ADHD and Childhood Obesity

The following study was published online in the Journal of the American Academy of Child and Adolescent Psychiatry on February 5, 2014:

“Childhood Attention-Deficit/Hyperactivity Disorder Symptoms Are Risk Factors for Obesity and Physical Inactivity in Adolescence.”  

The authors were Natasha Khalife, MSc, Marko Kantomaa, PhD, Vivette Glover, PhD, Tuija Tammelin, PhD, Jaana Laitinen, PhD, Hanna Ebeling, MD, Tuula Hurtig, PhD, Marjo-Riitta Jarvelin, MD, PhD, and Alina Rodriguez, PhD

It found that a diagnoses of ADHD, as well as that of conduct disorder, two supposed brain disorders (if you listen to the biological psychiatrist dogmatists), are major risk factors for the development of adolescent obesity.  

Not only that, but the mediating factor was shown to be physical inactivity and not binge eating.

So what’s so intriguing about this? Well think about it for a moment. What does the the “H” in ADHD stand for? Hyperactivity.

These supposedly hyperactive kids are somehow showing signs of an inactive lifestyle? This is even more amazing when you think about the fact that the main treatment for ADHD is drugs like Adderall, which are well known appetite suppressants.

"In general, people think of children with hyperactivity as moving around a lot and therefore should be slim" so this connection seems counterintuitive, senior author Alina Rodriguez was quoted as saying in a Medscape article about the study. What an understatement!

Maybe it's because they aren't hyperactive most of the time at all, but only under certain environmental conditions? Maybe it’s because they have parents who are poor disciplinarians? The parents not only let them eat whatever the hell they want, but let them lounge around the house all day doing as little as possible?

This is analogous to the study I discussed in my post of 8/7/13, in which high consumption of soda pop was linked to certain behavior problems in children. Everyone seemed to wonder whether soda consumption caused these problems, instead of asking the more obvious question: How come these kids were drinking so much soda? Where the hell were the parents? 

Mindfulness or Mindlessness?

“God grant me the serenity
to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference” ~ The Serenity Prayer

The latest fad in both psychotherapy and self help is “mindfulness.” Mindfulness, which is derived from Zen Buddhism and first made popular in psychotherapy by Marsha Linehan (founder of Dialectical Behavior Therapy [DBT] for borderline personality disorder [BPD]) and others, is basically a set of skills that one can use to better tolerate and cope with emotional distress.

Fads in psychotherapy are nothing new. For a while there seemed to be a new one every few weeks, from "neurolinguistic programing" to "solution-focused therapy." 

Even therapists who swear by the gods of empirical correctness that the techniques of Cognitive Behavior Therapy (CBT) - of which DBT is a variant - are so much more powerful than any other known therapy interventions are subject to fads just like anyone else. Besides mindfulness, there is  another current one, "Acceptance and Commitment Therapy (ACT)," which seems to all boil down to telling people that they "don't have to believe everything they think" in a variety of different ways. 

If CBT techniques are so darned powerful, why would practitioners need to keep discarding the old ones and coming up with replacements? Very amusing.

Anyways, getting back to mindfulness, Gregory J. Johanson, Ph.D. discusses it thusly: 

“For clinical purposes, mindfulness can be considered a distinct state of consciousness distinguished from the ordinary consciousness of everyday living (Johanson & Kurtz, 1991).  In general, a mindful state of consciousness is characterized by awareness turned inward toward present felt experience.  It is passive, though alert, open, curious, and exploratory.  It seeks to simply be aware of what is, as opposed to attempting to do or confirm anything. 

Thus, it is an expression of non-doing, or non-efforting where one self-consciously suspends agendas, judgments, and normal-common understandings.  In so doing, one can easily lose track of space and time, like a child at play who becomes totally engaged in the activity before her.  In addition to the passive capacity to simply witness experience as it unfolds, a mindful state of consciousness may also manifest essential qualities such as compassion and acceptance, highlighted by Almaas, R. Schwartz and others; qualities that can be positively brought to bear on what comes into awareness.

These characteristics contrast with ordinary consciousness, appropriate for much life in the everyday world, where attention is actively directed outward, in regular space and time, normally in the service of some agenda or task, most often ruled by habitual response patterns, and where one by and large has an investment in one’s theories and actions.

