Tuesday, March 27, 2012

What to Expect From Your Marriage

"In relationships, if you always do what you always did, you'll always get what you always got." ~ Amy Dickinson

A common complaint in letters to advice columns is that a spouse is chronically neglecting various needs of the complainer, or refuses to do something that the complainer fervently desires.  Sex may be the most common missing element described by people who write this type of letter – and women complain about the lack of it at least as often as do men – but it can be anything from refraining from cussing to refraining from describing embarrassing or quirky attributes of the complainer to outsiders.

To me, sexually frustrating one’s spouse seems to me to be the most strange of all such complaints, because it would be so easy and take so little effort to give the frustrated spouses what they say they want.  Do these spouses really care that little about keeping the other spouse happy?  That would seem really mean if not vicious.

After all, sex doesn’t take all that much effort, especially if you are not especially concerned about your own pleasure.  Why not make the other person happy occasionally even if you don’t enjoy it yourself?  A mere half hour every week or two might be just the ticket. 

You say it’s a chore?  So is going out and buying your spouse gifts on birthdays, Valentine's Day, and Christmas.  A lot of people seem willing to do those things.   How about meeting all of your other responsibilities at your job and at home?  Chores all, at least much of the time.  For most people, willing!

Even if the man is completely physically impotent and incurably so…and there's no G-rated way to say this... let’s just say his tongue probably works OK, doesn’t it?

Here is a typical example of a letter from a sex deprived wife, from the column Annie’s Mailbox from March 10, 2012.

"Dear Annie: "John" and I have been married for 15 years. He is a wonderful person and a great father...Our relationship is fine on the surface, but it's emotionally empty. There is little intimacy, which has been an issue throughout our marriage. It manifests itself periodically in arguments that never seem to get resolved… He wonders why I cannot "just be happy," because from his perspective, everything is fine. I have told him clearly that I need more attention and affection, but I have come to the realization that he is "just not that into me.

… Annie, I love my family. I am not asking for a magical romance. I don't think it's too much for a woman to need occasional loving physical gestures from her husband. I can't figure out why it's so hard for him to express his love if he cares for me as much as he says.

I don't want to leave, but things could be so much better if John would only put a little more effort into our marriage. Any suggestions on how to improve things? Or am I just destined to have an emotionless relationship?" 

The Annies answer: "There is a variety of reasons why a man may not show any interest in his wife: He could be gay, asexual, not attracted to you or having an affair. He could have low testosterone or other medical or emotional issues. The real problem is that he refuses to address it…"

Well those are all possibilities, but why would she have married someone like that in the first place if she craved affection so much?  It sounds from the letter like she just thinks hubby might just an A-hole, does it not?  I mean, she seems to think that he is someone who is depriving his dear wife of that which she craves, for no apparent reason.

But is that what is really happening?  Could be, but I have another, more likely explanation. The writer starts by saying that they have been married for fifteen years.  It doesn’t sound like this is a new problem, so what that probably means is that she has been putting up with this treatment for fifteen years.  And, after she mentions that, she praises the guy for being a “wonderful” person.  What, you may ask, is so wonderful about a guy who is more than willing to almost totally neglect your needs just because he can?

I find the husband’s response to be telling.   He asks her why she cannot "just be happy, because from his perspective, everything is fine.”  She also says that she has made it clear that the lack of intimacy bothers her a great deal.  So why would he think everything is just fine?  Why wouldn’t he already know the answer to the question of why she just “can’t be happy?”

Well, unless the guy has the IQ of a turnip, the only reasonable explanation for his apparent obtuseness and confusion is that he doesn’t believe her when she say she wants more intimacy.  Remember, she has been putting up with this for fifteen years.  In her letter she says he is wonderful and that she does not want to leave.   If we are hearing this in a letter she writes that may be up for public consumption, then the odds are extremely good that he has heard her say this stuff.  Many times.

The much less obvious explanation for this state of affairs – and so often the less obvious interpretation turns out to be the correct one for patients who I see in therapy - is that he takes her passive acquiescence of the state of affairs as a signal that she actually prefers it!  So, when she complains about it, he becomes confused and asks her why she is not happy, since he is doing exactly what he thinks she wants.  Maybe she really wants to avoid sex and affection, but also enjoys complaining!

