Tuesday, December 20, 2011

Ultra Rapid Cycling Bipolar Disorder

OMG! Watch out for flying pigs!  DUCK!

Pigs in Spaaace

Something I have been harping about for years was finally correctly set straight in - of all places - a throwaway, drug-company supported, pharmaceutical-advertisement infested psychiatry journal - Current Psychiatry. Frozen hell!

In an article by Joseph F. Goldberg M.D., a clinical associate professor of psychiatry at the Mount Sinai School of Medicine in New York, the following summary was highlighted as a "bottom line: "Ultra rapid cycling [bipolar disorder] has not been validated as a distinct clinical entitiy, and frequent mood swings should not be used as a criterion for diagnosing bipolar disorder."

In the diagnostic Bible, the DSM, a rapid cycling bipolar disorder is defined as an individual who has four episodes of depression or mania per year, not per hour.  Yet the "bipolar disorder is everywhere" crowd has insisted for decades that there was such a beast as an "ultra-rapid cycler."  Thus anyone who was moody, had a sudden mood change no matter how brief, or had  the unstable emotions characteristic of individuals with borderline personality disorder, was suddenly "bipolar" and in need of medication for his "bipolar spectrum disorder." 

"Psychotherapy? What's that?" they seem to say.

The supposed existence of rapid cycling was advanced as an argument against using anti-depressant medication in bipolar patients having a depressive episode, because the drugs allegedly induced it.  This argument was even picked up by Robert Whitaker, author of Anatomy of an Epidemic, as a possible reason to be cautious about using antidepressants in general.  An argument based on a phenomenon invented by some psychiatrists that does not even exist!

Funny how after having practiced for 35 years in two states, with a wide variety of clinical populations, and specializing in the treatment of borderline personality disorder, I have never seen rapid cycling, with the possible exception of one case in which sudden episodes of psychosis (not mood changes) would come and go without warning.  Maybe I've just been lucky.  Or rapid cycling could be so rare as to be nearly non-existant.

When I first saw the cover of Current Psychiatry under discussion, I must admit was prepared for the worst.  "Oh no, not again,"  I thought. At least, I figured, I would have more material for a new post with another scathing attack on the whole bipolar spectrum craze.

Then I read the article.  What a pleasant surprise.

Meanwhile, in other myths-about-bipolar-disorder news, a new small study seems to contradict a bit of current conventional wisdom about the disorder: A study published in the January issue of the Journal of Affective Disorders (Baldessarini et. al.,136, 2012 pp. 149–154reported: "Patients with bipolar I disorder show disease progression that is random or even 'chaotic.'"

After following 128 patients with bipolar I disorder for about six years to assess "inter-episode intervals (cycle length)," researchers found that "most current bipolar I disorder patients are unlikely to show progressive shortening of recurrence cycles."

In the past, the impression that bipolar patients had episodes more frequently as they got older, the authors believed, was a statistical artifact caused by a minority of patients with frequent recurrences!

As most of these subjects were being treated with medications, and were probably going on and off of them every so often as patients are wont to do, this is evidence that the treatments do not make bipolar disorder worse over time.

Friday, December 16, 2011

An Update of Some Earlier Blog Posts

There have been some new developments recently concerning some of the issues and stories I have discussed previously on this blog, so I thought I would write a new post that updates some of my previous ones.

First, apropos my post of May 25, Pro-death Florida Legislators Run Amok, about a recently-enacted Florida law prohibiting health care practitioners from even discussing health care concerns about gun ownership with their patents: it was temporarily blocked by Federal U.S. District Court Judge Marcia Cooke. The state plans to appeal the injunction blocking enforcement of the law.

Second, concerning the debate about SSRI antidepressants and whether they are better than placebos:  A Commentary in the December 2011 edition of the American Journal of Psychiatry pointed out that placebo response rates to antidepressants in studies have increased as much as 7% per decade since 1980. 