Mindfulness was even featured as a cover story on a recent issue of Time Magazine, pictured above. It often incorporates another concept pioneered by Marsha Linehan, radical acceptance. Radical acceptance means completely and totally accepting the reality of your own life. You stop fighting this reality and learn to tolerate it and go with the flow, so to speak. 

Practicing mindfulness techniques can indeed help you to stay calm when things are going badly without resorting to a tranquilizer or booze, although in a sense it accomplishes much the same thing. So therapists like to teach these skills to get their highly reactive, chronically upset, or emotionally unstable patients to calm down and not resort to acting out, such as cutting oneself or other self-destructive or self-defeating acts.

So, is there anything wrong with that?  Well, no, not intrinsically.  Certainly remaining calm and not going off the deep end in the face of adversity is a very useful skill.  Some people prefer learning skills to accomplish this over taking medication or having a stiff drink, although there’s nothing wrong with temporarily taking medications to keep calm either. 

But I started this post with the serenity prayer for a reason. Mindfulness is relevant to the first part of of the prayer – accepting things that one cannot change. What about changing things that need changing? Where does the wisdom to know which things can be changed and which cannot come from, and how does one go about changing them?

People feel emotional pain for the same reason they feel physical pain – it is a signal to the person that something in the environment is wrong and needs attention.  A metaphor I’ve used before:  What if another person is walking behind you continually stabbing you in the shoulder with a pen knife.  If I am a doctor, I can give you an opiate so you don’t feel the pain, and you can go on with your life.  But would it not be much better to get the guy with the knife to stop stabbing you?

Most of the non-psychotic people in therapy who are highly reactive, upset and emotional, and who are not in the midst of an episode of a major affective disorder, are reacting predominantly to the environment. Specifically, the social environment. Even more specifically, as anyone who reads this blog should know by now, the family social environment. Biological psychiatrists and some cognitive behavioral therapists seem to think that it’s all going on inside a patient’s head and has nothing to do with other people.  Bull.

Marsha Linehan herself acknowledges this.  In her Skills Manual for Treating Borderline Personality Disorder, she lists the following goals of the "skills training" portion of DBT treatment.

Goals of Skills Training: To learn and refine skills in changing behavioral, emotional, and thinking patterns associated with problems in living, that is, those causing misery and distress.

Specific Goals of Skills Training:

Behaviors to decrease:

1.      Interpersonal chaos

2.      Labile emotions, moods

3.      Impulsiveness

4.      Confusion about self, cognitive dysregulation

Behaviors to Increase:

1.      Interpersonal effectiveness skills

2.      Emotion regulation skills

3.      Distress tolerance skills

4.      Core Mindfulness skills

Notice that she talks about becoming more effective in dealing with the interpersonal environment before she even gets to her distress tolerance skills - numbers 2, 3, and 4.

Unfortunately, in practice, dealing with specific dysfunctional family interactions is one of the last things many DBT therapists get to, if they get to them at all. Marsha Linehan believes – with precious little of her beloved “empirical” evidence by the way - that the reactivity of patients with borderline personality disorder is both biologically innate AND caused by an “invalidating environment.”  As I pointed out in an earlier post, the invalidating environment is not described well or very specifically - although it seems to be the patient's family of origin - nor is there anything written about what makes family members act that way.

The Skills Training Manual is 180 pages long, including a section containing handouts that starts on page 105 and goes to the end.  Of the first 104 pages, only 14 are devoted to interpersonal effectiveness skills, and most of that strongly implies that the interpersonal problems experienced by someone with BPD are due to their own skill deficits rather than the fact that they are dealing with people who are difficult (if not nearly impossible) or frankly abusive or distancing.  Blaming the victim.

In the handout section, interpersonal effectiveness skills are only addressed from pages 115-133. The rest is all about emotional regulation. Almost all of the skills described in the interpersonal skills section are basic assertiveness skills or are descriptions of “myths” about interpersonal effectiveness such as “I can’t stand it when someone gets upset with me.”  Is that really the worst thing that can happen in a family?

Listing "myths" in a way that classifies them as some of cognitive therapy's irrational beliefs means that the problem is being thought of as a flaw that exists squarely in the mind of thinker. Paradoxically, telling a person with BPD that their thinking is skewed is incredibly invalidating!

