Guest Post: Is Social Media Offering a Safe Haven for Disordered Eating in Teens?

Anorexia, bulimia, and other eating disorders are generally frowned upon and discouraged among teens, and skin and bones isn’t attractive to the majority of people, no matter how you cut it. So why are so many teens still engaging in this harmful behavior? Log onto any social media site and you’re bound to see pictures of food, links to weight loss tips, and people complaining about their weight. That’s just normal, everyday life, right? Maybe. But maybe not. While you and I may seem these acts as normal, people who struggle with disordered views of their body may see it as an open door to encouraging eating less and working out more, to the point that they’re battling for their lives, even though they may see it as battling for a better body. 

Pinterest

Pinterest recently came under fire for inadvertently encouraging “thinspiration” for people suffering from anorexia, bulimia, and other disordered eating habits and views on how the body should look. Jezebel recently released an article detailing this “thinspo” phenomenon, showing how women were congregating together  and creating “thinspo” Pinterest boards where they pinned pictures of women who were bare bones to inspire them to be thinner as well.

Since then, when you search Pinterest for “thinspiration” a warning message will come up saying “Eating disorders are not lifestyle choices, they are mental disorders that if left untreated can cause serious health problems or could even be life-threatening.For treatment referrals, information, and support, you can always contact the National Eating Disorders Association Helpline at 1-800-931-2237 or www.nationaleatingdisorders.org.”

Twitter

A quick Twitter hashtag search for #proana will bring up everyone discussing any and all things related to pro-anorexia. Girls and guys alike post pictures of bones jutting out, siting this as #thinspiration and being #proana. There are tweets showing what #proanas do at restaurants, with a picture of coloring books. And there’s even a new pro-ana Twitter account that offers tips for those wishing to engage in a pro-anorexia lifestyle.

Facebook

Not to be left out, the largest social media site definitely has its place in the disturbing world of encouraging disordered eating and helping people strive for thighs that don’t touch and collar bones that stick out. One search of “thinspiration” and “pro-ana” brings up fan pages and support groups, giving people a place to swap stories and tips, and post goal pictures and (what is deemed to be) success pictures when they achieve a certain amount of thinness.

Encouraging Thinspiration

In our quest to eliminate obesity and encourage healthy habits, there is always the risk of people, teens especially, taking advice too literally and too far, especially with the extreme focus in the media of stars sporting unattainable bodies and going on crazy crash diets. However social media has given these type of people a new outlet and even community that encourages these views. It’s not necessarily the fault of social media, but it is definitely one of the consequences of connecting people around the world.

Author  Byline:

Monta the mother of three children serves as an Expert Advisor on multiple household help issues to many Organizations and groups, and is a mentor for other “Mom-preneurs” seeking guidance.  She is a regular contributor of “gonannies.com”.  You can get in touch with her at montafleming6Atgmail dotcom.

Talking Adult ADHD Blues

Despite popular demand that I shut the hell up, here at last is the music to my song, Another Dubious Hyped Disorder. Click the link to see.  In case you can't make them out, the lyrics are here.

How Do You Know if You Should Try Treating Your Depression With Medication?

I have frequently blogged in this venue about the efficacy of antidepressants in “depression.”  I have pointed out that “depression” has a wide variety of different meanings, and that there are also several different syndromes of depressive disorders in the diagnostic manual, the DSM.  While there is considerable overlap in the symptoms of the various syndromes, some are far more likely to respond, and respond dramatically, to antidepressant medication than others.

I have also ranted against physicians who use “symptom checklists” or other self-report “tests” to make a diagnosis of depression, rather than use an extensive clinical interview.  The tests often say very little about whether a symptom a patient complains of is clinically significant for a certain diagnostic syndrome or not.  Aside from not looking at the psychosocial context in which the symptom occurs, the tests usually say very little about three important qualities of clinically significant symptoms – their pervasiveness, persistence, and whether or not they are pathological.  They also do not clearly show whether the symptoms all cluster together at the same times.

As I have pointed out several times, in order to make sure the patient is giving the doc an accurate and complete picture of their mood state, a good doctor must often ask one or even several follow up questions whenever a patient says “yes” or “no” in answer to a question about the presence of a symptom.

But how about a potential patient?  How does a non-professional know whether or not to even consult a physician about their mood state?  Why not just ignore it and see if it goes away?  Alternately, why not just go to a psychotherapist and handle it with psychotherapy alone?

That’s a very important question.  A similar question has recently been widely featured in the media in response to a proposed change in the DSM.  How does a patient or a doctor know when normal grief after the death of a loved one morphs into a clinical depression that would respond to medication?  The argument has mostly been about how long a doctor should wait after such a death before making a diagnosis of clinical depression, (major depressive disorder). 

