Antidepressant Medication and Bipolar Disorder: The Lies and Confusion Continue

The continuing stoow-ry of psychiatric research that has gone to the dogs

In my last book, How Dysfunctional Families Spur Mental Disorders, I discussed my theory that the drug companies of Big Pharma seem to go out of their way to demonize entire classes of drugs once they are mostly available as generics, so that practitioners will use their new brand named drugs instead - regardless of whether or not they are as effective or more dangerous. This happened with benzodiazepines, which now seem to be referred to absurdly as the most addictive and dangerous substances on the planet and full of "side effects" - which don’t actually occur in the real world in the vast, vast majority of patients who take them.

(BTW. demonizing generics does not just occur in psychiatry. One patient told me that a relative was given an anticoagulant that was more dangerous than generic Coumadin because, according to the doctor, “That’s what the drug companies want us to do”).

I wrote that I suspected that the same strategy is now being applied to antidepressants. Most of them have gone generic. (The ones that haven’t yet are Viibryd, Cymbalta, and Prestique.  Although no more effective that the generics, it amazes me how many doctors seem to use them as first line drugs). All of sudden we are being deluged by both news and journal articles questioning whether the drugs are effective. I have written in previous posts on this blog that placebo response rates for antidepressants have gone up significantly every decade, indicating that the patient population being used in the studies is changing. 

Specifically, so-called contract research organizations are being given financial incentives for finding patients that they can diagnose with major depression, and potential patients are given financial incentives for exaggerating their symptoms so they can get paid for being research subjects. So the studies are using patients that don’t really have the diagnosis they are supposedly being treated for. No wonder they have a high placebo response rate. This higher rate makes the advantage of the drug over placebo in these studies seem highly questionable.

A similar process is happening in doctors’ offices all over the country. Diagnostic interviews are getting sloppier and more slipshod all the time. A new study published by Psychotherapy and Psychosomatics, according to the June 2013 issue of the newspaper Clinical Psychiatric News, seems to be highly consistent with this idea. The authors ascertained whether patients who were identified by their doctors as depressed actually met DSM criteria for major depressive disorder. Results with 5639 participants showed that only 38.4% of these patients actually met the criteria!

This phenomenon has led to a couple of ironic developments. First, the rabidly anti-psychiatry zealots point to the bad studies as “proof” that psychiatric meds are a hoax, while of course completely ignoring all the earlier studies that show that antidepressants are highly effective. The more severe the depression, the more likely a patient is to respond to them.

Second, people both inside and outside of the psychiatric profession unfairly rail against the diagnostic manual, the DSM, for not having valid criteria, when the real problem is in many cases that many doctors are not applying the criteria to the patients in making "diagnoses!"

Then there is the matter of the use of antidepressants in the depressed phase of bipolar disorder.  Of course, as I have said many times, the duration and pervasiveness criteria for bipolar episodes, either manic or depressed, are more and more often ignored, which calls into question whether the diagnoses in studies are even correct.

Anyway, in my book I brought up a study by Sachs and others in the New England Journal of Medicine, the most prestigious journal in all of medicine, that purported to show that antidepressants work worse than placebo in this population. I showed how the authors of the study used a sample of patients that were especially treatment resistant, having already failed a trial of at least one previous antidepressant, but did not acknowledge this fact in the paper at all. I was even able to question the author through a third party, since my e-mails directly to Sachs were ignored, and he steadfastly refused to answer the question, “What percentage of your sample had failed a previous antidepressant?”

Now comes another bogus study that purports to show the same thing as the Sachs study. According to an article in Medscape on May 20, 2013, “Investigators at Brown University in Providence, Rhode Island, found there was no difference in hospital readmission rates among patients who received antidepressants and those who did not." Since the authors are strongly implying that the patients had to be readmitted because their antidepressant was not working, this is taken to mean that antidepressants don’t work in bipolar depression.

