A recent headline in the Psychiatric News (6/18/10) proclaimed, "Imaging Studies May Someday Help Predict Behavior." Sounds a little scary, no? They are talking about a form of mind reading using brain scan technology. 1984, albeit at least 26 years behind schedule. Actually, when you read the article, it sounds like about the best that police and military interrogators might be able to obtain at some point in the future is a relatively fool-proof lie detector.
It seems a German neuroscientist (A German!) named John Dylan-Haynes has been seeking to "observe the point at which a subject has made a decision" about a simple sensory-motor exercize but "before he or she is aware of it." The tasks about which decisions are made are of no emotional significance to the subjects. Using brain scan technology, and with some people, he has been able to predict the decisions the subject makes up to a whole seven seconds before the subject acts. He admits he may just be seeing the person's bias or tendency rather than a full blown decision. Plus everyone's brain reacts slightly differently. It seems highly unlikely to me that scientists will ever break the full minute barrier in the crystal ball department.
Besides, if the experimenter and the subject were both made aware of the brain scan finding at the same time, seven seconds should be more than enough time for the subject to change his or her mind and do the opposite of the original plan. I think we can be safe from the fear that the government will be able to predict exactly what we are going to do before we do it any time soon. That is something only seen in Tom Cruise movies like Minority Report, and we know what an expert in psychiatry he is.
Still, psychological determinists who don't seem to believe that we have any real free will or choice in how we behave have had a lot of traction in the field. On the one hand are radical behaviorists like B.F. Skinner and radical family systems theorists who believe we are nothing more than billiard balls on the pool table of life. This type of behaviorist thinks we are entirely pawns of environmental rewards and punishments, while family systems extremists believe we are at the mercy of collectivist mandates from large social groups.
Of course, if these folks were right, then their theories were not the result of any objective scientific observations or well-reasoned thinking they may have done. They would have come by their theory because they were rewarded for thinking this way, or because they were mindlessly adopting a family myth. In that case, their theories could easily be wrong, so we should not believe them anyways.
On the other hand, radical "biological" psychiatrists believe we are completely at the mercy of our genetic makeup and must do what our genes dictate we do. Any real neurobiologist worth his salt knows, however, that the idea that a gene or group of genes can code for specific complex behavior patterns is utter nonsense. If we did not have the inherent capacity to quickly adapt to environmental contingencies, our species would have been killed off long ago.
Since the radical gene freaks know they are on shaky ground, they are now usually willing to admit that environmental factors do play at least some role in determining future behavior. They have now endorsed what I'd like to refer to as the radical middle ground.
In my post of March 2010, The Heritability Fraud, I explained how so-called biological psychiatrists misuse twin studies to try to determine how much of a psychiatric disorder is created by genetics, how much is created by the "shared" home environment (as if siblings are all treated exactly the same by their families), and how much is created by "unshared" environmental influences as seen in identical twins raised apart. In the studies, the prevalence rates of disorders are compared in identical and fraternal twins raised together and raised apart. Another fraudulant way that the statistic is used is that the study reporters just assume that the disorders in question are 100% determined by these three factors.
How this leaves free will out of the equation can be readily appreciated by looking at heritability studies done on specific behaviors like school truancy rather than on entire disorders. Again, the three factors are just assumed to add up to 100%. The percent of these behaviors that are caused in heritability studies by personal decisions, thinking, anticipating potential outcomes or rewards and planning accordingly? ZERO percent. By this reasoning, the designer of the studies must not have used any reasoning in figuring out how to do heritability studies. Even the guy who did the very first one. Well, come to think of it, maybe that is true in the case of people who do heritability studies.
I guess I like to think that I have free will. I just don't know about you.
Saturday, July 31, 2010
Tuesday, July 27, 2010
Mad, Bad, Blind, or Stupid
A long time ago in a galaxy far far away, a Viennese Jewish man by the name of Sigmund Freud noticed that some of his patients would engage in the same unproductive behavior over and over again with the same bad results each time. He called this phenomenon the repetition compulsion, and it has been observed over and over again by psychotherapists from a lot of different theoretical perspectives. Some of them may have called it something else, but they were all observing the same baffling phenomenon. Readers may have heard of the oft-told tales of, say, a woman with abusive parents who runs away and marries an abusive man, leaves him and then marries another abusive man, and so on over and over again. Or another who keeps ending up with alcoholics, but only tries to meet men in bars. Not to pick on women of course; some men have trouble, say, keeping a job because they keep picking a fight with a succession of different bosses.
Einstein said that doing the same thing over and over again but expecting a different result is the definition of insanity. Are people who repeat the same self-defeating behavior over and over again insane? I'm not talking about people who are psychotic here, so presumably they are somewhat sane. Maybe they are just incredibly stupid? If what they do hurts other people as well as themselves, maybe they are just evil. Mad, bad, stupid. Unfortunately most theoretical answers to the question of the reasons for the repetition compulsion presume that those who engage in it are one of these three things. Interestingly, when the offspring of abusive parents talk about their parents' motives, they usually also attribute the parents' horrid behavior to one of these three factors. Forgive them, for they know not what they do.
Freud thought that people repeated self-defeating behavior patterns because of unconscious motives, and were somehow not aware that they were contributing to their own misery. The feelings were too frightening to think about and so, he opined, the feelings and accompanying thoughts became unconscious. I always wondered how people could miss the fact that their behavior was repeatedly having the same negative results. Oh, you might rationalize what happened away the first couple of times, but then? I would think that these results would make the consequences of specific behavior patterns rather salient. Maybe it does make you nervous to think about it, but on the other hand, if your behavior repeatedly leads to your being hit over the head with a two by four, I think you would just have to notice.
This issue came up in a recent debate I got into on another blog called the Last Psychiatrist over the behavior of people labeled with narcissistic personality disorder (NPD). Such people bully, dominate, and control other people, demand to be given special treatment by everyone regardless of anyone else's needs, and are constantly seeking admiration and approval. Many posters to the blog thought these people were actually trying to get their way all the time, and were constantly striving to gain the admiration of other people.
Here is the DSM description of NPD:
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
(4) requires excessive admiration
(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
(8) is often envious of others or believes that others are envious of him or her
(9) shows arrogant, haughty behaviors or attitudes.
Gee, if your starved for admiration, can you think of a worse way to obtain it than by exploiting people, being completely unempathic for the plight of others, and acting arrogant and unjustifiably self-important? I can't. The English language has a word for people that behave like that: Assholes.
So, are NPD's too blind to notice all the people around them referring to them as assholes? Too stupid to see how their behavior contributes to that designation? Masochists who like to be thought of as assholes? Wait, I thought they wanted admiration. Well maybe that part shouldn't be part of their description. Maybe they are just evil mofo's who want to bully people to get their way because they are selfish and sadistic.
Mad, bad, stupid. A long time ago, but in this galaxy, and more recently than Freud, I began to wonder how I might be able to explain the repetition compulsion if I assumed that people are neither mad, bad, blind, nor stupid. What a concept! In the case of NPD, that could only lead to one conclusion. For some reason, NPD's were making themselves look like assholes on purpose. Eww. Masochists, huh? But how can someone really enjoy pain? Pain is supposed to be a physiological danger signal that says, "Get your finger away from the hot stove!" It is supposed to be unpleasant, almost by definition. Emotional pain serves a similar function. How on earth could people have evolved to be masochists? That trait should have been killed off, as people who cannot feel pain frequently are killed precisely because they don't have a physiological alert symptom.
What a mystery, huh? It is also very true that people who engage in self defeating behavior do not seem to understand that their behavior is getting them into trouble. But can they really be that stupid? Could it be that they are just pretending to be stupid? But they are so convincing at it! And why would anyone want to do that?
Some of my earlier blog posts have hinted at what I believe the answers to these questions to be. Stay tuned. In later posts, I will discuss more about hidden altruism, something else I call the Actor's Paradox, and another something else I call the Net Effect of Behavior. (Or you can read my first book, A Family Systems Approach to Individual Psychotherapy, in which I spell out the early versions of some of my ideas).
Einstein said that doing the same thing over and over again but expecting a different result is the definition of insanity. Are people who repeat the same self-defeating behavior over and over again insane? I'm not talking about people who are psychotic here, so presumably they are somewhat sane. Maybe they are just incredibly stupid? If what they do hurts other people as well as themselves, maybe they are just evil. Mad, bad, stupid. Unfortunately most theoretical answers to the question of the reasons for the repetition compulsion presume that those who engage in it are one of these three things. Interestingly, when the offspring of abusive parents talk about their parents' motives, they usually also attribute the parents' horrid behavior to one of these three factors. Forgive them, for they know not what they do.
Freud thought that people repeated self-defeating behavior patterns because of unconscious motives, and were somehow not aware that they were contributing to their own misery. The feelings were too frightening to think about and so, he opined, the feelings and accompanying thoughts became unconscious. I always wondered how people could miss the fact that their behavior was repeatedly having the same negative results. Oh, you might rationalize what happened away the first couple of times, but then? I would think that these results would make the consequences of specific behavior patterns rather salient. Maybe it does make you nervous to think about it, but on the other hand, if your behavior repeatedly leads to your being hit over the head with a two by four, I think you would just have to notice.
This issue came up in a recent debate I got into on another blog called the Last Psychiatrist over the behavior of people labeled with narcissistic personality disorder (NPD). Such people bully, dominate, and control other people, demand to be given special treatment by everyone regardless of anyone else's needs, and are constantly seeking admiration and approval. Many posters to the blog thought these people were actually trying to get their way all the time, and were constantly striving to gain the admiration of other people.
Here is the DSM description of NPD:
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
(4) requires excessive admiration
(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
(8) is often envious of others or believes that others are envious of him or her
(9) shows arrogant, haughty behaviors or attitudes.
Gee, if your starved for admiration, can you think of a worse way to obtain it than by exploiting people, being completely unempathic for the plight of others, and acting arrogant and unjustifiably self-important? I can't. The English language has a word for people that behave like that: Assholes.
So, are NPD's too blind to notice all the people around them referring to them as assholes? Too stupid to see how their behavior contributes to that designation? Masochists who like to be thought of as assholes? Wait, I thought they wanted admiration. Well maybe that part shouldn't be part of their description. Maybe they are just evil mofo's who want to bully people to get their way because they are selfish and sadistic.
Mad, bad, stupid. A long time ago, but in this galaxy, and more recently than Freud, I began to wonder how I might be able to explain the repetition compulsion if I assumed that people are neither mad, bad, blind, nor stupid. What a concept! In the case of NPD, that could only lead to one conclusion. For some reason, NPD's were making themselves look like assholes on purpose. Eww. Masochists, huh? But how can someone really enjoy pain? Pain is supposed to be a physiological danger signal that says, "Get your finger away from the hot stove!" It is supposed to be unpleasant, almost by definition. Emotional pain serves a similar function. How on earth could people have evolved to be masochists? That trait should have been killed off, as people who cannot feel pain frequently are killed precisely because they don't have a physiological alert symptom.
What a mystery, huh? It is also very true that people who engage in self defeating behavior do not seem to understand that their behavior is getting them into trouble. But can they really be that stupid? Could it be that they are just pretending to be stupid? But they are so convincing at it! And why would anyone want to do that?
Some of my earlier blog posts have hinted at what I believe the answers to these questions to be. Stay tuned. In later posts, I will discuss more about hidden altruism, something else I call the Actor's Paradox, and another something else I call the Net Effect of Behavior. (Or you can read my first book, A Family Systems Approach to Individual Psychotherapy, in which I spell out the early versions of some of my ideas).