While it is good that a doctor should not be overly hasty about making a diagnosis in this situation, in some genetically-prone individual, a stress of that severity can indeed trigger a major depressive disorder in a relatively short period of time.  Should that patient have to wait to be relieved of his or her suffering?  Certainly, any proposed “waiting period” specified in the DSM would have to be somewhat arbitrary.

To help patients figure out who to consult and when to consult a physician, a new self-report instrument is available that is significantly superior to the usual ones.  It is called the Post-Bereavement Phenomenology Inventory. It is meant to distinguish normal grief from major depression, but potentially it could also be used to distinguish major depression (likely to respond to meds) from another depressive syndrome, dysthymia (much less likely to respond to meds).

It was meant for physicians and not for patients to review for themselves, but even though it is better than most self-report instruments, IMO it should still not be used in place of a complete and wide-ranging clinical interview.  Context, prior history of major depressive disorders, family history of depression, and a whole host of factors need to also be considered.

But as a screening tool for patients, I think it might be helpful.  It uses a strategy called prototype matching.  This strategy focuses on the difference between depressive syndromes rather than the similarities.  The questions contain different descriptions of how each depressive symptom would present itself in classic cases of the two syndromes, and asks the patient, “[Which of the two descriptions] better describes how you have been feeling, thinking, or behaving for the past one to two months?”

Here it is.  I hope this will help potential patients decide whom to consult.  The first descriptions in each question are of the symptom presentation seen in major depression, while the second are of depressive symptoms that are less likely to respond to medication.  Of course, this is hardly foolproof, but generally the more you answer the questions one way or the other, the more likely you are to be experiencing one syndrome or the other. 


If someone's depression seems to conform mostly to the first prototype rather than the second, there are certain things that people often say to them that are both inappropriate and counterproductive.  An excellent list of such things can be found at http://www.medicalbillingandcoding.org/blog/11-things-you-should-never-say-to-someone-with-depression/

1.       I am filled with despair nearly all the time, and I almost always feel hopeless about the future.

versus

      I feel sadness a lot of the time, but I believe that eventually, things will get better.

2.      My sadness or depressed mood is near­ly constant, and it isn't improved by any positive events, activities, or people.

versus

       My sadness or depressed mood usually comes in "waves" or "pangs;' and there are events, activities, or people who help me feel better.

3.      When I am reminded of my loss (of a loved one, friend, job, etc), I feel nothing but pain, bitterness, or bad memories.

versus

    

       When I am reminded of my loss (of a loved one, friend, job, etc), I often feel intense grief or have painful memories, but sometimes I have good thoughts and pleasant memories. 

4.      I will probably never get back to feeling like my "old self" again.

versus

       Things are really tough now, but I'm hopeful that with time I will feel more like my "old self.”

5.      I feel like a worthless person who has done mostly bad things in life, and has let my friends, family, and loved ones down.

versus

       I feel like I'm basically a good person and that, in general, I have done my best for my friends, family, and loved ones.

6.      All I can think about lately is me and how miserable I feel; I hardly think about friends, family, or loved ones, ex­cept to blame myself for some failing.

  versus

       Even though I'm less social and out­going since my loss, I still think a lot about friends, family, and loved ones, often with good feelings about them.

7.      When friends or family call or visit and try to cheer me up, I don't feel anything or I may feel even worse.

   versus

       When friends or family call or visit and try to cheer me up, I usually "perk up" for a while and enjoy the social contact.

8.     I often have persistent thoughts or im­pulses about ending my life, and I often think I'd be better off dead.

     versus

     I sometimes feel like a part of me has been lost and I wish I could be reunited with the person or part of my life I am missing, but I still think life is worth living.

9.      Almost nothing that I used to like do­ing (reading, listening to music, sports, hobbies, etc) is of any comfort or con­solation to me anymore.

     versus

   The things that I have always liked do­ing (reading, listening to music, sports, hobbies,etc)  give me some comfort and consolation, at least temporarily.

10.  I feel "slowed down" inside, like my body and mind are stuck or frozen, and like time itself is standing still.

   versus

       My concentration isn't as good as usu­al, but my body and mind aren't slowed down, and time passes in the usual way.

   

     

There Is Also Big Money in Alternative and Complementary Medicine

Critics of Big Pharma, myself included, complain that they put profits way ahead of people's health, as evidenced by their deceptive marketing.  But they are hardly alone. "Alternative and complementary" medicine is also a big business, and when it comes to putting profits before people, their manufacturers can be even worse.  

According to a German newspaper:

A consortium of pharmaceutical companies in Germany have been paying a journalist €43,000 to run a set of web sites that denigrates an academic who has published research into their products. These companies, who make homeopathic sugar pills, were exposed in the German newspaper Süddeutsche Zeitung in an article, Schmutzige Methoden der sanften Medizin (The Dirty Tricks of Alternative Medicine.) This story has not appeared in the UK media. And it should. Because it is a scandal that directly involves the UK’s most prominent academic in Complementary and Alternative Medicine.