Besides, when the patient with BPD says "The other person would get upset with me," what they REALLY mean most usually is "All hell would break lose!"

In all of the DBT handouts, I find only one mention of the fact that it may be the environment that is the problem, not the person in the environment.  In the Interpersonal Effectiveness Handout #3 on page 117, it concedes that "Characteristics of the environment make it impossible for even a very skilled person to be effective."

So what happens if someone with BPD gets assertive with their families? In order to find out the true answer to this question for patients in therapy, the therapist usually needs to ask a version of the Adlerian Question such as: "What would happen if I could wave a magic wand and you could fearlessly stand up for yourself with your parents, and tell them to quit mistreating or invalidating you?

So what are the answers I get when I ask for details - without letting the patient go off on a tangent - about exactly what would happen next if the parents were "upset" with the patient?

Oh, nothing much, he said sarcastically. Just responses that include such minor inconveniences as violence, suicides, suicide threats, increased interpersonal chaos, increased drinking and drug use, parental infidelity or a break up with the patient being blamed for it, further invalidating the patient, taking anger out on other family members, literally exiling the patient or giving him or her the silent treatment for weeks on end. Just to name a few. Nothing too bad, really.

So back to the serenity prayer. Are these things one can change?  You betcha!!  It’s not easy, or the person could easily figure out how to do it and would have already proceeded. It’s emotionally trying.  It requires patience, persistence in the face of adversity, and ingenuity. It usually requires the services of a therapist who knows a little about the family dynamics of BPD.

So if your therapist is telling you to just tolerate the person stabbing you in shoulder with the pen knife, fire your therapist and find one who can actually help you.

Anecdotal Evidence and Inductive Conclusions in Psychiatry: Part II

Cherry picking: pointing to individual cases or data that seem to confirm a particular position, while ignoring a significant portion of related cases or data that may contradict that position

In part I of this post, I discussed the issue of inductive reasoning, and how it can be a source of quite valid scientific evidence. This brings up the question of what is a valid conclusion based on inductive reason versus an invalid conclusion based on one person’s personal experience.

The following comes from my book, How Dysfunctional Families Spur Mental Disorders.

Anecdotal evidence in medicine is often misleadingly defined as evidence based on only one clinician’s personal experience with a treatment or diagnosis in question. If that is the standard that is to be used, clearly many reasons exist to question the validity of inferences drawn from these experiences. Individuals are well known to have various biases that color their observations and the conclusions they draw from them. 

They may have blind spots because of their own emotional conflicts. They may ignore evidence that is contradictory to their point of view. Their observations may be limited by their pet theories about the phenomena in question. 

Perhaps even more importantly, they may be seeing unusual cases that are not representative of more “typical” cases in one way or another – a so-called selection bias.

An obvious case of selection bias was illustrated by a statement I heard made at a conference by a family therapy pioneer, the late Jay Haley. I had always admired Mr. Haley for many of his fascinating and utilitarian ideas and observations. However, in this case he betrayed some ignorance. He stated that he did not believe antidepressant drugs were ever effective because none of the patients referred to him had ever responded to them.

Of course, his being a well-known family therapist who did not believe in medication had a tremendous effect on exactly who would be referred to him. Not everyone does respond to drug treatment. Anyone who had responded to an antidepressant would, in all probability, rarely if ever darken his door. Hence, with his sample, he would be misled into thinking that the medicines were not effective for anybody. This form of bias is very common and can be quite subtle. For example, it can affect one’s beliefs about such matters as racial stereotypes or a determination of how trustworthy members of a city’s police department are.

Do these types of biases invalidate all clinical experience? Hardly. First of all, we have to distinguish between the descriptions of the actual events contained within specific anecdotes, and the conclusions or inferences which are drawn from these events. 

Let us first examine the descriptions of what actually happened. A specific anecdote may be accurately observed and described, or not so accurately. If important details are altered or left out entirely, the anecdote may indeed be worthless. However, the exact same thing can be said about empirical studies.

Important details may not even be known to an observer. Particularly with observations of family behavior within a practitioner’s or researcher’s office, important information is almost always hidden, either by design or unwittingly. In addition to the fact that one does not see the whole picture in any single context, there is also a basic problem inherent in the nature of interactions between intimates.

