Tuesday, February 24, 2015

Conventional Wisdom that Seems Obvious Once Again Found to be Actually True

As I did on my posts of November 30, 2011,  October 2, 2012, September 17, 2013, and June 3, 2014, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of No Sh*t Sherlock. My comments in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.


5/28/14.  Physical activity program may reduce mobility disability in seniors.

USA Today (5/28, Painter) reports that for seniors, “losing the ability to walk a short distance often means losing independence.” Now, “researchers say they have found a treatment that, for some, can prevent that loss of mobility,” and that is “a moderate exercise program.” The Washington Post (5/28, Bahrampour) reports that the study, “called the Lifestyle Interventions and Independence for Elders and funded by the National Institute on Aging and the National Heart, Lung, and Blood Institute, was the first of its kind to test a specific regimen of regular physical activity for sedentary older people.” The Boston Globe (5/28, Kotz) “Daily Dose” blog reports that the study, published online May 27 in the Journal of the American Medical Association, “found that elderly people who walked and did basic strengthening exercises on a daily basis were less likely to become physically disabled compared to those who did not exercise regularly.” The study control group consisted of people who were instructed to take health education classes. 

I guess it's still OK for seniors to sit very, very still while posing as nude models for art students.

6/17/14. Study Shows Association Between Mental Illness Severity and Employment and Income.

More severe mental illness appears to be associated with lower employment rates in recent years, and people with serious mental illness are less likely than people with no, mild, or moderate mental illness to be employed after age 49, according to the report, “Employment Status of People With Mental Illness: National Survey Data From 2009 and 2010,” published in Psychiatric Services in Advance.

We now know for sure that employers are not always hot to hire people who are too mentally impaired to perform the work.

6/20/14. Brain Injuries Linked To Higher Risk For Headaches.

HealthDay (6/20) reports that research scheduled to be presented at the American Headache Society meeting suggests that “U.S. veterans of the Iraq and Afghanistan wars who suffered brain injuries are at a much higher risk for headaches, especially migraines.” This “study included 53 veterans who had suffered a traumatic brain injury during deployment and...53 veterans without brain injuries.” Investigators found “that all of the veterans in the brain injury group said they experienced headaches, compared with about 76 percent of those in the control group.” Eighty-nine percent of the headaches in those with brain injuries were migraines, while just 40 percent of the headaches in the control group were migraines.

Now just a minute. Bodily injuries produce pain?? Since when?

9/1/14. The relationship between premorbid body weight and weight at referral, at discharge and at 1-year follow-up in anorexia nervosa

European Child and Adolescent Psychiatry, 09/03/2014: Focker M, et al.  In this study, the relationship between pre-morbid body mass index (BMI) percentile and BMI at admission was solidly confirmed. In addition to pre-morbid BMI percentile, BMI at admission and age were significant predictors of BMI percentile at discharge. BMI percentile at discharge significantly predicted BMI percentile at 1–year follow–up. An additional analysis that merely included variables available upon referral revealed that premorbid BMI percentile predicts the 1–year follow–up BMI percentile.

Oh, I did not see it before, but I get it now. More severe disorders have a worse prognosis.

11/25/14. Talk Therapy May Prevent Suicide in High-Risk Patients

Talk therapy may decrease risk for future suicide attempts and completions in patients who have already made a previous attempt, new research suggests. 

God, I should hope so, or I'm in the wrong business!!

1/13/15. Self-injurers experience greater negative emotionality, particularly self-dissatisfaction, compared to individuals with no NSSI history.

Self-injurers also reported less positive emotion, but these effects were smaller. The pattern of results was similar when controlling for Axis I psychopathology and borderline personality disorder.

And here I thought cutters and burners did so because their joy was just soooo unbearable.

1/30/15. Repeated Blows To Head In Boxing, Martial Arts May Damage Brain.

