Tuesday, November 24, 2015

Depression is a Symptom, Not a Psychiatric Disorder

Lately there have been a slew of articles about "depression" that seem to go out of their way to avoid discussing any specific psychiatric diagnosis listed in the DSM - instead strongly implying that "depression" is itself a disorder. These articles appear in the popular press, but, frighteningly, also in newsletters and newspapers for psychiatrists and psychologists. They explore such questions as "Do antidepressants work?" and "What is better for depression, drugs or cognitive behavioral therapy?"

These types of questions are completely meaningless. Depression is discussed as if it were a single phenomenon that, at best, exists on a continuum from "mild" to "moderate" to "severe." This type of wording is in fact completely ignorant, but does not necessarily reflect real ignorance. In many cases, different entities such as big Pharma have a vested interest in conflating several different psychiatric conditions.

In truth, "depression" is just a mood state, and as a symptom, it can be part of many different psychiatric disorders that are, despite some overlap in symptomatology, as different as night and day when it comes to their clinical presentations as well as their response to various treatments.

To name but a few actual diagnoses, there is major depression (both as part of unipolar and bipolar disorder), dysthymia, adjustment disorder with depression, depression due to a medical condition, and depression due to a substance. Medical conditions that can lead to depressive symptoms include hypothyroidism and some strokes. Substances that can do that include some steroids like prednisone and the "crash" that results when an acute cocaine high wears off.

Furthermore, "depression" as discussed in every day conversation can be a normal mood that is part of chronic unhappiness, or that occurs in response to grief at someone's death or due to any other loss or misfortune.

The most important diagnostic distinction for this discussion is between major or clinical depression and dysthymia. Although we don't know enough about the brain to know the exact causes of either one, and there is some overlap in symptomatology, they appear for the most part with very distinct clinical presentations, especially in their classic forms.

Dysthymia appears to be more of a psychological reaction, while major depression probably involves the more primitive part of the brain called the limbic system. The latter, unlike the former, is accompanied by a whole array of chronic, persistent (lasting all day every day for at least two weeks), and pervasive (coloring all aspects of the patient's mental life) physical symptoms - all at the same time - involving sleep, appetite, ability to experience pleasure, energy level and motivation, and concentration. Sufferers may have an unrelenting and constant sense of foreboding accompanied by inexplicable hopelessness and helplessness. We used to refer to these types of symptoms as vegetative symptoms.

Furthermore, someone in a major depressive disorder episode reacts completely differently to life's every day ups and downs than they do when they are not in the middle of such an episode. It's almost Jeckyl and Hyde territory.

These people stay depressed no matter what life events occur around them. They could literally win the lottery and would not really feel a whole lot better for more than a few minutes.

The most severe form of major depression is called melancholic depression. Most people who have never worked in a mental hospital have never seen a case, but the anti-psychiatry types who have not seen it blather on about depression incessantly as if they knew what they were talking about.

People with melancholic depression exhibit something called psychomotor retardation. People with this symptom move and think at a snail's pace.  It takes them longer to respond to any verbal interactions. They can even appear to have significantly impaired memory, although it is actually a more severe form of concentration impairment. That clinical picture is sometimes referred to as pseudodementia. 

You cannot spend more than an hour with such people without realizing that this condition has next to nothing in common with the type of "depression" people see in their everyday interactions with others, and that there is something seriously wrong with their brain functioning.

In severe major depression, doing any kind of psychotherapy (short of telling them, "take these pills") is a complete and utter waste of time. Sufferers literally do not have the mental wherewithal to deal with any kind of problem solving or other interactions with a therapist. And I say that as a major advocate of psychotherapy.

The symptom of depression in dysthymic disorder, on the other hand, rarely responds to antidepressant medication at all (although the drugs can be useful for other symptoms seen in patients with dysthymia such as panic attacks, obsessive ruminations, and the affective instability characteristic of borderline personality disorder). For these folks, psychotherapy is essential.

In my experience a very high percentage of the people who do drug and psychotherapy outcome studies, at least in adults, make almost no meaningful effort to differentiate dysthymia from major depression by: 1) Not spending any time making certain that patients understand the pervasiveness and persistence criteria that differentiate the symptoms of the two disorders; and by 2) Not taking a complete biopsychosocial history to distinguish psychological from limbic system factors.