With verbal behavior, for instance, linguists refer to a quality called ellipsis. What this means is that in conversations among people who have known each other for a while, certain information is not spelled out verbally because the other person already knows it. Strangers such as therapists who are listening in and who have not been privy to these prior experiences may think they know what the family is talking about, but they may in reality be completely clueless.

Let us now consider the separate issue of conclusions that are drawn from anecdotes, as opposed to their description. The questions raised by an accurately-described clinical observation can be quite valid, but the answers inferred from it can be completely wrong. Conclusions based on clinical “anecdotes” exist on a continuum from relatively accurate ones to those that are extremely biased to those that are based on spectacular inferential or logical leaps of faith.

Relatively unbiased clinical conclusions based on anecdotes by mental health professionals have many things in common: 

·   They are based on a sample that one has a reasonable expectation is at least somewhat representative of a larger population.

·    They make use, not just the practitioner’s observations, but of the observations of other professionals whom one knows to be reliable and open minded. These clinicians should also be ones known to take the time with their patients necessary to take a complete history. Widespread clinical experience by competent clinicians is something upon which someone can make a very valid inductive conclusion, and is not just “anecdotal evidence.” In fact, conclusions drawn from this source tend to be more accurate that those drawn from so called “empirical” studies. Many dangerous side effects from drugs that did not show up in the initial drug studies have been discovered in this manner.

  

·     They make use of other informants besides the patient when possible.

·     They take into consideration that people and their family members behave quite differently behind closed doors than they do in public, and therefore if at all possible include observations of patient behavior when patients are unaware that they are being observed.

·    They are based on longitudinal observations. That is, the patients on whom conclusions are based have been seen on multiple occasions over an extended period of time.

·     They are not contradicted by commonly observed examples of behavior in everyday life related to the behavior in question.

·      The person proposing the conclusion acknowledges potential biases, such as a financial stake in a certain drug or allegiance to a specific school of therapy, and acknowledges his or her limitations. What former president of the Society of Clinical Psychology, Gerald C. Davison, calls “ex cathedra statements based upon flimsy and subjective evidence,” a hallmark of some psychotherapy gurus, are always highly suspicious. In fact, charlatans are relatively easy to spot. They have a tendency to sidestep challenges. I will give an example of this shortly.

  

·     The conclusions reached should lead to predictions of patient behavior under certain circumstances that prove to be accurate in a significant number of cases. This is called predictive validity. Of course, human behavior being as unpredictable as it is, at times the predictions will not be completely accurate even if the conclusions are valid, and so this fact must also be taken into account.

·     Conclusions based on anecdotes about treatment efficacy or the reasons for certain observed behavior should consider several alternate possible explanations for the observations. If several explanations are possible, one must make a judgment about which ones are more likely and which are less likely based not on the anecdote alone, but on all sources of data available. These sources include empirical studies, but also include observations from everyday life, as well as material seen in some relatively reliable media such as reputable newspapers.

Now of course stories in the media also do not tell the whole story or may be biased, so one needs to realize again that one can be fooled, and take this into account as well. I used to believe the common myth, for example, that in nature under certain conditions the animals called lemmings would follow each other off a cliff and commit mass suicide.

I was surprised when I learned that this was untrue because I had as a child in 1958 seen a film clip of said mass suicide that was part of a Disney “True Life Adventure” nature movie called White Wilderness. I later learned that, because the Disney crew could not find a real example, they had from behind the scenes driven the group of lemmings off the cliff for the cameras.

On the other hand, many people believe that men have never been to the moon and that films of the moon landings were made in a movie studio using special effects. I must say, I tend to believe that those film clips are real, but few know for certain.

·   If other anecdotes about similar patients and treatments seem to contradict the conclusions based on a given anecdote, an attempt should be made to account for this difference.

As an illustration of the latter point and an example of a the “quick step side step” in scientific presentations. I once heard an expert present new evidence from neuroscience that certain capabilities of which human brains are capable seem to develop only at certain times during early childhood development. This brain development could be adversely affected by a baby’s early social environment. Of course, that is somewhat true.

Like psychoanalysts will, however, the expert went on to conclude that if the adverse early experiences had taken place, the child had no chance of growing up to be normal. I raised my hand and asked about those children who come from horribly adverse backgrounds, are adopted away at an age past the alleged crucial developmental time, and yet still turn out wonderfully. The expert then changed the subject without ever addressing my question.  