Saturday, July 24, 2010
Counting Symptoms that Don't Count
A horrible trend has been taking off for the last decade in psychiatric offices across the country. As fees for psychiatrists were ratcheted down by managed care insurance companies, especially for psychotherapy, psychiatrists have tried to keep up their income by becoming primarily prescription writers and seeing as many patients per hour as they possibly can. This has let to the infamous ten or fifteen minute "med check." In this short period of time, the context of the patient's life experiences as it affects a patient's psychological condition is seldom even evaluated, let alone taken into account, in making a determination of which medications and dosages are appropriate for a particular patient.
The time squeeze has also adversely affected the patient's initial diagnostic evaluation. A comprehensive evaluation takes at least forty five minutes, even if the doctor only superficially touches on all the relevant information that needs to be elicited from the patient. Initial evaluations now are often squeezed into a half hour, which often includes the time the doctor has to write his note, return phone calls, and/or go to the bathroom. If any reader plans to see a psychiatrist who does not schedule an hour for a new patient, I would advise that reader to run as fast as you can in the opposite direction!
So what does a doctor who spends so little time with a patient do to save time? I mean besides completely ignoring the patient's relationships, history of truama, humanity, etc. (One of my patients reported being screamed at by his last psychiatrist, "I don't want to hear about your mother!! I just do meds!"). Well, one thing they can do is ask only about symptoms, and blindly accept the patient's yes or no answer without even checking to see if the patient understands the difference between a transient mood state and a psychiatric symptom. Better yet, before the doctor even sees the patient, he or she can have the patient fill out a symptom checklist, and base his diagnosis entirely on that. (Of course, his secretary could make a diagnosis doing that, so the patient really wouldn't even have to talk to the doctor at all).
So, is it not true that the DSM, the diagnostic Bible in psychiatry, just lists symptoms as diagnostic criteria, and says how many of them you need to make a given diagnosis? No! It requires a doctor to also make a clinical judgment about the diagnostic significance of any symptom a patient reports. This involves asking follow up questions like a good newspaper reporter. Just because a patient reports staying up all night without feeling tired for seven days in a row does not mean that the patient also remembered to report that he was sleeping during the day, or was on a cocaine binge.
To illustrate better what I mean, I would like discuss the contents of an article called Avoiding Diagnostic Deficit Disorder in Bp Magazine. Bp Magazine is a periodical about patients' experiences with bipolar disorder. The disorder, which used to be called manic depression, is characterized primarily by distinct periods of severe mood elation and other periods of severe depression, separated by normal periods (euthymia) in between.
I was not able to find much online about the publishers of this magazine, and what I found may be faulty, but apparently the publisher, Green Apple Courage Inc., was founded by one Bill MacPhee, a patient with schizophrenia who was finally stabilized on medication and became productive again.
The primary advertisers for BP Magazine were listed on one web site as "Platinum sponsor Pfizer Inc. and Gold sponsors Bristol-Myers Squibb Company, Otsuka America Pharmaceutical, Inc. National mental health association advertisers include the Child and Adolescent Bipolar Foundation, Depression and Bipolar Support Alliance, Mental Health America and the National Alliance on Mental Illness." I started getting the magazine in the mail for free unsolicited, which usually means a pharmaceutical company is paying for mailing the publication to psychiatrists like me. Draw your own conclusion about whose interest the magazine might be best serving.
Anyway, the article expresses concern that bipolar patients might be misdiagnosed with something else, when the real danger nowadays is that a patient with something else will be misdiagnosed as "Bipolar II," which in my humble opinion is part of the Bipolar, My Ass Spectrum Disorder. So it advises potential patients to tell their doctor about symptoms such as agitation, impulsivity, racing/obsessive/cluttered/busy thoughts, hypersexuality, hyperbuying, euphoria, decreased need for sleep, and use of alcohol or other agents to relax. It advises that they report these other symptoms last: depression, anxiety, panic, and trouble concentrating.
The article neglects to point out the fact that in mania, these symptoms all have to occur at the same time, and be totally atypical for the way the person normally functions. I mean, true bipolars are like Jeckyl or Hyde (not both at the same time) for an extended period of time. They do things while manic that are totally out of character for them. These characteristics of the symptoms are absolutely essential for determining their diagnostic significance.
We speak of the three p's: pervasiveness, persistence, and pathological. The symptoms of mania in particular have to affect every aspect of the person's life regardless of the person's changing external circumstances, they have to continue for a full week at the very minimum, and they have to cause significant distress or impairment. (Hypomania, hallmark of bipolar II, only has to last four days. Not four minutes, four days. It is the only condition in the entire DSM that does not require distress or impairment). One also has to take into consideration the state of a patient's current relationships in order to rule out normal reactive mood changes.
But wait, there's more! Every symptom that the article recommended reporting first is non-specific. That means that each and every one of them can be symptoms of several different psychiatric disorders, depending on their other characteristics, or they may just be normal personal variants or the result of having a bad day. I mean, anyone here ever go on a spending spree and buy more than they should have? The nation's huge credit card debt screams out that this is hardly a phenomenon only seen in manic or hypomanic patients.
Let's take irritabilty, for another example. It can be a symptom of mania, but it can also be a symptom of major depression, dysthymia, generalized anxiety disorder, panic disorder, a personality disorder, the abuse of a variety of different drugs and alcohol, side effects of medications, having just had a big fight with your mother, or just feeling irritable for that day for no particular reason at all.
Now, the doctors who think everyone who comes to them is bipolar and is in serious need of drugs object to the DSM bipolar criteria for duration of symptoms. That may be a legitimate criticism, but so far there is not a single shread of evidence linking brief mood swings like going into a rage to true bipolar I disorder. The doctors pushing this idea basically pulled the idea that they are related out of their asses.
To prove this, however, they do studies in which they diagnose people who do not meet the duration criteria for mood episodes as "bipolar not otherwise specified (NOS)," which is a diagnosis that is listed in the DSM. What the NOS designation is supposed to be used for is people who just barely miss DSM criteria, like someone having manic symptoms for six rather than the required seven days. It is not supposed to be used for people who miss the criteria by a country mile, like a person having a ten minute mood episode. I would call the tactic of using the NOS category for patients like that as Nothing Other than Stupid.
They then do studies which include patients that they have diagnosed with their version of the NOS disorder, thereby gathering a sample of subjects that contains a certain number of people who have ten minute mood swings. They then look at their overall sample to see how many of their "bipolars" have this symptom, and voila! A significant percentage do, therefore "proving" that bipolars can have ten minute mood swings. If you don't understand the term circular argument, you can look up the term circular logic. It might say that circular logic means the same as circular reasoning. If you don't know what circular reasoning means, you can look that up and find out that it means the same as circular argument.
One blog reader asked me why I do not believe in brief mood swings. Of course I believe in them. They are just not symptoms of bipolar disorder.
The time squeeze has also adversely affected the patient's initial diagnostic evaluation. A comprehensive evaluation takes at least forty five minutes, even if the doctor only superficially touches on all the relevant information that needs to be elicited from the patient. Initial evaluations now are often squeezed into a half hour, which often includes the time the doctor has to write his note, return phone calls, and/or go to the bathroom. If any reader plans to see a psychiatrist who does not schedule an hour for a new patient, I would advise that reader to run as fast as you can in the opposite direction!
So what does a doctor who spends so little time with a patient do to save time? I mean besides completely ignoring the patient's relationships, history of truama, humanity, etc. (One of my patients reported being screamed at by his last psychiatrist, "I don't want to hear about your mother!! I just do meds!"). Well, one thing they can do is ask only about symptoms, and blindly accept the patient's yes or no answer without even checking to see if the patient understands the difference between a transient mood state and a psychiatric symptom. Better yet, before the doctor even sees the patient, he or she can have the patient fill out a symptom checklist, and base his diagnosis entirely on that. (Of course, his secretary could make a diagnosis doing that, so the patient really wouldn't even have to talk to the doctor at all).
So, is it not true that the DSM, the diagnostic Bible in psychiatry, just lists symptoms as diagnostic criteria, and says how many of them you need to make a given diagnosis? No! It requires a doctor to also make a clinical judgment about the diagnostic significance of any symptom a patient reports. This involves asking follow up questions like a good newspaper reporter. Just because a patient reports staying up all night without feeling tired for seven days in a row does not mean that the patient also remembered to report that he was sleeping during the day, or was on a cocaine binge.
To illustrate better what I mean, I would like discuss the contents of an article called Avoiding Diagnostic Deficit Disorder in Bp Magazine. Bp Magazine is a periodical about patients' experiences with bipolar disorder. The disorder, which used to be called manic depression, is characterized primarily by distinct periods of severe mood elation and other periods of severe depression, separated by normal periods (euthymia) in between.
I was not able to find much online about the publishers of this magazine, and what I found may be faulty, but apparently the publisher, Green Apple Courage Inc., was founded by one Bill MacPhee, a patient with schizophrenia who was finally stabilized on medication and became productive again.
The primary advertisers for BP Magazine were listed on one web site as "Platinum sponsor Pfizer Inc. and Gold sponsors Bristol-Myers Squibb Company, Otsuka America Pharmaceutical, Inc. National mental health association advertisers include the Child and Adolescent Bipolar Foundation, Depression and Bipolar Support Alliance, Mental Health America and the National Alliance on Mental Illness." I started getting the magazine in the mail for free unsolicited, which usually means a pharmaceutical company is paying for mailing the publication to psychiatrists like me. Draw your own conclusion about whose interest the magazine might be best serving.
Anyway, the article expresses concern that bipolar patients might be misdiagnosed with something else, when the real danger nowadays is that a patient with something else will be misdiagnosed as "Bipolar II," which in my humble opinion is part of the Bipolar, My Ass Spectrum Disorder. So it advises potential patients to tell their doctor about symptoms such as agitation, impulsivity, racing/obsessive/cluttered/busy thoughts, hypersexuality, hyperbuying, euphoria, decreased need for sleep, and use of alcohol or other agents to relax. It advises that they report these other symptoms last: depression, anxiety, panic, and trouble concentrating.
The article neglects to point out the fact that in mania, these symptoms all have to occur at the same time, and be totally atypical for the way the person normally functions. I mean, true bipolars are like Jeckyl or Hyde (not both at the same time) for an extended period of time. They do things while manic that are totally out of character for them. These characteristics of the symptoms are absolutely essential for determining their diagnostic significance.
We speak of the three p's: pervasiveness, persistence, and pathological. The symptoms of mania in particular have to affect every aspect of the person's life regardless of the person's changing external circumstances, they have to continue for a full week at the very minimum, and they have to cause significant distress or impairment. (Hypomania, hallmark of bipolar II, only has to last four days. Not four minutes, four days. It is the only condition in the entire DSM that does not require distress or impairment). One also has to take into consideration the state of a patient's current relationships in order to rule out normal reactive mood changes.
But wait, there's more! Every symptom that the article recommended reporting first is non-specific. That means that each and every one of them can be symptoms of several different psychiatric disorders, depending on their other characteristics, or they may just be normal personal variants or the result of having a bad day. I mean, anyone here ever go on a spending spree and buy more than they should have? The nation's huge credit card debt screams out that this is hardly a phenomenon only seen in manic or hypomanic patients.