He will never tell her about such thoughts because he knows that the thoughts will probably be greeted with great defensiveness, outright derision, or indignation from her that he is blaming her for his problem with intimacy.  That will get him exactly nothing but grief, so why bother?

More important, he is helping her to not face her issue with sex and affection, because he is volunteering to pretend to be the bad guy by denying her.

So could she really be covertly avoiding sex as much as he is?  And if so, why?  Well, the answer to the first question is a resounding, hell yes.  This does not mean that on some level she really does wish for more sex, but that for some reason she is more comfortable with the current state of affairs than with the “improved” version.  The answer as to why might be a one of many possible issues between her and her own family of origin, but she does not give us any clues in her letter about what those issues might be.

And what happened to his libido?  Again, we don’t know.  Maybe he has a whore/madonna conflict about his wife being a sexual being.  But it could also be many other things.

The point is, they are both avoiding sex, not just him. 

A different letter writer in the Dear Abby column of 3/15/12, says that she has been married for 32 years, and for all these years her husband has lied continually.  He fabricates the most outlandish stories, and the whole family knows it.  Furthermore, he is said to never own up to anything he has done wrong, but instead blames the letter writer for his actions. If she confronts or challenges him, he gets defensive and says she’s "always" belittling or challenging him in front of others. 

The probably translation, according to my scenario, is that she covertly thinks that he has a need for continuous humiliation - so she helps out by humiliating him -  and he thinks his wife needs to humiliate him - so he gives her plenty of opportunities.  After all, from the perspective of each, that is exactly what the other has always done.  For 32 years.

"In relationships, if you always do what you always did, you'll always get what you always got." 

Tuesday, March 20, 2012

Immaturity Officially a Disease: You Saw It Here First

The kid in red is in the same grade and classroom as the other four

In my post of September 20, 2010, Immaturity in YoungChildren: Officially a Disease, I described two studies published in a very obscure journal, the Journal of Health Economics, that both found nearly identical data about the diagnosis of ADHD in school children.  In the these articles, two different research groups (Evans, Morrill, &Parente, 29, 2010 657–673; Elder, 29 2010, 641–656) using four different data sets in different states came to the same conclusion. 

In one, roughly 8.4 percent of children born in the month prior to their state’s cutoff date for kindergarten eligibility – who typically become the youngest and most developmentally immature children within a grade – were diagnosed with ADHD, compared to 5.1 percent of children born in the month immediately afterward. The study also found that the youngest children in fifth and eighth grades were nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD!  The results of the second study were quite similar.

Translated into numbers nationwide, as Steindór summarized in his comment on my blog, this would mean that  between 900 thousand (Elder) and 1.1 million (Evans et al. 2010) of those children under age 18 in the US diagnosed with ADHD (at least 4.5 million) are misdiagnosed.  

Now, a year and a half later, another study, published in a more widely read journal and reported widely in the news, came up with the exact same conclusion.  (“Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children” by Richard L. Morrow, et. al., Canadian Medical Association Journal, published on line March 5, 2012). 

In a cohort study (a study of a group of individuals with something in common followed over time) of more than 900,000 Canadian children, researchers found that boys born in the month of December (the cutoff birth date for entry to school in British Columbia) were 30% more likely to be diagnosed with ADHD than boys in their grade who were born the previous January.
This number was even more dramatic in the girls, with those born in December 70% more likely to be diagnosed with ADHD than girls born in January.
In addition, both boys and girls were at a significantly higher risk of being prescribed an ADHD treatment medication if they were born in the later month than in the earlier one.
 "It could be that a lack of maturity in the youngest kids in the class is being misinterpreted as symptoms of a behavioral disorder," said lead author Richard L. Morrow.  

Could be?  About about “is?”
Some of these behaviors could include not being able to sit still, not being able to focus and listen to the teacher, or not following through on a task, he added.

"You wouldn't expect a 6- and 9-year-old to behave the same way, but we're often putting a 6- and 7-year-old in the same class. And we're learning that you can't expect the same behaviors from them," he added. "We would like to avoid medicalizing a normal range of childhood behaviors."  No sh*t!

