Tuesday, August 31, 2010

SSRI Tales

In 23 years of clinical experience prescribing them since they first made the scene, I have found that the type of antidepressant medications called Selective Serotonin Inhibitors (SSRI’s) are, for the majority of patients (with some important exceptions described in the next paragraph), relatively side effect free. Especially when combined with a long acting benzodiazepine tranquilizer such as Clonazepam, they are also highly effective for many patients who have major depression, panic attacks, obsessive compulsive disorder, PTSD, or the extreme emotional hyper-reactivity characteristic of borderline personality disorder.

Just so I don’t have to keep answering the same question, YES, some people do indeed have nasty side effects from them. YES, the drugs can increase suicidal ideation for some patients under some circumstances. YES, they often wreck havoc on sexual functioning. YES, they can have nasty withdrawal symptoms if stopped cold turkey, especially Paxil. YES, they do not work for everyone. But NO, there is not a shred of clinical or experimental evidence to back up Robert Whitaker’s assertion that patients who get better with the meds in the short run are made worse by them in the long run

In my new book I talk about how first benzodiazepines and now antidepressants are being demonized by the drug companies ever since most of the drugs in each class became available (or were about to) as cheaper generic medications. The only antidepressant that is really different that is not available as a generic is Cymbalta, which is technically not an SSRI. (Lexapro and Prestiq are just old drugs in new packages, as per my blog post of June 14).

Cymbalta has been trying to position itself as the drug best for people with chronic pain – but the old antidepressants like Elavil work just as well for that – and for the wastebasket diagnosis of fibromyalgia. (Another disclaimer: just because fibromyalgia is a made-up disease does NOT mean that “neurogenic” pain is not very very real and significant, so please, no nasty missives on that subject).

Back in January, the headline "Antidepressants May Only Be Effective in Treatment of the Severest Depression" was seen in newspapers around the country and even made the network newscasts. It was based on a meta-analysis, which means that the results of several different individual studies were combined.

The headline was sort of true in some ways but was extremely misleading. It is true that a milder type of depression called dysthymia is less likely to respond to drugs than a more severe variety of depression called major depression. Dysthymia tends to involve the thinking parts of the brain more and is usually more amenable to psychotherapy; major depression tends to involve a more primitive part of the brain called the limbic system more and tends to respond better to drugs. Of course there is considerable overlap between the two syndromes because all parts of the brain are highly interconnected, so diagnosis can at times be an issue.

The news stories did not mention psychotherapy at all and left the vague impression that current drugs should not be used much. Maybe doctors should be adding Abilify, just as the commercials say. NOT!

Only six studies were used in this meta-analysis. All of them did a poor job of distinguishing major depression from dysthymia. All six studies compared anti-depressants to placebo (sugar pill) and only tested one drug. Clinically, that is not the way the drugs are used by psychiatrists. Patients who do not respond to one of the antidepressants often will respond to another. Sometimes we have to try three or four before meeting success. There are diminishing returns with each switch, but the total response rate to antidepressants is the sum of the response rate to drug one plus the response rate to drug two, and so on. The type of study I am criticizing makes the drugs look way less effective than they actually are.

Not only that, but in at least one of the studies, the antidepressant was severely under-dosed! Do you think the authors were trying to make it look bad or something?

In my book, I also tear apart an article in the usually well-respected New England Journal of Medicine that purported to show that antidepressants do not work in depressive episodes seen in bipolar disorder. That paper was dishonest as the day is long.

Now comes a brand new attack on  something called the STAR*D study.  The STAR*D study attempted to study antidepressants in the way that clinicians actually use them, rather than the way they are used in studies. It did indeed show that if one antidepressant does not work after the required amount of time, then another should be tried and so on, and if this is done then the total response rate to antidepressants is actually fairly high in properly diagnosed patients with major depression.

The authors of the attack (Psychother Psychosom. 2010;79:267-279) pointed out that “the effectiveness of antidepressant therapies was probably even lower than the modest one reported…with an apparent progressively increasing dropout rate across each study phase."

“We found that out of the 4041 patients initially started on the SSRI [selective serotonin reuptake inhibitor] citalopram in the STAR*D study, and after 4 trials, only 108 patients had a remission and did not either have a relapse and/or dropped out by the end of 12 months of continuing care,” lead study author Ed Pigott, PhD, a psychologist with NeuroAdvantage LLC in Clarksville, Maryland, told Medscape Medical News.