That antidepressants do not work in bipolar depression is a flat out lie. Psychiatrists like myself have been using antidepressants successfully in bipolar patients for thirty five years. Of course, true bipolar  patients need to be on a mood-stabilizer first, preferably lithium, so they don't switch from depression into mania.

So what’s wrong with this study? Well, just about everything. First of all, we do not know if these patients were correctly diagnosed for the reasons discussed above. Another huge problem: all over the country, hospitalized patients with borderline personality disorder are being misdiagnosed with bipolar disorder because of the “everything is bipolar" craze, coupled with the fact that insurance companies will often not pay for hospital stays if the patients are given the correct, "lesser" diagnosis! 

The subjects in this survey were undoubtedly a very mixed lot. The study did not address whether the patients even took their medication after they were discharged. Non-compliance rates for all medications are very high according to every available study that has looked at this issue. Also, we do not know what percentage of these patients may have fallen into the “treatment resistant” category described above. Most depressed patients are treated as outpatients, not inpatients, so the ones that are hospitalized have often failed a trial of outpatient medication.

Adding to this is the fact that antidepressants do not work for at least a couple of weeks, while managed care insurance companies will not pay for that length of stay. Therefore, patients on antidepressants are often discharged before the doctor knows whether a particular antidepressant even worked. Often patients do not respond to one antidepressant but do respond to a different one. 

Hence, discharge and re-hospitalization rates tell us pretty much nothing about the effectiveness of antidepressants in the depressed phase of bipolar disorder.

The International Society for Bipolar Disorders (ISBD) Task Force recently released its long-anticipated recommendations on antidepressant use in bipolar disorders. "The take-home message is that antidepressants have a questionable benefit-risk and should only be used in certain cases in bipolar disorder," said Dr. Eduard Vieta, who presented the recommendations on behalf of the ISBD Task Force, in an interview.

Eduard Vieta

"First, they shouldn't be used in mania or in mixed episodes, they should only be used in bipolar depression in patients with a history of a good response in the past to antidepressants and no history of rapid cycling or switches into mania right away," he said.

“Further, antidepressants should not be used in patients with bipolar disease with mixed features during a depressive episode or some manic symptoms during depression.” 

The recommendations said that antidepressants should not be used as monotherapy for bipolar depression, or in rapid cycling. 

I have a few reactions to this.  

1. Duh! We've known about the risks of using antidepressants alone in Bipolar I patients since the sixties. We've also known that they are perfectly safe and highly effective if a bipolar patient in a depressive episode is on an effective mood stabilizer, preferably Lithium.  

The way that the recommendation is made, however, is highly misleading. Antidepressants indeed should not be used as "monotherapy," but not because they are ineffective for depression. It may sound to some doctors that this is what is being said. The real reason is because patients need to be on a second drug to prevent switching into mania.

2. What are they defining as "rapid cycling?" A majority of patients who get this diagnosis nowadays are not bipolar at all, but have anxiety disorders, mixed anxiety and dysthymia, and/or personality disorders - otherwise known as 'crappy childhood syndrome." A lot of drugs can cause these folks more harm than good if improperly used!  Why single out antidepressants?

3.  How are we supposed to know if a patient will respond to an antidepressant in cases of patients who have never taken one, if we are not supposed to use them unless the patient already has a history of responding to them? That would be quite a trick! Additionally, a history of a switch into mania is not a contraindication for antidepressants unless this history took place when the patient had been adequately medicated with a mood stabilizer. If they switched when not taking one, that fact would be completely irrelevant. Even the Sachs study showed patients on a mood stabilizer don’t switch into mania with antidepressants.

4. As for so-called mixed episodes, they are in reality manic episodes, with the difference being that the patient feels really uncomfortable instead of the more typical euphoria. Since they are in a manic state and not a depressed one, of course antidepressants should not be used!

Medical Racism in America: a Giant Mind-Boggling Game Without End

An explosive book that came out last year, Black and Blue:  the Origins and Consequences of Medical Racism, should have reverberated throughout the medical community and caused we physicians to closely examine our own prejudices and how they have affected the behavior of, and our relationships with, our black patients. 