If the data doesn't fit your pre-conceived conclusions, just change the subject!

Remember, there are NO empirical, placebo-controlled, double blind controlled studies on whether parachutes reduce the incidence of deaths or injuries after falling out of airplanes. Or that appendectomies are effective in preventing complications and deaths from appendicitis. And yet we all take those things for granted.

Treatment Resistant Depression and Borderline Personality Disorder

On October 18, 2013, John Gunderson, perhaps the most internationally recognized expert on borderline personality disorder (BPD), wrote a piece in the American Psychiatric Association’s newspaper, Psychiatric News. He opined that many if not the majority of cases of treatment resistant depression (TRD - depression that does not respond to antidepressant drugs) may in fact be undiagnosed cases of patients with BPD.  This opinion is totally consistent with my own clinical experience.

John Gunderson, M.D.

Of course, the psychiatric-industrial-Pharma complex immediately went on the offensive. On his Medscape blog, Nassir Ghaemi - a fan of  bipolar m.a. - wrote a two part rebuttal. He expressed the opinion, asserted and not backed by any particular review of the literature, that the DSM criteria for BPD are invalid. In the past, he has also expressed the belief that the DSM duration criteria for manic and hypomanic episodes in bipolar disorder are far too restrictive, and seems to liberally substitute his own personal criteria for these disorders in his arguments

He goes on to assert that the “…bland, broad DSM definition allows Dr Gunderson and other borderline experts to diagnose the condition in a large chunk of persons with mood illness, not just bipolar illness but also simple depression, since depression entails relationship problems, is often associated with irritability and paranoia, frequently involves mood reactivity, often involves suicidal attempts, and can also entail nihilistic thoughts of feeling abandoned or empty.”

Nassir Ghaemi, M.D.

As I shall discuss a little later, these symptoms, when all taken together as a group, are not typical for your average run-of-the-mill case of Major Depressive Disorder (MDD), but are extremely typical of depression in BPD.

Dr. Ghaemi's statement here is misleading, because, while any given patient with major depression and no BPD may indeed have any one or two of these characteristics, they usually do not have almost all of them together. Omitting mention of this pertinent fact is a tactic frequently employed in arguments from the everyone-who-is-moody-is-bipolar crowd.

As a reference for his assertion, Ghaemi cites a study by Angst, who is another bipolar disease monger whose circular pseudo-logic I dissected in a previous post.  

Ghaemi then goes on to focus on one of Gunderson’s statements in his article: Gunderson cited a study that showed that the presence of BPD was a major predictor of persistence of depression over time in a sample of persons who met MDD criteria.

I agree with Dr. Ghaemi that such a study does not prove, in isolation and by itself, that BPD is the most common cause of TRD, as there could very well be very many other even more common causes.

His impeccable logic: “It does not follow that if x makes y worse, then most cases of treatment resistant y are examples of x. Substance abuse makes the course of MDD worse; but it does not follow - it is scientifically incorrect and illogical - to then conclude that most cases of TRD are cases of substance abuse, end of story."

Of course, the fact that Gunderson cited this one particular study did not mean that he thought he was providing a complete literature review, but Ghaemi seems to be implying that Gunderson is saying that this one study is the only evidence he is relying upon - which he didn’t say. There are a host of studies, btw, that show that severe personality disorders are often predictive of a poor response to all sorts of psychiatric medications for all sorts of psychiatric disorders.

Ghaemi himself, on the basis of some highly questionable studies, opines that the most common cause of TRD is “unrecognized bipolarity.” He of course cites references produced by his fellow bipolar m.a. disease mongers in Hagop Akiskal’s incredibly biased Journal of Affective Disorders.

Their logic has always been a one or another version of the following:

Treatment resistant depression is often accompanied by symptoms such as racing thoughts or  hyperactivity

Racing thoughts, hyperactivity, and other such symptoms can look vaguely similar to symptoms of mania

Therefore, such patients must be bipolar

This is every bit as invalid as the logic that Ghaemi is attributing to Gunderson. In fact, anxiety disorders can and do produce, superficially, all of the symptoms that Ghaemi and his buddies attribute to an underlying “bipolarity.” When looked with a more discerning eye, of course, the symptoms of anxiety disorders and mania look very, very different.

