Monday, March 28, 2011

How Children Respond to Double Messages from Parents, Part II

In Part I of this post, I began the discussion of how children decide how to respond to consistent double messages about what is expected of them from their parents.  I mentioned that they respond according to three general principles of ranking the conflicting elements of the double message, and described the first.

Hmmm.  I find myself questioning your gesture

In this post, I will describe the other two.  Actually, the first two general principles are merely examples of the third, overaching principle.

Principle #2.: Children pay more attention to what adults say to each other, or to generalizations they make about various issues, than to any direct instructions or admonishment said to children.

For instance, a mother might verbally prod her daughter, in a compulsive repetitive manner, to get married - after having spent years telling anyone who would listen about what jerks all men are, and how unhappy she is with her own spouse (her daughter’s father). The degree of the mother's preoccupation with both the subject and her daughter's stand on the issue would quite likely lead the girl to the conclusion that her choice regarding marriage is of major concern to the mother.

Once again I will ask you to suspend your disbelief and assume that the daughter's appraisal of the mother's opinion, right or wrong though it may be, will be a major determinant of what the daughter does, regardless of the daughter's own personal preference. So what to do? The mother's negative comments about men, according to principle #2, would seem more important than the direct admonition to marry, so most likely the daughter would not marry.

However, once again, she will face criticism if she stays celibate. A possible solution is for the daughter in such a situation to end up picking a series of jerks with which to hook up, in order to satisfy both ends of the double message. That is, she follows her mother’s instructions and keeps trying to find a husband, but proves that her mother is correct about how men really are.

Whether she dates a series of jerks or actually marries and then divorces a series of jerks will usually depend on other relationship issues in her family of origin, such as what role her father plays in this family drama.

This leads us to the general principle, principle #3. When someone compulsively engages in repetitive behavior, family members will invariably conclude that this behavior is quite important to the perpetrator. In the example from principle #1, as mentioned, they conclude that mother likes to do housework AND complain about it. In the example from principle #2, they conclude they have to try to do what they are told while conforming the way they do it to the parent's apparent expectations. 

Far be it for a child to deprive a parent of a cherished role. In the first case, they will “help” their mother by making sure that she has plenty of housework to do, and plenty to complain about.

In order to do so, they may appear to be oppositional to the parent, but the oppositionality is merely an illusion. To borrow a phrase from Marshall Mcluan as co-opted by psychoanalyst Leston Havens, the medium of the total picture of the mother's behavior over the entire history of the relationship takes precedence over single element - particularly any verbal message. The mother's total spectrum of behaviors, in context, is more important that what she says on any specific occasion.

Keeping these three principles in mind, it becomes easy to see why oppositional behavior is so common in dysfunctional families. In cases where parents are ambivalent about themselves, they induce children to appear to disregard verbal messages in favor of some other factor.

This may have biological roots. Attention to non-verbal behavior preceded attention to verbal behavior in the evolution of social animals.

Wednesday, March 23, 2011

Debunking De Biederman

Joseph Biederman, the Harvard guru who advocates for the use of antipsychotic medication on children, is a psychiatrist who almost single-handedly started the current craze of psychiatrists and primary care doctors diagnosing acting-out children as having bipolar disorder.  I discussed in previous posts some of the issues involved both in Dr. Biederman's behavior and in the diagnosis of "pediatric bipolar disorder," particularly in my post of March 9, 2010, Recipe for Producing Frequent Temper Tantrums in Children.

Dr. Joseph Biederman

Dr. Biederman argued that the symptoms of bipolar disorder in children are very different from those of adult bipolar disorder.  In particular, he said that manic or depressed mood episodes, required by the DSM to last for a minimum of four to seven days in adults for mania and two weeks for bipolar depression, could last for mere minutes in children. Symptoms of bipolar disorder seen in children but not in adults, he opined, included temper tantrums and "explosive irritability."  Not that he had any clear scientific evidence connecting such symptoms to adult bipolar disorder. I'm guessing he just pulled these ideas out of his butt.