HealthDay (1/30, Preidt) reports that research published in the British Journal of Sports Medicine “supports the notion that repeated blows to the head in boxing or the martial arts can damage the brain.” Investigators studied “93 boxers and 131 mixed martial arts experts,” as well as 22 individuals who had never suffered a head injury. “MRI brain scans and tests of memory, reaction time and other intellectual abilities showed that the fighters who had suffered repeated blows to the head had smaller brain volume and slower processing speeds, compared to non-fighters.”

So I guess I should quit beating my head against the wall trying to get researchers to actually look into things we actually do NOT already know.

1/30/15.  The US Food and Drug Administration (FDA) has approved lisdexamfetamine dimesylate (Vyvanse, Shire) to treat binge eating disorder (BED) in adults.
The drug is the first FDA-approved medication to treat this condition. "Binge eating can cause serious health problems and difficulties with work, home, and social life," said Mitchell Mathis, MD, director of the Division of Psychiatry Products in the FDA's Center for Drug Evaluation and Research. "The approval of Vyvanse provides physicians and patients with an effective option to help curb episodes of binge eating." The efficacy of Vyvanse in treating BED was shown in two clinical studies that included 724 adults with moderate to severe BED, as reported by Medscape Medical News. In the studies, participants taking Vyvanse experienced a decrease in the number of binge eating days per week and had fewer obsessive-compulsive binge eating behaviors compared with patients in a placebo group.
Shocking new finding: appetite suppressants reduce eating.
January 2015.  Alcohol, Depression potent risk factors for suicide.

BERLIN– Alcohol dependence and major depressive disorder are similarly potent yet independent risk factors for suicidal behavior, according to Dr. Philip Gorwood. Although alcohol use disorder and major depression are extremely common and often comorbid, the mechanisms by which they boost the risk for suicidal behavior are very different, he said at the annual congress of the European College of Neuropsychopharmacology.

Insert your own joke here. No prize will be awarded for best gag, but let's see what you got!

And yes, it is OK to joke even about suicide. Black humor often helps us all to squarely face up to very serious issues, and is therefore to be encouraged. 

Tuesday, February 17, 2015

The Sacrifice of One's Own Children: Abraham and Isaac

In my blog post from 1/2/2011, Of Hormones and Ethnic Conflict, I described a biological rationale for why, under some circumstances, people are not only willing to sacrifice their own lives for their kin or ethnic group, but to sacrifice the lives of their children as well. How else to understand such diverse phenomena as mothers gladly sending off their sons to war or even to be suicide bombers, female infanticide in China, and so-called honor killings in the Middle East?

The later is especially strange - fathers or brothers kill their own daughters/sisters because they have besmirched the family honor, usually through some sexual transgression - even if involuntary! Women who have been raped can suffer this fate.

The mass appeal of the Jesus story, in which God sacrifices His only son in order to save mankind from the fires of hell, is probably due to this characteristic tendency of human beings. 

In the Old Testament, there is another widely cited story of the willingness of a parent to sacrifice a child. It is the story of God ordering Abraham to sacrifice his son Isaac as a test of his faith. He is about to do the deed when God tells him he does not have to.

An interesting sidelight to this story is that in almost all artwork that depicts this incident, Isaac is portrayed as a little boy. This can be seen in the painting at the top of the post. Not so! I was surprised to recently learn that, in fact, most Biblical scholars believe, from other things in the Bible happening around the same time, that Isaac was about 37 years old!

Abraham was supposedly over 100 years old at this time, so Isaac could have undoubtedly overpowered him. What this means is that Isaac must have been just as willing to be sacrificed as his father was willing to sacrifice him. Self sacrifice and the sacrifice of children often go hand-in-hand.

The idea from evolutionary biology that covers this willingness, kin selection, is often criticize by many in that field due to what I believe to be a misinterpretation of the phenomenon. Indeed, it is quite true that many people are not willing to sacrifice themselves or their children at those times when most of the people within their peer group are. The willingness to follow the herd into sacrifice is an inherited biological tendency, not a mandate.