Not coincidentally, this bizarre inflation of placebo response rates correlates very well with the timing of the rise of the so-called contract research organization, or CRO (  These organizations are usually doctors in private practice who are hired by drug companies to do their randomized controlled studies of medications.  These doctors get paid - quite handsomely - for each subject that they successfully recruit for the study. 

The subjects are, in turn, recruited through offers to pay them for their participation. ABC News recently did a story about stay-at-home moms who turn themselves into guinea pigs to earn extra cash. The use of paid subjects has led to the phenomenon of the "professional research subject" who participates in multiple drug trials.

Under these circumstances, both the doctors and the patients are being given cash incentives for exaggerating their symptoms in the initial evaluation so they can qualify for the study!  Once they are picked, no one then has a financial incentive to exaggerate symptoms on follow-up exams.

No wonder placebo response rates have skyrocketed.

CRO Newspaper ad clues in potential research subjects who wish to get paid as to what symptoms to complain about

Last, there are two developments concerning schizophrenia and its treatment with antipsychotic drugs. 

First, as the states have been cutting back on funding for community mental health centers due to the economic downturn, we are seeing a lot of what is described in the following news article:

After closing psychiatric hospitals, Michigan incarcerates mentally ill

"Wayne County Sheriff Benny Napoleon spoke for most sheriffs when he said, during a community meeting earlier this year, that his jail had become his county's largest mental health care institution.
Over the last two decades, changes in state policy and big cuts in funding for community mental health care have pushed hundreds of thousands of mentally ill people into county jails and state prisons...

"'We closed too many (hospitals), too quickly,' Mark Reinstein, president of the Mental Health Association in Michigan, told me this month. "It wasn't done in a planned, rational way."
Community mental health agencies -- which were supposed to take up the slack but never received the resources to do so -- face continuing budget cuts. The state has resumed warehousing its mentally ill -- this time behind bars...

 "In 1999, a Department of Community Health study -- conducted by Wayne State University -- of jails in Wayne, Kent and Clinton Counties found that more than half their populations were mentally ill and one-third were seriously afflicted, suffering from schizophrenia, bipolar and other psychotic disorders... Since 2008, the state has slashed $50 million from community mental health agencies, with Wayne County absorbing more than half of the cuts.

"Treating one client in a community program costs about $10,000 a year, compared with $35,000 a year to house one prisoner.  Statewide, more than 200,000 people a year use community mental health services, but experts say at least twice that many need them."

To really understand what happens when funding to community mental health centers is cut significantly, one has to realize that fewer patients with schizophrenia will get treated with anti-psychotic medication. Such medication is all the treatment that community mental health centers are providing nowadays.  In addition, those patient with schizophrenia who are seen will be seen much less frequently.  We know from multiple sources that lack of close follow-up highly exacerbates the issue of people not taking prescribed medications (non-compliance).

Off their meds, psychotic patients still end up being incarcerated, but as this story indicates, in jail, not in a hospital. Paradoxically, psychotic inmates are usually then prescribed anti-psychotic medications in prison - at a much higher cost.

One wonders how author Robert Whitaker (Anatomy of an Epidemic), who believes that antipsychotic medications make psychotic people worse, explains away how people with schizophrenia somehow become far more likely to end up in jail when they do not take antipsychotic medication.  Or perhaps he thinks that this development is the result of a malicious government plot .

The question of whether schizophrenia is in fact a real brain disease, and why it has been so hard to pin down the actual pathology, was recently addressed in a newspaper column by neuroscientist  par excellence John J. Medina. 

John J. Medina
An excerpt:

"... a biological explanation for the disease seems heartbreakingly just out of reach. Schizophrenia has a powerful genetic component (heritability percentage is in the low 80s), something I’ve known for years, something that could make it low-hanging research fruit. There is also a large clinical base on which to do studies: schizophrenia afflicts millions of people (the estimated prevalence rate is about 1% of the global population). Despite these seeming advantages, a molecular mechanism capable of describing all aspects of schizophrenia has almost completely eluded researchers.
"There’s a simple reason for this. A deep understanding of schizophrenia at such an intimate level has been hampered by a single technical bottleneck: the lack of a robust in vitro [in the lab as opposed to in the body] disease model.

