NAMI, Big PHarma, and Family Therapy

Back in the beginning of June 2019 I received an e-mail from a manager in marketing and communications in NAMI inviting me to write a blog post for them, as they were planning on featuring articles in August about personality disorders. I replied that I would be happy to do so. However, I wrote, since I discuss the relationship between family dynamics and personality disorders, what I write might be offensive to some of NAMI readers. The manager then suggested to me that I could avoid that and write about what it means to have a personality disorder and how they are diagnosed. 

I agreed to do it, but had a strong suspicion that they would not like what I would write. I believe that personality disorders are different from other diagnoses in the DSM diagnostic manual and that the now-eliminated separate classification (Axis II) should have been retained. A copy of said blog post follows this introduction.

I was right. Soon after I turned in the post, I received an e-mail from higher up on the NAMI food chain, the Director of Marketing Communications.

She wrote: “…it appears there may be a misunderstanding about the agreed upon blog topic about what it means to have a personality disorder and how they are diagnosed. There are elements in your submission that do not align with NAMI’s position and educational materials about personality disorders. We align with the DSM-5 categorization of personality disorders as mental illness.”

I wrote back thanking them for the opportunity, but basically saying that I was not going to write a post as if the definition of "mental illnesses" in the DSM diagnosis list was not broad, and that it obviously covered some behavioral syndromes that are not brain diseases. Furthermore, by design,the DSM says nothing about etiology (causes of the disorders).

So why did I sort of know this would happen?

NAMI started out in life as advocates for the severely and chronically mentally ill – mostly people with schizophrenia. In the past, they had done some great work in this regard. I know that members were rightfully furious with both psychoanalysts and especially family systems therapists for blaming what is essentially a biological brain disease on family dysfunction. Of course, stressful family environments can make the presentation of any psychiatric or physical illness worse, but most readers probably know by now that I do not believe that schizophrenia is caused by family double binds or schizophrenogenic mothers.

Unfortunately, the NAMI membership morphed into those who dislike anyone who would dare suggest that ANY diagnosis in the DSM just might be created by severe family dysfunction. This position was attractive to the guilty parents I mention in the masthead of this blog, who do not want to look at their own family dysfunction, and therefore put a lot of store on phony “biological” psych disorders like pediatric bipolar disorder and adult ADHD. They joined the parents of people with actual brain disorders in the advocacy group.

In the post I submitted, I purposely did not mention adverse childhood experiences or family dysfunction in making the case that personality disorders (not including Cluster A – see the post) were behavioral syndromes and not brain diseases. Still, some members of NAMI might suspect that that was the implication of the piece. Unfortunately, there was also a second thing going on at NAMI that, although I cannot absolutely prove that the two factors led to the rejection of my post. They clearly seem to point in that direction.

This second process happened around the time that there was a major change in how NAMI derived the bulk of its funding. In October of 2009, the New York Times reported that Senator Charles Grassley had been looking into how patient advocacy groups like NAMI were getting a good portion of their funding from big PHarma. He found that drug makers from 2006 to 2008 contributed nearly $23 million to the alliance, about 75% of its donations. NAMI has long been criticized for coordinating some of its lobbying efforts with drug makers and for pushing legislation that also benefits industry.

Although I was unable to find more recent reports, there is little reason to think that this has changed significantly. Of course, if all DSM diagnoses were brain disorders, then they should be treated with pills, not psychotherapy. This increases drug sales. NAMI has clearly fallen under their spell.

Here’s the rejected post:

Is a Personality Disorder a Brain Disease?

Personality disorders (PD’s) are mental disorders defined as problematic, lasting patterns of behavior, thinking, and inner experience, exhibited across many social contexts – but, importantly, not all contexts. This latter point is seldom appreciated. The patterns are in fact often dependant on specific types of interactions and situations with certain other people, and may completely disappear at other times. People who exhibit symptoms of one of the more severe disorders, borderline personality disorder (BPD), are well known for creating arguments between doctors and nurses on hospital wards by acting sweet around one set of them, while acting horribly around the other set (the infamous staff split).