So of course there has hardly been a whimper in the medical community. I did see a rather bland, "balanced" (almost namby-pamby) review by two African-American psychiatrists in the American Journal of Psychiatry, the official journal of the American Psychiatric Association. I don’t think much will come of it.

The author of the book, University of Texas professor John Hoberman, explains many of the reasons why the medical profession does not look at itself much in this regard, most of which I will not discuss in detail here. One of the biggest reasons can be summed up in one phrase: the mutual estrangement of puzzled Whites and resentful Blacks.

John Hoberman

Just to be extremely clear, there is no doubt that the problem of racist beliefs in medicine started with white racists and not their black victims. Many of the ideas about physical and mental differences between Blacks and Whites came from the colonialist opinions of Europians that Africans were more primitive than white people – less further along than Whites on the evolutionarily scale and therefore sub-human. Thus, their bodies and minds were supposedly simpler and therefore less or more prone to certain diseases. 

As seen originally by colonialists,  the black body, being more simple, was hardier than the white one. Black skin, for example, was thought to be tougher. This conveniently provided slaveholders a justification for working their slaves in the cotton fields for long hours in the hot sun. At the same  time, being supposedly simpler mentally, slaves could be thought of as less likely to get depressed, so the myth was born of the happy black slave, grinning from ear to ear with his strong white teeth while eating watermelon, content being taken care of by his benign white masters.

While physicians in general no longer express these ideas, derivatives of them became part of medical folklore and were passed down as an oral tradition from medical student to medical student. For example, observations by white doctors of what a non-naïve individual would see as the understandable reluctance of Blacks to be put under anesthesia (and therefore under the complete control of a potentially racist doctor), was instead put together with the notion of black hardiness, and voila!  Black patients are far less likely even today of being given adequate anesthesia during surgery.

Hoberman describes in detail how racist ideas from the past have morphed into medical folklore about Blacks concerning the treatment of diseases of nearly every organ system.

Disparities in the health care of white and black patients such as the one just mentioned have been endlessly documented, so their existence should not be in the least controversial. White doctors unfamiliar with the racist history of American medicine, however, are likely to misinterpret the mistrust of their black patients as an innate tendency to be non compliant - or just plain lazy - which in turn makes the white doctor reluctant to put a whole lot of energy into convincing black patients to follow their advice.

Black patients have good reasons for their mistrust of the medical profession, including of psychiatrists.  White physicians tend to think that 1962 was a long time ago.  That was the year the American Medical Association stopped deferring to Southern state medical associations (doctors have to join the state and national associations at the same time), and allowed all African American physicians to become members.

Then again, I guess 1972, while more recent, seems like the distant past to such physicians.  That was when the Tuskeegee Syphilis Experiment came to public light -  a clinical study conducted between 1932 and 1972 by the U.S. Public Health Service to study the natural progression of the untreated disease in rural African American men who thought they were receiving free health care from the U.S. government. The men were never told they had syphilis, nor were they ever treated for it.

When I moved to Memphis, I was impressed that seemingly every African American I spoke with was aware of this history – even those who were not particularly educated.  For white doctors, not so much. Unfortunately, human beings have very long memories. The Serbs and Albanians, for example, still have strong feelings about a battle that was fought in the year 1389! 

It doesn’t help when white doctors like conservative commentator Sally Satel blame treatment disparities entirely on the resistant attitudes of black people without any reference to this history.  She also writes that racial profiling is important in medicine and justifies this idea (http://www.nytimes.com/2002/05/05/magazine/i-am-a-racially-profiling-doctor.html?pagewanted=all&src=pm) with the example of the implications for choosing medications based on the real difference in the racial distribution of different versions of enzymes that metabolize certain drugs (different alleles on the genes responsible for producing the metabolizing enzymes). 

In picking on one of the extremely few areas where there actually are racial differences, she ignores the far greater quantity of ideas within medical folklore purporting differences that do not in fact exist.  Like the supposed proneness of the black brain to produce hallucinations in psychiatric disorders, for example (originally attributed by doctors to its “primitive” state).

