Words Do Matter in Psychiatry

I was pleased to see that in the June 2018 issue of one of the newspapers for psychiatrists, Clinical Psychiatry News, a psychiatrist by the name of Carl T. Bell wrote about something I have been harping about in this blog and elsewhere for years: the sloppy use of psychiatric terminology by both the public and by many psychiatrists themselves.

Glad to know I’m not the only one who has noticed this.

He brings up three examples: the use of the words (two of which also have a common meaning separate from the corresponding terms in psychiatry): traumatized, depressed, and bipolar.

Colleagues of his had used the word traumatized as something that happened to a person who was the subject of a statement by another person that has come to be known as a “microaggression.” A microaggression is defined as “a statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group such as a racial or ethnic minority.” 

Worrying about that sort of thing has become endemic on college campuses recently. Especially if it unintentional, the result of the big ado is a communication to individuals that they are so fragile and vulnerable that they can’t handle anything. It also has led to a suppression of free speech.

As far as I know, there has never been an example of a microaggression, or even a direct verbal insult, in and by itself leading anyone to develop post traumatic stress disorder (PTSD). According to Dr. Bell, being stressed by something like that, or by your boss chewing you out, is a far cry from being traumatized. Being distressed by something like the death of a parent is a little worse. It can come up from time to time, like on the anniversary of the death. However, in both of these cases, unlike in PTSD, “the mind is able to make peace with the reality…and life goes on.

“Traumatic stress, on the other hand,” he adds, “is an event so painful and disruptive that it runs the risk of breaking the mind’s ability to make peace with the event…[and it] disrupts or destroys normal psychic life.”

I would add that if everyone around you treats you like you are so fragile that the slightest stress will do that, you start to believe it even though you probably aren’t that fragile at all. And if you feel like that, you are probably not going to take measures to actively oppose and undermine things like racism, sexism, and homophobia. If enough people think like that, it is paradoxically a great boon to racists, sexists, and homophobes everywhere.

I’ve already covered the misuse of the term depression in my post of November 24, 2015, Depression is a Symptom, not a Psychiatric Disorder. Major depression is a clinical condition has many physical symptoms and is something that can be quite disabling, while being unhappy, sad, grieving or even demoralized is not the same thing at all. The latter conditions do not respond to antidepressants in the least, but researchers doing current studies on antidepressant efficacy have become very sloppy and often do not exclude the latter people as they should.

Bell then addresses how the term “bipolar” is creeping into common usage to cover things such as being moody and having difficulty regulating one's moods and having a bad temper (especially in kids, I might add). For maybe thirty minutes or an hour. And many psychiatrists just take patients at their word when they misuse the term, and prescribe unnecessary and ineffective mood stabilizers.

In that vein, another article in the April issue of the same newspaper quoting a Gabrielle Carson M.S. talks about the issue of tantrums in children. It advocates investigating the child’s symptomatology to rule out bipolar and other mental disorders, as well as clearly behavioral problems like so-called disruptive mood dysregulation disorder, ADHD, and oppositional defiant disorder. 

The only mention of environmental factors that might lead to the tantrums is a quick and superficial reference to child abuse and school bullying. But the article says absolutely nothing about the far most common cause of frequent tantrums by children (as discussed by child psychologist and columnist John Rosemond as well as other people who actually look at what goes on in the child’s home): problematic parenting practices such as acting like a friend to your kids instead an authority figure, letting them make decisions that should be made by the adults, compulsive yelling or lecturing, and inconsistency in administering discipline.

Adventures in the Veterans' Hospital Mental Health Clinic - Part I

Kafkaesque: of, relating to, or suggestive of Franz Kafka or his writings; especially:  having a nightmarishly complex, bizarre, or illogical quality.

Rube Goldberg machine: a contraption, invention, device or apparatus that is deliberately over-engineered or overdone to perform a very simple task in a very complicated fashion, usually including a chain reaction. The expression is named after American cartoonist and inventor Rube Goldberg (1883–1970). Over the years, the expression has expanded to mean any confusing or complicated system.

Much to my own relief, I retired recently from my part-time job at the Veteran's Affairs (VA) hospital seeing patients in the mental health outpatient clinic. While I found the patients interesting and challenging, the VA bureaucracy was at times as infuriating as one might guess. 