With the exception of the Cluster A disorders, described below, they are likely not brain diseases but problems with functioning, especially in relationships with others, and in my opinion the behavior patterns are learned responses. Because the behavior can be quite extreme, some people and clinicians think they simply must be brain diseases, but the neuroscience does not support that. The fact that the behaviors appear and disappear depending on social context shows this; real brain diseases like Alzheimers are not like that. Furthermore, findings on fMRI studies and heritability studies, often cited to “prove” that PD’s are brain diseases, are misleading or fraudulent. Readers can follow the links here to understand how.

Another odd characteristic of PD’s is that there can be over a hundred different combinations of traits that all lead to the same diagnosis. Some traits may even seem contradictory. Narcissistic personality disorder requires at least 5 of 9 different characteristics— Any 5— or any 6, 7, 8, or all 9. One trait is an excessive need for admiration, but another is “takes advantage of others.” It is hard to think of a worse way to gain people’s admiration that to make them feel used!

A patient can also simultaneously show symptoms of several different PD’s in any possible combination. One study showed that once someone is diagnosed with BPD, they also qualify, on average, for 1.6 other PD’s. Any others.

The traits that make up PD’s are said to be maladaptive. This means they cause problems for the intimates of the involved individuals, but also in the long run are self-destructive or self-defeating for the person with the disorder. Over the short run, these traits may be used to solve certain types of interpersonal problems, but the “solution” does not last and prevents the use of better ways to resolve ongoing problems.

PD’s were at one time thought by psychiatry to be different from all other psychiatric disorders. They were placed on a separate “axis” from other disorders - Axis II. Of course, all human behavior involves the brain, but as I have argued, PD’s are likely “functional” or behavioral disorders. For this reason, I was in favor of keeping Axis II. However, because insurance companies often refused to authorize treatment for them— despite the fact that they can be highly disabling and require extensive therapy—Axis II was eliminated. (Psychiatry does not consider causation in describing its diagnoses, because the true “causes” of almost all of them are not known for certain).

As mentioned, the personality disorders are subdivided into “clusters” that have common themes. The first, Cluster A, consists of disorders that are usually a prelude to more serious brain conditions such as schizophrenia, and probably have little in common with the PD’s in the other two “clusters.” For this reason, I believe that they should not have been classified as personality disorders in the first place, and they will not be discussed further here.

The most serious personality disorders are seen in Cluster B, the “dramatic” disorders. Antisocial p.d., the most difficult to treat, is characterized by disrespect and disregards for the rights of others, often leading to criminal behavior. They rarely come to therapy voluntarily.

BPD is currently the most common. I have noticed a marked increase in its prevalence since I was in training back in the mid 1970’s, which makes me think it is related to ongoing developments and changes in our culture. It is also seen much less commonly in traditional cultures. People with BPD often react with strong anger or panic to seemingly minor slights. This has led some psychiatrists to believe that BPD is a variation of bipolar disorder, but good evidence says otherwise. People with BPD are impulsive, self-destructive, and may cut themselves or engage in other self injurious behaviors. They often worry about being abandoned by loved ones. A history of overt physical or sexual child abuse is a feature in the backgrounds of many of them, although certainly not all of them.

Cluster C personality disorders exhibit highly prevalent anxiety or fearfulness. Those with avoidant PD, for example, are socially inhibited, feel inadequate, and are hypersensitive to negative evaluations by others. They constantly worry about what other people think about them,

Because of their now-you-see-it, now-you don’t nature, a variety of information must be taken into account to make an accurate PD diagnosis. Good clinicians specifically ask about some of the more severe symptoms and behavior in a good psychiatric diagnostic interview, which includes a complete history of the patient’s upbringing and relationships over the course of their lives – things asked about less and less recently. Often it takes more than one session for the clinician to see the patterns. A patient’s behavior with the doctor and with the staff also provides clues. Interviews with the patient’s significant others may reveal important information, although they may at times be just as misleading as patients sometimes are.

Performance versus Ability: Another Issue Frequently Ignored in Psychiatry Research

In previous posts, I have discussed some bizarre assumptions made in psychiatry research papers when the data is analyzed. I wrote about how, for example, differences in brain area size and functioning between different groups on fMRI scans are automatically interpreted as abnormalities.