The mistrust of racism in medicine has unfortunately led a significant proportion of Blacks to believe in some seemingly far-fetched conspiracy theories. Many Blacks believe HIV and birth control programs were invented and designed by the white establishment in order to commit genocide against minority groups. 

These conspiracy theories even reached all the way to Africa, leading to the disasterous AIDS policies of South African president Thabo Mbeki. To most Whites, these theories sound completely irrational and paranoid. Of course, historically, Planned Parenthood was indeed founded by an Anglo-American eugenicist, one of whose goals was to limit the number of children of east European immigrants to the United States, whom she considered genetically inferior beings.

There is also a rather crazymaking problem for Whites who attempt to take an interest in the whole problem of the consequences of racism on black folks. This problem was exemplified by the vicious attacks on Senator Patrick Moynihan for his 1965 report, “The Negro Family: The Case for National Action.” The report discussed the “pathology” that racism had created for many Blacks and their families.

According to the Hoberman’s book, the black intelligentsia protested the report with sentiments something akin to, “How dare some white social scientists tell black people who and what they are?”  They thought that the report pathologized and stigmatized black urban culture, and that it seemed to be an oblique endorsement of old racist biology that regarded black people as inherently diseased and beyond salvation.

This has led to a situation where even today it is considered a breach of academic etiquette for any white social scientist to theorize about Black culture. I personally was crazy enough to do some of that in my first book, since a problem seen frequently in the Black urban poor community provided the clearest example of a point about the development of family system dynamics I was trying to make. Fortunately - I guess - that section of my book was completely ignored by reviewers. Whew!

So one of the reasons that white doctors are reluctant to look at their own attitudes and the history and consequences of medical racism is a fear of open discussions about that very subject. They do not want to be considered racists. So what are they supposed to say?  That racism did not create a host of problems for African Americans, so they do not seem to pathologize them and over-generalize about them? If it did not, then what is the big deal? If they ignore the problems, they could then be accused of covertly wanting racist practices to continue. Damned if you do, damned if you don’t.

Maybe if we just do not bring up the subject, no one will notice. Except maybe for that troublemaker Hoberman.

So here we have the explanation  for the “mutual estrangement of puzzled Whites and resentful Blacks” phenomenon. To oversimplify a bit, Blacks will not tell doctors that they are mistrustful of white doctors (and of Black doctors as well, for reasons discussed in the Hoberman’s book) for fear of being labeled as paranoid, and white doctors are afraid of getting labeled as racist no matter how they discuss the problem!

This is a perfect example of the family system game without end on a larger, societal scale, which makes solving this problem so devilishly difficult. No one trusts anyone else who claims they want things to be different, so anything anyone does or says can be - and invariably is - reframed as just the same old thing – just another manifestation of the Black belief in the incorrigible racism of all Whites, or of the White belief in the presence of innate Black pathology and inferiority. No wonder we get stuck!

This game without end can lead to paradoxical and at times bizarre situations. Hoberman bemoans the fact that black kids are much less likely to get stimulants for “ADHD” than white kids, which he attributes partially to white doctors’ subconscious belief in the stereotype of the “happy Negro” described above. Black mothers, on the other hand, do not want their kids to take these drugs because they believe that the drugs would be used to pacify young black males and rob them of their spontaneity, thereby making social control of Black people easier.

I doubt that the motives of most White doctors are that pernicious, but the mothers are actually right about the effects of the drugs. In this case, the idea that stimulants are being used to control behavior is correct, and the black kids are better off not getting the drugs. The problem is not, as Hoberman implies, that black children are not getting a needed medication, but that too many white kids are getting medication they do not need instead of getting family therapy! Of course, black families are not getting as much of that as white families either.