This problem has been complicated recently by the fad of "redshirting" children for kindergarten: overachieving parents purposely starting them at age six rather than five in order to give them a competitive advantage academically over their classmates.  Now children in the same class may be as much as two years apart in age.
The study authors went on to  note that potential harms of overtreatment in children include increased risk for cardiovascular events, as well as effects on growth, sleep, and appetite.  There was no mention of the harm of making this diagnosis and using these potentially toxic medication instead of investigating and addressing possible psychosocial reasons for “hyperactivity” such as a chaotic family environment or abusive and/or inconsistent parenting practices.
This brings up the issue of the risk to the heart and the rest of the cardiovascular system posed by stimulant use.  There have been several studies recently published that have been reported in both the medical and lay media that claim that this risk is minimal.  

This is in an interesting contrast to the publicity about an article, published this week in BMJ Open (the online version of the British Medical Journal)  that purported to show that the use of sleeping pills increases the risk of dying from all causes by a factor of 4 over just two and a half years.  Sleeping pills are generally regarded as far less dangerous and less likely to be abused than stimulants.  The FDA categorizes benzos as "Schedule IV" (lower likelihood of abuse) and stimulants as "Schedule II" (most likely to be abused short of the illegal "Schedule I" drugs).
That study about sleeping pills seemed to me to be a bit hard to believe, especially since epidemiological studies are notoriously unreliable.  But even if the numbers are valid, the fact that the risk of death from all causes increases most likely means that there is  some other characteristic, or a bunch more characteristics, of the population of people who are prescribed sleepers that are not characteristic of other populations. Those additional factors might explain the findings.
As for stimulants, in the February, 2012 issue of the American Journal of Psychiatry, there is an article on methylphenidate (Ritalin and its variations) and risk of heart problems in adults. Using a large medication database, researchers matched about 44000 methylphenidate (MPH) users and about 176,000 controls. 

They looked at main the incidence of a cardiac event defined as a myocardial infarction, stroke, ventricular arrhythmia, or sudden death. They found a 117% increased risk - or over double the risk – in the Ritalin group. After adjustment for some potential confounding factors, the risk was still 84% higher.
The news stories about the study on the benzo’s seemed to be meant to scare people out of using them, while the stories about increased risk in stimulant users seemed to be meant to reassure people about using them.  Of course, both of these studies described relative risk and not absolute risk (See my post from November 2, 2011).   

This means that  “double the risk” means the risk might go from, say, a tenth of a percent to two tenths of percent.  Double a very small risk is still a very small risk.  The absolute risk in this example would have gone up just one tenth of one percent.  Still, if millions of people are getting the prescriptions, this increased risk can still turn out to apply to a sizeable number of people.

Physicians will not be able to see the increased risk in their clinical experience.  As Nassir Ghaemi says,They don't happen in 10-20% of patients in our practice; they happen in 1-2% (or 0.1-0.2%), and so, the average clinician, faced with a welter of patients, doesn't make the causal connection.”

The question should be, what are the risks versus the benefits from taking the medication.  For sleeping pills, for instance, one might want to know if there is a much larger increased risk of death for people who are sleep deprived.  For example, before the practice was stopped, medical interns would routinely work 36 hour shifts.  Fatal accidents on the car trip from the hospital back home were not all that unusual.

Then there is the whole question of other, non-pharmacological treatments, which is relevant for both the use of sedatives and stimulants.  Of course, they do not work for everyone either.

An editorial in the same issue of the American Journal of Psychiatry as the study of Ritalin in adults sounded reassuring about stimulant use.  Based on that study, I’m not so reassured.  

Tuesday, March 13, 2012

Ve Have Vays of Making You Talk, Part VIII: Countering Logical Fallacies

In Part I of this post, I discussed why family members hate to discuss their chronic repetitive ongoing interpersonal difficulties with each other (metacommunication), and the problems that usually ensue whenever they try. 

I discussed the most common avoidance strategy - merely changing the subject (#1) - and suggested effective countermoves to keep a constructive conversation on track. In Part II, I discussed strategies #2 and #3, nitpicking and accusations of overgeneralizing respectively. In Part III, I discussed strategy #4, blame shifting. In Part IV, strategy #5, fatalism.