Nassir Ghaemi, a blogger on Medscape with whom I have had some strong disagreements about borderline personality disorder and bipolar disorder, nonetheless had a great quote on this with which I wholeheartedly agree:
             

"All things biological are not disease, even though we can define disease in such a way that all diseases are biological. This matter is obvious once pointed out. A few assumptions,  which seem either patently true or very likely: all human psychological experience is mediated by the brain; each person only has one brain; therefore the brain will always be biologically changing as we have psychological experiences. Reading a blog post about the brain is a psychological experience. Having delusions from schizophrenia is a psychological experience. The first brain change does not reflect disease; the second does. So showing MRI changes with adult ADHD or borderline personality does nothing to demonstrate that those conditions are diseases. If you watch TV and play video games inordinately, you will have changes in your brain, and you might also develop clinical symptoms of ADHD. If you are repeatedly sexually abused, you will have changes in the brain, and you might also develop clinical symptoms of borderline personality. But those changes in the brain do not have the same causal role as the neuronal atrophy that happens with trisomy 21, or with schizophrenia, or bipolar illness..."

Another major nonsensical assumption that litters the psychiatric literature (the literature littering alliteration?) is that one can totally disregard the motivations of research subjects as well their past experiences and the environmental context in which they live when evaluating their performance on psychological tests. 

I mentioned an example of how this is utter nonsense in a previous post: The performance of African-Americans on IQ tests just might be related to the fact that for several generations Blacks who looked too smart were at high risk of being lynched. Do you think they are just as motivated as other folks to want to look smart on an IQ test which is being administered by White researchers?

What I have seen more and more lately, particular in the personality disorders literature, are studies that look at differences between various diagnostic groups on such issues as how much "impulsive aggression" they show, or how and how well they read the emotional state of ambiguous faces of strangers in photographs. When differences are found, once again the "lower" performing groups are just assumed to be "impaired" or "abnormal."

This, of course, confuses performance with ability. Without knowing anything about what the subjects in the experiments are motivated to do in their daily lives on any particular dimension for whatever reason, or what environmental contingencies they are worried about that may relate to the task at hand, it is literally impossible to say for sure whether any difference in their performance is related to what they would be able to do if those other issues were not operative.

Patients with borderline personality disorder, for example, grow up in families in which double messages are flying in all directions, and with parents who can switch from being over-involved to neglectful at the drop of hat. They are bound to have a higher index of suspicion about what facial expressions on strangers might mean than someone who grew up in a more consistent and predictable environment. If they did not, they would be morons.

Another major issue ignored in the literature is the difference between a research subject's real self versus their persona or false self in certain social situations. We all present different "faces" to the outside world depending on social context. Researchers who do not consider this must think that men, for example, present themselves exactly the same way around their children, their bosses, and their mistresses. Really?

With personality disorders, as I described in several previous posts, people play social roles designed to stabilize family homeostasis. These roles are merely a much more pervasive version of the different roles played by the above "normal" man interacting with different people. So someone with antisocial tendencies, for example, which are part of the role of avenger, are motivated to show more impulsive aggression than other people - on purpose - and have literally trained themselves to be like that. They do so habitually, automatically, and without thinking. Of course they will show more impulsive aggression in the experiment! Why wouldn't they? 

In fact, showing a lot of impulsive aggression might be considered to be part of the definition of antisocial behavior. The experiments therefore do nothing more than prove that anti-social people act habitually in an anti-social manner. Like, duh!

These types of results in no way indicate any "deficits," "deficiencies," or "abnormalities." One wonders how people who make these ludicrous assumptions ever manage to get through medical or graduate school.

Why Does Psychotherapy with Patients With Personality Disorders Take So Long?

The type of psychotherapy I do with my patients who suffer from personality disorders is called Unified Therapy. It integrates ideas from all of the main schools of psychotherapy about both the causes and the treatment of significant and ongoing self-destructive as well as anxiety-producing and/or depressogenic behavior patterns. 

Briefly, it posits that the parents in the patient's family of origin experience ambivalence and emotional conflicts about the demands of certain family roles that they have learned are required of them. They learned these roles from their own families of origin. 

The roles were initially culturally determined. As a consequence of this ambivalence, they make contradictory demands on, and give double messages to, other members of the patient's family of origin about what is expected of them.