The author’s solution to the problem of medical racism, although he probably does not know about the concept of the game without end nor necessarily totally appreciate the intricacies of interpersonal miscommunication, is for medical schools to teach the history of medical racism and about the presence of incorrect folkloric beliefs that many physicians still hold. This way, the doctors would hopefully not misinterpret the lack of cooperation they receive from their black patients, and take time to explain more about what they are recommending, and reassure the patients that they understand any reluctance the patient may have to follow their doctorly advice. 

Hoberman admits, however, that there are not very many people available who are qualified to even begin to teach such a course.

As to his book itself, it is sometimes annoyingly repetitive, and at time a little confusing. When he discusses discrepancies in the care of black and white patients, it is sometimes unclear if his examples are due in his opinion to medical mythology, a misunderstanding of actual differences, black mistrust of white doctors, or all of the above. Nonetheless, since there aren’t many books that take this whole subject on, I recommend it.

An Internet Article about Abusiveness

http://saludify.com/why-do-people-abuse-psychology-of-abuser/

Guest Post: The Good Enough Parent: How Children from Abusive Families Sometimes Do Not Seem To See Their Own Abusiveness

Today's guest post is by Sara Dawkins. This is the second post in which a writer recounts his or her own experience in a family with a problematic history. She addresses the confusion a child can feel when parents who have themselves been abused by their own parents do unto others what had been done to them. ~ D.A.

This is a topic that is very close to my heart so it is difficult for me to write about. Let me start with something that is a little easier. First of all, I will talk about my partner. His father, to be precise. My partner’s father was abused as a child. As was his father. I am sure the cycle continued for many generations. However what got me to really recognize this idea in my own life was something my partner said to me the other day:

“My father is proud of the fact that he is a better father than his father was, but that’s not very hard to do.”

Wow. He was so right. Just because the father came from an abusive home, that did not mean that his own abusive behavior was better in some way. As a matter of fact, my partner’s father can’t even see how abusive he is, as a father and as a spouse.

That brought me around to thinking about my own family. Both my mother and grandmother were from abusive homes, as was my father.

My father was practically abandoned for most of his life and when his parents were around they were verbally and physically fighting with one another. Although he was not hurting in material things, he did not get any instruction about how to behave, and was left to his own devices. He turned into a very selfish individual. Instead of trying to avoid repeating his history of abuse with his children he simply gave up. He stayed home for much of my young life, yes, but withdrew to his bedroom as soon as he got home and only left it to go to work. He did not interact much with my brother and I;  when he did it was only the minimum required so that he could feel as if he had “done his duty.” 

Eventually the stress of even that much involvement got to be too much for him and he left. He never did seem to see that he was falling into the same cycle of abuse that he had suffered through. After all, he could tell himself, he didn’t leave… for a while.

Likewise, my grandmother came from a difficult home. Her father was an alcoholic and the family lived in basements and with relatives because he would drink away his paycheck or simply not go to work at all. From this lifestyle my grandmother learned to work hard and try to keep everything as perfect as possible so that she, hopefully, would not have him get angry at him when he got home. 

She later married a man who was much like her father, and as her children grew up under his verbally and physically abusive hand, she cleaned and kept everyone looking good. To this day she defends her father and is in denial about the abuse she lived through. By keeping everything whitewashed in her mind, she was simply repeating the process of enabling abusers and was keeping the process going.

Needless to say my mother grew up feeling abandoned by her mother and abused by her father. Shockingly, she chose to fight the trend. Although she could not fight off the effects completely, she did not give into the same habits that had plagued the generations before her. Don’t get me wrong. She still had many issues. She was prone to rage and verbal abuse. However, she decided that her children were not going to suffer like she had. 

She was determined to break the cycle. I have to admit, she works really hard to do so. She is not perfect by any means, but when she does fall into those bad habits she always makes sure to apologize for them and tell us what she should have done instead. By thusly changing the pattern, she has been successful at breaking most of the bad habits that plagued our family. Although we are not completely unaffected, my brother and I are moderately well adjusted. I believe that the most important thing she taught us is to be mindful of our actions.