Group pressure to be willing to sacrifice can indeed be very powerful - often leading resistant individuals to an almost overwhelming sense of terror known as existential groundlessness or anomie as described in this post. This does not mean, however, that everyone simply must go along. The thinking parts of the brain can choose to ignore their fears and can override the biological tendency to follow the kin group.

People who resist the herd are often in danger of being attacked or even killed themselves from others from within their group who condemn their independent ways. People may give in to these threats, but they can also stand up to them even at great peril. 

Where does such courage come from? That is an interesting question, and I do not think we know the answer.

Tuesday, February 10, 2015

Dumb Hidden Assumptions in Drug Abuse Research - An Update

And do not forget the private prison system and racist people in positions of power who want to ruin the lives of as many African-American youths as possible.

In my post of November 21, 2014, I reported on a study that showed that regular adolescent marijuana use was associated with a reduced likelihood of finishing high school, among other things. The authors of the study attributed these results to marijuana essentially causing brain damage, rather than to the fact the kids who feel the need to get stoned all the time have other problems which could easily account for their poor performance. Almost none of these other problems were controlled for in the study.

I asked, "What on earth makes people who draw the conclusion that the drug was the primary cause of the lower achievement become so stupid that they don't see that frequent drug use is a sign that the teens already had emotional problems before they even started smoking - and that it was these problems that predate the drug use that were the real cause of both the drug use AND the poor performance?"

Well guess what? Two new studies show exactly what I was talking about.

First was a new, ongoing study funded by the U.K. Medical Research Council, the Welcome Trust, and the University of Bristol, whose authors had no financial conflicts of interest. It's key clinical point: Previous research findings showing poorer cognitive performance in cannabis users may have resulted from the lifestyle, behavior, and personal history typically associated with cannabis use rather than the cannabis use itself.

Occasional to moderate cannabis use at a young age was not found to be associated with detrimental effects on cognition or educational performance. It was true that adolescents with heavier use – defined in the study as self-reported lifetime use of cannabis 50 times or more by age 15 – had a modest 2.9% decrease in educational performance on a compulsory school exam given at age 15 or 16, compared with never-users. However, heavier use had no impact at all on IQ scores measured at age 15 after adjustment for potential confounding factors.

"Previous research findings showing poorer cognitive performance in cannabis users may have resulted from the lifestyle, behavior, and personal history typically associated with cannabis use rather than cannabis use itself,” said Claire Mokrysz, of University College London.

She reported on 2,612 children who had their IQ tested at ages 8 and 15. Adolescents with heavier cannabis use by age 15 had a nearly a 3-point lower IQ at that age than did never-users, after adjustment for IQ at age 8. However, upon further adjustment for maternal education, pregnancy, and early-life factors, and use of tobacco, alcohol, and other recreational drugs, the difference in IQ between heavier and never-users vanished.

Heavier users of cannabis scored an initially impressive 11% lower than never-users on the standardized educational performance exam in an unadjusted analysis. After adjustment for the potential confounders, however, the difference shrank to a modest 2.9%. 

Performance, by the way, is not the same thing as ability. Even in this study, no effort was made to control for the motivation of test subjects, or for whether they were being distracted by ongoing problems such as family chaos at home.

The authors added that the belief that cannabis is particularly harmful may detract focus from and awareness of other potentially harmful behaviors. Not to mention other more important psychological and family issues.

The second study was done by neuroscientists at the University of Colorado at Boulder and published January 28, 2015 in the Journal of Neuroscience. Its major finding: Daily marijuana use is not associated with brain shrinkage when using a like-for-like method to control for the effects of alcohol consumption on those who both drink and toke up.

Kent Hutchison, a clinical neuroscientist at the University of Colorado, Boulder, and the senior author of the study, said his team reviewed a number of scientific papers that showed marijuana causes different parts of the brain to shrink, and his team found the studies were not consistent.

"So far, there's not a lot of evidence to suggest that you have these gross volume changes" in the brain, Hutchison said. 

I wonder how often Nora Volkow and other leaders of the National Institute on Drug Abuse will discuss these two studies or even mention them in their public presentations opposing marijuana legalization. Probable answer: NEVER.