The ambivalence in the parents, in turn, is created by learned and ingrained family rules which became obsolete when the ambient culture changed quickly. In other words, the family rules lag behind changes in the requirements of the ambient culture.

The double messages are believed to reinforce (in the behaviorist sense and on a variable intermittent reinforcement schedule) the patient's intrapsychic conflicts and the resultant dysfunctional behavior. The patient's responsive behavior then simultaneously reinforces ambivalent, dysfunctional behavior in the rest of the family.

Most of the psychotherapy treatment protocols for significant personality disorders practiced today require long-term therapy, and my model is no exception. It usually takes between 70-120  sessions - sometimes more - which take place at a frequency of once every two weeks (most other therapy paradigms are based on weekly sessions). I wish I knew of a faster way to help these patients. If I could find one, please believe me, I would be the first to employ it.

So why does it take so long? 

The first reason is that, in the beginning of treatment, the therapist has to gain the trust of the patient. Most of these patients have been betrayed in one way or another by their own close family members - the very people whom they are supposed to be able to trust the most. Furthermore, they feel ashamed of both their own and their family's behavior.  

Even more important, they feel guilty if they don't keep the family's deep dark secrets to themselves.  

Given their experience, they would have to be idiots to trust a therapist - a complete stranger - right out of the box.

Even after they begin to open up, it also takes quite a while for the patient and therapist to understand what motivates all of the patient's family's bewildering behavior. Even figuring out the right questions to pose can be a challenge for the therapist. 

The reasons that problematic patterns exist usually involve historical events that have taken place over at least a couple of generations, and sometimes start even further back than that. Important historical events which might explain them better may not be discoverable because there are no longer any relatives alive who are old enough to know about them.

However, these are not the primary reasons for the length of therapy. The main reason is because personality disorders are not only highly complex and complicated, but extremely well ingrained into the brains of sufferers. As I have discussed in previous posts, behavioral reactions to the social environment are literally branded into the primitive part of their brains known as the limbic system over many years due to repetitive interactions with parents and/or other primary caretakers.

Patients may in some cases change their problematic behaviors fairly quickly over the short term, but the changes often do not last. Doing short-term interventions may seem to work if one does not follow the patient for very long, but these interventions work sort of like a fad diet. Those who go on fad diets lose a lot of weight quickly, but if you look at them a couple of years later, they usually have gained it all back. Often they gain back even more weight than they initially lost.  

Psychotherapy outcome studies that do not look at the frequency of certain behavior patterns and psychological symptoms two years after treatment has ended are highly misleading.

Dealing with family members who feed into the patient's self-destructive behavior, whether inadvertently or on purpose, leads to a whole new level of complexity. Their behavior patterns are also branded into their brains for the very same reasons! Not only that, but as family-systems therapists first pointed out decades ago, the whole group of family members automatically pushes back against someone attempting to change the old patterns. 

This is called family homeostasis. Everyone literally gangs up on the poor patient with invalidation of their new behavior. It is accompanied by the implicit instruction, "You are wrong, change back." I listed some of the ways this is done in a previous post.

Altering these dynamic family interactions is like a game of three dimensional chess, only with even more dimensions. Whenever I coach a patient on strategies concerning how to respond to a parent's problematic behavior, each move leads to a counter-move on the part of the parent which is designed to keep everything unchanged. 

These counter-moves do not necessarily occur immediately after the patient initially does what we have decided on in therapy sessions, but may occur suddenly at any time - often when least expected.

For therapy to work, the therapist and patient have to come up with a whole series of moves and responses in order to address each of the countermoves. Countermoves may also include a parent trying to rope in a third party - such as the other parent or a sibling. Sometimes the patient and I can figure out two or three of these moves in this game in advance, but not usually.

Furthermore, all of us have a seeming natural reluctance to discuss sensitive family dynamics with our parents and other primary attachment figures, so this whole process is usually interrupted by significant periods of time in which patients cannot seem to get their homework assignments done before the next session.

This type of therapy therefore requires a major investment of time and money and energy. It requires courage, nuance and subtlety as well. The alternative, however, is not only the continuation of the patient's personal misery, but the likelihood that dysfunctional patterns will be passed through to future generations of the patient's family.  

DSM Jive

After all the hoopla, looking through the new DSM-5, it's incredible how few substantive changes there really are from DSM-IV. 