Sometimes people that have been abused do not seem to see the abuse that carries on in their lives. They have many of those same habits and ways of thinking. Sometimes they just assume that they are better parents because they do not do exactly the same thing or do not do everything their parents did. Being a ‘better’ parent does not make you a good parent or even a non-abusive one.

It really hurts me to see that my uncles are not as cognizant of this as my mother is. They have many of the same abusive behaviors in their homes and yet they act as if they can’t understand why their children are acting out, being rebellious, running away, or just giving up. They don’t see that they are just continuing a cycle of abuse.

I know how difficult it is to break habits that you have grown up with and I am thankful that my mother was able to give me some understanding and insight into her mind. This has helped me to break the cycle within my own relationships and live a healthier, more balanced life.

Author Bio

Sara is an active nanny as well as an active freelance writer. She is a frequent contributor of http://www.nannypro.com/.  Learn more about her at http://www.nannypro.com/blog/sara-dawkins/.

Of Ethnic Norms and Ethnic Stereotypes

In my post of June 18, The Historical Backdrop of Family Dysfunction, I stated:

" ...a knowledge of history, when combined with a knowledge about typical ethnic group norms (subject of a later post), can be extremely useful in making an educated guess about how and why certain family behavior patterns may have developed. These patterns were then transferred to succeeding generations through a process known as the intergenerational transfer of dysfunctional behavior."

This post is of course is the aforementioned later post. So how does one obtain knowledge of ethnic group norms for all of the various ethnic groups in the United States and elsewhere? And if we are thinking about cultural norms, how do we avoid stereotyping people in pernicious ways? 

In 1982, a book called Ethnicity and Family Therapy, edited by Monica McGoldrick, John K. Pierce, and Joseph Giordano was released. It is currently in its third edition, the last one having been released in 2005. This book was a landmark in family therapy because it described the typical culture and family relationship patterns of Americans who descended from a wide variety of different ethnic and national groups.  Gaining familiarity with these group characteristics gives therapists a leg up in understanding the behavioral interactions of the family members in front of them, and sometimes helps a therapist to understand otherwise seemingly inexplicable family behavior.

Monica McGoldrick

This can be particularly important in cases of intermarriage between ethnic groups. For example, when a Jewish boy marries an Irish girl, he may often want her to complain if she’s sick, but to her an illness may not be bad enough to complain about, because when she’s suffering she believes that it is punishment for her sins. So the differences in viewpoint are perplexing to the members of the couple, and each feels the other person is either crazy or bad.

The editors point out in the introduction to the first edition: 

"Problems (whether physical or mental) can be neither diagnosed nor treated without some understanding of the frame of reference of the person seeking help.” They asked the authors who were writing in the book about various American groups to answer the following questions, relating them specifically to a family therapy context:

1. What do they define as a problem?

2. What do they see as a solution to their problems?

3. To whom do they usually turn for help?

4.   How have they responded to immigration?

5.   What are the typical family patterns of the group?

6.   How do they handle life cycle transitions?

7.  What may be the difficulties for a therapist of the same background or for a therapist of a different background?”

Of course, whenever anyone deals with subjects such as this, they are in serious danger of feeding into or even creating cultural stereotypes, which often then become caricatures of the culture that are then used to denigrate an entire group. We have all seen malignant and vile stereotypes such as the alcoholic, bar-brawling Irishman, the cheap Jew, and the thuggish mafioso Italian. And those are just some of the Caucasian ones! Alleged negative attributes are used to justify discriminating against members of the groups for various and sundry unethical and/or sinister purposes.

The editors of the book under discussion are well aware of this peril. They are also aware that many members of any ethnic group do not conform to even relatively valid cultural norms that arise from the historical experiences of their group.

Many factors will determine the extent to which particular families will fit into a traditional paradigms, such as migration experiences, whether they lived in an ethnic neighborhood in the United States, their upward mobility, socioeconomic status, educational achievement, rate of intermarriage, and the strength of their political and religious ties to their group.