This post is the fourth in a series about strategy #6, the use of irrational arguments (previously: non sequiturs; post hoc reasoning; begging the question). Descriptions of this strategy have been subdivided into several posts because, in order to counter irrational arguments, one first has to recognize them.  Until this post, I have held off describing the basic strategy to counter irrational arguments until after I finished describing some of the most common types.  Today’s post will be the last concerning these irrational arguments, and will also describe the basic countermeasure.

Irrational arguments are used in metacommunication to throw other people. Listeners either become confused about, or unsure of the validity of, any point they are trying to make or question they are trying to ask.  Fallacious arguments are also frequently used to avoid divulging an individual's real motives for taking or having taken certain actions. 

Today’s post will describe arguing from worst case scenarios, and ad hominem or personal attacks.

An argument is often made that a particular course of action is ill-advised because of difficulties that might arise in a worst-case scenario. In other words, one asks the question, "If I did so and so, what would be the conse­quences if everything possible went wrong?"

Posing a worst-case scenario does not always mean that the poser is engaged in an illogical maneuver. Indeed, for certain questions, such as whether to build a nuclear reactor near an earthquake fault, looking at worst-case scenarios can be a matter of life and death. Residents of Fukushima, Japan, will know exactly what I am talking about.

The worst-case argument becomes logically suspect if it is being used as an excuse to avoid some action when either of two con­ditions is present. The first is when the worst case is so unlikely to occur as to be almost meaningless. The second is when the worst case is preventable.

The most common usage of the maneuver in psychother­apy cases occurs when patients attempt to suppress some ­aspect of themselves by frightening themselves with the thought of dreadful consequences should the characteristic of self ever be expressed. One of the most often seen examples of this involves the ques­tion of whether or not to express anger.  

I once was the therapist for a group where every single member was in complete agreement that anger should be kept to oneself. They all painted a most shocking picture of the dire results that might ensue if their anger were ever unleashed. The anger would be destructive to the nth degree.

Everyone present said they had so much anger inside that if some of it got out, a dam would burst and a flood of violent fury would come pouring out. They might murder all of their loved ones and bomb government buildings. They would all suddenly become completely crazed, and each might end up in a mental institution or worse. They might tear the objects of their rage limb from limb and end up on death row. 

If thoughts like that did not scare them into keeping their anger quiet, nothing would.

The worst-case scenario that was proposed by the group members is illogical for several reasons. First, it is based on the non sequitur "If I let out some of my anger, I'll let it all out." Forgetting for the moment the unlikelihood that the rage they fear is as extensive as they believe it to be, how did they come to the conclusion that they would have more difficulty restrain­ing themselves once some of the anger had emerged than before the process started? They were each masters at self-restraint.

While it is often true that people who have been stuffing their anger may suddenly explode when there is a "last straw," this usually occurs in the heat of the moment, not when one is planning how to bring up for discussion anger-provoking behavior.  For this reason, 
the situation is not really analogous to the Dutch boy with his finger in the dike. One can always catch oneself. 

Indeed, the extra guilt these people probably would feel for having exhib­ited angry feelings might make it even easier for them to re­strain themselves in the future. This worst case, in which all of a limitless amount of anger would come out in a deluge is a highly unlikely worst case. Furthermore, this worse case is preventable.

Acting out the anger is hardly the only way to express it. One can talk to the anger-provoking person in a constructive attempt to get them to knock off the provocations. 

The use of terrifying imagery to scare oneself out of a course of action  is a very clear example of what I mean by mortification. In this case, an aspect of self, the emotion of anger, is suppressed by frightening oneself with worries about horrific conse­quences.

One last fallacy that I would like to briefly mention is ad hominem. This translates from the Latin as "to the man." This fallacy is based on the non sequitur "if a person is reprehensible in some respect, then everything that person has to say is incor­rect." This fallacy is frequently encountered outside the metacommunicative realm in the area of politics. 

Politicians can have repulsive views on certain issues or may be self-serving liars. Nonetheless, any single assertion that they make might still be true or correct. One cannot reason logically that because their views are unpopular or because they have lied in the past, then any current assertion they make is false. 