"That may all be about to change. The results from a study that used cells derived from a deceased patient’s skin tissue has recently been published. Findings from the study may provide just such a model. It is not yet full-fledged schizophrenia-in-a-dish, but the findings portend a powerful future for the field."

Medina then goes on to explain a new technology - a way to produce something called Pluripotent stem cells (iPSC's) which I will not go into here.  Basically, they are re-programmed stem cells.  He then goes on to say:

"With these technologies in mind, I now have the tools needed to understand how to create a dish-bound model of schizophrenia. It involves answering some simple questions: What if you took the skin cells from patients who had schizophrenia and turned them into neurons? Would they exhibit behaviors of typical, healthy cells? Or would they exhibit behaviors reminiscent of previously determined properties of neurons in patients with schizophrenia? If the latter were observed, would you have a robust cellular model of schizophrenia, the missing link in this line of work? A consortium of researchers decided to to find out."

Skin cells from diseased patients made iPSCs that were similar to cells that were obtained from unaffected people.

"The most interesting result came from what happened next. Even though the reprogrammed cells were clearly neural tissue, they did not behave like typically functioning neurons. Several observed differences were eerily similar to previous findings other researchers had seen in tissue samples from patients with schizophrenia."

Despite what you may hear from mental illness deniers, neurons (brain cells) derived from patients with previously diagnosed schizophrenia "exhibit specific, aberrant properties."  I do not wish to get into highly technical neuroscience on this blog, but anyone interested might want to look up definitions for the following terms, and learn about how brain cells from people with schizophrenia differ from those who do not show symptoms of the disorder:

Dendritic arborization,  neuregulin expression, and Global gene expression changes.

After pointing out that this technology does have some problematic aspects to be resolved, Medina concludes: "Having a dish filled with cells that carry many characteristics of a human disease is a lot like having a flashlight in a dark cave. The greatest utility is in the ability to illuminate molecular mechanisms that might go undetected without such a model. It can go a long way toward relieving the frustration often associated with this line of work. Give it enough time and it might even—someday—illuminate a cure."

Undoubtedly, mental illness deniers will find something wrong with any evidence that schizophrenia is a brain disease.  It's in their nature.

Thursday, December 8, 2011

The Cognitive Behavioral Mafia

I recently posted on my Psychology Today blog what I had written in a previous post from this blog, The Limits of Cognitive Therapy.  In it, I had the audacity to criticize one very prominent technique used in Cognitive Behavioral Psychotherapy (CBT), and discussed how it neglects a type of cognition that is central in personality pathology (the family myth). I also complained that CBT therapists grossly exaggerate the strength of their evidence base from randomized controlled psychotherapy outcome studies while simultaneously blocking funding research into other forms of treatment.
Researchers who look at other psychotherapy techniques and are members of the Society for Psychotherapy Research (a group I used to hang with for several years), refer to the "cognitive behavioral mafia" at the NIMH, which systematically blocks grants for research into other therapy schools.  Leading trauma researcher Bessel van der Kolk couldn't get a psychotherapy research grant at one point because of it!
They also blocked me from getting a small grant to study my therapy paradigm, unified therapy.  The grant I had applied for was supposed to be for researchers to get preliminary data – called pilot data – for new ideas.  Although the rejection I got did point out some very valid things I needed to change with the proposed study design (and would have been readily agreeable to doing so and then resubmitting the grant proposal), their biggest criticism of my proposal was that I did not have any pilot data! 