The newspaper accuses the companies of funding the journalist, Claus Fritzsche, to denigrate critics of homeopathy. In particular, the accusation is that Fritzsche wrote about UK academic Professor Edzard Ernst on several web sites and then linked them together in order to raise their Google ranking. Fritzsche continually attacks Ernst of being frivolous, incompetent and partisan. The newspaper said, It is simple to use Google to pillory someone: all it needs is a professional-looking Web page in which a person’s credibility is undermined. Then the name of the person to discredit should be mentioned in the text as often as possible. The page will be automatically ranked in the top results when someone searches for the person.

Homeopathy, as stupid as it is on the face of it, has actually been scientifically debunked.  Thoroughly.  These companies are basically selling water!!

For more details, see http://www.quackometer.net/blog/2012/07/german-homeopathy-companies-pay-journalist-who-smears-uk-academic.html?utm_source=rss&utm_medium=rss&utm_campaign=german-homeopathy-companies-pay-journalist-who-smears-uk-academic

Getting Significant Others to Tell You the Truth, Part II: Descriptions Masquerading as Explanations

Descriptions Masquerading as Explanations

In part I of this series of two posts, I introduced them with the following:

As I have mentioned in many posts in this blog, the key to effective problem solving for dysfunctional families is to initiate metacommunication (talking about the nature and manifestations of rules by which the family operates, as well as talking about the way the family communicates), and then learning how to do it effectively.  Many strategies were discussed previously in my two series, Ve Have Vays of Making You Talk and How to Disarm a Borderline. 

In this new series of two posts, I will describe situations in which individuals with whom one is attempting metacommunication seem to be answering the questions that have been posed to them but are, in actuality, avoiding answering the questions.

In the previous post, I covered a problem that crops up when one family member questions another family member about his or her relationship with a third party:  judgments masquerading as descriptions.  


In this post, I will describe a strategy used by people who do not want to tell you their real motives for why they did or did not do something – for any of a variety of reasons – and therefore block your efforts to understand them and their motives better by confusing the issue: descriptions masquerading as explanations.

In attempting to obtain an undistorted or honest explanation of a family member’s conscious reasons for engaging in a particular course of action, a metacommunicator should be alert to instances of this. Often, when a metacommunicator asks family members to explain their motives for certain behavior or the reasons they are fearful of some action, they respond by paraphrasing an earlier description of their state of mind. 


The response sounds like an explanation for their motives or fears but in fact explains absolutely nothing. Here once again, the use of follow-up questions is essential in clarifying what the family member’s actual motives are.

The most common example of a description masquerading as an explanation is the statement, "I won’t do such and such because I don’t like doing that" or “I do that because I like to." This sort of “explanation” might be used to explain away extremely self-defeating acts such as frequent confrontational behavior with bosses at work that causes the speaker to get fired from jobs, or habitually avoiding intimacy and ending up alone in life. In such cases, the family member seems to be saying that the decision to choose or avoid a course of action is based merely on a personal idiosyncrasy, on the order of not particularly enjoying the sport of bowling.

It is far more likely in such cases that the decision is based on past experiences with the course of action in question. Usually there was a history of unintended adverse consequences to making the “healthier” choice. The metacommunicator needs to ask family members specifically what they think might happen if they were to make a different choice. What are the plusses and minuses that went into the family member’s decision, and what makes the family member give a lot of weight to some of them and little weight to others? Are the feared consequences sufficiently onerous to account for the family member’s behavior?

To consider an example from a client in psychotherapy, let us look at the case of a lonely woman who explains her isolation by saying, “I prefer to live alone; I like it better." On the surface, this answer does seem to provide an explanation, albeit one with which a therapist can do very little. The client has indicated that she is basing her choice to live alone on personal preference, much as one might like chocolate ice cream while disliking mocha. One's preferences have to do with the tastes of one's true self, and are otherwise inexplicable.

On further inspection, however, it became clear that the patient was being evasive in answering the question. Choosing isolation over relationships is not a simple choice, but one based on a relative preference. Adults do not dislike living together in the same way that they dislike liver. There are pro's and con's which must be appraised individually and then balanced against one another. Yes, descriptively, the client did prefer to live alone, but why was that? What were the pro's a con's upon which she based her decision? More importantly, if something can be done about the con's, would she make a different choice?

A variation on this theme is the family member who attributes an aversion to an essential course of action to having a simple phobia, perhaps based on a single disturbing incident in the past.  I call such a proposed "reason" the single traumatic event hypothesis.

For example, one woman refused to go to school to get retrained in a new occupation after an on-the-job injury halted her previous career. She said she was just “uncomfortable in classrooms” - all because of an incident in which her seventh grade English teacher embarrassed her in front of the class.