In truth, if a study has a lot of dropouts, then it can just as easily underestimate as overestimate drug effectiveness. This is especially true for antidepressants because they must be continued for a few months after remission is achieved, and patients will often quit taking them prematurely precisely because they feel better. They then relapse. It is disingenuous to the utmost to count drop outs as non-responders!

I agree that the Star-D study was poorly designed to determine sustained efficacy, because that was not its main purpose. The initial good results on the patients who did not drop out are pretty much identical to what is seen clinically.

It is important to follow depressed patients very closely and have a therapeutic relationship with them to emphasize the need to stay on the medication for a while. Some patients have also significant psychosocial stressors that they do not tell the doctor about either because no one asked, or because of shame. A doctor has no hope of sorting out antidepressant response from other variables - often difficult under the best of circumstances - if he or she does not know about the psychosocial context in which symptoms are seen. The type of relationship in which such information becomes readily available to the doctor just does not happen in studies.

In general, drop outs in almost all studies are not tracked, so we have no way of knowing how many might relapse.

Two of the authors of the attack paper, H. Edmund Pigott, PhD, and Gregory S. Alter, PhD., are founders of NeuroAdvantage, LLC, a for-profit "neurotherapy" company. This is a company that has products that one can reasonably assume are competition for antidepressants. The company “offers a number of light & sound neurotherapy (LSN) programs designed to decrease symptoms of depression and anxiety as part of an overall treatment plan. Numerous clinical researchers have found that LSN is a robust treatment effective in facilitating profound relaxation and meditative states.” (From their website).

The first SSRI that was FDA approved was Prozac. As mentioned earlier, that was 23 years ago in 1987. Paxil, Zoloft, and Luvox followed soon thereafter. Isn’t it amazing, after all that time, that a whole bunch negative “new “information about SSRI’s is coming out just as they are all going generic?

Of course, I cannot prove that Big Pharma or alternative medicine is behind this.

Certainly, Big Pharma does want as many depressed patients as possible to be put atypical antipsychotics like Abilify while they still have the patents. More frightening potential evidence is that the drug company giant GlaxoSmithKline sat on data that showed that Paxil caused a huge number of birth defects in pregnant rats (teratogenesis) that they had known about since the drug first came out. Now, after twenty years and like magic, this data suddenly has seen the light of day!

Coincidence? You be the judge.

Friday, August 27, 2010

Falling Off the Wagon

When it comes to assessing one's personal role in family dysfunction or even domestic violence...

Blaming oneself or others in a moralistic sense is toxic for problem solving and makes problem resolution impossible.  It almost always leads to fight, flight or freeze reactions, rather than useful communication.  In order to resolve and stop repetitive dysfunctional family interactional patterns, one should focus on only three questions:  What are the patterns, what are they for, and how do we put a stop to them?  Leave questions of guilt and innocence to the justice system.  If a family member (or even you yourself) has been abusive, ask yourself this:  What is more important?   Is it punishing the guilty and making them eat crow, or putting a stop to the abuse and reconciling?

It pays to remember that it is impossible to forgive someone else who refuses to acknowledge what they did, denies ever having done it at, or puts all the blame for their own bad behavior on you.  Step up to the plate and look at your own role in problematic interactions.  You'll be glad you did.

Tuesday, August 24, 2010

When Human Behavior is Not Flexible

In my post of August 7, 2010, Is It Live or Is It Memorex? The Actor’s Paradox, I wrote that patients with personality disorders are very adept at acting in certain ways that may often be a mask or cover-up of what they are really thinking, feeling or doing. They have a false self.  I also mentioned that they "often give themselves away to therapists, however, precisely because their behavior is so polarized – they act as if they absolutely must act a certain way all the time even when external circumstances would seem to require a bit more flexibility."

In this post, I will elaborate on that a bit.  Looking for polarized behavior is one among several of the ways that therapists can uncover a patient's true self when the patient is strongly inclined to hide it.  Like the Germans say in World War II movies, "Ve haff vays of making zem talk!"

That sounds ominous, of course, but the process is really quite benign.  Good therapists are quite empathic with patients' need to hide parts of themselves.  When we think the patient is ready to hear it, we very gently point out to them when something they are doing or saying, or their body language, contradicts something else that they are saying, or something they have said repetitively in therapy previously.

A good therapist does not accuse a patient of keeping secrets, but expresses puzzlement over the contradiction and asks the patient to explain it.

So what are some other examples of polarized behavior?  The types of behaviors that are most frequently affected can be thought of and listed as extreme opposites.  When people always behave at either one or the other of the extremes, or if they behave at one extreme for awhile and then suddenly switch to the opposite extreme, the therapist suspects that a false self is being covered up through rigid adherence to the opposite of the underlying impulse (a reaction formation).