Tantrums, rage, emotional instabilty, low frustration tolerance and the like are all symptoms of borderline personality disorder in adults.  These types of symptoms fall under the rubric of affective instability or mood dysregulation, also called neuroticism by personality theorists. 

Individuals high on this variable get depressed, anxious, or angry quite easily and take much longer to calm down than average person. Patients with borderline personality disorder are frequently misdiagnosed as bipolar in the world of today's psychiatry (see my post of April 7, 2010, Borderline or Bipolar?).

Is similar diagnostic bungling being seen today with out of control children who exhibit affective instability?  Well, according to a new review of all of the existing studies in the February 2011 edition of the American Journal of Psychiatry by Ellen Leibenluft, the anwer is quite clearly yes.

From the abstract: "An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood.

Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups."

In the absence of validated biological laboratory tests for a psychiatric disorder, the time course of symptoms, clustering of the symptoms in close family members, and differences in brain physiology and mental abilities on various mental tasks are the most important indirect ways of assessing whether two similar appearing psychiatric syndromes have something important in common. In each of these ways, comparing short-term affective instability to the longer term symptoms seen in bipolar disorder shows that the phenomena are not the same thing.

It is also important to note that irritability is a criterion for at least six different psychiatric diagnoses in children (manic episode, oppositional defiant disorder, generalized anxiety disorder, dysthymic disorder, posttraumatic stress disorder, and major depressive episode).

Of course, not even Leibenluft discusses the possibility that -  just maybe - affective instability in children is reactive to a chaotic family environment.  Interestingly, in an interview in the January 21, 2011 Psychiatric News, she was quoted as saying, "The phrase we commonly hear from parents is that they have to 'walk on eggshells.'"

Translation: the kids in these families are determining what the adults do or say, not the other way around.  A situation in which parents seem to be afraid of their own children is very bad for children, who tend to badly need to be taken care of and given limits by their adult caretakers - despite the kids' protestations to the contrary.  There is very strong evidence from the attachment literature that such situations actually create affective instability in children.

So what might Biederman's answer be to this new data?  Amazingly, according the Leibenluft, Biederman's research group and some other groups maintain that it is "nonetheless reasonable to apply a bipolar diagnosis to children with such a clinical presentation. One important argument for this position is that children with severe nonepisodic irritability manifest severe mood symptoms and are as severely impaired as those with classic bipolar disorder, but without a diagnosis of bipolar disorder their access to the mental health services they need might be limited."  (p.129-130).

Wow. In other words, we should label kids who actually have behavior problems as having bipolar disorder, so instead of doing family therapy, we can treat them with sedating drugs that have not been approved as safe or efficacious in children, and which have a lot of potentially extremely serious toxic side effects (metabolic syndrome) in people including death. 

An amazing display of sick, twisted phony logic worthy of Ann Coulter.

(See a great review of the issues involved in the case of a child named Rebecca Riley who died at the hands of parents who were trying to bilk the psychiatric disability system.  It also shows how easy it is to fool some psychiatrists).

Friday, March 18, 2011

Patient Advocates, or Unwitting Drug Company Shills?

In my post of May 3, Preying on Human Misery, I discussed how big Pharma took advantage of the parental desperation that I described again in the recent (February 26) post, Couch Potatoes UnleashedMany of today's parents absolutely panic whenever their kids start acting out or having even the most inconsequential of emotional problems.  They at first obsess about whether or not they might have done something terribly wrong to cause it, but soon begin to look for something else to blame - anything else - that might account for the problem that does not involve family relationships.

Thinking their children's problems might be due to family discord tends to make them feel even guiltier and even more panicky. Often they do not realize that it is their own guilty and panicky behavior which feeds into their kid's problems and makes those problems far worse then they might be otherwise.  And thus, a vicious circle is created.  More parental guilt and anxiety leads to more acting out and more emotional distress in the child, which leads to more parental guilt and anxiety, and so forth.