The problem with this “explanation” is that just about everyone has been embarrassed by his or her seventh grade English teacher at one time or another. While the event probably had something to do with her apparent aversion to school, there just had to be something more than that in order to cause what appeared to be a full-blown school phobia. The extent of her "trauma" was in no way commensurate with a fear that was so all encompassing that she was prepared to live a life of poverty rather than get retrained.  To use a term used in psychology studies, the traumatic event does not account for the variance.


Follow-up questions might include: Did something else happen after the event? What was the reaction of your parents to what your teacher did? What seems to make you focus only on this event? Why do you think you are unable to overcome it? What have you done to try to overcome the problem, and if nothing, why? 


If the family member replies to the latter question with, “I just didn’t think there was anything I could do about it,” the metacommunicator should inquire if the family member had even looked into possible solutions, and if not, why not.

Another example of a description masquerading as an explanation, in this case for a family member’s lack of assertiveness was, "I always keep my anger to myself because I have trouble dealing with angry feelings." This is obviously no explanation at all. It is probably true, but it clarifies nothing. In fact, it is merely another way of describing the very state of affairs it purports to explain. 


The person and his or her audience probably both presuppose that someone who has difficulty dealing with anger either has trouble appropriately expressing it, or flies off the handle too readily.  We already know that this guy is explaining his passivity.  Therefore, for him to say that he has trouble dealing with his angry feelings means the same thing, in essence, as the statement that he always keeps his anger to himself.

For another example, a metacommunicator might ask a family member whose career might be adversely affected why he or she is refusing to make an important business presentation. If the family member answers, “I am afraid of public speaking,” the family member seems to be saying that he or she has a very common simple phobia, and that is all there is to it.  After all, public speaking fears are common; almost anyone might be completely paralyzed by them. 

What remains unexplained, however, is both the true source of the family member’s anxiety, and the reasons why the family member has not yet done anything to remedy it.  As we know from cognitive therapy, there is usually an underlying automatic cognition that is an assessment of what might happen in a feared situation.  What is it?  If the feared consequence the family member reports is highly unlikely, what makes the family member focus on it? 

In addition, successful business people who have troubles with public speaking will usually search actively for solutions; they may ask for medication, practice speaking at Toastmasters, read books about others who have overcome similar troubles, and so forth. What has the family member done?

Upon hearing someone volunteer such a pseudo- explanation, a family member should pursue the questions of what thoughts the phobia is based upon and what the family member has done previously to get over the phobia.  If the problem is long standing and the family member has done nothing about it so far and refuses to go to therapy, what exactly has been stopping him or her? 


Inquiring minds want to know. 

Pro-Death Florida Legislators Shot Down - a Follow-up

This is a brief follow-up to my post of May 25, 2011, 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. 

The law would have prohibited a pediatrician, for example, from discussing gun safety issues with the parents of the child. 

It had absolutely nothing to do with Second Amendment gun ownership rights (which I favor).

This just in (Psychiatric News, 7/6/12):

Judge Says Doctors Can't Be Barred From Discussing Guns

Florida physicians will again be able to ask their patients about the presence of guns in their homes now that a federal judge has ruled illegal a state law barring physicians from discussing the subject. Judge Marcia Cooke said the law violates the freedom-of-speech protections in the First Amendment of the U.S. Constitution. The Florida Psychiatric Society and other physician organizations challenged the law, which was introduced by gun advocates in the state legislature who claimed that asking patients about gun possession violated the Second Amendment protection of the right to bear arms. The law made such discussions a felony and passed by a wide margin in the Republican-controlled legislature.

Psychiatrists and others argued that asking patients about the presence of guns in their homes would help them evaluate whether patients might pose a danger to themselves or the community and that such discussions would go a long way toward preventing suicides. They maintained as well that the law illegally infringed on the doctor-patient relationship by interfering with their ability to provide the medical care their patients might require. Cooke said in her ruling that censoring what physicians could talk about during medical visits has had a "chilling" effect on medical care. "What is curious about this law," she said, "is that it aims to restrict a practitioner's ability to provide truthful, non-misleading information to a patient, whether relevant or not at the time of the consult with the patient." The Florida Department of Health hasn't announced whether it will appeal the ruling.

Childhood Bipolar Disorder: The View From Abroad

Is Pediatric Bipolar Disorder (PBD) a “culture-bound syndrome” of the USA?

The following is a guest post from Dr. Peter Parry, an Australian psychiatrist and senior lecturer at the University of Queensland, who is a co-conspirator of mine in the fight against the pernicious practice of psychiatrists and pediatricians diagnosing acting-out children as having the major psychiatric disorder bipolar disorder (manic depressive illness).