The following is a list of some of the more commonly seen polarizations.  Many of them overlap or are subcategories of one another.  I make no pretense that the list is anywhere near complete.

1. Spontaneous versus planned activity.

2. Giving versus taking.

3. Career versus family life.

4. Work versus play.

5. Emotionality versus stoicism.

6. Activity versus passivity.

7. Dependence versus independence.

8. Dominance versus submission.

9. Sexual expression versus sexual inhibition.

10. Caretaking versus caregiving.

11. Saving for the future versus spending for the moment.

12. Attention seeking versus remaining inconspicuous.

13. Taking all the blame versus blaming others.

14. Responsibility versus irresponsibility.

15. Competence versus incompetence.

16. Geographical and social mobility versus staying put.

17. Changing unhappy circumstances versus learning to accept them.

18. Change for the sake of change versus constancy and continuity.

19. Togetherness versus allowing "space" in relationships.

20. Ambition versus lack of ambition.

21. Loyalty versus disloyalty.

22. Respect for authority versus freethinking or rebelliousness.

23. Curiosity versus lack of curiosity.

24. Sociability versus preferring one's own company.

25. Priority for children versus priority for parents’ needs

Friday, August 20, 2010

Final Destination: The Net Effect of Behavior

Continuing some of the themes of two of my previous blog posts, (Mad, Bad, Blind or Stupid from 7/27, and Is It Live or Is It Memorex: the Actor’s Paradox from 8/7 about the repetition compulsion, I would now like to discuss two other concepts. I refer to them as the Net Effect of Behavior and the Principle of Opposite Behaviors.

In the previous post, I brought up the question of why people would continue with the same disastrous behavior patterns over and over again with the exact same disastrous results if they are not mad, bad, blind or stupid. To answer this, we first must figure out exactly what the self-destructive or self-defeating behavior patterns are designed to accomplish. I previously used the example of narcissists who continues to make most other people think they are assholes. They seem to feel entitled and superior to everyone, but that may be a manifestation of just how good actors they are, because of the Actor’s Paradox.

To answer the question, one must look at the end result of their repetitive behavior. It is usually something that is absolutely obvious to everyone but them and the people who form intimate, romantic relationships with them. The spouses, lovers, etc are, I submit, co-conspirators, who continually make lame excuses for the seemingly nonsensical behavior of their partner. This idea is analogous to the AA concept of the co-dependent.

The fact that their excuses are so obviously lame – again to everyone outside of the couple – tells me that the co-conspirators are also engaged in the repetition compulsion, because I believe that they too are neither mad, bad, blind, or stupid.

The upshot, if you will, of seemingly irrational behavior is what I refer to as the behavior’s net effect. If the net effect of the narcissists' behavior is that most everyone thinks they are assholes, and if they are not mad, bad or stupid, then that must be what they are trying to accomplish. They must want, at some level, to be thought of that way.

Actually, in therapy we always find that they are in fact ambivalent about the net effect of their behavior. They seem to compulsively act in ways that produce the desired final result, but at the same time the results make them miserable, and they are well aware of that as well!

So why would anyone want to be thought of that way? Are such people masochistic? Actually, I do not really believe in masochism either, and would add masochism to the list of things that people are not, in addition to mad, bad, etc. Pain is meant to be a warning device that should in most circumstances lead to a decrease in the behavior that caused it. For pain to be pleasure in some people is not only Orwellian doublespeak, it makes no sense from the standpoint of evolution.

In order to answer the question of why compulsive repeaters act in seemingly masochistic ways, I would have to discuss the whole concept of kin selection, which I do in my books but will have to save until some later post to discuss in this blog.

First, a little more about the counterintuitive conclusions one must draw if one follows this line of thinking. In western cultures where other options are available, if a woman stays in an abusive relationship, or moves from one to another to another, at some level she is aiming to produce this result. OOH, how non politically correct of me! This does not mean, however, that it is all her fault that she is being abused, or that the abuser should get a "Get Out of Jail Free" card. It just means that it is also not true that she has nothing at all to do with her plight. Yes, of course the abuser may stalk and even kill her if she leaves, but he may also kill her if she stays. The longer she stays in the abusive relationship, the higher the risk.

I recommend listening to the lyrics of the Eminem/Rihanna song I Love the Way You Lie, a link to which is posted on my Facebook fan page.