In other words, the members of the different ethnic groups, while having certain commonalities, are still a very diverse group of people. Even further complicating matters is the tendency of some families, or some family members within a particular family, to react against cultural norms, and go to opposite extremes to disprove the stereotype. This tendency often divides members of a particular group into two subgroups that seem like polar opposites of one another on a particular dimension. The contradictory images are nonetheless caricatured by other groups and included in a stereotype, without any attention to the inherent contradictions in these prejudices.

With Jews, for example, the dangers of being too conspicuous in Russia, where that could get you killed during a pogrom, led some immigrant families to value not drawing attention to themselves. On the other hand, we have the gold-chain laced, Rolex-wearing Jewish man in the entertainment business and the “Jewish-American Princess” (an appellation coined by Jews themselves), who seem to go out of their way to be as ostentatious as humanly possible.

With this amount of diversity, and the risks of creating discrimination and hate, and the fact that no therapist can become an expert on all ethnic groups, what good are the chapters in the book that describe the various ethnicities? 

The authors make the following arguments, as exemplified by Dr. McGoldrick in the introduction to her chapter about her own Irish heritage, with which I agree:

“What follows is a greatly simplified outline or paradigm within which to consider Irish-American families. The characterizations may or may not be accurate in any individual instance, and we hope it will be read in the spirit of providing a new provisional hypothesis to help therapists understand their Irish families. Describing ethnic patterns necessitates using cultural stereotypes or simplified pictures of the culture. There are obvious disadvantages to this, and these generalizations are meant to serve only as a framework within which to expand clinical sensitivity and effectiveness. 

The paradigms in these chapters are used not as "fact", but rather as maps which, although covering only limited aspects of the terrain, may nevertheless provide a guideline to an explorer seeking a path. This focus can mean emphasizing certain characteristics which may become problematic while ignoring certain others, such as the Irish people's great hospitality and charm, which are not problematic. By no means is it meant to add to any tendency toward negative labelling or stereotyping of the Irish.”

In other words, like with any patient in front of them, knowledge of the culture of that person serves the same function as the diagnosis of a personality disorder (or at least that is what a personality disorder diagnosis should function as): a starting point in order for the therapist to more quickly begin generating hypotheses, or educated guesses, about what might be going on with that patient or family, based on a sort of statistical likelihood. Such hypotheses must be then tested with an open mind before the therapist jumps to any firm conclusions.

Facts and patterns begin to reveal themselves as therapy progresses, and the therapist must see whether these facts and patterns are consistent with an initial hypothesis, inconsistent with it, or require some alterations to it. Knowledge of both ethnic norms and common combinations of dysfunctional personality traits often saves the therapist and the patient a great deal of time.  

Some critics of the field complain that personality disorder diagnoses label and pigeon-hole patients, just like ethnic stereotypes. Well, they can do that, but they do not have to! Almost anything can be misused, but this is hardly an argument against the usefulness of anything.

Stereotypes are bad, but you have to begin somewhere.

To point up the belief that Irish children are not praised enough because their parents don’t want to spoil them, Dr. Pearce was quoted (Pittsburgh Post Gazette, 2/9/80) as saying that when he said that to an Irish mother, she replied, “I praise them.  Kevin here, he’s not so bad.”  

Drug Company Financed Biederman on a Tear

In their continuing effort to label every acting-out child with bipolar disorder, Harvard doctor Joseph Biederman and his band of colleagues are now trying to add a THIRD disorder into the mix along with "comorbid" ADHD. 

According to a new journal article in the Journal of Clinical Psychiatry, "30% of the bipolar probands with bipolar I disorder met criteria for autism spectrum disorder." 

All the more reason to give autistic kids dangerous brand-named meds that don't do anything except drug them into oblivion, I guess. 