A “culture-bound syndrome” [http://rjg42.tripod.com/culturebound_syndromes.htm]  in psychiatry is used to describe psychiatric disorders that generally occur in exotic indigenous communities and developing countries due to cultural factors.  Examples include “Koro” - a disorder of group hypochondriasis that occurs in epidemics in parts of south-east Asia where men start to believe that their penises are shrinking into their abdomens; “Dhat” - a disorder in India associated with anxiety and fatigue in men related to fear of losing too much semen; “Bebainan” - a disorder where young women from Balinese nobility, who in everyday life must behave with extreme politeness and be very demure, vent their anger in seemingly irrational brief rage attacks.  The last of these can be seen to have a useful function for individuals whose emotional lives are otherwise highly socially constrained.

In a couple of blog posts on “The Geography of Pediatric Bipolar Disorder” [http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder] on Psychology Today  I concluded by posing the question: “is Pediatric Bipolar Disorder (PBD) a culture bound syndrome of the USA?”.  As I explained in the first post, PBD, despite becoming the most common diagnosis for pre-pubertal children in US inpatient units 10 years ago [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001259/], has barely rated in the rest of the world. 

This is not to say that there haven’t been a few academic research centers who have investigated PBD in places like Spain, Switzerland, the Netherlands, Brazil, India and Australia.  These research centers have usually collaborated with prominent American PBD research centers such as Prof Biederman’s center at MGH-Harvard.  In clinical practice outside the USA there have been a few isolated pediatricians and rarely child psychiatrists who have adopted the American clinical practice of diagnosing PBD in pre-pubertal children.  But the vast majority of practicing clinicians and academics in child psychiatry and pediatrics in Britain, Europe, Australia, New Zealand and to lesser extent Canada have simply not accepted PBD as a valid diagnostic entity in clinical practice.

Here in Australia, one group that seriously researched the PBD diagnostic constructs was based in Sydney.  Their follow-up research found that few cases went on to true bipolar disorder.  Prof Philip Hazell who led much of this research was quoted in the Australian media [http://www.theaustralian.com.au/news/health-science/moody-teens-wrongly-diagnosed-with-bipolar-disorder-psychiatrist/story-e6frg8y6-1226191879545] saying “There are about 10 times as many people with 'lookalike' mood dysregulation as there are people with bipolar disorder”.

Now it is true that bipolar disorder often first manifests in adolescence and early manic or hypomanic symptoms can be mistaken for extreme adolescent emotionality, risk-taking or substance abuse.  But until an unequivocal manic episode erupts it is difficult to make the diagnosis.  The “BCOS study” [http://www.jad-journal.com/article/S0165-0327(07)00047-X/abstract] was a study of 240 adults mostly in their 40s with classical Bipolar-I or Schizoaffective Disorder in Melbourne and Geelong in Australia.  The BCOS study found that the diagnosis was often made years late.  The study asked the adults when their symptoms first began.  The median age of onset for the first hypomanic/manic episode was 24.1 years old.

Yes bipolar disorder is a severe mental disorder that needs to be detected earlier in life than it often is.  But it is still a disorder that doesn’t usually start until late adolescence or young adulthood.

Another study that asked middle aged adults with bipolar-disorder when they thought their first symptoms of bipolar disorder began was published in the British Journal of Psychiatry [http://www.jad-journal.com/article/S0165-0327(07)00047-X/abstract].  The authors of this study were quite favorably disposed towards PBD.  The remarkable aspect of the study is the discrepancy in recall of symptom onset between the European subjects with adult bipolar disorder (Dutch and Germans) and the American subjects.

Is there something about childhood in the USA that brings on a severe psychotic mental disorder such as bipolar disorder so much earlier than in other countries?  Or is there simply an over-diagnosis fad in operation, one that colors the memory recall of childhood?  Notably the American adults in this study had features more suggestive of milder “bipolar” and more personality and substance use problems than the Europeans who had more classic euphoric manic symptoms.

A 20 year follow-up study [http://www.jaacap.com/article/S0890-8567(09)64566-4/abstract] in New Zealand (NZ) was published in the Journal of the American Academy of Child & Adolescent Psychiatry in 1991 (before the creation of the PBD phenomenon).  It was based on all inpatient admissions to the child and adolescent psychiatric ward for a catchment area of 1 million people.  In those 20 years there were 59 children under age of 18 who presented with a confirmed psychotic illness that included schizophrenia, schizoaffective disorder or mania/bipolar disorder.  Age of diagnosis was based on reports of first symptoms, not date of admission to the inpatient unit.  Of these 59 children and teenagers, only 3 were aged 12 or under at onset of symptoms.  One of these 3 children was reported to have had their first manic episode at age 9, the youngest who later turned out to have schizophrenia was aged 7 at onset of first symptoms.