Let's take irritabilty, for another example. It can be a symptom of mania, but it can also be a symptom of major depression, dysthymia, generalized anxiety disorder, panic disorder, a personality disorder, the abuse of a variety of different drugs and alcohol, side effects of medications, having just had a big fight with your mother, or just feeling irritable for that day for no particular reason at all.
Now, the doctors who think everyone who comes to them is bipolar and is in serious need of drugs object to the DSM bipolar criteria for duration of symptoms. That may be a legitimate criticism, but so far there is not a single shread of evidence linking brief mood swings like going into a rage to true bipolar I disorder. The doctors pushing this idea basically pulled the idea that they are related out of their asses.
To prove this, however, they do studies in which they diagnose people who do not meet the duration criteria for mood episodes as "bipolar not otherwise specified (NOS)," which is a diagnosis that is listed in the DSM. What the NOS designation is supposed to be used for is people who just barely miss DSM criteria, like someone having manic symptoms for six rather than the required seven days. It is not supposed to be used for people who miss the criteria by a country mile, like a person having a ten minute mood episode. I would call the tactic of using the NOS category for patients like that as Nothing Other than Stupid.
They then do studies which include patients that they have diagnosed with their version of the NOS disorder, thereby gathering a sample of subjects that contains a certain number of people who have ten minute mood swings. They then look at their overall sample to see how many of their "bipolars" have this symptom, and voila! A significant percentage do, therefore "proving" that bipolars can have ten minute mood swings. If you don't understand the term circular argument, you can look up the term circular logic. It might say that circular logic means the same as circular reasoning. If you don't know what circular reasoning means, you can look that up and find out that it means the same as circular argument.
One blog reader asked me why I do not believe in brief mood swings. Of course I believe in them. They are just not symptoms of bipolar disorder.
Monday, July 19, 2010
Do Antidepressants Cause Suicide?
Readers of comments to this blog may have noticed that I have had frequent discussions with readers who question all use of psychiatric medications. They know that I believe (actually I know) that medications can be extremely useful in some properly diagnosed patients with disorders known to respond to the medications who are also monitored for the emergence of side effects.
I have had some interesting conversations on the back channel with people who are absolutely convinced that loved ones committed suicide directly because of having taken an antidepressant. Psychiatrists counter that antidepressants prevent suicide because they treat depression, which is itself - obviously - a cause of suicide.
There is some data that indicates that antidepressants can increase suicidal ideation (but not necessarily completed suicides) in teens and young adults who take antidepressants. So what gives?
Before I answer that, I would like to point out that anti-depressants take two to six weeks to work, and often we have to increase the dose or change drugs which makes this period of time much longer, so people are at risk for suicide because of the underlying depression before the drugs have kicked in. Frequent follow up and a good suicide evaluation usually can prevent tragedy. Also, as I have posted before, there are different types of depression. The less severe type, dysthymia, will often not respond to meds at all, while significant major depression usually does.
But yes, antidepressants per se can indeed cause increased suicidal ideation, suicidal behavior, and completed suicides. However, I believe this only happens in three very specific situations, all of which can be managed by a competent psychiatrist.
The first situation is when a patient develops a side effect known as akisthesia, which is extreme agitation in which a patient can barely sit still. Milder agitation can also be a side effect. Studies clearly show that a mix of depression and anxiety greatly increases the risk for suicide. The psychiatrist can warn patients about this side effect and tell them to call the doctor if it develops. Tranquilizers usually take care of this problem, but some patients must be switched to a different antidepressant, which may or may not cause that particular side effect.
Second, if a patient has bipolar disorder but has not yet had a manic episode or has been misdiagnosed, an antidepressant can unpredictably cause them to switch into mania. Some mania is not characterized by euphoria as it is in most typical mania, but can instead be "dysphoric mania" in which the patients are miserable rather than elated. Suicide risk is high in this condition. Again, family members can be warned to look for signs of this and stop the patient from taking any more antidepressant until the doctor is reached.
Third, in a severe form of depression called melancholia, patients have a lot of clear-cut biological symptoms like thinking in slow motion and having no energy for anything. When treated with an antidepressant, their energy tends to come back well before they felt better subjectively. They suddenly develop the energy to kill themselves whereas before they did not. This is well known to psychiatrists - or should be well known - as a very dangerous time for suicide attempts.
We warn patients and families about this, and tell them to get guns and other possible means of suicide out of the house during this crucial time, as well as to keep an eye on their depressed family members. We are not seeing as much melancholia these days as we used to probably because patients usually get an antidepressant before their illness develops to the point where it is that severe - indirect evidence that the drugs are effective, by the way.
Readers of this blog also know I am highly critical of both pharmaceutical company marketing tactics and "biological" psychiatrists who think that pills can cure every human foible, that psychotherapy is a bunch of bull that has never been validated in randomized controlled studies (totally not true), and who tend to exaggerate the benefits of drugs in those conditions in which they are indicated.
I have not had many comments from these latter type of folk on the blog. So, in the spirit of being an equal opportunity critic, I thought I would post a debate I had on another blog called Medscape with other psychiatrists. Parts of the debate are somewhat technical, so I will put explanatory material in brackets and italics. I am not including every post on this particular thread, but only the ones that I respond to or that respond to me, and I've edited out some comments that are not relevant to the points I am trying to make.
The debate was started by a posting by the blogger, Nassir Ghaemi, MD about the finding that antidepressants may increase suicidal ideation in teens and young adults.
Dr. Ghaemi, MD: ...In reviewing the published FDA meta-analysis [combining the results of several different studies, often using different methodology, and running statistics on the combination] of the randomized clinical trials (RCTs) of antidepressants, [a researcher] summarized the rather clear finding that antidepressants seemed to have an age-dependent effect on suicide risk: In children and young adults below age 25, they increased the risk ...in later adult years they were neutral ...and in middle age and in the elderly they were protective... When all these age groups are summarized, antidepressants have a small protective benefit for suicide ...In all these analyses, suicidality (defined as actual suicide, suicide attempts, or notable increase in suicidal ideation) is being assessed, one should say, rather than completed suicide. There were only 8 suicides in 77382 subjects, though 2 were on placebo and 6 on antidepressant.
Predictors of antidepressant-related suicidality with antidepressants were interesting: Suicide attempts (i.e., actual behavior) were more associated with antidepressants rather than increase in suicidal ideation (thoughts without behavior). Also, non-depressed persons (e.g., studies of antidepressants in other conditions such as anxiety disorders or PTSD) were more likely to be suicidal with antidepressants than those diagnosed with clinical depression (major depressive disorder).
[The researcher] also addressed the common critique that adolescent suicides increased after the FDA warning, which led to a decrease in antidepressant prescriptions in children. He reviewed data showing that suicides per 100,000 population for adolescents occurred at rate of 7.3 in 2003, 8.2 in 2004, 7.6 in 2005, and 7.2 in 2006. The FDA warning came out in 2004, but that increase in suicide rates occurred before the decline in antidepressant prescription rates for adolescents, which happened more in 2005 and 2006, corresponding to a decrease in adolescent suicide rates.
It is a not entirely appealing aspect of our profession that we wish to criticize, but not be criticized: Many of us are critical of the pharmaceutical industry, or of diagnosing mental illnesses like bipolar disorder in children, and yet we react angrily when asked to restrain our use of drugs. Instead, we should think seriously about the clear question arising from these data: Why are antidepressants preventive of suicide in later adulthood, and causative of it in younger age?
MD #1: "Why are antidepressants preventive of suicide in later adulthood, and causative of it in younger age?"
The qualifier there is in RCTs for FDA drug approval. There are many reasons these days why clinical populations are different.
My only criticism of the pharmaceutical industry is that they have not found many safe and effective drugs. I would like to be able to prescribe a mood stabilizer to a bipolar patients where I did not have to warn them that in 20 years there is a small but substantial risk of kidney failure. I would be quite happy to provide psychotherapy alone to bipolar patients if it prevented them from killing themselves or otherwise destroying their lives. In fact, it would be much easier to provide therapy than obsessing about lithium toxicity.
MD #2: It's a peculiar to read criticism of pharmaceutical industry for "not found[ing] many safe and effective drugs" along with favorable (at least the way I read it) mentioning of psychotherapy which failed to provide anything substantial and replicable for suicide prevention whatsoever. While pharmaceutical limitations are measurable and evident, psychotherapeutic shortcomings are hidden behind self-congratulatory process. It's de rigueur in psychiatric narrative nowadays to insert reverences toward "psychotherapy" together with BigPharma admonitions (a form of psychiatric PC, I suppose) without any critique of the former or balanced view about the latter.
The response to the criticism 'why the pharmaceutical industry have not found many safe and effective drugs' is unprecedented, enduring assault on the industry from angry psychoanalysts, greedy selfish government, opportunistic politicians, and many busybodies. I am surprised BigPharma stayed in business this long - there are less vexing ways to make a buck.
Me: What a bizarre conversation! Talking about "drugs" or "psychotherapy" or even "depression" as if they were monolithic entities is insane.
Treating a melancholic depression with any type of psychotherapy is indeed a waste of time, as is treating most cases of dysthymia with just drugs alone.
As to suicide with antidepressants, [I list the clinical situations mentioned earlier in this post].
And of course we need better drugs. With all current antipsychotics, for instance, you get to pick between a significant risk for metabolic syndrome and a significant risk of tardive dyskinesia [a long-term neurological side effect]. What a wonderful choice. And of all the things one can choose to criticize big pharma for, I don't think that problem is one of them.
MD #2: It would be nice if one could comfortably tell one type of depression from another and expect at least half of his colleagues to agree. But your dysphoric mania is another man's agitated depression and the third one's depression with ADHD. And someone else's frontotemporal dementia. Before we start claiming superiority of one treatment over another shouldn't we first sort out the nomenclature?
The irony about "wonderful choice" is misdirected. Consider oncological drugs and their side effects. I don't see oncologists mocking BigPharma. Psychoanalytic/dynamic psychiatrists, OTOH, do. They are still convinced that the world is flat and if you keep moving ahead you can fall from the edge of the earth.
Me: I agree there is a lot of diagnonsense around, but if a psychiatrist can't tell a severely melancholic depression from a typical dysthymia, he or she needs to go back to medical school. While the DSM contains a lot of b.s., much of it is also highly consistent with both clinical presentation and treatment response.
About the "wonderful choice," what I said was that should NOT be blamed on big Pharma. However, if you think big PhARMA science is so honest, perhaps you should read The Truth About the Drug Companies by Marsha Angell, former editor of the New England Journal of Medicine, and see if you still think so. Or check out the Zyprexa marketing documents on FuriousSeasons.com, or the US Justice Department settlements with FIVE different big Pharma companies, available on the DOJ website, for a description of highly misleading and pervasive marketing of psychotropic drugs - including ghostwriting journal articles and paying big name "experts" to sign on as authors. Get your head out of the sand!
By the way, I'm not a psychoanalyst in the least. I agree that old line psychoanalysis was wrong about a lot of stuff, but not everything, and hardly any therapists practice it anymore anyway. I mean, biological psychiatrists have stopped doing insulin shock, so I don't continue to hold that against them now.
MD#2: I see the fine line separating constructive criticism from vilification is permanently erased by critics. Even if we dispense with objectivity, slamming BPharma is plain impractical. We see several leading manufacturers exiting the stage. Another Pyrric victory?
It was refreshing to see your trust in the US DOJ as a pillar of fairness. When thugs put on suits and badges, does it make shake-down palatable? One can grudgingly accept governmental thuggery but applauding would be a bit exuberant, wouldn't it? Any other gov organization in line for blind love and trust? BTW, the data on Zyprexa side effects were available from the get go for anyone who cared to check, but laziness and ignorance of our colleagues found excuses in pharma bashing.