A few years ago, Big Pharma took one look at the Child and Adolescent Bipolar Foundation (CABF) and decided that here was a great population to exploit in their continued efforts to expand the definition of bipolar disorder in order to sell more atypical antipsychotics to unsuspecting patients (See my post of March 22, The Zyprexa Documents).

They helped fund the CABF and used their paid-off "experts" like Joseph Biederman, as well as their sophisticated psychological marketing techniques, to spread the word that  a brain disease was the source of these children's problems, and that their medications were the solution.  Soon, entire families began to label their members with various and sundry psychiatric disorders, a few of which were completely bogus, and others of which they simply did not have.

To their credit, CABF eventually stopped accepting drug company money.  But by then the damage had already been done.

Big PhARMA's strategy of using advocacy groups to increase sales was by no means limited to CABF, and by no means limited to psychiatry.  This marketing strategy is ingenious, hard to catch, very sneaky, and very effective. According to a new study in the American Journal of Public Health, not-for-profit patient health advocacy groups like the American Diabetes Association also get money from drug companies in the form of grants that—more often than not—are not disclosed to the public by those groups. 

These grants are not made because the drug companies have the best interests of the common man at heart.  What they want is for the patient groups to help push their drugs and medical devices.  It works.

The National Alliance on Mentally Illness (NAMI) has been a major target for Big Pharma.  This group was already on the warpath against psychotherapists - particularly family therapists and psychoanalysts - for unfairly blaming major mental illnesses like schizophrenia and autism on poor parenting.  Many members were all too anxious to absolve dysfunctional family interactions of having any role at all in any psychiatric disorder or behavior problem at all for the reasons discussed above, and so became easy targets for the pharmaceutical industry.

Like the famed Pied Piper, the industry played a tune that members of the advocacy group were delighted to hear - that they had absolutely no control over the way their children acted or turned out, and that the proper medication would solve all of their problems.
The website ProPublica reports: 

"From 2006 to 2008, the group took in nearly $23 million in drug company donations—about three-quarters of its fund-raising. At the time, NAMI’s executive director told The New York Times that “the percentage of money from pharma has been higher than we have wanted it to be” and promised greater disclosures.

In the area of neurosciences, [drug company Eli] Lilly gave NAMI $450,000 for its Campaign for the Mind of America. NAMI has advocated that cost should not be a consideration when prescribing for patients. 'For the most severely disabled,' insisted NAMI, ‘effective treatment often means access to the newest medications such as atypical anti- psychotic and anti-depressive agents. . . . Doctors must be allowed to utilize the latest breakthrough in medical science . . . without bureaucratic restrictions to the access for life-saving medications.’ To the degree that NAMI’s campaign succeeded, the market for Lilly’s neuroscience drugs expanded."

PhARMA marketing departments often seem to know more psychology than many mental health providers.

Saturday, March 12, 2011

Parents of Patients With Schizophrenia Can Stop Feeling Guilty Now

Schizophrenia is not something I really wanted to focus on much in this blog.  Certainly, family dysfunction (and a variety of other stresses including someone just leaving home for the first time to go to college or join the military - an extremely common scenario) may trigger or exacerbate a first psychotic episode in a vulnerable patient, leading to the hallmark delusions and hallucinations. 

However, the vast majority of neuroscientists, physicians, and psychologists no longer believe schizophrenia to be primarily a "functional" (psychological or behavioral) disorder.

As I have mentioned several times, given the current state of our knowledge about neural networks in the brain (100 billion nerve cells with over a thousand separate connections each), the idea that schizophrenia is a brain disease is extremely difficult to "prove" beyond a shadow of a doubt, as some mental illness deniers insist we must. 

It would be hard to believe that the brain is the only organ in the body that is immune from any chronic developmental disease that would cause microscopic deterioration to its parts - in this case its neural network connections.