Writing two books on psychotherapy and having 20 years of clinical experience (at that time) did not count at all.  I did not get a low score, I got no score. Roughly translated: faggetaboutit.
In response to my Psychology Today post, not surprisingly The CBT folks went on the attack.  In fact, another blogger on Psychology Today named Robert L. Leahy posted a rebuttal on his blog. I was accused of being a – horror of horrors – psychoanalytic psychotherapist, which I of course am not in the least.
While I can see how many people might have mistaken my post, because of my broad style, for an attack against the entire CBT treatment model - which if you read the post carefully it decidedly is not - I was accused of mischaracterizing the entire field because I was talking about one specific although very central intervention they use.

Cognitive therapy pioneer Albert Ellis called it active disputation and the other cognitive therapy pioneer Aaron Beck called it collaborative empiricism. Interestingly, some other commenters implied that the technique I focused on  is no longer being used at all by the other main innovator of CBT, Aaron Beck.   This is patently untrue.  He just changed the name to cognitive restructuring  or guided discovery.
In the post, I had given an example of a family myth in action in a psychotherapy case.  In the early 1980’s, I was trying out a technique from paradoxical psychotherapy called reframing, in which a family member labels something as bad and the therapist changes the valence to good.  For instance, an acting out child is described as the savior of the parents marriage because he or she is distracting them from their arguments.  (Technique used best by family systems therapy pioneer Salvador Minuchin). 

I was accused by the critics of “arguing with my patient” and that I was both doing and oversimplifying the cognitive therapy technique. Some of them also seemed to dismiss Albert Ellis in favor of Beck, as Ellis definitely did argue with patients until he died, although in a very empathic way. 
Salvador Minuchin

This contention might be true if one’s definition of argument is limited to the type of argument seen in Monty Python’s argument clinic:
 “Yes it is.”
“No it isn’t!” 
“Yes it is!”
 “No it isn’t!” 
What Beck does instead is examine the “empirical evidence” for the patient’s “irrational” thoughts to see if it is consistent with the facts.  That, my friends, is a form of argument (as is reframing –also not merely contradicting the patient).
From a discussion of cognitive therapy on Psych Central: “Cognitive-behavioral therapy, in a nutshell, seeks to change a person's irrational or faulty thinking and behaviors by educating the person…”  They won’t get an argument from me.
Another thing I was accused of was that I did not acknowledge that CBT has changed from the early days and has become a much more complete treatment, even though my original post clearly stated:
It is interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in severe personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do.  
This criticism was actually one I considered to be fair, and I quickly acknowledged that CBT has evolved considerable from its early days.  However, I pointed out that the evolution mostly consisted of stealing, slightly reinterpreting, and renaming concepts and techniques from other psychotherapy schools.  Even the central psychoanalytic concept of transference, vehemently denied by both behavior therapy and cognitive therapy since their inception, is merely redesignated as “the client's underlying schema about themselves and others.”
Speaking of schemas, the critics particularly complained that I wasn’t acknowledging them because I said that both Beck and Ellis (not CBT in general) have both said repeatedly that they believe that human beings are fundamentally irrational.  The concept of schemas, or mental models of how relationships and other things in the world are supposed to work, did not originate completely within CBT circles. 

Mardi Horowitz was one of the first widely read psychotherapists to talk about it - and he was psychoanalytically-oriented.  The concept of life scripts, which are basically several schemas linked together to form a plan for one’s life, was originated by another therapy school called transactional analysis.
I also happen to know Jeff Young, who is the main champion of using cognitive schemas in therapy.  He had in fact been a protégé of Aaron Beck, and was one of the cognitive therapists in the big NIMH collaborative study on depression in the 80’s (which incidentally also found interpersonal therapy equally effective to CBT in "depression"). Jeff personally told me that many of his former colleagues in cognitive therapy circles turned on him when he started to talk more about issues such as the effects of child abuse.
It is also true that Jeff Young had to go to Holland to get funding for a psychotherapy outcome study of schema therapy.