A corollary to the Net Effect of Behavior is something I refer to as the Principle of Opposite Behaviors. One can accomplish the net effect of behavior using a wide variety of different strategies. There is always more than one way to skin the proverbial cat. Some of these strategies may on the surface appear to be completely opposite or contradictory. For instance, if you are trying to make sure that other people never give you what you need from them – the mark of counter-dependency – you can accomplish this by never asking anyone for anything. That way no one really knows what you need from them, so you never get it.

You can also accomplish the exact same net effect or end result by asking for way too much, way too often. If you are a bottomless pit who is constantly demanding the moon from others, they get angry with you. When they are angry like that, they will run from you, unless they are prone to being co-conspirators. That way, you never get what you need from these people. The exact opposite behavior produces the exact same net effect.

Well, what about the co-conspirators? Does the counter-dependent get what he or she needs from them? A third strategy to not get what you need from others is to ask for what you want from people who are unable to provide it for you: alcoholics, deadbeats, sociopaths etc. Oh, and narcissists! These people do not end up giving you what you need either; hence, once again you have accomplished what you have set out to do: not get what you need from others.

This dynamic may be what is behind a common type of couple seen by couples therapists, the narcissistic male married to the female with borderline personality disorder. But that too is a subject for another post. Watch this space.

Tuesday, August 17, 2010

So Sue Me!

According to, a website for business managers, the large drug company AstraZeneca (AZ) has agreed to pay about $198 million to settle lawsuits alleging that its promotional material neglected to mention the significant risk of getting diabetes from its anti-psychotic drug, Seroquel.

Of course, any doctor who prescribes this drug should already know about this risk, regardless of how the drug is promoted.  It should be said that the drug is a very effective drug for many people who have hallucinations and delusions. Lately, however, it is being widely prescribed for anxiety, insomnia, and depression, as well as for generalized anxious moodiness misdiagnosed as bipolar disorder. 

Somehow the risk of a patient becoming addicted to insulin is deemed by these idiot doctors to be much less significant than the risk of becoming addicted to a far more appropriate tranquilizer or a sleeping pill.  (Actually, the most dangerous consequence for most people who become dependent on a tranquilizer is that they are dependent on a tranquilizer).

Anyways, Astra Zenica had already paid $656 million for its own legal expenses on Seroquel cases and $520 million to resolve similar allegations from the U.S. Department of Justice.

According to Bnet, "Despite that, AZ’s sales force continues to hand out leaflets that don’t contain the legally required warning that Seroquel may cause diabetes, according to this FDA 'untitled' letter from July 29."

So why is the company folding on the lawsuits while continuing to hand out these leaflets?  Well to know for sure you would have to ask them, and they would probably lie to you if you did.  However, as the Bnet article points out, Seroquel makes $1.2 billion per quarter for the company.  You do the math. 

The most logical answer to the question I raise in the last paragaraph is that AZ sees paying legal settlements as just a minor business expense while the company tries to maximize its profits on the drug while it still has the exclusive patent on it.

Saturday, August 14, 2010

The N-word

Dr. Laura Schlessinger, a radio and television pseudo-psychologist (her doctorate is in physiology) and pseudo-moralist (she had a history of extra-marital affairs, one with Los Angeles early rock and roll radio pioneer Bill Ballance of KFWB, in which she allowed him to photograph her in the nude) got into some hot water the other day because of her repeated use of the “N-word” in a conversation with a listener.

Actually she was trying to make the point, not invalid, that black people use the N-word on themselves all the time, as can be clearly heard in many a rap song. The Black comedian Chris Rock did a whole monolog about this phenomenon. Of course, the N-word means something different when used by a white person.

Or does it really?  

Bill  Ballance
It’s always politically incorrect for a white person like myself to theorize about African-American culture, but worries about political correctness never stopped me before. What I am going to say, however, is not much different from what many black academics have said, or what has been pointed out by black celebrities from Spike Lee to Michelle Obama.

A few disclaimers:  I am making some generalizations here that do not apply to many of the people to whom it could apply.  I am discussing very complex behavior that has many other determinants in addition to the ones I am mentioning. Other groups may have similar dynamics. Sometimes to get to the core of an issue, one must oversimplify.

I would suggest that the N word-usage by blacks in reference to one another is an example of what psychologists refer to as internalization. Internalization refers to the process by which an individual adopts the attitudes of the surrounding culture as germane to themselves. Internalizations are usually “swallowed whole,” without question and without any intellectual processing or digestion of the attitudes in question.

In this case, some black people have unfortunately internalized the negative attitude towards themselves that was prominent among the predominant racist white culture during the days of slavery and before the Civil Rights Movement was successful. When black people call other black people the N-word, they may be, in essence, seeing themselves just like Ku Klux Klan sees them.