Immigration and Family Dysfunction

In psychotherapy with American patients who are repetitively self-destructive and self defeating, we attempt to create an emotional/historical family tree (genogram) that looks at the events and personalities in earlier generations that seemed to combine to create the ongoing dysfunctional family roles and interactions that we see in the present. These stereotypical interactions, the subjects of many of the posts in this blog, both trigger and continue to reinforce my patient’s problematic behavior. The behavior is a family role that helps to stabilize the way the family functions to a degree, at least over the short term. 

A good example was presented in my discussion of the resentful female caretaker role in some Mexican-American families, described as part of my post about borderline family dynamics.

A frequently ocurring historical factor seen in many of my patients’ genograms is the immigration of parents, grandparents, or even great-grandparents to the United States, particularly from countries that have more traditional, collectivist social structures. The process of immigration to American, depending to some extent on the reason for the move, often led to situations in which children seem to have one foot in their traditional culture and the other in American culture.

Such kids go to school along with typical, individualistic American children and will try to fit in, but in doing so their behavior may upset their parents, who see their children becoming, in their view, licentious and/or disrespectful. These parents tend to socialize mainly with other adults from their own ethnic group, who all maintain some of their “traditional family values.” 

Nonetheless, the adults are also exposed to the American siren song of “living with all the gusto you can,” to quote an old beer commercial. Yet they feel far less free than their children to succumb to its charms. 

Meanwhile, they are often dependent on their children to help them interface with the larger American culture when they have a need to do so. Their kids speak the language, so to speak, and are more familiar with it and therefore can negotiate it more easily than their parents.

This can set up a situation in which the parents seem to push their progeny to become acculturated, while at the same time objecting vociferously if they dare to do so. The potential for double messages and the creation of ongoing dysfunctional behavior patterns is very high in many of these cases.

One of the worst examples of same that I heard tell about was the case of a female physician from India who did her post-medical school training (her residency) here in the States after her family emigrated here. As with most of her ethnic group, her parents had made specific arrangements for her marriage with a suitable suitor from her caste and ethnicity back home.

The only problem was, the woman had fallen in love with another American doctor who was not of her ethnic background, and was planning to marry him. 

I only heard about this second hand, so I cannot vouch for any of the details of this story, but what I heard was that she ended up committing suicide.

Due to my interest in the genesis of dysfunctional family dyanamics, I was pleased to see a seminar at this year’s annual meeting of the American Psychiatric Association (APA) about this very type of phenomenon, entitled Accultural Family Distancing:  Developmental and Clinical phenomena for Children of Immigrants. It was put on by Drs. Dawn Sung, Andres J. Pumariega, and Shashank V. Joshi.

Since I use the term distancing in a different, although somewhat related sense, I prefer the more general term “acculturation gap” in discussing this. 

Research in this field is obviously a highly complex endeavor and therefore quite difficult to do, and that research which has been done is, I sense, not informed by family systems theory, let alone by my unified therapy perspective. The studies that have been done show somewhat mixed results.

After attending the APA session, which did seem to have a point of view that was similar to mine, I located two studies, [Hwang et. al., Child Psychology and Human Development 40(1), Mar. 2009; Farver et. al., Journal of Family Psychology 16(3), Sept. 2002] - one with Asian-Americans and Latinos, and the other with Asian Indian families - which support the idea that this acculturation gap does seem to create family conflict and psychological stress.

I found a third study using Mexican-American families (Lau et. al., Journal of Family Psychology 19(3), Sept. 2005) that did not show that. Interestingly, the latter study had the rather surprising finding that more problems occurred when the member of the younger generation was more aligned with the traditional culture than the parent!  Sometimes the patterns that I see on patients’ genograms do seem to show that a role reversal pattern does occur in a lot of families. The underlying game being played, to use an analogy, is often quite similar, but the players change sides. The pattern is much like that of a modern family characterized by an aggressive, careerist wife and a submissive and subservient househusband.

My own presentation at the APA meeting centered on how social psychological factors such as the ones discussed in this post are often completely ignored in research about the nature and treatment of dysfunctional personality traits within individuals. Many of the sessions at the meeting were attuned to the current prototypical “nothing but biology” mentality. Now that is crazy.