The fact that our current treatments for psychosis suck big time, while an important issue in itself, is not really relevant to the argument about the nature of the illness. 

Still, because some of my readers keep bringing schizophrenia up, I would like to describe a new study that I think should finally lay at least one argument to rest.  The study is brilliantly designed and the results very clear.

In my post Antipsychotics Are for Psychosis, Not Insomnia, I discussed an earlier study that looked at the role of antipsychotic medications in the development of severe brain shrinkage (cerebral atrophy) that is seen in many severe cases of chronic schizophrenia.  That study concluded that both the underlying disease and the medication both contributed to this phenomenon.  The study was not conclusive, however, because there was no actual control group.

At last, we now have the very first prospective study about this issue by Andrew M. McIntosh, David C. Owens, William J. Moorhead, Heather C. Whalley, Andrew C. Stanfield, Jeremy Hall, Eve C. Johnstone, and Stephen M. Lawrie.  It has been published on line in the journal Biological Psychiatry. 

A prospective study is one that follows over time a group of similar individuals (cohort) who differ with respect to certain factors under study, in order to determine how these factors affect rates of a certain outcome.  In this case, 162 individuals at high genetic risk of schizophrenia and 36 healthy control subjects were followed over 10 years. 

The high risk subjects had at least two first- or second degree relatives affected with schizophrenia.  None of the subjects in the study had any psychotic symptoms or other evidence of schizophrenia at the beginning of the study.

Participants received detailed clinical and up to five MRI scan assessements at 2-year intervals. The results?  17 of the 146 high-risk subjects who were scanned developed schizophrenia over the 8 years of the study. People at high genetic risk of schizophrenia had significantly greater reductions over time than the control group for whole brain volume and left and right prefrontal and temporal lobes.

Greater prefrontal reductions were shown in high-risk subjects who subsequently became unwell compared with those who did not. These changes were significantly associated with increasing severity of psychotic symptoms.

In other words, cerebral atrophy was developing in these patients before they had been treated with any antipsychotic medication.  In fact, it started to develop before they even had any symptoms!  So the atrophy is clearly present in the absense of any treatment at all.

Oh, and guess what?  The study was not funded by the drug companies, nor do any of the authors declare any drug company connections.

So, if you are the unfortunate parent of a person with schizophrenia who is dead set on blaming yourself for the condition of your child, I would ask two questions.  These are rhetorical questions, since I have no way of evaluating the accuracy of your anwers:

First, were you an abusive or neglectful parent or the spouse of an abusive or neglectful parent?  If not, what on earth are you feeling so guilty about?

Tuesday, March 8, 2011

How Children Respond to Double Messages from Parents, Part I

Double, Double, Toil and Trouble

In late 1987 and early 1988, a 9 year old girl named Sharon Batts, from an evangelical Protestant church group, got her 15 minutes of fame.  She sang on a record called Dear Mr. Jesus whose lyrics petitioned Jesus with a prayer to stop child abuse ("You cannot petition the Lord, with prayer!" - Jim Morrison, when he was a lad in seminary school).  The record, which was actually recorded three years earlier, received a lot of airplay leading to some notoriety for the girl.

She was interviewed on a news program with her mother and father.  The interviewerer asked the girl how she was handling her new-found fame.  The girl looked up at her parents before answering.  They asked her what would happen if she became too proud.  "I'll fall flat on my face," came the reply. 

In the back of the TV picture the parents sat smiling and were, as any child could see, absolutely beaming with pride. 

A bit of a double message, no?  If pride goeth before a fall, as the parents seemed to have coached the girl to say, then why were they availing themselves of it so readily? 

I believed that the girl was most likely coached to answer as she did because a short time later, on January 11, 1988, the girl was interviewed by People magazine.  In that interview she made the statement, "Sometimes whem peole get famous, they fall flat on their face."  Odd that she would make it a point to use the same words twice like that. 