I first noticed this strange reverse-twist during the Black Power movement during the sixties when I was in college. Ostensibly, this movement was about countering racist attitudes with black pride and empowerment. However, I came across a book by a Panther that denigrated college education as being nothing more than the collected thinking of dead white males. Therefore, it was useless and should not be persued. Widespread adoption of this attitude by African-Americans would have gladdened a Klansman’s heart.

The reason I bring up this issue in a family dysfunction blog is because this whole phenomenon provides a picture-perfect example of how dysfunctional behavior patterns are transmitted from one generation to another. Not only that, but it shows clearly how a dysfunctional pattern gets started in the first place.  This transmission is hardly limited to African Americans. In this case, the original attitudes against education had major survival value back in the days during which any black trying to get ahead through education was “uppity” and in significant danger of being lynched.

Although the danger of such retribution has for the most part passed (which is not to say in any way that white racism is not still alive and well), the original anxiety about pursuing an education has been passed down from one generation to another while the original source of the anxiety has often remained hidden. Hence, black kids in the inner city who try to act too smart or are too interested in education are often criticized by other black kids for trying to “act white.”

This is probably the reason that black kids score lower than whites, on average, on IQ tests. These kids have no motive for taking the test seriously because they have little interest in appearing to be intelligent. The thing about psychological testing is that there is no way to control for the subjects’ motivation to do well or answer honestly.

Many people are too young to remember the days of segregation, which are often referred to as the days of “Jim Crow.” Not too long ago, TV producers all had a policy that they would never portray a financially successful black person on a TV program (if they showed one at all). Even before TV, successful blacks were not seen in movies. The fantastic dancing duo, the Nicholas Brothers, would show up in movies in the North in segments that would be excised when the movie got to the South. Great care was taken so that the excision could be done cleanly without affecting the movie’s plot. In movies, Blacks were epitomized by an actor named Steppin Fetchit, whose character was portrayed as stupid and lazy.

The worst manifestation of the internalization of negative stereotypes in today's inner city black culture (middle and upper class Blacks have moved away from this to a great extent) is the “stop snitching” movement. Originally coming from a rap song by Tangg da Juice in 1999, the idea began to be pitched that black people should never report to the police the illegal activities of other black people . The slogan eventually began to appear on tee shirts. In 2007, the rapper Cam’ron publically opined that if a serial killer moved next door to him, he might move away, but he would not report what he knew about the killer to the cops.

Since the vast majority of the victims of Black violence are other Blacks, this movement is essentially ageeing with racists who say that a black life is not worth anything.  So why bother reporting his murder! Again, this attitude would gladden a Klansman’s heart.

Here are five other aspects of current “ghetto” culture, in no particular order, that I believe have been passed down from one generation to another and that come from the days of Jim Crow - and even from the days of slavery:

1. The drive-by shooting. These look suspiciously like Klan firebombings, which were terrorist attacks against houses in the black community by white racists. In my experience in Southern California, drive-bys seemed to start in South Central Los Angeles, back in the days before that part of town turned Latino. The newspapers did not take notice of them for quite some time - until an Asian woman was gunned down on the streets of Westwood - a mostly white theater area.

2. Light skinned African Americans are often favored over darker skinned ones, even within their own families, although this is sometimes reversed. This was the subject of Spike Lee’s movie, School Daze. It stemmed from the time when white slave owners routinely raped and impregnated their slaves, and enslaved their own children. The mixed raced children were usually treated better than the others.

3. Korean grocers would set up successful and profitable stores in Black inner-city neighborhoods, but the local Blacks did not seem to be able to do it. Characters in Spike Lee’s Do the Right Thing are seen questioning why this is so, but offering no answers.

4. Public housing for Blacks would quickly become shabby and run down, reminiscent of the horrid housing conditions that slaves had to endure, particularly if they worked in the fields and not in the plantation house.

5. In slave times, blacks would literally be bred with each other in order to increase the wealth of the plantation owner. The slave parents, particularly slave fathers of slave children, would routinely be sold, breaking up the black family. Children would then be raised by non-relatives. In today’s ghetto culture, men impregnate women and then many of them basically disappear from their child’s life. When I moved to the South, I encountered the term play (relative), usually play aunts or play uncles. This term referred to non-blood relatives of Blacks who would help raise them, and who were considered to be as much family as any blood relative.

I could go on.  These "coincidences" are not random, and can most easily be explained by the intergenerational transmission of dysfunctional family behavior patterns.