From the standpoint of in­ductive reasoning, one can be highly suspicious of their state­ments because of their past behavior and motivation, but in order to actually disprove their thesis, one needs corroborating evidence. Just because Castro is a Communist autocrat, for example, one could not con­clude that he is always lying whenever he made accusations against the United States government.

In metacommunication, family members will frequently discount an idea because of the alleged motivation of the person making it, without addressing the actual merits of the idea.  The metacommunicator might be accused of being insincere or having some sort of ulterior motive for making an observation while the target completely ignores the merits of the observation itself.  

Invalidation is a form of an ad hominem attack.  The person bringing up a past event is accused of distorting it, or even making it up.  This situation usually leads to a fight or flight response on the part of the metacommunicator, which stops the effort to solve interpersonal problems in its tracks.

And now at long last, what does the metacommunicator do when faced with a person who uses illogical arguments to avoid dealing with an uncomfortable interpersonal issue.

The basic response is what many therapists refer to as the Columbo style of response. Columbo was a TV detective played by the actor Peter Falk who often got suspects to incriminate themselves by, in a sense, playing stupid.  He would point out discrepancies in the suspect’s story and kind of scratch his head, acting if he were the one who was not bright enough to figure out the explanation. 

Peter Falk as Columbo

He would never act as if he believed that the suspect were purposely misleading him, although he obviously knew that was really the case.  The suspect would then try to “help out” the hapless cop by clarifying the apparent discrepancy, much to his own detriment.

In metacommunication, the object of this strategy is of course not to make the other person incriminate himself or herself, but to get past the block to appropriate, metacommunicative problem solving.

In response to a logical fallacy, the metacommunicator tactfully expresses confusion about what the target is saying, or points out seeming contradictions. This is done in an almost apologetic fashion.  Rather than accusing the other of purposely being misleading or confusing, metacommuncators try to indicate that they themselves are taking responsibility for any lack of interpersonal understanding.

In addition to decreasing the target’s need to become defensive, with this strategy the target often feels obliged to clear up the patients’ confusion.  In order to do so, he or she must drop the logical fallacy.  When this happens, it is important that the metacommunicator seem grateful for the new clarity, and not have a kind of “I told you you were irrational” attitude.

Now maintaining this bemused, self-effacing sort of style is often particularly difficult to do if there is an ad hominem component to the target’s irrational argument.  

In that case, as mentioned above, it is the metacommunicator who usually becomes defensive, and who derails the effort for problem solving.  In this case, learning and practicing many of the strategies described in my series of posts on how to disarm a patient with borderline personality disorder, such as giving the other person the benefit of the doubt and acknowledging one’s own contribution to the problematic past interactions, come in very handy.

Tuesday, March 6, 2012

Re-labeling Depressive Symptoms as Manic Symptoms by Fiat

They look alike.  Madonna must really be a goat.

Another cartoonishly mischaracterized study described in a journal article was recently published in the Journal of Affective Disorders.  One of the editors of this journal is Hagop Akiskal  (I have discussed my opinion of Dr. Hagop Akiskal’s work in a previous blog post).  The article's title is Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes.  

The authors are Lewis L. Judd, Pamela J. Schettler, Hagop Akiskal [the very same], William Coryell, Jan Fawcett, Jess G. Fiedorowicz , David A. Solomon, and Martin B. Keller.

These authors suggest that the presence of something that they label as subsyndromal manic symptoms (that is, symptoms that they believe are the same as those that are usually seen in mania episodes but which are “below the threshold for mania" - whatever that means) are seen in the major depressive episodes (MDE’s) that are also characteristic of bipolar disorder.  

For those unfamiliar, patients with true bipolar disorder have both manic and major depressive episodes, obviously at different times, that are separated by relatively long periods of normal moods called euthymia.

They discuss how some other authors reported that “the most common manic symptom during bipolar MDEs was irritability (present in 73.1% of the sample), followed by distractibility (37.2%), psychomotor agitation (31.2%), flight of ideas or racing thoughts, (20.6%), and increased speech (11.0%). 