Assume for the sake of argument that determining the parents' attitude towards the issue of pride was a pressing concern for this girl, and would function as an internal road map for how she would behave under a variety of circumstances. Let us further assume that a wrong determination would cause a tremendous uproar within her family. 

If this little girl were desperate to solve this problem, how would she go about making sense of her parents' behavior under these circumstances? How would she answer for herself the question of why there was such a discrepancy between their verbally expressed attitude towards the dangers of pride and their absolute pleasure in basking in it themselves? Would she think that she ought to be proud or humble?

First, could she come right out and ask them to explain the contradiction? In some families, this might be possible. However, I have reason to believe that in this family, it might not be possible. I of course could not prove it unless I had some form of verification from the family itself, but the very fact that an ambiguity exists, created by the mixed nature of the parents' behavior, might indicate that they were, unbeknownst to their daughter, highly conflicted about, and struggling over, the issue of pride themselves. 

Pride feels good, but I suspect it might be contrary to the group ethos expressed by the evangelical church to which this family belonged, where pride might be seen as hubris, an affront to God.

The rules by which the family operates might hinge on conforming to this view. It is indeed possible that family tranquility might be in part predicated on religious conformity and denying one's own specialness. On the other hand, the larger American culture, through the mass media and other methods, extols the virtues of unfettered individuality. Thus, pride might hold a bit of an allure. 

Under these circumstances, a question from the daughter concerning their apparent hypocrisy could create for the parents a state of anxiety, which could conceivably lead to a negative reaction. They might, for example, shift uncomfortably in their chairs and change the subject. Alternatively, they could get angry and deny any incongruity at all. They could become incensed that the girl would even dare question what was told to her verbally. Some parents in such a situation might even become abusive. If any of these responses were forthcoming, the girl would soon learn that direct questions are best avoided. She would need to come up with some other way to make a determination. 

Please keep in mind that a nine year old girl would be very unlikely to come up with the explanation that her parents were of two minds on the subject. Research indicates that the concept of ambivalence in human motivation does not begin to develop until the ages of 10-15, and that the practical application of such knowledge does not come into play until considerably later than that. Unfortunately, learned habits about role functioning in interpersonal relationships tend to develop far earlier in life, and tend to become almost reflexive or automatic in familiar-appearing situations.

Children and adults will tend to react to significant others as though they had only one goal or desire in each type of situation. This by no means indicates that adults function at the cognitive level of children, only that one often does not stop to think about habitual behavior.

So, how will our child decide which part of the double message to heed? I have found that the conclusions that children will reach in such a situation are rather predictable, and based on three general principles of hierarchically ranking mixed elements of a message. The first and perhaps the second of these principles may seem so obvious as to be truisms, but their axiomatic nature is belied by the ease with which they are forgotten in emotionally charged situations.

Principle #1:  As we all know, actions speak louder than words.  This is not as simple as it sounds, however, because the act of saying something is also an action itself.  Linguists talk about what they call speech acts.  If I come up to you and say, "I hear you're having a party next week," I am not only relaying to you what I heard about your plans for next week, but I am also fishing for an invitation.  So how can actions speak louder than words if words are also actions?

I will tell you. For example, say that a mother is constantly complaining about doing the housework, but faithfully and compulsively does it every single day, while consistently rejecting all offers of help. Children and other family members will draw not just one conclusion, but two conclusions: First, mother really does want to do the housework, and wants to do it all by herself. That's what she does.  Actions speak louder than words.  She also complains.  Therefore,  she must also enjoy complaining, even while doing things she likes to do. Actions speak louder than words.

No one will really think about the possibility that Mom really hates the work, but feels duty bound to perform it. Despite internal (intrapsychic) conflict being the mainstay of psychoanalysis, concepts from which are everywhere in our culture, this possibility does not seem to gain much traction in real life.

