declared at the annual congress of the European College of Neuropsychopharmacology…Having built the case for circadian disruption as an underlying cause of both ADHD symptoms and the commonly comorbid sleep problems…Multiple studies have shown that roughly 75% of children and adults with ADHD have sleep-onset insomnia.”

Shared etiology for sleep problems and certain childhood behavioral disorders like ADHD? Well, duh. Both are caused by parents who don't know how to discipline their kids. In the case of ADHD, they let them stay up half the night playing video games. And then the kids are too sleepy to concentrate the next day. 

This sleep pattern leads to the circadian rhythm disturbances (getting days and nights mixed up, in a way) described by Kooij. Of course, the discipline problems in the houses of these kids are hardly limited to bedtime. Inconsistent, abusive, and/or just plain absent discipline lead to children acting out. You know, “oppositional defiant disorder” and “conduct disorder.” Like I said, acting out.

Tuesday, November 7, 2017

A Psychiatric Diagnosis: Behavioral Problem or Brain Disease?

When the first edition of the DSM (the manual of psychiatric diagnoses published by the American Psychiatric Association) came out in 1952, it listed about 100 different psychiatric diagnoses. By the time the fifth edition was published in 2013, it listed over 550 separate ones! One has to wonder if early psychiatrists were just missing a bunch of them, or if normal but repetitive everyday problems in living due to trauma, stress, and interpersonal dysfunction have been turned into diseases. I vote for the latter.

At any rate, the DSM uses the word “disorder” to fudge this question somewhat, leaving a “to be determined” answer as to whether any of the diagnoses are brain diseases or just psychological or behavioral problems experienced by normal brains. So how do we go about making an educated guess as to which it is?

The question is complex because the phenomena under discussion are very complex. While our understanding of the brain is increasing by leaps and bounds, it is still very rudimentary. That is because the brain is literally the most complicated and complex object in the entire known universe, with about a trillion constantly changing connections between nerve cells. Remember when computers would go crazy and produce the infamous “blue screen” when two programs would conflict, and you would have to restart it? Imagine what might happen if the computer were not hard wired!

A lot of people, including many in the various mental health professions, seem to be prone to highly simplistic “either-or” thinking. If even one of the 550 DSM diagnoses is a brain disease, then they all must be. Or if one is a behavioral/psychological disorder, then they all must be. That is just stupid. But throughout the history of psychology and psychiatry, the field has often lurched back and forth between brainlessness and mindlessness (as described in Chapter One of my last book), incorporating what turned out to be ridiculous or misguided theories.

Autism is caused by refrigerator mothers. Schizophrenia is just a different way of experiencing the world or due to being placed in a double bind by your family. Sexual promiscuity is a genetically determined trait, and certain races are genetically inferior to others. Acting out by children is caused by underlying bipolar disorder. Obsessive compulsive disorder is caused by harsh toilet training. A central part of women’s psychology is penis envy. The list of nonsensical and grossly mistaken theories like these is nearly endless. I’m surprised that no one ever theorized that the memory deficits in Alzheimer’s disease are really a result of the defense mechanism of repression.

But even without such simplistic thinking, determining which diagnoses are truly diseases and which are primarily behavior problems caused by problematic learning and stress is not easy. You cannot just do an fMRI brain scan, as I described in an earlier post, because that test alone does not distinguish an abnormality from a normal conditioned response to a particular social environment.

And even if something is a brain disease, family stress and dysfunction can make it worse – just like with many physical diseases. Then there’s this: having a parent who gets manic and runs naked through the streets creates huge stresses for a child who observes it. Such children are at risk both genetically and environmentally.

Not only that, but you get into a chicken and egg situation: does having a controlling family create anorexia nervosa, or is having a child who is starving herself to death lead parents to become overly controlling? A child who is more temperamental is often somewhat more difficult to raise than one who is not, leading some parents to engage in problematic parenting practices with one of their children but not others.

The whole question of “what causes” a disorder is further complicated by the fact that with the vast majority of psychiatric diagnoses, there are no necessary or sufficient causes of any sort – only risk factors that increase the odds someone will develop a disorder, and mitigating factors that decrease those odds. And there are usually hundreds of these factors operating over time.

So what standards do I use in forming my opinions about various disorders? To me, by far the most important metric is whether the symptoms of the disorder only appear under certain social conditions, and disappear when the social conditions change. Real brain diseases like schizophrenia do not do that; they are present almost all the time. You see victims “responding to internal stimuli” whether you are talking to them one-on-one or observing out of the corner of your eye on a ward in a state hospital them when they don’t realize they are being observed by staff. They show them no matter who is talking to them, or even if they are put alone in a room in a psychiatric ER with a hidden video camera keeping a watchful eye on them.

Someone with, say, a melancholic depression reacts at a snail’s pace compared to the way they usually react (psychomotor retardation) every waking moment no matter where they are or who they are with, and stay in that state all day every day, sometimes for weeks at a stretch. Luckily, when I trained we could keep patients in the hospital that long so we could see this; today’s trainees do not get to do that any more, so are more easily fooled.

On the other hand, borderline personality disorder symptoms are not like that at all. I would see patients with the disorder acting out with staff in a psychiatric hospital, but behaving completely appropriately with the other patients when they didn’t know I was observing them. In fact, they are famous for acting one way in the presence of certain staff members and exactly the opposite when in the presence of others, leading the two groups to fight with each other (the staff split)!

I’ve seen people I know who have the disorder out and about at music festivals and theaters acting as normally and appropriately as anyone else. In therapy, certain emotional reactions and provocative behavior would come out of them if the therapist did one thing, but would disappear quickly if the therapist changed to doing something else.

In looking at neuroscience evidence, an important metric in distinguishing disease from mere dysfunction is the sheer number of different types of brain anomalies and other neurological findings. As I said, a single fMRI finding alone tells you nothing. But a whole bunch of different fMRI abnormalities with some of them completely unrelated to the symptoms of the disorder suggests a brain disease. For example, people with schizophrenia tend to have a lot of different abnormalities, many of which have nothing to do with delusions or hallucinations. One cannot be certain, of course, but I would be hard pressed to explain many of these neurological findings in terms of conditioned responses to particular social environmental stimuli.