All of the fancy biological research is not being complemented by good old fashioned clinical typing.

Furthermore, with the private Contract Research Organizations that do a lot of the studies, experimenters get paid only if they recruit a subject, and subjects get paid only if they get recruited - giving a financial incentive for everyone to exaggerate symptoms in order to qualify.

And people with suicidal ideation, comorbid (other, co-occurring) conditions, and significant personality pathology are excluded from studies. Those "exclusions" eliminate the vast major of subjects that have any of the psychiatric disorders in which depression is a symptom.

Garbage in, garbage out.

By the way, you can also have something called double depression. Such people are generally dysthymic but every so often can have a superimposed episode of major depression. So they have both conditions.

Once a major depressive episode starts to occur, it takes on a life of its own. However, being chronically unhappy, anxious, or stressed out may be risk factors for triggering a major depressive episode to begin with.  If you are genetically vulnerable to an episode of major depression, being chronically unhappy might make an episode more likely.

This is another reason why the question, "Should you treat these people with medications or therapy" is a really stupid question. It's a bit like asking, "Which treatment should people who have extensive, severe, cardiovascular disease get, bypass surgery or high blood pressure medication?" 

These treatments address completely different aspects of the disorder. In major depressive disorder, drugs should be used during the acute disorder, but psychotherapy should be given later to address personality  and relationship risk factors - in order to reduce the likelihood of subsequent episodes.

Friday, November 13, 2015

Parenting: How Criticisms and Nagging Backfire

Children give their parents what the parents seem to need

Mell Lazarus, the cartoonist who created Miss Peach, writes a very creative comic called Momma. I wish it were in a lot more newspapers. He understands something paramount about family dynamics that it seems a lot of so-called parenting experts do not address or even seem to notice. 

Psychiatrists and pediatricians who prescribe medications for children who supposedly have "ADHD" or "Pediatric Bipolar Disorder" never even ask their teenage patients about it - or inquire in any detail about much of anything that goes on at home between them and their parents.

I've included in this post several of his strips that demonstrate how tuned into this process Mr. Lazarus is. The dynamics can be described quite simply in three sentences:

1. If a parent repeatedly criticizes a child or a teenager about the very same behaviors, the child will not only not stop them, but will continue or even dramatically increase them.

2. If a parent continually nags a child or teenager to do the same things, the child will not only refrain from doing what the parent is ostensibly asking for, but will studiously avoid doing so - or even do the exact opposite.

3. If a parent continually tells children or teenagers they have some trait, or lack some trait, the children will compulsively act out the trait they have been told they have, and/or will compulsively avoid doing anything that suggests they actually have any trait they have been told they lack.

So why is this? Well, if parents obsessively do something, children will conclude that they parents either need to do it and/or enjoy doing it, even if the parents repeatedly deny it. Actions speak louder than words. Far be it for any child to deprive a parent of a cherished role.

So, if the parents seem to like or need to nag or criticize, their children will continue to misbehave. If the parents compulsively state or predict that the child has or will develop a negative trait, their children will continue to prove them right. They do these things so that the parents will feel good about themselves, not because they enjoy have negative traits.

Tuesday, November 3, 2015

Where Psychotherapy Goes Wrong

In my post of November 4, 2014, I discussed something called the fundamental attribution error. As described by Richard Nisbett and Lee Ross, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.” That post discussed how this error results frequently in mistaken conclusions that are drawn based on studies of people with personality disorders.

It is also the main reason why psychotherapy has not really progressed much as a science in the last 25 years or so.  The 1980's and early 1990's were a period of amazing creativity in the field, during which new ways of looking at human behavior and new interventions to help change that behavior seemed to be coming out every day. In particular, family systems thinkers began to realize that the causes of behavioral problems like self-destructiveness, as well as the causes of symptoms like chronic dysphoria and anxiety, do not reside entirely within the heads of the people coming for help.  

Some of it can be a normal and adaptive response to a very abnormal interpersonal environment. The "attachment" literature, which is fairly strong, shows that kin behavior has a huge effect on the psychological stability and the relationships of all human beings.  Much more so, I always say, than the food pellets and electric shocks favored by behaviorists.

Due to the wide variety of independent factors listed in the masthead of this block, family systems ideas have, unfortunately, been left behind to a significant degree, and therapists are back to looking at people as if their problems were "all in their heads."