My personality disorders research group argued back and forth for years about radically changing that section, taking out certain disorders, adding "dimensions," etc. Turned out that the DSM left the section pretty much completely unchanged! 

They did put another chapter in the back of the book for anyone interested in the suggested "new" paradigm. No clinicians will be interested. They already "defer" personality disorder diagnosis as it is.

My prediction: The DSM 5 will lead to precisely NO changes in the way psychiatry is practiced today by anyone, myself included.

Book Review: Transcending the Personalty Disordered Parent: Psychological and Spiritual Tactics.

Self-help books for the adult offspring of highly dysfunctional, personality-disordered parents are in woefully short supply. Children raised in such households often grow up to have high emotional vulnerability,  a poor self image, and a high degree of confusion about what kind of people they are supposed to be or what they should expect from their relationships.  Worse yet, they sometimes become just like their parents in some way, even if they try to do things in an exactly opposite way.

If they do not have access to a therapist for whatever reason, is there anything they can do in order to better understand what has happened to them, and how to think about the problems that have resulted from their bewildering and traumatic upbringing? 

In a new book, academic psychiatrist Randy Sansone and academic psychologist Michael Wiederman attempt in ordinary language to help such individuals recognize the dysfunctional parenting styles they had been subjected to, and to understand a little bit about what makes their parents act the way they do. 

They describe in detail how such parents may do any or all of the following, among other things:  

• ·     They act like monsters with their family members, but are liked and highly-respected outside of the home - creating an almost Jeckyl and Hyde situation. 
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• ·     They seem to think that their children should be taking care of them - but undermine any effort the children make to actually try and do so.
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• ·     They seem to see children a big burden, yet won’t them go.
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• ·     They pit one of their children against another, creating even more widespread family discord.
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• ·     They accuse their children of the very negative traits that they themselves display in spades.
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• ·     They seem to over-react to seemingly minor transgressions made by family members, and in response become abusive and bullying.
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• ·     They seem to be in a constant state of denial about past misdeeds.  Or are they maybe just lying about it?
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• ·     They oscillate between intruding on the lives of their children when they don't need help, and neglecting them when they do.

The authors go on to suggest ways in which readers who have grown up with parents like these can conceptualize and think about their family experiences. 

Although they do not cite her by name, many of their recommendations seem to stem from the concepts of “mindfulness” and "radical acceptance" that come from the work of Marsha Linehan with personality disordered patients.  These ideas involve the adult children giving up trying to completely make sense of their dysfunctional parents, completely accepting their situation as it is, stopping efforts to make their parents change, and viewing their experiences as an opportunity for growth rather than as an obstacle to it.

As I mentioned, there is a serious need for a book like this, and I applaud the authors for their efforts. I also think many of their suggestions are indeed helpful, especially for those who are not seeing a family-systems oriented psychotherapist for whatever reason.

I do, however, have some quibbles with their explanations for the personality disordered parents, and I frankly strongly disagree with a couple of their recommendations.

The authors do try to be somewhat empathic with the plight of the dysfunctional parents, but their descriptions of them, understandably, veer away from that. The authors could benefit from an understanding of family systems theory. They come ever so close to Murray Bowen’s three generational understanding of the origins of self-destructive behavior, but just miss it.

For example, they discuss how the reader may have been given what Transactional Analysts call a “script” by their parents – in which the recipients of the script act out in ways that seem to be for the benefit of their parents at the expense of their own happiness. The authors do not mention, however, that perhaps the dysfunctional parent is also the unfortunate recipient of such a script from the grandparents.

In the same vein, the authors, like Marsha Linehan herself, mix up the personality disordered parent’s true self with his or her false self or persona. Is the exemplary behavior seen by outsiders the "true" nature of their personalities, or is it within their hidden-from-view dysfunctional family behavior?  This issue is somewhat analogous to my problem with Linehan’s idea of apparent competence – that somehow people can demonstrate through performance an ability they do not in fact have. How is that possible?

One father who they describe was a physician who was loved and idealized by his patients, but treated his children like crap. The authors seem to assume that the father’s “real” personality was the one he exhibited at home, while the one he exhibited at work was a fraud. Could it not be in fact the other way around?