A certain type of anxiety mixed with depression, is, as I shall discuss in a bit, one of the major qualitative factors that distinguish depression in BPD from other types of depression. I think the articles that Ghaemi is quoting are not only consistent with what Gunderson is arguing, but could have been used by him as clear evidence for his main thesis!

I have met Professor Gunderson. I think he is more than capable of telling the difference between BPD and bipolar disorder. 

It’s not subtle.

Dr. Ghaemi shows such limited understanding of BPD that I suspect that, in all likelihood, he has never or rarely sat down with such patients in long-term psychotherapy and painstakingly dissected the environmental and interpersonal context in which their depressive symptoms come and go.

Another person who, like myself, has done this with patients is my colleague, academic psychiatrist Ken Silk. He did a far more complete literature search [“The Quality of Depression in BPD and the Diagnostic Process.” Silk, K. Journal of Personality Disorders 24 (1), 2/2010] than was presented in the discussions by either Dr. Ghaemi or Dr. Gunderson.

Kenneth Silk, M.D.

He points out that, rather than restricting the diagnosis of MDD to those who clearly display a biologic depression - the cases that used to respond to tricyclic antidepressants back when they were the dominant drugs - the diagnosis has spread along with the assumption that most presentations of depression are some form of major depression and, even if not MDD, should respond to antidepressants. The term depression is now used in academic discussions to refer to a mood rather than an actual diagnostic construct.

He lists the qualitative difference between the symptoms of MDD and those of depressed BPD’s. Besides the fact that the BPD patients meet criteria for BPD, not to mention that they also exhibit the family dynamics typical of those with the disorder, the quality of their depression is characterized by the following [My comments in italics]:

1.      A“mad-bad” depression closely tied to anger and hostile behavior.

2.      Mood symptoms that are very sensitive to interpersonal situations in which the patient feels abandoned, lonely, or empty in the absense [or in the presence for that matter] of a longed-for important other.

3.      Depressed moods can come on quickly and disappear quickly [the opposite of true MDD] depending on the reactions of an attachment figure.

 

4.      The depression is at times more closely related to chronic self-criticism and a feeling of intrinsic “badness” than in MDD without BPD.

 

5.      It is associated with chronic self destructive behavior [including self-injurious behavior like cutting].

 

6.      It is associated with a loss of gratification and frustration.

 

7.      Recovery from BPD facilitates recovery from MDD when it is co-occurring, rather than the other way around.

 

8.      The depression often comes from exhaustion and demoralization from repeated unsuccessful battles with chronic and overwhelming anxiety. [BPD often is accompanied by panic disorder].

9.      Patients with BPD often exhibit impulsive aggression (a hair trigger leading to rage). [Patients with true major depression, especially of the melancholic variety, tend not to show this characteristic at all. They are usually extremely passive because they do not have the energy to strike out].

Important questions glossed over by Dr. Ghaemi include: in what context do symptoms appear? How attached is the low mood to specific interpersonal events? Is affective dysregulation (high reactivity to interpersonal problems) prominent? 

An important additional point is that these qualitative differences in depression  that Dr. Silk lists are not measured clearly by any of the standard symptom rating scales used in the vast majority of psychiatric studies. Therefore, citing any studies which employ these instruments in this debate is sort of irrelevant to the basic question. 

A few final caveats.  People with BPD can still have depression that does respond to an antidepressant. And even when the depression in BPD does not improve with SSRI antidepressants directly, other symptoms such as panic attacks can improve dramatically with these drugs (especially if the SSRI is combined with certain benzodiazepines).  SSRI’s can also decrease reactivity by raising the bar, so to speak, so that it takes somewhat more extreme behavior by an attachment figure to create a severe emotional reaction. 

In patients in which either or both of these two things happen, their depression may improve indirectly because of the effects of the drug on the other symptoms, as opposed to in MDD, in which the decrease in low mood is a direct effect of the drugs.

Finally, patients can also have both BPD and true bipolar disorder. In fact, patients with bipolar disorder, when not in the midst of a manic or a depressive episode (when they are euthymic), can have just about any psychological or psychiatric reaction or personality issue in addition to bipolar disorder.  That is because, when they are euthymic, they are basically just like anyone else! 

Writers in the Journal of Affective Disorders just love to merely assume that any emotional reaction a patient with bipolar disorder has simply must be due to the underlying bipolar disorder.  What hogwash.