The lead author of the study is now Emeritus Professor of Child & Adolescent Psychiatry in Auckland, NZ, Prof John Werry.  In a survey that I and colleagues organized of Australian and New Zealand (ANZ) child psychiatrists [http://onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2008.00505.x/abstract] on PBD that found high levels of skepticism (including that only 3% thought that PBD was not over-diagnosed in the USA), Prof Werry sent a hard hitting comment for public airing:

“I do not see any juvenile bipolar disorder below adolescence and I think that the American view is mostly nonsense as do many of my American colleagues.”

The second author of the NZ study was one of his “American colleagues”, Dr Jon McClellan, a child & adolescent psychiatrist who returned to the USA and is based in Seattle.  Dr McClellan was one of the very few child psychiatrists to have a dissenting article [http://www.jaacap.com/article/S0890-8567(09)61468-4/abstract] on PBD published in the Journal of the American Academy of Child & Adolescent Psychiatry.  With regard to PBD his article concluded:

“the rate of psychotropic agents being prescribed to preschoolers is skyrocketing…Labelling tantrums as a major mental illness lacks face validity and undermines credibility in our profession.”

One very prominent US psychiatrist, Prof Allen Frances who was chair of the DSM-IV task force, has called PBD a “fad” [http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1551005] diagnosis.

What I found when attending the American Academy of Child & Adolescent Academy (AACAP) meeting in Hawaii in 2009 is that Werry, McClellan and Frances were spot on.  Many US child psychiatrists were very troubled by the PBD diagnostic fad, the bad effects on the children and families of a spurious diagnosis and wrong treatment, and the undermining of credibility in our profession.  I received mainly supportive comments from my US colleagues when I presented my poster of our Australian and New Zealand survey showing high levels of skepticism about PBD in ANZ.  These comments helped to explain what it was about the culture of the USA that had spawned the PBD fad epidemic.

Firstly – the US health system is mainly a private insurance system and much more fragmented than the universal health cover that exists in nearly all other 30 developed nations in the OECD [http://www.oecd.org/dataoecd/24/8/49084488.pdf].  US health insurers are more likely to restrict reimbursements on the basis of diagnosis than health insurers in other countries.  Also pharmacotherapy is favored over the psychotherapies. 

At the Hawaii AACAP conference an American child psychiatrist told me that if she is seeing a boy with emotional and behavioral problems embedded in difficult family dynamics, with some insurers she has to phone the insurer in the first session and is asked to give a diagnosis. If she says she has no diagnosis at that early stage, the insurance clerk says no reimbursement. If she says the diagnosis is a “parent-child relational problem” (which is a non Axis I DSM diagnosis) she may also be told no reimbursement. If she says it is an “adjustment disorder” (an Axis I DSM diagnosis) then she may be allowed 1 or 2 sessions to fix the complex problems. But if she says it is “bipolar disorder” then ongoing sessions are likely to be reimbursed. 

This is effectively diagnosis by medically untrained health insurance clerk.  It is also an expensive system, the USA spends 17% of its GDP on health care whereas other OECD nations spend between 8% and 11%.  A lot of money goes into paying medically untrained clerks and profits to shareholders.

Secondly the pharmaceutical industry has focused its influence on medical research and public opinion more in the USA than elsewhere.  The pharmaceutical industry is globally the most profitable industry on the planet.  In 2002 the 10 Pharma companies in the Fortune 500 had greater profits than the other 490 world’s biggest companies combined.  In 2008 they averaged 18% profits whilst the rest averaged 0.9% profits in the global recession.  Pharma spend 3 times as much on marketing to the medical profession and (mainly in the USA) the public than they do on Research and Development.  The biggest market for medications, particularly psychotropics, is the USA and direct to consumer advertising (DTCA) is only legal in the USA and New Zealand (but NZ has a tiny market).  Thus the American public have been flooded with advertising of psychotropic drugs and often ads about bipolar disorder whereas the public in other nations have not (though the internet is changing this).

Another US child psychiatrist colleague told me at the ANZ child psychiatry conference in 2007 that in working as a locum in NZ he had never had parents come to see him stating their child had “such and such diagnosis” and demanding a related medication, rather they asked him what he thought.   Conversely parents invariably were fixated on a diagnosis and drug or two when they came to consult him in the USA.  He had also trained at an academic child psychiatric unit prominent in PBD research and was trained to ask himself “is it bipolar?” and diagnosed half a dozen cases of PBD, yet in NZ he’d never seen a case of PBD and had started to question his training.

The pharmaceutical industry provides considerable funding to researchers and to academics to provide “continuing medical education” (CME) to other doctors.  Internal industry documents [http://www.healthyskepticism.org/global/news/int/hsin2009-12] revealed that Pharma saw broadening of bipolar diagnoses in adults and children as useful to selling more atypical antipsychotic agents.  Such CME is a global phenomenon and has been harshly criticized [http://www.psychiatrictimes.com/display/article/10168/1570483] in recent years.  However proponents of PBD providing CME were mainly confined to the USA.