Wednesday, August 11, 2010

50 Best Child Psychology Blogs

Here's a website with an excellent list of blogs covering all aspects of child psychology including therapy and mental health, child and infant development, and parenting:

Tuesday, August 10, 2010

Freddie the Freeloader and Minnie the Moocher

Hey, all you youngun's. If you don't know who Minnie the Moocher and Freddie the Freeloader are, look up Cab Calloway and Red Skelton.

In the advice column Annie's Mailbox of a couple of days ago (, a letter writer expresses dismay that his twenty year old son bailed out of home schooling by getting a GED.  His wife had corrected all of his son's homework before it had been submitted, but the son still could not seem to handle high school.  He now works a whole two hours a day, will not help around the house, and has an attitude problem. 

The writer complains that his wife refuses to charge the son rent, and pays for his car, insurance and cell phone.  The father had to kick the son's girl friend out of the house and stopped the son from " filching beer from our refrigerator."   His wife tells the writer to cool it when he gets upset.  Meanwhile, two younger brothers are beginning to play follow the leader with their deadbeat slacker older bro.

Is it just me, or is everyone seeing more and more twenty somethings who are freeloading off of their parents with their parents' cooperation? (You can discount the parents' complaining about the kids - after all, that's what their children do). Of course, the fact that the father in this case complains about his wife but does nothing to stop her from enabling the son might remind readers of my blog post of March 9, 2010 about younger children, Recipe for Producing Frequent Tantrums in Children.  The parents' behavior, as time goes on, produces the future Freddies and Minnies.

I am certain that if these twenty somethings were dragged to many psychiatrists, they would be immediately diagnosed as "Adult ADHD" or some other bullsh*t diagnosis.

Why do children react to their parents enabling behavior in this crazy way? My theory is that, because the parents compulsively do everything for their kids and expect nothing from them, their kids get the idea that providing for children is an extremely vital activity for their parents.   If the parents fight over what to do with the kids but never come to any kind of agreement or compromise, the kids think they like to do that as well.  Far be it from children to deprive their parents of a cherished role.

Do children really give a damn about what their parents expect from them?  Readers, what do you think about all of this?

Saturday, August 7, 2010

Is It Live or Is It Memorex? The Actor’s Paradox

       Things are seldom what they seem
       Skim milk masquerades as cream
                --W.S. Gilbert, from H.M.S. Pinafore

We all have a “mask” that we present to the outside world which may or may not reflect the way we are really feeling inside. In fact, we have several. Obviously, we act very differently when we are in the presence of just our spouse, our children, our buddies, our colleagues at work, and our bosses. We seldom reveal our true opinions about everything to anyone for fear of creating offense or getting ourselves into hot water.

How many times do we hear a news story in which the neighbors of someone who has committed some horrible crime, say a workplace mass murder, all say, “But he seemed so nice! Everyone loved him! He was so kind to the neighborhood kids. I never imagined that he would ever do something like that!”

We all have aspects of ourselves that we do not like and try to hide at one time or another. Sometimes we even try to hide them from ourselves. Additionally, we often need to mask our true feelings because we feel we must deceive other people in order to get what we need or what we want from them. Primate studies have shown that the ability to deceive fellow members of one’s species has powerful survival value, and would therefore be a trait that is selected for by the forces of evolution.

We really admire people who are the most adept at fooling us, because fooling others is a skill we practice every day. Why are about 95% of trained stage and screen actors unemployed most of the time, barely scraping out a living, while the other 5% are paid millions? We may have seen DeNiro or Streep in scores of different roles, yet we forget who they really are and accept them to be the characters they play. The best actors command an incredible fee.

In order to be effective actors, individuals must pretend that they really are the characters that they are portraying. They must pretend that they really feel and are experiencing all the different ways that their character is supposed to be feeling in the different scenes. This is a fundamental tenet of what is called method acting. Of course, this creates a paradox. At some level even great actors still know who they really are and the way they really feel while they are playing someone else. Yet they are somehow able to forget about this and to “lose themselves in the character.”

A great example of method acting was seen in a film clip that was taken of Robert DeNiro and Robin Williams interacting while they were between takes of a movie called Awakenings. Even though they were not filming a scene at the time, DeNiro remained in his movie character. Williams was trying to get him to come out of character by trying to get him to crack up. He could not do it. Robin Williams, for heaven’s sake! If he could not get DeNiro to come out of character that way, who could?

Sometimes, the mask that people wear in their daily lives is more pervasive. It is one that they never ever take off in public. In psychological terms, people who have psychological problems often present with what is called a false self. Jung termed this the persona. They play a role within their social system which is, in a sense, fake. They act as if their opinions and desires are other than what they really believe and want inside. The opinions and desires they do express are instead those they think others in their social system believe and want. They do this compulsively so as not to slip up and give themselves away to the others. Because of the actor’s paradox, this false self feels real to them, while their true self feels phony.