Tuesday, February 3, 2015

Book Review: Unhinged by Anna Berry

I breathe you in again just to feel you
Underneath my skin, holding on to
The sweet escape is always laced with a
familiar taste of poison
~ Halestorm

In female patients with borderline personality disorder (BPD), a behavior pattern is sometimes seen in which the woman quickly gets involved with a seemingly charismatic but at base highly narcissistic male. At the beginning of the relationship, it's love at first sight. There is a whirlwind romance in which both partners seemingly have found their soul mates, and love is professed - occasionally with even a hasty marriage proposal, sometimes within just a couple of weeks. The couple spends all their free time together and can not seem to get enough of each other either physically or mentally.

Before too long, however, the man reveals his true nature. He usually becomes extremely controlling, hyper-jealous and possessive. He wants to know where the woman is every second, and tries to isolate her from her friends and family. All the while, he may lie about his own whereabouts and compulsively cheat on the woman. Not infrequently, he becomes physically abusive to her.

Alternatively, the seemingly exact opposite may happen. Without warning, the man seems to lose interest in her entirely, but nonetheless continues to string the relationship along for a considerable period of time.

In many such cases, after the couple finally breaks up, the woman repeats a nearly identical pattern with another man. She never seems to learn from her mistakes, and denies that she has ever seen any red flags that indicate that things might go awry.

What on earth is going on in the mind of such a woman?  In her new book, author Anna Berry  (a pseudonym) does a marvelously detailed, brilliantly written, and entertaining job of describing her experiences with instances of her involvement with three such men. The memoir is an excellent introduction to the inside of the head of someone like her.

In another part of the book, she describes an experience in which she sort of toys with a psychiatry resident serving as her therapist, demanding that he help her to get back a guy who has treated her like crap and then dumped her. The therapist persists in gamely confronting her about how obviously ill-advised and self-destructive such a course of action would be, if it were even possible.  

As described by the author, the resident seems to be following the suggestions of James Masterson, one of the early psychoanalytic pioneers in the treatment of BPD, to confront, confront, and confront some more. Such confrontations are supposed to be done empathically, however, and in this the therapist falls short, at least in the descriptions of the author.

At some point he even tells her she is a hopeless case - something a therapist should never say to a patient even for effect. She is often snide and sarcastic to him in therapy, yet she continues to see him and even feels abandoned when he has to move away.

The author eventually got herself out of her self-destructive lifestyle and then does pretty well for herself. So what is her explanation for her earlier, crazy-sounding behavior?  

Well, she says it was because she was (and still is) both mentally ill herself, and comes from a crazy family. She at times uses the word delusional to describe herself, and also states categorically that she had brief psychotic episodes - although as I will discuss, from what she describes in her writing, she never once says anything that would clearly illustrate a delusion, hallucination, or any other evidence of psychosis. What she describes so well is something else entirely. So why, even though she does things that seem crazy, does she insist on labeling herself psychotic?

Having never evaluated the author myself, I can only guess, although I certainly can speculate and offer a possible hypothesis. More on that later.

The confusion about whether the author is mentally ill or just self-destructive arose when I was approached by the publisher to write this review.  Initially, it sounded like the book was about the difficulty in growing up in a family with a parent who was chronically and persistently mentally ill, possibly schizophrenic. 

While having a psychotic parent can certainly create family dysfunction and personality problems in offspring, it also sounded like the author herself was struggling with psychosis, and psychotic illnesses per se are not the main focus of this blog. When I asked them for clarification on this, the answer I got did almost nothing to clearly answer my question.

In the book, the patient discusses her own diagnosis, and implies that BPD was the closest thing in the diagnostic manual, the DSM, to what she had. Nothing in the book would cause me to doubt that proposition. She also discusses how she was also diagnosed by different mental health practitioners with a different psychiatric disorder almost every time she saw a different clinician - clinical depression, bipolar disorder, bipolar II, multiple personality disorder, episodic depression, seasonal affective disorder, dysthymia, cyclothymia, anti-social personality disorder, histrionic personality disorder, schizotypal personality disorder, and post traumatic stress disorder.