And why shouldn't pharm co's aggressively advertise and market? Are there laws against it?
After descending from planet Utopia to our sinful Earth, maybe misdeed of E Lilly & Co won't look so evil and the US government so white and fluffy.
PS I am curious what entails "not everything" that "old line psychoanalysis were wrong about"? In regard to psychiatry, I mean.
Me: I am not out to vilify the drug companies. We need them. I'm a capitalist myself. I have no objection to marketing if it's even relatively honest. Make your best case. Buy me lunch, even. I don't care. However, the horrendous tactics described in the DOJ agreements go far far beyond that, and they can readily be observed every day at sponsored promotional talks, in regular and throw-away journals, and in DTC advertising. I don't have to make it up. The so-called science behind sponsored clinical trials has become almost comically biased.
You think the government has been too hard on big business? I'd say they're more often partners in crime. We all know that unrestrained big business never does bad things - just look at those paragons of virtue, Enron and BP. And don't big insurance companies always give both patients and us physicians a fair shake?
You're right about the side effects of Zyprexa being (or should have been) common knowledge a long time ago. I actually wasn't concerned about that. What I was concerned about was that, according to the company own memos (which were not even supposed to be released according to the agreement with the "thugish" DOJ, but a journalist got a hold of them), there was a conscious marketing decision to deceive doctors into expanding the definition of bipolar disorder to include any patient who was both anxious and depressed, without regard to any duration criteria, in order to sell more atypicals [expensive brand named anti-psychotic medications].
I have to admit I'm shocked by how many doctors fell for this, but if all you have is medication to offer, everything looks like a brain disease. There's an excellent study by Zimmerman and others that showed that in his sample, 40% of patients who had seen a previous psychiatrist and who clearly met DSM criteria for borderline personality disorder, and who did not even come close to meeting DSM criteria for bipolar disorder, had been diagnosed as bipolar by the previous doctor. Argue with the DSM definitions if you will, and I often do, but I think they got a lot things right.
There's plenty of b.s. in the psychotherapy literature as well. Your question about what is right and wrong about analytic theory would take a book to answer, so I won't even try. What I will say is that any neuroscientist can tell you that the brain is plastic and is literally shaped by interactions with primary attachment figures and other social influences on an ongoing basis. There's a ton of hard science available to back up that assertion.
MD #3: What a profoundly dispiriting exercise reading these comments has been. With one or two exceptions the desire to make a point has created only a painful experience of heat and smoke with precious little light.
Let's face a few facts:
What we don't know is enormous, for all of us. What we don't know we don't know is even greater. Therefore it behoves us all, myself included, to have humility in the face of our ignorance....
I am saddened to see that the arguments which rage for and against Big Pharma, necessary but venal, and psychoanalysis, unpalateable and frequently misused, are just infantile. They each have a place and each have contributed to where we are today. The exciting findings of today in neurophysiology in relation to infant attachment and trauma confirm the prescience of early psychoanalysts, their other failings not withstanding.
The absence of healthy doubt is dangerous. Let's have more doubt.
MD #2: It's unusual to see anyone to be so emotionally perturbed with tepid professional discourse and experience pains while reading opinions different from his/her own. "Let's have more doubts" appeal might work for dogmas (psychoanalytical and others), not for emerging, vibrant, and already highly controversial field like biological psychiatry..
"The exciting findings of today in neurophysiology in relation to infant attachment and trauma", IMO, are not exciting, specific, replicable, practical, and measurable. They serve a purpose, though, - resurrection of fading psychoanalytical orthodoxy. Good luck with that.
Suicide is too serious problem to trifle with psychoanalytic nonsense. There was steady, linear increase in teenage suicide rates for more than half a century during heydays of psychoanalysis in absence of other viable treatments until 1990, when (as some might remember) SSRI’s was introduced. Then, there was a 15 years of suicide decline (first time in recorded history). The decline reversed when first reports of suicidal thoughts related to SSRI treatment initiation emerged in the literature accompanied by sharp decrease in prescriptions
http://www.emaxhealth.com/1/22/24448.html
http://www.sciencedaily.com/releases/2007/09/070907221530.htm
http://www.infoplease.com/ipa/A0779940.html
http://teenadvice.about.com/b/2008/09/05/teen-suicide-rates-growing-in-us.htm
http://www.afsp.org/index.cfm?fuseaction=home.viewpage&page_id=050fea9f-b064-4092-b1135c3a70de1fda
We ought to talk about suicidality (i.e. suicidal thoughts) only in conjunction with discussion about protective role of medications contrasted with measurable (!) impact of other treatment modalities on suicide. Otherwise the discussion turns into fear mongering and emotional plea for "healthy doubt".
Me: No dogmas in biological psychiatry? How about every difference found between diagnostic groups and normals on an fMRI [a brain scan] being automatically labeled as an abnormality when it might instead be a conditioned response or even an adaptation? London taxi drivers have more grey matter in their posterior hypothalamus [part of the more primitive section of the brain] than controls. I suppose that driving a taxi is a disease?
How about the complete ignorance by biological psychiatrists of the vast literature in social psychology, which shows that, given the right environmental context, most people can be induced to do almost anything?
The effect of trauma on the hypothalamic-pituitary axis [the part of the brain that is responsible for regulating the release of stress hormone in the body] not specific or replicable? That's factually incorrect.
I agree that antidepressants, properly prescribed and in patients who are closely followed for the emergence of side effects, do reduce the suicide rate in some patients. Unfortunately they don't work for a significant number of suicidal patients.
Following epidemiological trends is suggestive but proves nothing, however. There are unfortunately almost no drug OR psychotherapy outcome studies that directly involve suicidal patients (for obvious ethical and practical reasons), so I think making overly broad statements about which treatments are most effective in preventing suicide (without regard to the evaluation of the individual patient) is both naive and extremely premature.
MD #2: Let's sort out confusions and contradictions. First paragraph is critical of "every difference found ... on an fMRI being automatically labeled as an abnormality when it might instead be a conditioned response or even an adaptation."
Third paragraph categorically refutes any suggestion that "the effect of trauma on the hippothalamic-pituitary axis" is not specific and replicable.
When a biopsychiatrist finds correlation then it is fatuous, unless it's convenient finding. Then it's alright.
The studies, BTW, found certain degree of ASSOCIATION - not cause-effect relationship, as implied, - between trauma and "dysregulation" (!) of HPA (blunted HPA-axis reactivity ) which was neither indicative nor specific for the type of trauma or associated diagnoses. Similar "dysregulations" were found in physical trauma, chronic disease, maternal undernutrition, substance abuse, and every mental disorder in DSM). It is a nonspecific finding in medicine, akin elevated sed rate, that don't demonstrate, less so proof, anything. There might be confusion btwn HPA studies and hippocampal volume decrease (cell death and cell atrophy )and corresponding increase in amygdala size and activation associated with chronic abbuse (http://www.isps-us.org/koehler/trauma_brain.html)
These studies indeed demonstrated that CHRONIC repetitive trauma in certain (not all) vulnerable individuals might produce anatomical and physiological changes. But these do not explain psychiatric disorders in children who were never abused and lack of mental disorders in many chronically abused.
Some biopsychiatrists my not be familiar, as was suggested, with "vast literature in social psychology" (this particular biopsychiatrist is an exception) but why should they if this literature, as interesting as it might be, has little to do with diagnosis and treatment of debilitating mental disorders. From social psychology viewpoint, hypothalamus and hippocampus are just two Greek words. Biopsychiatrists would disagree.
Another quote: "...given the right environmental context, most people can be induced to do almost anything". Not to develop a psychiatric disorder, they don't.
Now, back to our suicidal patients. It is irresponsible, IMO, not to consider the role of medications in suicide prevention. We may not know to what extent if any medications protect from suicide, but we can convincingly assume that psychoanalysis is as good as useless in these cases.
Me: Good point about my inconsistency on the hypothalamic-pituitary axis example. What I should have said was that this finding was found frequently in, as you say, chronic repetitive trauma, and of course not everyone is genetically susceptible. My bad. This finding has been replicated, however.
There are NO necessary or sufficient "causes" for almost any psychiatric diagnoses, only risk factors. No matter what biological, psychological, or social risk factor you look at, there will always be a lot of people who have a lot of it but don't develop any disorder, and a lot of people who have very little of it that do develop a disorder. And almost all risk factors like child abuse or the short allele of the MAOI [An enzyme that degrades chemicals in the brain] gene are risk factors for any number of different disorders. Totally non-specific.
Looking for necessary or sufficient causes in psychiatry is for the most part a fool's errand, and as statisticians (e.g. Cook & Campbell) will tell you, any study results that suggest otherwise are in most cases presenting a statistical artifact generated by where continuous variables were dichotomized [coded as present or absent].
I would also fault social psychologists who are not aware of biology. If one is going to truly understand human psychology, one needs to include ALL sources of information. Yes, there were horrendous historical mistakes made by the analysts with schizophrenia and autism. There were also horrendous historical mistakes made by the biological psychiatrists - i.e., eugenics [the theory that weaker members of society should be prevented from reproducing or even eliminated to improve the human gene pool]. Brainlessness versus mindlessness, as Eisenberg pointed out.
Not all psychiatric diagnoses are created equal - and many of them are probably not brain diseases in the way schizophrenia is. (and yes, even that dichotomy is simplistic).
I agreed with you, by the way, that NOT considering the role of medication in suicide IS irresponsible.
And please, everyone, quit conflating all psychotherapy with orthodox psychoanalysis. I personally think DBT [dialectical behavior therapy, a type of psychotherapy that does not directly involve psychoanalytic theory or technique] is an incomplete treatment for borderline personality disorder, but replicated randomized controlled studies do show it is quite effective for reducing suicidal and parasuicidal behavior in that population, at least for the first year after therapy. That's more than I can say for almost any drug study you care to look at.
[I did not mean to give myself the last word on purpose; MD #2 never responded to my last post, and it's been over a week].
I have had some interesting conversations on the back channel with people who are absolutely convinced that loved ones committed suicide directly because of having taken an antidepressant. Psychiatrists counter that antidepressants prevent suicide because they treat depression, which is itself - obviously - a cause of suicide.
There is some data that indicates that antidepressants can increase suicidal ideation (but not necessarily completed suicides) in teens and young adults who take antidepressants. So what gives?
Before I answer that, I would like to point out that anti-depressants take two to six weeks to work, and often we have to increase the dose or change drugs which makes this period of time much longer, so people are at risk for suicide because of the underlying depression before the drugs have kicked in. Frequent follow up and a good suicide evaluation usually can prevent tragedy. Also, as I have posted before, there are different types of depression. The less severe type, dysthymia, will often not respond to meds at all, while significant major depression usually does.
But yes, antidepressants per se can indeed cause increased suicidal ideation, suicidal behavior, and completed suicides. However, I believe this only happens in three very specific situations, all of which can be managed by a competent psychiatrist.
The first situation is when a patient develops a side effect known as akisthesia, which is extreme agitation in which a patient can barely sit still. Milder agitation can also be a side effect. Studies clearly show that a mix of depression and anxiety greatly increases the risk for suicide. The psychiatrist can warn patients about this side effect and tell them to call the doctor if it develops. Tranquilizers usually take care of this problem, but some patients must be switched to a different antidepressant, which may or may not cause that particular side effect.