A key researcher in neuroimaging children diagnosed with PBD, Dr Mani Pavuluri, presented findings at the Hawaii AACAP meeting.  The research appeared to be of high technical quality.  The findings (overactive right amygdale, underactive right frontal lobe) were identical to findings in children who had suffered attachment trauma and abuse.  I and others in the audience asked why not call such children “affect dysregulated” rather than PBD.  Dr Pavuluri agreed that would be a more neutral term, but stated “if we don’t call them bipolar we don’t get funding for our research”.  Such a dependence on a presumed result favored by funders reverses the scientific process.

Also at the AACAP Hawaii conference I asked Dr Melissa DelBello about attachment trauma in her group’s research, the interchange was recorded by Dr. David Allen on this blog here [http://davidmallenmd.blogspot.com.au/2010/04/attachment-latest-dirty-word-in.html].

I did an extensive review [http://cdn.intechopen.com/pdfs/29393/InTech-Paediatric_bipolar_disorder_are_attachment_and_trauma_factors_considered_.pdf ] of the PBD literature for exploration of attachment, trauma and abuse as possible contextual factors and found that the PBD literature was extremely lacking in consideration of these very obvious markers of distress in childhood. 

Why this is so is a very interesting question.  Denial and repression of trauma is a feature of humanity, be it at individual, family or societal levels.  Whether this is more the case in the USA is unlikely but it is possible that American parents have been more indoctrinated with the neurobiological paradigm for children’s behavioral problems and this helps them avoid “parent blaming”.  As an aside, I find it helpful to discuss with parents how parenting in modern societies is incredibly difficult compared to how parenting evolved in small hunter-gatherer ancestor tribes. 

But other modern societies have similar epidemics to the US PBD epidemic.  Instead of PBD in Europe, Canada and Australasia there is a tendency to also over-diagnose autistic spectrum disorders and ADHD as ways of overlooking more complicated attachment, trauma, family dynamic, learning difficulties, bullying and other contextual problems.  To a great extent I think the simplistic checklist approach to diagnosis fostered since DSM-III plays a role in this [http://www.clinicalpsychiatrynews.com/views/commentaries/single-article/diagnostic-labels-and-kids-a-call-for-context/5783d363fe823984bafbef98b0ffaa75.html]

According to DSM-IV: “Not all (culture-bound syndromes) are considered pathological in their society of origin, and may be seen as "idioms of distress”, a way of communicating distress in a way which is culturally understood and, to varying degrees, accepted.”  Thus for a society that has been “educated” to see mental, emotional and behavioral problems as based in neurochemistry fixable with medications, where “parent blaming” is considered unsociable, where health insurers value pharmacotherapy over more talking therapies and insurance clerks request more serious diagnoses from clinicians before reimbursing sessions, and where funding of research comes largely from pharmaceutical companies – to diagnose the moodiness and rages of distressed toddlers, preschoolers and older children as bipolar disorder has to varying degrees become accepted. 

Prescribing polypharmacy psychotropic cocktails to toddlers can be seen as the ultimate in a Huxleyan “brave new world”, the ultimate end point of “Pharmageddon” [http://www.socialaudit.org.uk/60700716.htm].  The recent book by Dr David Healy expands on how we arrived at such a point [http://www.ucpress.edu/book.php?isbn=9780520270985].  PBD can also be seen as an emblematic diagnosis for an era of “mindless psychiatry” [http://www.tandfonline.com/doi/pdf/10.1080/15299732.2011.597826].

The US is not alone to suffer from these factors, but it seems to suffer more than other jurisdictions and hence PBD can be seen as a culture bound syndrome of the USA.  That is not to say it couldn’t spread to other nations if the same predisposing factors were to arise, and ADHD and Autistic Spectrum Disorders do to some extent represent a similar phenomena outside the USA.

Anti-Psychiatry Civil Rights Activists Drop the Ball

There is a fairly large and vocal contingency of people who protest the involuntary commitment and involuntary treatment of people who doctors label with the diagnoses of schizophrenia or other psychotic disorders. They think this practice is a gross violation of the civil rights of these patients, who are, they claim, being persecuted by society merely because they are different and do not fit in.  Such patients should have the right to, say, walk uninvited into their neighbor's house in the nude, or live in cardboard boxes on Skid Row if they so choose.


These activists also believe people who most of us would label as “psychotic” are merely misunderstood.  Delusions and hallucinations do not signify a brain disease, they say, because there are no gross anatomic lesions associated with them.  (You know, like early Parkinson’s Disease).  In fact, they really do not believe in brain diseases at all. 