They often give themselves away to therapists, however, precisely because their behavior is so polarized – they act as if they absolutely must act a certain way all the time even when external circumstances would seem to require a bit more flexibility. Old time psychoanalysts referred to this defense mechanism as reaction formation. The behavior exactly opposite to the way they behave in public is often the true inclination that they are trying to hide. Evangelist Jimmy Swaggart preached loudly against the sins of the flesh while in secret he was cruising for prostitutes. Lay people are aware of this sort of dynamic, as evidenced by the Shakespearian line, “Methinks he protests too much.”

On my blog post of July 27, Mad, Bad, Blind or Stupid, I brought up a discussion that I had been engaged in on another blog over the nature of narcissistic personality disorder (NPD). People with this disorder act as if they are superior to everyone else and are always entitled to special treatment over everybody. They appear to have no empathy for others, and often bully people to get what they want. The constantly seek admiration, particularly from people they consider valuable.

An old debate came up in the other blog that I did not describe in the post. I had pointed out that people with NPD, while acting as if they have a superiority complex, actually have hidden low self esteem. Why else would they be starved for admiration? Not only that, but sometimes they may be making themselves appear to be the bad guy in their relationships when in fact they are really trying to take care of their mate but feel helpless to do so.

Someone else replied that some professionals now think that NPD’s really do have high rather than low self esteem, and that they in truth are just obnoxious bullies. I have seen this argument alluded to in professional publications.

My take is that the reason this is a bone of contention in the first place is because of the actor’s paradox. NPD’s are so good at acting like obnoxious bullies with an inflated sense of self importance that we cannot really know for certain what they really feel about themselves inside. In the previous post, I mentioned some of the evidence that things may not be what they seem.

Wednesday, August 4, 2010

My New Book is Out!

My new book, How Dysfunctional Families Spur Mental Disorders: A Balanced Approach to Resolve Conflicts and Reconcile Relationships, is now available

Get the book by clicking on the image on the right of the blog homepage or on:

You can also get it at Barnes and Noble on line at

Or from the publisher:


Millions of Americans have psychological issues or are affected by those of their family members, ranging from anxiety and bipolar disorder to mood and personality disorders. The growth of Big Pharma, combined with an increasing desire of managed care providers to find simple and "quick fixes," has resulted in an often myopic focus on biological causes of dysfunctional symptoms. There is plenty of evidence to indicate that this propensity to only prescribe pills is often deeply misguided, however.This book examines the role of dysfunctional family interactions in the genesis and maintenance of certain behavioral problems. The author presents a case for regaining a balance in terms of the biological, psychological, and family-system factors in psychiatric disorders and suggests a way to accomplish this.

Advanced Praise:

"All too often, mental health practice is being driven by downright bad science as well as conclusions that are being leapt to before all the scientific evidence is in. The result is treatment that does the patient a disservice. Dr. Allen does a superb job in sorting out what we really know, what is speculative, and what is completely bogus in the field. This volume is essential reading for both consumers and providers alike."

----------------John Rosemond, family psychologist, internationally syndicated columnist, speaker, and author of 14 best-selling parenting books, and The Diseasing of America's Children: Exposing the ADHD Fiasco and Empowering Parents to Take Back Control

Tuesday, August 3, 2010

Don't Ask, Don't Tell

I had the following exchange with another psychiatrist in the midst of a discussion on a Medscape blog about the frequent misdiagnosis of bipolar disorder:

Me:  I am saying that someone may appear bipolar when in fact he or she is really just acting out in response to family chaos or other environmental disturbances.  Mis-diagnosis stems from a failure of the practitioner to evaluate what is going on at home and under what circumstances the patient acts up, and to consider alternate possible explanations.

Family members will not usually volunteer the whole truth during a superficial visit with a doctor. Anyone who thinks that family members act the same way at home as they do in front of an authority figure, or that they will be totally honest about things like family violence or abuse, needs to get out more.

Psychiatrist #1:  This broad statement essentially implies and equates pediatric mental disorders with the family abuse and neglect. Misconceptualization of pediatric pathology is characteristic of orthodox thinking that always looks for proximal cause. The reasoning goes along the line "if child has problems, someone in the family caused them". And if the family does not offer any evidence of maltreatment,they are lying. A fundamental fallacy, in my opinion, that for decades prevented psychiatrists from understanding the nature of mental disorders.