Second, if a patient has bipolar disorder but has not yet had a manic episode or has been misdiagnosed, an antidepressant can unpredictably cause them to switch into mania. Some mania is not characterized by euphoria as it is in most typical mania, but can instead be "dysphoric mania" in which the patients are miserable rather than elated. Suicide risk is high in this condition. Again, family members can be warned to look for signs of this and stop the patient from taking any more antidepressant until the doctor is reached.
Third, in a severe form of depression called melancholia, patients have a lot of clear-cut biological symptoms like thinking in slow motion and having no energy for anything. When treated with an antidepressant, their energy tends to come back well before they felt better subjectively. They suddenly develop the energy to kill themselves whereas before they did not. This is well known to psychiatrists - or should be well known - as a very dangerous time for suicide attempts.
We warn patients and families about this, and tell them to get guns and other possible means of suicide out of the house during this crucial time, as well as to keep an eye on their depressed family members. We are not seeing as much melancholia these days as we used to probably because patients usually get an antidepressant before their illness develops to the point where it is that severe - indirect evidence that the drugs are effective, by the way.
Readers of this blog also know I am highly critical of both pharmaceutical company marketing tactics and "biological" psychiatrists who think that pills can cure every human foible, that psychotherapy is a bunch of bull that has never been validated in randomized controlled studies (totally not true), and who tend to exaggerate the benefits of drugs in those conditions in which they are indicated.
I have not had many comments from these latter type of folk on the blog. So, in the spirit of being an equal opportunity critic, I thought I would post a debate I had on another blog called Medscape with other psychiatrists. Parts of the debate are somewhat technical, so I will put explanatory material in brackets and italics. I am not including every post on this particular thread, but only the ones that I respond to or that respond to me, and I've edited out some comments that are not relevant to the points I am trying to make.
The debate was started by a posting by the blogger, Nassir Ghaemi, MD about the finding that antidepressants may increase suicidal ideation in teens and young adults.
Dr. Ghaemi, MD: ...In reviewing the published FDA meta-analysis [combining the results of several different studies, often using different methodology, and running statistics on the combination] of the randomized clinical trials (RCTs) of antidepressants, [a researcher] summarized the rather clear finding that antidepressants seemed to have an age-dependent effect on suicide risk: In children and young adults below age 25, they increased the risk ...in later adult years they were neutral ...and in middle age and in the elderly they were protective... When all these age groups are summarized, antidepressants have a small protective benefit for suicide ...In all these analyses, suicidality (defined as actual suicide, suicide attempts, or notable increase in suicidal ideation) is being assessed, one should say, rather than completed suicide. There were only 8 suicides in 77382 subjects, though 2 were on placebo and 6 on antidepressant.
Predictors of antidepressant-related suicidality with antidepressants were interesting: Suicide attempts (i.e., actual behavior) were more associated with antidepressants rather than increase in suicidal ideation (thoughts without behavior). Also, non-depressed persons (e.g., studies of antidepressants in other conditions such as anxiety disorders or PTSD) were more likely to be suicidal with antidepressants than those diagnosed with clinical depression (major depressive disorder).
[The researcher] also addressed the common critique that adolescent suicides increased after the FDA warning, which led to a decrease in antidepressant prescriptions in children. He reviewed data showing that suicides per 100,000 population for adolescents occurred at rate of 7.3 in 2003, 8.2 in 2004, 7.6 in 2005, and 7.2 in 2006. The FDA warning came out in 2004, but that increase in suicide rates occurred before the decline in antidepressant prescription rates for adolescents, which happened more in 2005 and 2006, corresponding to a decrease in adolescent suicide rates.
It is a not entirely appealing aspect of our profession that we wish to criticize, but not be criticized: Many of us are critical of the pharmaceutical industry, or of diagnosing mental illnesses like bipolar disorder in children, and yet we react angrily when asked to restrain our use of drugs. Instead, we should think seriously about the clear question arising from these data: Why are antidepressants preventive of suicide in later adulthood, and causative of it in younger age?
MD #1: "Why are antidepressants preventive of suicide in later adulthood, and causative of it in younger age?"
The qualifier there is in RCTs for FDA drug approval. There are many reasons these days why clinical populations are different.
My only criticism of the pharmaceutical industry is that they have not found many safe and effective drugs. I would like to be able to prescribe a mood stabilizer to a bipolar patients where I did not have to warn them that in 20 years there is a small but substantial risk of kidney failure. I would be quite happy to provide psychotherapy alone to bipolar patients if it prevented them from killing themselves or otherwise destroying their lives. In fact, it would be much easier to provide therapy than obsessing about lithium toxicity.
MD #2: It's a peculiar to read criticism of pharmaceutical industry for "not found[ing] many safe and effective drugs" along with favorable (at least the way I read it) mentioning of psychotherapy which failed to provide anything substantial and replicable for suicide prevention whatsoever. While pharmaceutical limitations are measurable and evident, psychotherapeutic shortcomings are hidden behind self-congratulatory process. It's de rigueur in psychiatric narrative nowadays to insert reverences toward "psychotherapy" together with BigPharma admonitions (a form of psychiatric PC, I suppose) without any critique of the former or balanced view about the latter.
The response to the criticism 'why the pharmaceutical industry have not found many safe and effective drugs' is unprecedented, enduring assault on the industry from angry psychoanalysts, greedy selfish government, opportunistic politicians, and many busybodies. I am surprised BigPharma stayed in business this long - there are less vexing ways to make a buck.
Me: What a bizarre conversation! Talking about "drugs" or "psychotherapy" or even "depression" as if they were monolithic entities is insane.
Treating a melancholic depression with any type of psychotherapy is indeed a waste of time, as is treating most cases of dysthymia with just drugs alone.
As to suicide with antidepressants, [I list the clinical situations mentioned earlier in this post].
And of course we need better drugs. With all current antipsychotics, for instance, you get to pick between a significant risk for metabolic syndrome and a significant risk of tardive dyskinesia [a long-term neurological side effect]. What a wonderful choice. And of all the things one can choose to criticize big pharma for, I don't think that problem is one of them.
MD #2: It would be nice if one could comfortably tell one type of depression from another and expect at least half of his colleagues to agree. But your dysphoric mania is another man's agitated depression and the third one's depression with ADHD. And someone else's frontotemporal dementia. Before we start claiming superiority of one treatment over another shouldn't we first sort out the nomenclature?
The irony about "wonderful choice" is misdirected. Consider oncological drugs and their side effects. I don't see oncologists mocking BigPharma. Psychoanalytic/dynamic psychiatrists, OTOH, do. They are still convinced that the world is flat and if you keep moving ahead you can fall from the edge of the earth.
Me: I agree there is a lot of diagnonsense around, but if a psychiatrist can't tell a severely melancholic depression from a typical dysthymia, he or she needs to go back to medical school. While the DSM contains a lot of b.s., much of it is also highly consistent with both clinical presentation and treatment response.
About the "wonderful choice," what I said was that should NOT be blamed on big Pharma. However, if you think big PhARMA science is so honest, perhaps you should read The Truth About the Drug Companies by Marsha Angell, former editor of the New England Journal of Medicine, and see if you still think so. Or check out the Zyprexa marketing documents on FuriousSeasons.com, or the US Justice Department settlements with FIVE different big Pharma companies, available on the DOJ website, for a description of highly misleading and pervasive marketing of psychotropic drugs - including ghostwriting journal articles and paying big name "experts" to sign on as authors. Get your head out of the sand!
By the way, I'm not a psychoanalyst in the least. I agree that old line psychoanalysis was wrong about a lot of stuff, but not everything, and hardly any therapists practice it anymore anyway. I mean, biological psychiatrists have stopped doing insulin shock, so I don't continue to hold that against them now.
MD#2: I see the fine line separating constructive criticism from vilification is permanently erased by critics. Even if we dispense with objectivity, slamming BPharma is plain impractical. We see several leading manufacturers exiting the stage. Another Pyrric victory?
It was refreshing to see your trust in the US DOJ as a pillar of fairness. When thugs put on suits and badges, does it make shake-down palatable? One can grudgingly accept governmental thuggery but applauding would be a bit exuberant, wouldn't it? Any other gov organization in line for blind love and trust? BTW, the data on Zyprexa side effects were available from the get go for anyone who cared to check, but laziness and ignorance of our colleagues found excuses in pharma bashing.
And why shouldn't pharm co's aggressively advertise and market? Are there laws against it?
After descending from planet Utopia to our sinful Earth, maybe misdeed of E Lilly & Co won't look so evil and the US government so white and fluffy.
PS I am curious what entails "not everything" that "old line psychoanalysis were wrong about"? In regard to psychiatry, I mean.
Me: I am not out to vilify the drug companies. We need them. I'm a capitalist myself. I have no objection to marketing if it's even relatively honest. Make your best case. Buy me lunch, even. I don't care. However, the horrendous tactics described in the DOJ agreements go far far beyond that, and they can readily be observed every day at sponsored promotional talks, in regular and throw-away journals, and in DTC advertising. I don't have to make it up. The so-called science behind sponsored clinical trials has become almost comically biased.
You think the government has been too hard on big business? I'd say they're more often partners in crime. We all know that unrestrained big business never does bad things - just look at those paragons of virtue, Enron and BP. And don't big insurance companies always give both patients and us physicians a fair shake?
You're right about the side effects of Zyprexa being (or should have been) common knowledge a long time ago. I actually wasn't concerned about that. What I was concerned about was that, according to the company own memos (which were not even supposed to be released according to the agreement with the "thugish" DOJ, but a journalist got a hold of them), there was a conscious marketing decision to deceive doctors into expanding the definition of bipolar disorder to include any patient who was both anxious and depressed, without regard to any duration criteria, in order to sell more atypicals [expensive brand named anti-psychotic medications].
I have to admit I'm shocked by how many doctors fell for this, but if all you have is medication to offer, everything looks like a brain disease. There's an excellent study by Zimmerman and others that showed that in his sample, 40% of patients who had seen a previous psychiatrist and who clearly met DSM criteria for borderline personality disorder, and who did not even come close to meeting DSM criteria for bipolar disorder, had been diagnosed as bipolar by the previous doctor. Argue with the DSM definitions if you will, and I often do, but I think they got a lot things right.
There's plenty of b.s. in the psychotherapy literature as well. Your question about what is right and wrong about analytic theory would take a book to answer, so I won't even try. What I will say is that any neuroscientist can tell you that the brain is plastic and is literally shaped by interactions with primary attachment figures and other social influences on an ongoing basis. There's a ton of hard science available to back up that assertion.
MD #3: What a profoundly dispiriting exercise reading these comments has been. With one or two exceptions the desire to make a point has created only a painful experience of heat and smoke with precious little light.
Let's face a few facts:
What we don't know is enormous, for all of us. What we don't know we don't know is even greater. Therefore it behoves us all, myself included, to have humility in the face of our ignorance....
I am saddened to see that the arguments which rage for and against Big Pharma, necessary but venal, and psychoanalysis, unpalateable and frequently misused, are just infantile. They each have a place and each have contributed to where we are today. The exciting findings of today in neurophysiology in relation to infant attachment and trauma confirm the prescience of early psychoanalysts, their other failings not withstanding.
The absence of healthy doubt is dangerous. Let's have more doubt.
MD #2: It's unusual to see anyone to be so emotionally perturbed with tepid professional discourse and experience pains while reading opinions different from his/her own. "Let's have more doubts" appeal might work for dogmas (psychoanalytical and others), not for emerging, vibrant, and already highly controversial field like biological psychiatry..