Another person commenting accused me of "whining" about the CBT mafia because I mentioned that I was blocked by them from getting research funding.
Still another thing that I was accused of doing was denigrating psychotherapy research in general, which is also something I did not do.  I had merely opined that the CBT people were over-selling the strength of their research results. 

Critics immediately jumped into my favorite form of sophistry: circular reasoning.  They basically made the point that because cognitive therapy was scientifically proven (not!), money should not be wasted on studying other paradigms!  In other words, why do we need more studies when we're already convinced.
Many of the critics also seemed to be saying that CBT was some sort of monolithic entity and did not acknowledge that there are several sub-schools of CBT which all approach patients differently  and which argue among themselves about who is right.  There is ACT, REBT, DBT, and schema therapy, to name but a few.  Schema therapy in particular is quite unlike the original form of cognitive therapy, as it not only looks at the developmental origins of so-called irrational ideas but sees the origins as central to the actual therapy. 
At least one critic went on to accuse me of being unscientific because I was not using CBT therapy exclusively with my patients, as well as being possibly unethical because I used "unscientific" treatments:  “It is also clear you practice a therapy with no established evidence base. An eclectic mix that where you've picked and chosen what you like from different schools without the package being subject to evaluation. Overall this sounds like deeply unethical (and potentially dangerous) clinical practice.”
Oh, like that isn't what all therapists do - including CBT therapists who pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them without having their "whole package" subject to evaluation. Of course, by the critic's reasoning, the originators of all the CBT techniques were all unethical because they undoubtedly tried them out on patients before packaging them for outcome studies.

This critic illustrates another point of confusion: a basic misunderstanding of psychotherapy research. As I said, CBT therapists in treatment studies pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them and then subjecting the "whole package" subject to evaluation. Since every therapist in the study is doing something somewhat different with each patient, a truly scientific evaluation of “the “package” would be quite a feat!

In fact, outcome research does not focus on specific techniques but on some overall strategies. Finding out which techniques were valuable and which superfluous on their menu of interventions would require something called dismantling studies, which are few and far between. Psychotherapy process research, on the other hand (of which there is a huge literature that dwarfs the outcome research) does focus on specific techniques, and often shows that techniques used by more humanistic and relational therapies are highly effective for certain therapeutic goals.

Adherence to the therapy model by the different therapists participating in an outcome study is another big issue. If it is measured at all, it almost always shows wide variation. There is usually no "red line" by which, if a therapist's adherence to the model goes below a certain point, his or results are not included in the study! So what really worked?  We don't know. 

The critics on both Psychology Today blogs seem to be proving my point that CBT grossly exaggerates its science base. When I and another commenter pointed out specific and highly significant weaknesses in their literature, the silence was deafening.

Also noteworthy that not a single critic had anything to say about the issue that was the main point of my blogpost – the existence and importance of family myths. I asked them for references where this issue or where any social psychological concept that was similar had been discussed by CBT therapists. Not a word.

To my knowledge, cognitive therapists have never written about how many allegedly irrational ideas are held collectively by kin groups.  Ignoring collective phenomena is actually a problem with almost all forms of individual psychotherapy, because therapists are entirely wrapped up only with what goes on inside people's heads.

The sole complaint of the only critic that even mentioned family myths was that I had not brought it up until the tenth paragraph of my original post. (That was because I had to explain some concepts from cognitive therapy before my criticism would make sense). So sue me.