Now, of course, they do not mention that these very same symptoms are also seen in the major depressive episodes of people who never have had or will have a manic episode. And who respond to antidepressant medication and have no response at all to lithium (which is highly effective in bipolar disorder). Back in ancient history (the 70’s and 80’s) we labeled depressed patients who show such symptoms as having an agitated depression.  

Other patients with depression who are not agitated but are in fact extremely slowed down - as if on heavy sedatives - were said to have a retarded depression.  We stopped making this distinction between agitated and retarded major depressive episodes because we found that both types of depression usually respond to the same medications, (although agitated depressions seemed to have, on average, a somewhat worse prognosis for medication response).

This authors of this article state that irritable and agitated qualities of MDEs, defined in various ways, are prominent in the clinical and research literature on bipolar patients with yet another clinical entity called a mixed depressive state. In the opinion of a lot of psychiatrists like myself, a mixed state is something better characterized by the name dysphoric mania. The patient has all the symptoms of mania but, instead of the highly elevated, euphoric mood as most people in a manic state have, they feel awful.

I find I cannot use the definition of a "mixed state" that is used in the official diagnostic manual, the DSM, because it is actually impossible.  To have a mixed state according to DSM criteria, “The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day.”  This is impossible since many of the symptoms of mania and depression are polar opposites of one another, so that one cannot have both at the same time!

Anyway, the authors of the article under discussion described their study population thusly:

 “Subjects entered the NIMH CDS at five academic medical centers from 1978 to 1981, while seeking treatment for a major affective episode. Intake research diagnoses were made using Research Diagnostic Criteria (RDC) based on the Schedule for Affective Disorders and Schizophrenia (SADS) interviews ... as well as available medical and research records. Patients with bipolar disorder (type I or II) entering the CDS in a major depressive episode (MDE) were selected for these analyses. We excluded from the analysis all patients who were manic at intake (N=60), along with a small group of patients (N=5) who met DSM-IV-TR criteria for a mixed episode at intake (i.e., had full concurrent MDE plus mania).” 

Notice that they "found" and then excluded anyone that might possibly meet the contradictory DSM criteria for a “mixed state,” which is what they were talking about earlier as if it were the population of patients who were about to be described in their study, which in fact it was not.

52  of their patients were diagnosed as bipolar I and 90 were bipolar II.  As most of my readers know, I think bipolar II is a phony diagnosis in the first place. 

They go on: “Irritability and psychomotor agitation are included in the SADS interview not only as manic/hypomanic symptoms, but also in the depression section of the interview, as qualifiers for the MDE (i.e., specifically for periods of the intake MDE when the subject did not have evidence of a manic syndrome).”

“We have included these two characteristics of intake MDEs as subsyndromal manic symptoms because we believe they are clinically indistinguishable from criteria A-2 and B-6 for mania and may, therefore, represent a subtle and little recognized form of mixed bipolar MDE.”

The authors are subtly defining by fiat any depressed person with irritability as having a “subthreshold” manic symptom!  Sez who??  This is especially interesting considering that they used what is essentially a symptom checklist to make their diagnosis in the first place, and were not really using clinical judgment to tease out differences in the presentation, pervasiveness, and persistence of symptoms that may just look alike during evaluations done at one point in time.

The similar symptoms are, in fact, clinically distinguishable, precisely because the symptoms occur in different clinical states – that is, manic episodes and depressive episodes.  The authors use the word “may” in the sentence about the symptoms being a little recognized form of mixed bipolar, and then proceed entirely from the assumption that they are just that. 

To really sort this out, maybe they should have compared a sample of patients with bipolar depressive episodes to patients with unipolar depressive episodes (patients who get depressive episodes but not manic episodes).  But of course, if these authors found these symptoms in unipolar depressives, they could easily redefine the unipolars as bipolars because of the symptoms.  

Voila! Almost anyone who has a depressive episode is immediately re-categorized as bipolar!  Because they define it that way.

Actually, retarded depression is more common in bipolar patients than agitated depression.  

About the only valid conclusion one can draw from the data presented in the article is that bipolar patients who have an agitated depressive episode may have a somewhat worse prognosis, and may be more likely to experience a quick shift into a manic state, than bipolar patients who have retarded depressive episodes.

Of course, we knew that decades ago.