"The exciting findings of today in neurophysiology in relation to infant attachment and trauma", IMO, are not exciting, specific, replicable, practical, and measurable. They serve a purpose, though, - resurrection of fading psychoanalytical orthodoxy. Good luck with that.
Suicide is too serious problem to trifle with psychoanalytic nonsense. There was steady, linear increase in teenage suicide rates for more than half a century during heydays of psychoanalysis in absence of other viable treatments until 1990, when (as some might remember) SSRI’s was introduced. Then, there was a 15 years of suicide decline (first time in recorded history). The decline reversed when first reports of suicidal thoughts related to SSRI treatment initiation emerged in the literature accompanied by sharp decrease in prescriptions
http://www.emaxhealth.com/1/22/24448.html
http://www.sciencedaily.com/releases/2007/09/070907221530.htm
http://www.infoplease.com/ipa/A0779940.html
http://teenadvice.about.com/b/2008/09/05/teen-suicide-rates-growing-in-us.htm
http://www.afsp.org/index.cfm?fuseaction=home.viewpage&page_id=050fea9f-b064-4092-b1135c3a70de1fda
We ought to talk about suicidality (i.e. suicidal thoughts) only in conjunction with discussion about protective role of medications contrasted with measurable (!) impact of other treatment modalities on suicide. Otherwise the discussion turns into fear mongering and emotional plea for "healthy doubt".
Me: No dogmas in biological psychiatry? How about every difference found between diagnostic groups and normals on an fMRI [a brain scan] being automatically labeled as an abnormality when it might instead be a conditioned response or even an adaptation? London taxi drivers have more grey matter in their posterior hypothalamus [part of the more primitive section of the brain] than controls. I suppose that driving a taxi is a disease?
How about the complete ignorance by biological psychiatrists of the vast literature in social psychology, which shows that, given the right environmental context, most people can be induced to do almost anything?
The effect of trauma on the hypothalamic-pituitary axis [the part of the brain that is responsible for regulating the release of stress hormone in the body] not specific or replicable? That's factually incorrect.
I agree that antidepressants, properly prescribed and in patients who are closely followed for the emergence of side effects, do reduce the suicide rate in some patients. Unfortunately they don't work for a significant number of suicidal patients.
Following epidemiological trends is suggestive but proves nothing, however. There are unfortunately almost no drug OR psychotherapy outcome studies that directly involve suicidal patients (for obvious ethical and practical reasons), so I think making overly broad statements about which treatments are most effective in preventing suicide (without regard to the evaluation of the individual patient) is both naive and extremely premature.
MD #2: Let's sort out confusions and contradictions. First paragraph is critical of "every difference found ... on an fMRI being automatically labeled as an abnormality when it might instead be a conditioned response or even an adaptation."
Third paragraph categorically refutes any suggestion that "the effect of trauma on the hippothalamic-pituitary axis" is not specific and replicable.
When a biopsychiatrist finds correlation then it is fatuous, unless it's convenient finding. Then it's alright.
The studies, BTW, found certain degree of ASSOCIATION - not cause-effect relationship, as implied, - between trauma and "dysregulation" (!) of HPA (blunted HPA-axis reactivity ) which was neither indicative nor specific for the type of trauma or associated diagnoses. Similar "dysregulations" were found in physical trauma, chronic disease, maternal undernutrition, substance abuse, and every mental disorder in DSM). It is a nonspecific finding in medicine, akin elevated sed rate, that don't demonstrate, less so proof, anything. There might be confusion btwn HPA studies and hippocampal volume decrease (cell death and cell atrophy )and corresponding increase in amygdala size and activation associated with chronic abbuse (http://www.isps-us.org/koehler/trauma_brain.html)
These studies indeed demonstrated that CHRONIC repetitive trauma in certain (not all) vulnerable individuals might produce anatomical and physiological changes. But these do not explain psychiatric disorders in children who were never abused and lack of mental disorders in many chronically abused.
Some biopsychiatrists my not be familiar, as was suggested, with "vast literature in social psychology" (this particular biopsychiatrist is an exception) but why should they if this literature, as interesting as it might be, has little to do with diagnosis and treatment of debilitating mental disorders. From social psychology viewpoint, hypothalamus and hippocampus are just two Greek words. Biopsychiatrists would disagree.
Another quote: "...given the right environmental context, most people can be induced to do almost anything". Not to develop a psychiatric disorder, they don't.
Now, back to our suicidal patients. It is irresponsible, IMO, not to consider the role of medications in suicide prevention. We may not know to what extent if any medications protect from suicide, but we can convincingly assume that psychoanalysis is as good as useless in these cases.
Me: Good point about my inconsistency on the hypothalamic-pituitary axis example. What I should have said was that this finding was found frequently in, as you say, chronic repetitive trauma, and of course not everyone is genetically susceptible. My bad. This finding has been replicated, however.
There are NO necessary or sufficient "causes" for almost any psychiatric diagnoses, only risk factors. No matter what biological, psychological, or social risk factor you look at, there will always be a lot of people who have a lot of it but don't develop any disorder, and a lot of people who have very little of it that do develop a disorder. And almost all risk factors like child abuse or the short allele of the MAOI [An enzyme that degrades chemicals in the brain] gene are risk factors for any number of different disorders. Totally non-specific.
Looking for necessary or sufficient causes in psychiatry is for the most part a fool's errand, and as statisticians (e.g. Cook & Campbell) will tell you, any study results that suggest otherwise are in most cases presenting a statistical artifact generated by where continuous variables were dichotomized [coded as present or absent].
I would also fault social psychologists who are not aware of biology. If one is going to truly understand human psychology, one needs to include ALL sources of information. Yes, there were horrendous historical mistakes made by the analysts with schizophrenia and autism. There were also horrendous historical mistakes made by the biological psychiatrists - i.e., eugenics [the theory that weaker members of society should be prevented from reproducing or even eliminated to improve the human gene pool]. Brainlessness versus mindlessness, as Eisenberg pointed out.
Not all psychiatric diagnoses are created equal - and many of them are probably not brain diseases in the way schizophrenia is. (and yes, even that dichotomy is simplistic).
I agreed with you, by the way, that NOT considering the role of medication in suicide IS irresponsible.
And please, everyone, quit conflating all psychotherapy with orthodox psychoanalysis. I personally think DBT [dialectical behavior therapy, a type of psychotherapy that does not directly involve psychoanalytic theory or technique] is an incomplete treatment for borderline personality disorder, but replicated randomized controlled studies do show it is quite effective for reducing suicidal and parasuicidal behavior in that population, at least for the first year after therapy. That's more than I can say for almost any drug study you care to look at.
[I did not mean to give myself the last word on purpose; MD #2 never responded to my last post, and it's been over a week].
Thursday, July 15, 2010
It's the Relationship, Stupid!
Two of my friends recently e-mailed me an article in the New York Times by a Psychiatrist named Dr. Richard Friedman entitled Accepting That Good Parents May Plant Bad Seeds (http://www.nytimes.com/2010/07/13/health/13mind.html).
Before I could blog about it, I noticed that my fellow family issues blogger, pediatrician Dr. Claudia Gold, had beat me to the punch, with an absolutely spot-on critique of the article entitled, Neither Bad Parents Nor Bad Seeds (http://claudiamgoldmd.blogspot.com/2010/07/neither-bad-parents-nor-bad-seeds.html).
Still, I did not realize just how pernicious Dr. Richard Friendman's column was until I saw a comment on Claudia's Blog from someone calling himself J.C. He made the comment that the column made a strong implication that "Children are not dynamic, they can come broken just like computers, without any inherent ability to adapt." Reading the column again, I saw that it implied that the "son" described in the article had apparently come into the world with a heavy genetic loading for rude behavior!
His opinion: "the fact remains that perfectly decent parents can produce toxic children." Toxic children? The very phrase reminded me of Susan Forward and Craig Buck's famous (and still selling) 1989 self-help book, Toxic Parents: Overcoming Their Hurtful Legacy and Reclaiming Your Life. While Dr. Forward did hold out some hope for the adult products of abusive family environments reconciling with their parents, many therapists took note of the title and started advising their patients to divorce their "toxic" parents in order to feel better.
That sounds like good advice until you read the attachment literature. It shows that the best predictor of how well your relationship with your own children will turn out is the nature of your relationship with your own parents. This happens regardless of whether you remain in continuous contact, or not. In fact, since you unfortunately carry your parents around in your head forever (regardless of whether either you or they wish it so), "divorcing" your parents may not prevent the intergenerational transmission of highly dysfunctional family patterns. It may in some cases actually help foster it.
An awful lot of my patients try awfully hard to be the "unparents." They vow they will never treat their children the way that their parents treated them. Unfortunately, they tend to go to the opposite extreme and often end up with kids who have the same problems they do, or who have a polar opposite but still related problem.
If they felt neglected by their parents, for example, they may become overinvolved with and overprotective of their children. If you want to know what might be likely to happen if they do that, please read my very last blog post.
If their parents were alcoholics, for another example, they may compulsively drug-test their kids and repeatedly search the kids' room for contraband before the kids have ever done anything - thereby giving their children the inadvertent message that they expect their kids to abuse alcohol. In working on emotional family trees called genograms, therapists sometime see a generation of alcoholics followed by a generation of teetotalers followed by a generation of alcoholics. Try explaining that one with the concept of a genetic predisposition to alcohol. I dare you.
So were abusive parents born toxic children? Was the 17 year old boy described in Friedman's article born to be "...unkind and unsympathetic to people...rude and defiant at home, and often verbally abusive to family members"?
Friedman trots out the ignorant old warhorse explanation that the boys behavior could not possibly have been caused by "bad parenting" because "this supposedly suboptimal [parental] couple had managed to raise two other well-adjusted and perfectly nice boys. How could they have pulled that off if they were such bad parents?"
First of all, who even said that they were bad parents in the first place? Second, parents do not even remotely treat all of their children the same. Anyone with a sibling or more than one child can tell you that. Anyone remember the Smothers Brothers' comedy team schtick, "Ma always liked you best?" They built a huge career around that one routine. Do you think it might have struck a chord with anyone?
In Claudia Gold's blog post, she describes a family that she treated in which a behavior problem that was similar to the one in the Friedman article was present. She describes exactly how and why a negative pattern of interactions between a parent and a child was set in place, despite everyone's best intentions. I highly recommend her post.
Warning: speculation ahead, based on similarities to many other cases I have treated, and which may or may not apply to this one:
In the case of the particular adolescent described in the Friedman column, a clue as to what might have happened in this family was the observation Friedman himself made that ""it was clear that her [the mother's] teenage son had been front and center for many years."
Maybe too front and center. If the parents were obsessed with their son's negative attitudes and repeatedly lectured him about them ad nauseum, they may have unwittingly given him the message that they would be disappointed if they were deprived of the right to go on lecturing him. In response, he might continuously give them that opportuntity by maintaining the bad attitude.
In addition, it is possible that the parents gave signs to the boy of covert approval when he was rude to other family members. A son sometimes takes on a role that psychotherapy integrationist Sam Slipp called the avenger, in which he acts out his parents unacknowledged and for them forbidden hostility. This allows the parents to vicariously experience the expression of their negative feelings without having to own or be responsible for them.
Psychoanlysists refer to this interpersonal phenomenon as projective identification. They speak of "superego lacunae" or holes in the parents' conscience that prevent them from expressing certain feelings but which lead them to indirectly validate the expression of those very same feelings in their children, even while criticizing the children unmercifully for having done so.