I was too lazy to quote a bunch of studies to demonstrate the weaknesses in their science, and I figured they would merely cherry pick some counter-examples and then summarily declare victory.  However, another reader came to my rescue.
****Submitted by Philip on November 26, 2011 - 6:34am.
I have been reading a number of outcome studies recently because I am seriously worried by claims that 6 to 20 sessions of cognitive behavioural therapy are sufficient to cure such disorders as major depression and anorexia nervosa.
Allow me to summarize, briefly, the findings of a meta-analysis of CBT for bulimia nervosa. The rate of recovery for patients who completed treatment was found to be around 45%. This is quite substantial - a substantial minority of patients recover after and average of 12 sessions of CBT or behaviour therapy (they are equivalent in effect). It should be noted that there is very little follow-up data by which to judge whether or not these patients remained well.
However, consider the following:
20% of patients dropped out of treatment. 40% of patients who were initially considered for inclusion in the studies were excluded from treatment. This is because, as Dr Allen correctly noted, such studies exclude co-morbid patients (those with multiple diagnoses). Thus, the treatment samples are composed of less complex cases.
As an aside, most outcome studies of CBT for depression exclude around 60-70% of patients - again, because these cases are considered too complex to treat with CBT.
Back to bulimia. On average, after completing treatment, patients continued to binge/purge twice per week. So, although the treatment resulted in a statistically significant reduction in symptoms, many - perhaps most - patients remained symptomatic.
Thus, 45% of a restricted sample (which excluded severely disturbed patients bulimia, patients with bulimia and drug or alcohol addictions, suicidal patients with bulimia and patients with 'borderline personality' disorder and bulimia) reportedly recovered (with little follow up data to support this conjecture).
One of the authors of a study reporting these results concluded that CBT is the "treatment of choice" for Bulimia Nervosa. It is the only treatment that has been adequately studied. This is what Dr. Allen is referring to when he notes that the credentials of CBT are exagerated.
If we actually think about Bulimia in the real world - where most patients have severe co-morbid disorders, and 50% also have a borderline pattern of symptomalogy - these studies tell us little about the efficicy of CBT. In the lingo of researchers, outcome studies have little 'external validity'.
Why is it that researchers are unwilling to apply CBT to complex or co-morbid cases? They claim it is because they want to exercise experimental control - they want their studies to have internal validity. That is, they want to know which treatment works for which disorder.
It is also very likely that, were researchers to attempt to treat severely disturbed patients with CBT, they would fail to obtain results which reflect well on CBT. They also would have a hard time getting their work published, for journals do not like to publish null [negative]-findings.
If one is willing to read the research carefully, and has a basic education in statistics and research methods, the evidence supporting the effectiveness of CBT is very modest. Indeed, CBT contains a smaller and less diverse 'evidence base' than does cotemporary psychoanalytic psychotherapy.
What CBT has more of than other psychotherapies is outcome research. However essential outcome studies are, they "prove" nothing about the validity CBT. For all they show, the patient might be cured because of a placebo effect or because of cognitive restructuring. Same same but different.
This is called, by the way, the dodo bird effect: the finding that all treatments are equivalent (whether they be behavioural therapy, CBT, 'psychodynamic' therapy, interpersonal therapy and so on). That's what outcome studies tell us. And we don't know why. It seems that the debate is only just starting, and some have already declared CBT the winner.
Thanks, Philip.
When it comes to getting people to change their behavior, thoughts and feelings, there is always a multitude of ways to skin the proverbial cat.  And every patient responds to interventions differently. This is where social sciences differ from hard sciences like physics.

"CBT therapists are superior to therapists from all other schools of thought, so come see us." This exaggeration of the research results by CBT folks looks a lot like the same phenomenon seen in drug studies these days: it isn’t so much science as marketing.

Friday, December 2, 2011

Mainstream Media Finally Covers a Scandal

Kudos to ABC news for finally reporting on the scandal in which disturbed children in foster care are being drugged to shut them up - rather than being treated for the trauma of coming from abusive or neglectful homes and then being passed around from foster family to foster family. 

Bizarre and pharmacologically absurd cocktails of powerful central nervous system drugs are prescribed after five minute visits with doctors.  Foster parents are often pressured to go along with the practice.

You can find the story at

The government report that ABC describes is the only thing that's "new" about this story.  I have seen  this discussed for several years in the professional media.

Only problem is, while foster kids get treated like this more often than other children, they are hardly the only ones getting this sort of "treatment."