Family, as the cause of psychiatric illness is a dangerous fantasy. Suspecting family members of hiding "the whole truth" is a regrettable statement from a professional.

Wow.  I never said I was equating pediatric mental disorders with family abuse and neglect, or that I assumed that if a child has a problem, someone in the family caused it.  I just said the family situation needs to be evaluated just like everything else.  It sounds to me like it is the writer who is saying that poor discipline or even child abuse is never an issue at all!  Family a cause of psychiatric illness?  How about behavior problems being mistaken for psychiatric illness?

Suspecting a family of hiding the whole truth in a superficial interview a regrettable statement?  Obviously this psychiatrist has never done any serious psychotherapy, or he would know that a patient may not reveal absolutely essential information about their situation until they have been seeing a therapist for months.  I once had a patient who did not reveal until one year into therapy that her father had been a junkie during her entire adolescense.

Let me see.  The other psychiatrist must think that his patients are all experts on psychiatric symptomatology so they can just volunteer all the important clinical information necessary for the doctor to make an informed clinical judgment.  They are so well read in psychiatry that they just know all the relevant factors a doctor needs to know about their home situation right off the top of their heads, even if they are not asked about something specifically. 

Of course, no one ever withholds information because they are ashamed of something, or guilty about something, or because they are not sure they can trust a complete stranger with their deepest darkest secrets and the skeletons in their family closet.  And all parents are completely aware that their trouble setting limits and saying no is feeding into their children's temper tantrums.  And we all know that people who are guilty of child abuse just love to tell everyone they know about it, especially someone who is legally obligated to turn them in to child protective services!  Why, everyone is just chomping at the bit to have their children taken away from them.

Oh, and one study showed that only 10% of the parents of children who are given complementary or alternative medicines tell their pediatricians about them.  The whole truth in a superficial interview?  I think not.

I know it is just a television show, but ever watch Supernanny?  When a family calls for her to come help them with a family problem, is she ever surprised by what she finds when she actually watches them in action at home?   Unrealistic or staged?  I doubt it.

I treat many patients who cut or otherwise injure themselves, and most of them know better than to tell the average doctor about it, because the average doctor will freak out.  Even psychiatrists.  They may get thrown in a mental hospital when being there would make their mental state even worse than it had been before they got there.  Who feels better being thrown in with a bunch of psychotic people?

Many of my patients have been abused and betrayed by almost everyone in their lives they were supposed to have been able to trust.  Yet when they are not completely open with a new doctor, who again is a complete stranger, they are accused of having pathological "trust issues."  In truth, they would have to be completely crazy if they did trust anyone implicitly after what they've been through.

When it comes to specific problematic or dysfunctional family interactions which trigger a patient's bouts of depression, panic attacks, impulsive acting out, or mood instability, in my experience people will not volunteer this information unless specifically asked about who says what to whom about whatever problem they bring to treatment.  It's a case of don't ask, don't tell.  If the therapist does not ask, they do not think to tell.

Since I was initially trained in psychotherapy by psychoanalysts, I was never trained to ask questions like, "What does your mother say about your being so depressed all the time?" or even "What does your father-in-law say about these fights you and your husband keep having? "  Once I started to ask questions like that, a whole bunch on new types of information I had never heard before came flowing out of patients.  The type of psychiatrist who calls all mood swings evidence of bipolar disorder never asks this type of question.

In the Medscape discussion, a patient jumped in added her two cents to the discussion about doctors believing everything they hear:

I am a survivor of domestic violence. My husband and I were going to marriage counselling. During counselling my disclosures about our marriage led my husband to decide that I had to be committed to our local hospital's mental health unit. He completed the necessary paperwork and told the psychiatric staff that he believed I had bipolar disorder with persecutorial delusions about him. The consulting psychiatrist believed him and his "proof" of my deteriorating mental health and I was given a confirmed diagnosis of bipolar disorder with persecutorial delusions. I was hospitalised for five weeks based on this confirmed diagnosis. During this time I was told that unless I took medication (zyprexa) I was not going to be discharged. When I contested and challenged the diagnosis, I was placed on an involuntary treatment order because I was so unwell I lacked insight into the severity of my unwellness.

I do not have bipolar disorder with persecutorial delusions. If the psychiatrist had not been so quick to diagnose and had had a watch and wait approach as well as performed a more thorough case history into my domestic situation and life with my husband, then I would not have been given this mis-diagnosis.

I would of course want to hear both sides of the story before I made up my mind about anything.  Shame on doctors who think they can read minds and perhaps that the only people who should not be believed are the ones who claim they are being abused.