It is not toxic people that create a dysfunctional family, but toxic relationships. Affixing moralistic blame to one individual in the family just makes matters worse. It turns that person into what family systems therapists refer to as the identified patient, when the real patient is the whole group. The identified patient is often a scapegoat.
Even when parents or children do horrible things to each other, labeling them as bad seeds is counterproductive.
In dealing with a toxic relationship, the choice that an adult from a dysfunctional family has is not between self-exile and continuing to put up with abusive behavior. There are types of psychotherapy which can help people repair dysfunctional relationship patterns, solve problems, and reconcile with their loved ones. In my new book, I tell which psychotherapy paradigms are designed to do this. Not all therapists know how. It's not an easy task to detoxify a toxic relationship because feelings run very high, and defenses can be formidable, but it can be done.
IMHO, we need to help put a stop to the intergenerational transmission of dysfunctional family patterns, and these treatments are the best way to do that.
It is interesting that next to Dr. Friedman's article is a still from the 1956 movie, The Bad Seed, about a pretty little girl from a fine family who develops into a young murderess for no apparent reason. Such things, unless a baby comes out brain damaged in some way, happen only in lurid novels and movies.
Before I could blog about it, I noticed that my fellow family issues blogger, pediatrician Dr. Claudia Gold, had beat me to the punch, with an absolutely spot-on critique of the article entitled, Neither Bad Parents Nor Bad Seeds (http://claudiamgoldmd.blogspot.com/2010/07/neither-bad-parents-nor-bad-seeds.html).
Still, I did not realize just how pernicious Dr. Richard Friendman's column was until I saw a comment on Claudia's Blog from someone calling himself J.C. He made the comment that the column made a strong implication that "Children are not dynamic, they can come broken just like computers, without any inherent ability to adapt." Reading the column again, I saw that it implied that the "son" described in the article had apparently come into the world with a heavy genetic loading for rude behavior!
His opinion: "the fact remains that perfectly decent parents can produce toxic children." Toxic children? The very phrase reminded me of Susan Forward and Craig Buck's famous (and still selling) 1989 self-help book, Toxic Parents: Overcoming Their Hurtful Legacy and Reclaiming Your Life. While Dr. Forward did hold out some hope for the adult products of abusive family environments reconciling with their parents, many therapists took note of the title and started advising their patients to divorce their "toxic" parents in order to feel better.
That sounds like good advice until you read the attachment literature. It shows that the best predictor of how well your relationship with your own children will turn out is the nature of your relationship with your own parents. This happens regardless of whether you remain in continuous contact, or not. In fact, since you unfortunately carry your parents around in your head forever (regardless of whether either you or they wish it so), "divorcing" your parents may not prevent the intergenerational transmission of highly dysfunctional family patterns. It may in some cases actually help foster it.
An awful lot of my patients try awfully hard to be the "unparents." They vow they will never treat their children the way that their parents treated them. Unfortunately, they tend to go to the opposite extreme and often end up with kids who have the same problems they do, or who have a polar opposite but still related problem.
If they felt neglected by their parents, for example, they may become overinvolved with and overprotective of their children. If you want to know what might be likely to happen if they do that, please read my very last blog post.
If their parents were alcoholics, for another example, they may compulsively drug-test their kids and repeatedly search the kids' room for contraband before the kids have ever done anything - thereby giving their children the inadvertent message that they expect their kids to abuse alcohol. In working on emotional family trees called genograms, therapists sometime see a generation of alcoholics followed by a generation of teetotalers followed by a generation of alcoholics. Try explaining that one with the concept of a genetic predisposition to alcohol. I dare you.
So were abusive parents born toxic children? Was the 17 year old boy described in Friedman's article born to be "...unkind and unsympathetic to people...rude and defiant at home, and often verbally abusive to family members"?
Friedman trots out the ignorant old warhorse explanation that the boys behavior could not possibly have been caused by "bad parenting" because "this supposedly suboptimal [parental] couple had managed to raise two other well-adjusted and perfectly nice boys. How could they have pulled that off if they were such bad parents?"
First of all, who even said that they were bad parents in the first place? Second, parents do not even remotely treat all of their children the same. Anyone with a sibling or more than one child can tell you that. Anyone remember the Smothers Brothers' comedy team schtick, "Ma always liked you best?" They built a huge career around that one routine. Do you think it might have struck a chord with anyone?
In Claudia Gold's blog post, she describes a family that she treated in which a behavior problem that was similar to the one in the Friedman article was present. She describes exactly how and why a negative pattern of interactions between a parent and a child was set in place, despite everyone's best intentions. I highly recommend her post.
Warning: speculation ahead, based on similarities to many other cases I have treated, and which may or may not apply to this one:
In the case of the particular adolescent described in the Friedman column, a clue as to what might have happened in this family was the observation Friedman himself made that ""it was clear that her [the mother's] teenage son had been front and center for many years."
Maybe too front and center. If the parents were obsessed with their son's negative attitudes and repeatedly lectured him about them ad nauseum, they may have unwittingly given him the message that they would be disappointed if they were deprived of the right to go on lecturing him. In response, he might continuously give them that opportuntity by maintaining the bad attitude.
In addition, it is possible that the parents gave signs to the boy of covert approval when he was rude to other family members. A son sometimes takes on a role that psychotherapy integrationist Sam Slipp called the avenger, in which he acts out his parents unacknowledged and for them forbidden hostility. This allows the parents to vicariously experience the expression of their negative feelings without having to own or be responsible for them.
Psychoanlysists refer to this interpersonal phenomenon as projective identification. They speak of "superego lacunae" or holes in the parents' conscience that prevent them from expressing certain feelings but which lead them to indirectly validate the expression of those very same feelings in their children, even while criticizing the children unmercifully for having done so.
It is not toxic people that create a dysfunctional family, but toxic relationships. Affixing moralistic blame to one individual in the family just makes matters worse. It turns that person into what family systems therapists refer to as the identified patient, when the real patient is the whole group. The identified patient is often a scapegoat.
Even when parents or children do horrible things to each other, labeling them as bad seeds is counterproductive.
In dealing with a toxic relationship, the choice that an adult from a dysfunctional family has is not between self-exile and continuing to put up with abusive behavior. There are types of psychotherapy which can help people repair dysfunctional relationship patterns, solve problems, and reconcile with their loved ones. In my new book, I tell which psychotherapy paradigms are designed to do this. Not all therapists know how. It's not an easy task to detoxify a toxic relationship because feelings run very high, and defenses can be formidable, but it can be done.
IMHO, we need to help put a stop to the intergenerational transmission of dysfunctional family patterns, and these treatments are the best way to do that.
Monday, July 12, 2010
All Joy and No Fun
An article in New York Magazine from July 12 contains a cover story by Jennifer Senior on why a lot of parents today seem to hate parenting. People often think, before they have children, that having them will make them happier. Instead, they find that taking care of them is a pain in the ass. A study by Dale Kahneman, a behavioral economist, was quoted in the article as saying that on a survey of 909 working Texas mothers, child care ranked 16th out of a list of 19 as a pleasureable activity. Housework was rated higher.
There are some interesting statistics given in the article. In spite of the rush of women into the American workforce, both parents actually spend more time with their kids today than they did in 1975. Today's parents have less leisure time. In one survey, 71% of married mothers and 57% of married fathers crave more time for themselves. Nonetheless, 85% thought they still didn't spend enough time with their children!
The amount of time married couples spend alone with each other each week has also decreased - from 12 hours a week in 1975 to 9 hours per week today. (Parenting columnist John Rosemond points out that parents neglecting the marital relationship is bad for the children).
All of this time spent with kids led one psychologist quoted in the article to exclaim, "[children] are a huge source of joy, but they turn every other source of joy to shit!"
The author of the article suggests that cultural changes may have fundamentally changed the nature of raising children for the worse. Two career families, the view that children need to be groomed, the idea that you have to spend an inordinate amount of time talking to children, etc. Or maybe we should be more like Scandinavia, where affordable child care, once you go back to work, is free with state subsidies, and where people are no longer "wondering how to pay for your children's education and health care (because they're free)."
On another blog called The Last Psychiatrist (http://thelastpsychiatrist.com/2010/07/why_parents_hate_parenting.html), the blogger has a different explanation. He points out that "... you know, no Scandinavian women ever kill themselves at double the rate of Americans."
He thinks the issue is parental narcissism. Parents are upset because they see their children as mere extensions of themselves instead of as separate people. If the kids don't act the way the parents think they should, the parents go bananas. Another comment: "The author of a parenting book still cannot help but see children as a reward, as a cherry on top of a cake, not because she is brain damaged but because for 40 years she has been told by people, like herself, like New York Magazine, that they were."
His advice is simple: "Your kid doesn't want to be around you that much. No one does. This isn't because you're a bad person but because you're an ordinary person. You are not such a unique, creative, intelligent or even interesting person that the kid benefits from constant exposure to you. When you have something to offer, maximize and concentrate that time, and then get the hell out of the way."
I don't remember wanting to hang with my parents all the time when I was a kid, so I think I know what he means. This doesn't mean, of course, that parents should completely ignore their children, either.
I have my own ideas about what maybe going on here that I go into detail about in my new book. The summary I give here may come across as more simplistic than it is because I'm being very brief, but I think the bigger picture is an explosion of parental guilt. Among the sources of guilt, and there are many more: The Phylis Shafley's of the world (a career woman who made a career out of attacking career women) and their ilk constantly bemoaning the loss of the stay-at-home mother. Studies that purport to show that children of two-career families tend to do worse in some respects on average than children where one parent stays home. Old school grandparents who feel that their grandchildren are being neglected and then criticize their working daughters - while simultaneously envying the hell out of their careers.
The parents come home tired from work and guilty and try to make up for lost time by giving their kids everything the kids want and giving into their every whim. Then they wonder why the kids throw temper tantrums when they don't get their way. So their kids are out of control and never do what they're told, and the parents' guilt starts to get mixed in with rage at their kids. The rage then makes the parents feel even more guilty as well as inadequate, so they give the child even more of themselves, if that's even possible, and a vicious cycle goes on and on.
Saturday, July 10, 2010
An Unpleasant Diversion
Statistics using the term drug diversion usually refer to the sum of the amount of prescription drugs being abused by the person to whom the drug was prescribed and the amount of drugs being sold to or given to other people. So, what class of prescription drugs do you think is most frequently "diverted" for non-medical uses? Opiate narcotics like Oxycontin, Vicoden, and Percodan? How about sleeping pills and tranquilizers like Xanax and Ambien?
Not even close! Far and away the most commonly diverted prescription drugs are stimulants like Ritalin, Adderall, and Concerta - drugs that are prescribed for ADHD. According to a study in the Journal of Clinical Psychiatry, about 60% of students with a prescription for ADHD medication shared or sold the medication for non-medical use. Other studies have quoted somewhat lower figures (22-50%), but comparably, people who deal in their oxycontin prescriptions are complete pikers!
Stimulants, a class of drugs which also includes street drugs like cocaine and methamphetamine, are well known to be performancing enhancing drugs. They not only help kids with attention problems concentrate and focus, they help anyone concentrate and focus. And with them, you can stay up all night and study. On college campuses across the country, they are known as academic steroids.