Now, having drawn these two conclusions, a problem is nonetheless created. If the children help with the housework, they may be stopped in their tracks, most usually with the verbal comment that they are not doing the housework well enough or correctly. If they do not help, they are criticized for not helping. Damned if they do; damned if they don't. What to do? 

One ingenous solutions is to not only refuse to help, but to make even more of a mess.  That way, their mother gets to do both more housework and more complaining.  Perfect! She should be so pleased. 

On the surface they may seem to be oppositional and defiant, but underneath that veneer they are actually giving their mother exactly what they think she needs from them.

I will cover Principles #2 and #3 in Part II of this series.

Wednesday, March 2, 2011

How to Disarm a Borderline, Part VI: Respect Their Intelligence

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12).  The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

This post will continue with specific countermeasures to the usual strategies in the BPD bag of tricks used by them to distance and/or invalidate you, as well as to make you feel anxiously helpless, anxiously guilty, or hostile.

Today we discuss #3, countering illogical statements and absurd arguments.

People with BPD will sometimes say the most inane-sounding things as if they believe them with all their hearts.  Things like, "I need cocaine.  I don't feel normal without it."  Or, "I should to be able to walk down dark alleys at 3 AM in seedy parts of town with $100 bills hanging out of my pockets."  Upon hearing this, anyone with a lick of sense will feel like talking some sense into the person with BPD.

This presumes, of course, that the person with BPD has no common sense.  In fact, it presumes that he or she is a complete moron.  If there is one thing I have learned over the years, it is that, despite appearance to the contrary, people with BPD have just as much common sense as anyone else.  Usually, they are of above average intelligence.  So why would they say such ignorant sounding things?

You were expecting a good argument?

The first thing to notice is that the statements above are actually true.  If you are addicted to cocaine, indeed you do not feel normal without it.  One should have the right to walk anywhere unmolested, shouldn't one?

The problem is of course that the cocaine is making these folks feel worse in the long run, and that taking such walks is a foolish thing to do, rights or no rights.

So the natural response to such statements is to want to argue with what the person with BPD says.  Of course, this is actually invalidating to the person with BPD, because they are intelligent enough to already know what the other person is arguing for.  In response, the person with BPD will then dig in and take the position, "My mind is made up; don't confuse me with the facts!"  They will then start making arguments that actually are stupid, under the theory that the other person expects them to be stupid! 

Individuals with BPD are extremely generous that way: they will give you what they think you expect of them.

If you want to make an obvious point as a springboard for a discussion, you have to use a disclaimer.  You have to acknowledge that the person with BPD already is well aware of the point you are making.  You might say, "But as you already know, cocaine is distructive in the long run."  Or, "Of course you should have the right to do that, but as I am sure you are aware, actually doing it is dangerous. I do not understand why you want to take such a risk."

An important caveat is that you want to keep your statements as brief as possible, and NOT go on to explain what you just said or give additional information that justifies your opinion.  The individual with BPD already knows why you think what you think, so there's no point in it.  Going on again presumes that the other person is stupid.

The individual with BPD may then explain why they want to take the risk, or he or she may not.  Generally, they will just drop the argument altogether.  This may not calm your concerns about the risky behavior of  persons with BPD, but as I discussed in Part V, you are really helpless to stop them if they are set on doing what they say.

What if the person with BPD does not drop the subject, does not accept the change in the conversation that you are suggesting (that is, talk about why the person wants to do something dangerous rather that argue stupidly about whether or not the something is dangerous), and/or says something that is inherently stupid? My advice:  Refuse to argue.  You might say something like, "I'm not going to insult your intelligence by arguing with you about that."

If you do not like that one, you can also just say nicely, "I disagree with you."  Disagreement is not invalidation.  It does not inherently make one person right and the other wrong.  It is just a difference of opinion and nothing more.  Many people with BPD have never experienced a respectful disagreement in their entire lives.

No matter what else the person with BPD throws at you after that, do not address it other than to state that you will not argue about it any further.  Repeat as necessary.