I disagree with the authors recommendation that children of dysfunctional parents give up the idea of ever truly understanding their parents' behavior. I believe that through the use of three generational family histories called genograms that it is indeed possible to understand parental misbehavior (which, BTW, does not entail approving of it).

The authors also seem to be saying that nothing will ever change in their relationship with their parents, and that there is nothing the child can do about it. Those who read this blog know that I believe that, while adults (not children) are indeed powerless to change their parents, they  certainly do have the power to change their relationship with those parents.

The authors provide an example (p.187) purportedly showing the futility of getting personality-disordered parents to even admit that they did anything wrong in the past:  

“A patient was on the telephone with her highly dysfunctional mother. The mother was intoxicated with prescription analgesics, which was typical for her. The patient broached the issue of a babysitter who molested her and her sister for an entire year during their childhoods. At the time, both girls had told their mother about the molestation by the female sitter, but the mother continued to employ the sitter anyway. During the telephone conversation, the mother defensively stated in a slurred voice, “She only molested you girls a few weeks,” as if this nullified the injustice. Understandably, the patient exploded and proceeded to call her mother a number of obscenities.”

The authors concluded that the mother lacked the ability to validate her daughters feelings. The daughter therefore would never be able to get this validation, for which she longed.

I completely disagree. Let’s look at what happened in more detail. First of all, the daughter called the mother when the mother was intoxicated. I understand that it might be difficult to find a time to call when she was sober, but that fact alone guaranteed that the daughter would fail in her efforts to obtain validation. Second, I suspect that the way that the daughter brought up the molestation made it obvious to the mother that the daughter was highly critical of the mother’s lack of responsibility - as obvious as that lack of responsibility was. To the both of them, I might add. 

When anyone is attacked, they tend to respond with defensiveness, flight, or a returned attack. This is especially true in this case since I would wager that the mother really did, covertly, feel terrible about what she had done, and believed that the daughter was right to hate her for it.  Furthermore, I find that such parents feel they deserve hatred, and that their children are really better off without them.  

Mother therefore responded in a very hateful manner, which very helpfully gave the daughter more righteous justification for her hatred, and pushed her away to a place in which the mother viewed the daughter as safe from the mother’s pernicious influence.

If this daughter really wanted validation, she went about asking for it in exactly the wrong way, and the horrific response was entirely predictable.

Not that the right way is something easy to devise or to do, or that the complicated techniques that do in fact work are obvious. And this problem is further complicated by the fact that the right approach is different in every family and must be customized to each family member's sensitivities. Generic assertiveness skills are often useless.

Confronting maladaptive family patterns may in fact be extremely dangerous if done poorly. It almost always requires the coaching of a therapist who does this sort of work. As I have said repeatedly in this blog, finding such a therapist is well worth the effort.

Is Dysfunctional the New Normal?

In my new book, How Dysfunctional Families Spur Mental Disorders (shameless plug), I spend some time describing why the actual prevalence of child abuse and neglect in the United States (and other countries) is sometimes a contentious issue, and how certain advocacy groups have an agenda to exaggerate its prevalence while others have an agenda to minimize it. 

In the strange world of pots calling kettles black and people who are living in glass houses throwing stones, these groups ironically use the obviousness of the exaggerations of the other side as evidence for their own side.

Advocacy groups (and individuals with similar points of view) on a wide range of issues do this sort of thing all the time.  When I speak of the importance of psychotherapy for many psychiatric conditions, for examples, some biological psychiatrists love to point out that psychoanalysts used to mistakenly blame schizophrenia and autism on dysfunctional families.  I like to counter by bringing up eugenics and pointing out that biological psychiatrists used to blame poverty and sexual promiscuity on genetics.  When I say this, the bio folks howl, "But those ideas have nothing to do with contemporary biological psychiatry!"  I answer, "That's right, just like the old mistaken ideas of the analysts have nothing to do with contemporary psychotherapy."

This post is about a new study in the British Journal of Psychiatry (197, 193-9 Yang, Coid and Tyrer) about the prevalance of personality disorders (basically patterns of repetitive self-destructive behaviors).  This ties in with the issue of child abuse because patients who are diagnosed with certain personality disorders like borderline and antisocial have been found to have a very high rate of childhood adversity in their backgrounds. 