They are so commonly used in colleges by students and faculty alike to get a leg up on the competition that the satirical newspaper the Onion recently reported that Harvard awarded an honorary degree to Adderall ("In its 14 years of availability by prescription, Adderall has had a profound and wide-reaching effect on the works of countless academics, contributing to an estimated 3.2 million research papers and blazing the trail for the several thousand grants, fellowships, and high-grade point averages that followed."). (http://www.theonion.com/articles/adderall-receives-honorary-degree-from-harvard,17527/).
When was the last time you heard a news story about the horrors of illegal Valium abuse? Even if you have, which would make you a rare bird, compare that to how many news stories you have heard about the horrors of meth and cocaine abuse.
The FDA classifies stimulants and narcotics in the same category - Schedule II. (Only illegal drugs like Heroin are Schedule I). By comparison, benzodiazepines like Valium and Xanax are schedule IV - which means they are considered to have far less abuse potential. Instructive in this regards is the fact that calls to poison control centers regarding stimulant abuse rose 76% between 1998 and 2005, paralleling an increase in prescriptions for ADHD (Setlik and others, Pediatrics, 124 (3), pp.875-880, 2009).
Joseph Biederman, the Harvard Guru of using psychiatric drugs on Children, was active in ADHD research before he was pushing the diagnosis of childhood bipolar disorder. He published a paper that purported to show that kids who were prescribed stimulants were no more likely than anyone else to abuse drugs as adults. Maybe he should have talked to the kids' older siblings. Besides, if you get your drugs of abuse by prescription, you are still using the drugs. As if people in Methadone maintenance programs are not still opiate addicts. I wonder if Biederman's study was compromised by all that drug company money he's accepted over the years?
And how are kids on stimulants doing in school? One study showed that they gained about three more months in school over kids who were diagnosed with ADHD but were not given stimulants. How impressive. A little tutoring would have probably worked just as well. Other studies show that those who were given stimulants continued to have just as many problems in their adult personal life as those who were not treated. And they're shorter as well. Really.
Not even close! Far and away the most commonly diverted prescription drugs are stimulants like Ritalin, Adderall, and Concerta - drugs that are prescribed for ADHD. According to a study in the Journal of Clinical Psychiatry, about 60% of students with a prescription for ADHD medication shared or sold the medication for non-medical use. Other studies have quoted somewhat lower figures (22-50%), but comparably, people who deal in their oxycontin prescriptions are complete pikers!
Stimulants, a class of drugs which also includes street drugs like cocaine and methamphetamine, are well known to be performancing enhancing drugs. They not only help kids with attention problems concentrate and focus, they help anyone concentrate and focus. And with them, you can stay up all night and study. On college campuses across the country, they are known as academic steroids.
They are so commonly used in colleges by students and faculty alike to get a leg up on the competition that the satirical newspaper the Onion recently reported that Harvard awarded an honorary degree to Adderall ("In its 14 years of availability by prescription, Adderall has had a profound and wide-reaching effect on the works of countless academics, contributing to an estimated 3.2 million research papers and blazing the trail for the several thousand grants, fellowships, and high-grade point averages that followed."). (http://www.theonion.com/articles/adderall-receives-honorary-degree-from-harvard,17527/).
When was the last time you heard a news story about the horrors of illegal Valium abuse? Even if you have, which would make you a rare bird, compare that to how many news stories you have heard about the horrors of meth and cocaine abuse.
The FDA classifies stimulants and narcotics in the same category - Schedule II. (Only illegal drugs like Heroin are Schedule I). By comparison, benzodiazepines like Valium and Xanax are schedule IV - which means they are considered to have far less abuse potential. Instructive in this regards is the fact that calls to poison control centers regarding stimulant abuse rose 76% between 1998 and 2005, paralleling an increase in prescriptions for ADHD (Setlik and others, Pediatrics, 124 (3), pp.875-880, 2009).
Joseph Biederman, the Harvard Guru of using psychiatric drugs on Children, was active in ADHD research before he was pushing the diagnosis of childhood bipolar disorder. He published a paper that purported to show that kids who were prescribed stimulants were no more likely than anyone else to abuse drugs as adults. Maybe he should have talked to the kids' older siblings. Besides, if you get your drugs of abuse by prescription, you are still using the drugs. As if people in Methadone maintenance programs are not still opiate addicts. I wonder if Biederman's study was compromised by all that drug company money he's accepted over the years?
And how are kids on stimulants doing in school? One study showed that they gained about three more months in school over kids who were diagnosed with ADHD but were not given stimulants. How impressive. A little tutoring would have probably worked just as well. Other studies show that those who were given stimulants continued to have just as many problems in their adult personal life as those who were not treated. And they're shorter as well. Really.
Tuesday, July 6, 2010
Distancing: Early Warning
A letter writer to the advice column Dear Abby, an adult woman, complained about her mother’s clinginess. The writer said that the mother had had “no time for me when I was growing up” and had been verbally abusive, having even told her daughter that she wished she had aborted her.
After the mother’s husband (presumably the writer’s stepfather) died, the letter writer explained, the mother would call the writer at work at 8 a.m. demanding that she drive 20 miles on her lunch break to bring the mother food. Mom would also make frantic phone calls at 2 a.m. demanding the daughter come sit with her because she was "lonely,” but when the daughter arrived, Mom would be asleep! Mom would call the daughter at least four or five times a day.
An adult male patient of mine told a somewhat analogous story. His mother was constantly calling and demanding that he come and wait on her hand and foot. She would almost always call at times that she knew were the most inconvenient for him – as if he had nothing else to do- and was incessantly criticizing him for not paying more attention to her. The things that she wanted him to do for her were tasks that she could have easily done herself, or that she could have easily afforded to pay someone else to do to.
When the son did things for her, however, the mother was never satisfied. Either the jobs were not done quite right, or there were more to do than he could finish. Oddly, the mother was also constantly criticizing herself for taking up so much of his time.
Yet another adult male patient was constantly “on call” for his hypochondriac mother. Earlier in her life, she had been able to run several businesses behind the scenes (there were male figureheads), but now she could not seem to do anything for herself. One of her favorite pastimes was getting “sick” just as the patient had packed up his family to go on vacation - her son would then dutifully cancel the whole trip.
Both of the patients described above just assumed that their mothers were absurdly dependent and too crazy or stupid to realize that their “dependent,” behavior, by being extremely noxious, was in fact very close to driving the sons away from them completely. Of course, for this to be true the mothers would have to be extremely crazy or impossibly stupid. At least with these two patients, there was no evidence that their mothers were either.
In fact, all three of these mothers were sending a very mixed message: I badly want you to be here but I’m going to drive you so batty you will never want to come see me. When parents act in an obnoxious manner like this that pushes their adult children away, this is referred to as distancing behavior. I am often impressed by how much of this crap my patients are willing to put up with before they finally say, “enough!” – if they ever get to that point at all.
So what is going on here? In families where distancing like this transpires, I usually find that the mothers’ (or in somewhat fewer cases, the fathers’) behavior can be explained by one or both of two common patterns.
In the first pattern, as seen in the case of the two male patients described above, the mothers have a dependency conflict which really stemed from a gender role conflict. The mothers were both bright, capable and ambitious women who had been raised in families that valued exactly none of those traits in females. Females were supposed to get married, raise a family, and be totally dependent on men. In today’s culture, such earlier mandates sometimes lead older females to acquiesce to male dominance while at the same time seethe with secret resentment over being infantilized.
Such a situation, depending on other factors, can lead to a variety of different behaviors between women and their children. In the cases under discussion here, after the women’s husbands died, there was no man around left to “take care” of them. They acted as if they needed someone to take care of them but really resented anyone who dared try. Their poor sons would then receive the fallout from the conflict. The mothers engaged in distancing behavior in order to appear “dependent” while really trying to discourage anyone from actually taking care of them.
The second pattern might be the one that applies to the Dear Abby letter writer. Parents who know they were abusive, even if they do not admit it, may secretly believe that their children are better off without them. Hence, they engage in distancing to push their children away, thereby protecting the children from themselves. However, the parents also secretly long to have a healthy connection with their children, so they cannot seem to bring themselves to just cut off all ties directly. Their own conflict causes them to give off the double message inherent in distancing behavior: come here but get the hell away from me. Or as the singer Pink so aptly put it, “Leave me alone, I’m lonely!”
After the mother’s husband (presumably the writer’s stepfather) died, the letter writer explained, the mother would call the writer at work at 8 a.m. demanding that she drive 20 miles on her lunch break to bring the mother food. Mom would also make frantic phone calls at 2 a.m. demanding the daughter come sit with her because she was "lonely,” but when the daughter arrived, Mom would be asleep! Mom would call the daughter at least four or five times a day.
An adult male patient of mine told a somewhat analogous story. His mother was constantly calling and demanding that he come and wait on her hand and foot. She would almost always call at times that she knew were the most inconvenient for him – as if he had nothing else to do- and was incessantly criticizing him for not paying more attention to her. The things that she wanted him to do for her were tasks that she could have easily done herself, or that she could have easily afforded to pay someone else to do to.
When the son did things for her, however, the mother was never satisfied. Either the jobs were not done quite right, or there were more to do than he could finish. Oddly, the mother was also constantly criticizing herself for taking up so much of his time.
Yet another adult male patient was constantly “on call” for his hypochondriac mother. Earlier in her life, she had been able to run several businesses behind the scenes (there were male figureheads), but now she could not seem to do anything for herself. One of her favorite pastimes was getting “sick” just as the patient had packed up his family to go on vacation - her son would then dutifully cancel the whole trip.
Both of the patients described above just assumed that their mothers were absurdly dependent and too crazy or stupid to realize that their “dependent,” behavior, by being extremely noxious, was in fact very close to driving the sons away from them completely. Of course, for this to be true the mothers would have to be extremely crazy or impossibly stupid. At least with these two patients, there was no evidence that their mothers were either.
In fact, all three of these mothers were sending a very mixed message: I badly want you to be here but I’m going to drive you so batty you will never want to come see me. When parents act in an obnoxious manner like this that pushes their adult children away, this is referred to as distancing behavior. I am often impressed by how much of this crap my patients are willing to put up with before they finally say, “enough!” – if they ever get to that point at all.
So what is going on here? In families where distancing like this transpires, I usually find that the mothers’ (or in somewhat fewer cases, the fathers’) behavior can be explained by one or both of two common patterns.
In the first pattern, as seen in the case of the two male patients described above, the mothers have a dependency conflict which really stemed from a gender role conflict. The mothers were both bright, capable and ambitious women who had been raised in families that valued exactly none of those traits in females. Females were supposed to get married, raise a family, and be totally dependent on men. In today’s culture, such earlier mandates sometimes lead older females to acquiesce to male dominance while at the same time seethe with secret resentment over being infantilized.
Such a situation, depending on other factors, can lead to a variety of different behaviors between women and their children. In the cases under discussion here, after the women’s husbands died, there was no man around left to “take care” of them. They acted as if they needed someone to take care of them but really resented anyone who dared try. Their poor sons would then receive the fallout from the conflict. The mothers engaged in distancing behavior in order to appear “dependent” while really trying to discourage anyone from actually taking care of them.
The second pattern might be the one that applies to the Dear Abby letter writer. Parents who know they were abusive, even if they do not admit it, may secretly believe that their children are better off without them. Hence, they engage in distancing to push their children away, thereby protecting the children from themselves. However, the parents also secretly long to have a healthy connection with their children, so they cannot seem to bring themselves to just cut off all ties directly. Their own conflict causes them to give off the double message inherent in distancing behavior: come here but get the hell away from me. Or as the singer Pink so aptly put it, “Leave me alone, I’m lonely!”
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