Critics blasted systems ideas by focusing disingenuously on areas about which family systems theorists were completely wrong - like the genesis of such real brain diseases as schizophrenia (and yes, the evidence that schizophrenia is truly a brain disease is overwhelming, so spare me the "myth of mental illness" bullcrap). They pulled the usual slick ploy of making arguments based on black and white thinking: if family systems theorists were wrong about some things, then they must have been wrong about everything.

Because the effectiveness of psychotherapy interventions meant to change interpersonal behavior are hard to prove in a treatment outcome study, the systems people were also accused of being unscientific. As if observation were not the first step in the scientific method! (So much for much of what we know about astronomy). "Outcome studies" were touted as definitive proof of various treatment methods, despite the fact that they are extremely limited in their overall validity because there are almost an infinite number of variables that cannot be controlled. And they cannot be double blinded. And the therapists who are participating are not all doing exactly the same thing.

And the studies that are touted show only exceedingly modest effects in those subjects who do improve, as well as showing that a significant percentage of subjects did not get better at all.

Then there is another important fallacy that psychologists discuss: confusing an inference about an observation with the observation itself. Or, in other words, jumping to conclusions, and then acting like the those conclusions are facts. Andrew C. Papanicolaou, Ph.D, a neurobiologist at the University of Tennessee Health Science Center where I used to work, observes,  "Scientific discourse is unique in that it aims to maintain clear distinctions among assumptions, hypotheses and facts and treat each of them appropriately. Although this aim is often attained, it is rarely attained fully and occasionally is not attained at all."

Especially in psychiatry and psychology.

There's this rather big issue of what is really going on with patients, as opposed to what looks like is going on.  If you do not think people have hidden ulterior motives for their behavior, secrets about themselves that they don't want to share, and lack a complete understanding of the behavior of all of those around them who affect their lives, then I am afraid you are living in an alternate universe.

But still, therapists observe their client's performance, and confuse it with ability, as described in a previous post. Even when therapists look at what is basically interpersonal behavior, they make this error. Good examples of this are two of the current "evidenced-based" therapies for borderline personality disorder (BPD), Schema Therapy and Mentalization-Based Therapy. Both posit that people have mental models of how to behave in the interpersonal world, as well as of the motives and intentions of other people in their world. 

In schema therapy, the theory correctly asserts that these mental models or schemas are built up in childhood through interactions with primary attachment figures. It then goes about trying to change those schemas that it identifies as "maladaptive."  Surely, they are maladaptive in some ways, but that they serve no adaptive purpose at all is just assumed.

Although these therapists have started to look at how the primary attachment figures of their patients are behaving in the present , I have not seen much about the fact that schemas are continually updated (through the Piagetan process of assimilation and accomodation) during a person's ongoing interactions with those attachment figures. To understand what is really happening, you also have to look at the schemas of those other people.  The schemas of the various players in the family drama interact with one another!

Mentalization therapy also deals with a person's mental models of the motivations and intentions of other people, but just assumes that the mental models of their patients with BPD are distorted. This is based entirely on the way the patients respond to others, while completely ignoring the motivations and intentions on which that behavior is based. Maybe the patient wants other people to think they have distorted mental models. Why? Because they are playing the role of spoiler. The incorrect assessment of the accuracy of the patient's mental models is confused with the feigned actions of that patient.

Sorry, but we cannot read minds. You have to look at both the behavior and the history of everyone involved, and even then you can get a highly distorted picture yourself. So therapists should quit accusing their patients of what they themselves are doing - distortion.

People who have a history together base their behavior on that entire history, not just what is going on at any particular moment.  And when they talk, they can leave a lot out (ellipsis) and still understand each other, because they both already know what both of them already know. An outside observer does not know these things, and therefore their conclusions based entirely on what is said in front of them can be way off.

Of course, it is true that a therapist can never be absolutely certain of anything. For that, you would not only need a movie camera with sound on all participants 24 hours a day like in the Truman Show, but this equipment would have to be in place throughout the entire lifetime of the patient since birth!  

Still, the more information therapists can gather on the whole picture, the more likely it will be that they will better understand what might be going on and figure out what can be done to change it.

But first, they have to stop their myopic focus on that which is going on entirely in the patient's head.