Her conclusion from having had these different diagnoses was that people just don't fit neatly into the DSM diagnostic boxes. While that is somewhat true, and while it is also true that people can have more than one psychiatric condition (comorbidity), it seems that in her case these labels were applied to her when she in fact did not actually meet the diagnostic criteria at all. She cannot be bipolar if she never had anything resembling a manic episode, or be histrionic when she is primarily an introvert who usually hates to be the center of attention, or have seasonal affective disorder and be depressed at any time of year.

The diagnosis of the author's mother is rather obscure in the author's descriptions. Her brother clearly has severe schizophrenia, and in the beginning of the book it sounds as though the mother did too.  She clearly had psychotic episodes. At one point she throws a lot of the possessions in the house out because voices are telling her that the objects are dirty and if she doesn't throw them away, everyone in the family will get sick and die.

As the book progresses, it eventually becomes clear that the mother's psychotic episodes are episodic and accompanied by her talking non stop and staying up without any sleep for days at a time. Her psychotic episodes would be exacerbated by prescription drug abuse and alcohol - she would often get large quantities of benzodiazepines and other controlled substances from three different free clinics that never communicated with one another. Again, without examining her myself, true bipolar disorder would be the most likely diagnosis if these descriptions are accurate and complete.

Clearly growing up in a chaotic household had a bad effect on the author's mental stability, particularly as she was neglected quite a bit. There often was no food in the house. Dad was apparently too busy having sex with his mistresses openly in the house, with the kids there, to go to the grocery store.

But has the author ever been delusional? Well maybe, but not by her own descriptions in the book. What she describes as being delusional is really a description of her lying to herself while knowing the truth deep down. A real delusion is believed totally and without any doubt, and is certainly not shared by anyone else like a manipulative boyfriend. This is an essential distinction.

In describing her rush towards involvement with one of the problematic men, she says she "could have seen the warning signs a mile away" (p.29).  Although she does not explicitly say that she did not see them, it sounds like she made a concerted effort not to.  On page 74, she writes, " I still didn't have the insight to recognize my destructive relationship patterns, but I can feel the impending doom approaching deep in the pit of my stomach, the way a seasoned sailor can feel approaching storms in his very bones."

That clearly sounds like it was not insight into her relationship patterns that was lacking, but rather that she had decided not to think too much about them. Last time I checked, stomachs can't really think.

On page 87, she describes red flags going up in her brain, but then shrugging her concerns off.  Again, not a psychotic process. She also peppers the book with phrases such as "passive aggressive cry for help and state of denial." Not a psychosis.

She describes her "voices" as almost psychotic hallucinations, but they sound a lot more like the "tapes" we all have running in our heads left over from childhood that tell us what to do and not to do. They are not described as completely external voices like the ones we all hear every day coming from other real people. The hallucinations of psychosis are more like real external voices than inner thoughts.

The first clue that she had never been psychotic was actually a beautiful description of a person with BPD's inner experience - way back on page 5: "...the day-to-day torture of having to create inner and outer selves simultaneously, and maintaining both convincingly...perfect real world training for a professional actor."

So why does she keep telling herself how mentally ill she is? Well, one possibility is that, coming from a family where mental illness is sort of the norm, these thoughts provide her with a sense of belonging and familiarity. Those are powerful needs for most people. Again and again, she uses the same words to describe both herself and her mother, as if their psychiatric experiences were actually far more similar than they really were.

But of course she would be conflicted about thinking herself to be crazy, because, deep down, nobody really wants to be or thought of by others in that way. The author often lived in fear that someone would find out how crazy she was - before demonstrating it to them in spades.

On page 200, she indicates that one of the most important lessons she learned from her psychotherapy was "I am not my parents." More accurately, she probably learned she did not have to be like them. Her mother and brother would never have recovered the same way she did with just the treatment she eventually received that was helpful to her.