So I have a bone to pick with them. I think they have really dropped the ball when it comes to people labeled by society with "Alzheimer's Disease." These unfortunate victims are often locked up in nursing homes and never, ever let out!  Ever! They too are often drugged against their will, just to keep them manageable and quiet for the comfort and safety of Hispanic and Filipina nurses aides who are taking care of them for minimum wage.


How can activists who claim to be so concerned about civil rights NOT come to their rescue? Why should these poor elderly defenseless individuals be persecuted just because they don't keep track of the date, or care much about what locations they find themselves in? Shouldn’t they have the freedom to wander wherever they want?  Should they be locked up just because their memories don't conform to societal norms?!?  This is outrageous!!


I must admit that I am  a little concerned that some people might get the mistaken impression that I am actually being serious here. In reality, it has been becoming more and more difficult to involuntarily commit, hospitalize, and treat the seriously and persistently mentally ill, and this has become an unmitigated disaster for many mentally ill individuals and their families.


And the results can be horrific. An excellent first person account of what misery can be created was recently published by the New York Times entitled, When My Crazy Father Actually Lost His Mind.    


I recommend reading the whole piece.  To just briefly summarize, the writer's father, a beloved family man with a solid employment record, had an episode of mania. He spent a long time acting crazy on the street.  He could not be committed because he was deemed to not be dangerous enough by the powers that be, even though he threatened to "haunt" his wife forever.  He was, however, sane enough to be arrested and nearly put in jail.  

The family in question

The author continues, "And so for weeks, we had been locked in a game of chicken: waiting for my father to do something clearly dangerous; praying like hell that it would not be his suicide or accidental death or the death of someone else." When the mania finally abated - on its own because he never did get treatment - he returned home.  He later "lamented the time lost with his family. 'Those are days I will never get back,' he said."

The increasing difficulty in committing seriously ill individuals has been largely due to two factors:  First, tight state budgets in the recession have led to the elimination of large numbers of psychiatric hospital beds, so there is often no place to send severely impaired mental patients. This trend actually started way before the recession. Chronically mentally ill people were supposed to be treated as outpatients by Community Mental Health Centers - but those were never funded adequately.

The second factor is the "patient's rights" movement mentioned above.  


Now, just so I am completely clear, this movement initially addressed some very real and reprehensible abuses by the states in the US, and by the psychiatric profession itself. The practice of locking up mental patients in "snake pits" and throwing away the key (and sometimes this happened to people who were not, in fact, mentally ill - at the impetus of family members who were, for example, trying to get their hands on some family money) was widespread and unchecked.


Stopping such practices was a very good thing indeed.  


But as usual, eventually the baby got thrown out with the bathwater.


The first major commitment law that stopped the abusive practices was California's Lanterman-Petris-Short Act.  The act went into full effect on July 1, 1972.  The law mandated only time-limited commitment of mental patients, at least until they were judged to be mentally incompetent to make treatment decisions by a court of law and placed on a conservatorship. 


The law also mandated judicial review for anyone who was held for more than 72 hours.  If a patient was to be committed, police or psychiatric professionals would have to fill out a "72 hour hold," also known as a 5150 for all of you Van Halen fans.

The grounds for commitment were, first, that the patient had to have a diagnosable mental illness (being suicidal was allowed to be presumptive evidence of mental illness for all practical purposes, even though one does not necessarily have to be mentally ill to be suicidal). Then, you had to either be a danger to yourself, a danger to others, or be something called gravely disabled - on the basis of said mental illness.


Grave disability was defined as the inability to provide for one's own food, clothing and shelter because of the mental disorder.


When the law was first implemented, there were plenty of psychiatric beds available, and the patients rights advocates seemed satisfied with how the law was being applied.  


The patient had to only loosely meet the criteria.  If you were homeless because you were too paranoid to find adequate shelter or get a job, you would be considered gravely disabled.


If you walked into your neighbor's house in the nude because the voices told you to (this is NOT a hypothetical example, by the way), that was enough to make you a danger to yourself.  After all, the neighbor had the right to shoot you, and just might do so.  Likewise if your delusions led you to jump out of a moving car, that would make you a danger to yourself, even if the car was barely advancing.  


Now, those sorts of situations might lead to you be quickly released from a hospital or, in some cases, imprisoned in a jail for lawbreakers.


Slowly but surely, grave disability as a criteria also became rarer and rarer.  If you had a cardboard box on Main Street to live in and you were eating out of garbage dumps because of mental illness (as opposed to say, chronic unemployment or poverty), you were deemed to have the ability to provide for your own food and shelter.  Not committable! This would be true even if, after proper treatment, you would run away from that scene in absolute horror as fast as you possibly could.


As I have pointed out previously on this blog, more severely mentally ill people are now incarcerated in prisons than in hospitals.  BTW, they get forcibly medicated there as well.


This seems to be what these bat-guano crazy, so-called "civil rights" activists want.  And they have the unmitigated gall to claim to have the moral high ground. Shame on them.