The vast majority of studies that have been done that have looked into the childhood adversity issue in those disorders comes to pretty much the same conclusion, although obviously many people who exhibit these disorders were not physically or sexually abused or neglected as a child.  Abuse or neglect are risk factors, and no risk factor for any psychiatric disorder is either necessary or sufficient to cause it, as I have argued elsewhere.

The authors of this new study almost seem to have gone out of their way to come up with an exaggerated prevalence for personality disorders.  They surveyed 8886 people living in private homes in Britain selected at random, and asked the questions found in a psychological testing instrument called the screening questionnaire of the Structured Clinical Interview for DSM-IV Personality Disorders.  This test consists of 119 questions in which subjects are asked to answer either "yes" or "no" in describing themselves.  The authors of the study say they only asked 116 of these questions; I have no idea what happened to the other three.

The study concluded, based on the number of "yes" answers, that 48% of the population has some sort of "personality difficulties," 21% has a full blown "personality disorder," and another 7% has "complex" or "severe" personality disorders.  Only 22.5% had no personality disturbance!

So almost no one is normal??  And if this personality problem prevalence is even loosely correlated with dysfunctional families, that would mean that in all likelihood, the majority of families must be dysfunctional.  I mean, everyone has issues, don't they?

Acutally, it's studies like this that give mental health practitioners a bad name and trivialize people who come from real dysfunctional families and have significant personality problems.

The SCID-II Questionaire is a symptom checklist (checklists are always inadequate to make a psychiatric diagnosis) that was DESIGNED to have a lot of false positives (that is, people who seem to meet criteria on the questionnaire but do not really have the disorder - or the even the traits - in question).

The reason for this is that it is supposed to be followed by a SCID interview that examines the criteria in more detail, and asks important follow up questions.  The preliminary questionnaire is given to save examiners time because they don't have to inquire about the questionnaire items to which the subject gave a "no" answer, since those items are very unlikely to turn out to be positive in actuality.

If the questionnaire was all that was given to the subjects in this study, then the estimate of personality disorder prevalence will of course be astronomically higher than it really is.  The authors briefly acknowledge the false positive issue in the discussion section of the paper, but then go on to argue why that shouldn't matter that much.

So what IS the definition of a dysfunctional family? It's sort of like defining pornography - hard to define in words, but you know it when you see it. Good therapists are not dealing with trivial stuff, but with severe child abuse, neglect, domestic violence, absent or totally inconsistent disciplining of children, extreme invalidation, frequent double message giving, and the like. Ain't subtle!!!

There are good, more independent stats on the high numbers of child abuse/neglect cases that are discovered by the authorities in the US every year.  The numbers are high, but not THAT high.

Glorified Dope Dealers

According to Psychiatric News of 2/5/2010, a study from Arkansas Medicaid showed an explosion of prescriptions from 2001 to 2005 for potentially highly-toxic "atypical," brand-named antipsychotic medications given to non-psychotic children .

Almost half of these prescriptions were given to children diagnosed with conditions for which there is not a single published clinical trial that supports the drugs' effectiveness: ADHD, depression, conduct disorder, oppositional defiant disorder, and adjustment reactions. I suspect that many of the rest were misdiagnosed as bipolar disorder, for which the drugs are in fact indicated, based on specious diagnostic criteria.

This situation is not unique to Arkansas by any means. I have been seeing it here in Memphis and hearing about it from people and psychiatrists all over the country. Agitation, temper tantrums, and acting out have been fraudulently re-labeled as “mood swings.” In my opinion, these drugs are given to children to quiet them down and shut them up so they do not cause distress to their clueless parents and their overwhelmed teachers.

The explosion of the use of these medications in children is an extension of a trend that began in the psychiatric treatment of adults about 15 years ago. I treat patients with personality disorders and also supervise residents as they do initial evaluations in our outpatient clinic. Patient after patient who arrives with an obvious personality disorder, and who comes from highly chaotic dysfunctional family systems,has carried a previous diagnosis of bipolar disorder.

For the vast majority, there is not a shred of evidence that they ever even came close to meeting the well-accepted criteria for bipolar disorder. Many others were actively using cocaine or methamphetamines at the time of their earlier diagnosis, the use of which can mimic mania.