The Kafkaesque nature of the system in which I worked can best be illustrated by an experience I had with my picture ID card. The VA does extensive background checks on employees - as well they should - and requires fingerprinting when their identification cards get renewed every few years. 

The card contains a computer chip which allows the bearer access to the VA computer system, most notably patient electronic medical records. A few months ago, the computer chip in my ID card malfunctioned - way before its renewal date. I thought it should be no big deal to get it replaced. Yeah right. 

Not only did I have to get fingerprinted again and wait several days for them to be processed, making it extremely difficult to actually treat patients in the interim, but they also required me to produce two forms of picture identification.

The VA did not accept its own picture identification card for this purpose, which had not expired, as one of the two!

Before I go further with more bizarre stories about the place, let me make a couple of things clear. The fact that the VA is a government bureaucracy does not mean that private companies cannot be just as nuts - or even crazier. They can certainly be far more hostile. I used to work for one. As a friend of mine who worked for both of my former employers said, at least the VA bureaucracy was predictable in its crazy decision making, while the private firm we worked for was crazy but whimsical. Sort of like the Dilbert comic strip.

Let us turn to the issue that made the news: problems with scheduling patient appontments in a timely fashion. Much of the coverage in the news simply ignored the fact that an influx of new patients who are veterans of the wars in Iraq and Afghanistan has overwhelmed the VA healthcare system. There are just way more people reliant on VA than ever before. This happened without a commensurate increase in funding or staff until just recently, and there is still a lot of catching up to do.

In 2003, The VA expected to see 4.7 million veterans in its hospitals and clinics, up more than 54 percent just from 1996. The influx of newly-injured and/or mentally traumatized vets has continued every year since then as the wars dragged on, and funding of the system for the treatment of these wounded warriors did not keep up. Not even close. Frankly, the politicians who yell "support our troops" the loudest do NOT believe in supporting our troops after they leave the service.

In mental health in particular, visits to mental health clinics have skyrocketed as the military has attempted to change the "macho" culture that discouraged such visits in the past.

So what to make of the bureaucrats who kept phony schedules to hide the fact that veterans often had inordinate waits before they received an appointment? Well, when you give employees a mandate to do something as a condition of continued employment, and you don't give them the tools and resources needed to accomplish the mandate, they will naturally become passive-aggressive and do crap like that. They have no choice. 

And we know how bureaucracies treat whistleblowers, so everybody shuts up and goes about their business doing their best to get around the double bind they are all in.

To get patients seen in a timely fashion, you would think that the place would, at the very least, be very quick about putting in the appointment system the times when various doctors are available in their clinics to see and treat patients. Again you would be wrong. Whole clinic days of mine would disappear from my upcoming January schedule in the computer for an upcoming new year, and it would take two or three months of me complaining about it for the clinic times to reappear. I could not schedule anyone! 

I finally found out why it took so long. At least this is what I was told: There was just one person doing this job. Not one person for a few clinics. One person for the whole humongous medical center! 539 provider schedules, give or take.

Still, in the defense of the VA, at least part of the fault for patients not getting seen in time by a doctor may have in some cases lied with the patients. I can not speak for VA facilities in Phoenix or the rest of the country, but here is a photograph of an actual sign displayed prominently at the entrance to the VA hospital in Memphis:

In addition, at least in the mental health clinic I worked in, one of the doctors was always available to see every walk-in patient who came in without an appointment - even if they hadn't stopped near that sign to get checked in.

Furthermore, the hospital had what they called a "patient advocate's" office, where vets could complain about problems they were having getting seen. The patient advocate was usually very effective at getting them in.

If the patients described in the news media who died before they got in for an appointment were that sick, maybe they should have not just followed the instructions of the schedulers about how soon to come it. "I vas only following orderz" is not a good excuse.

Still, it is clear that the VA does tend to be a lot more concerned with looking good rather than actually doing good. For an illustrative example, a mandate came out that veterans who were diagnosed with mental trauma and post traumatic stress, either from war or military sexual assault, had to receive a certain number of psychotherapy sessions within a prescribed period of time after their initial evalutation.

The hospital administrators recently bragged in an e-mail to the department that they had met the target. 

What they actually did was to put all of these patients into group therapy, which in my experience was, in a lot of cases, next to worthless - instead of giving them the much more effective individual treatments. The VA where I worked does not have nearly enough psychologists on staff to provide individual treatment to everyone who needs it, and the ones they do have are mostly busy doing other things because they are maldistributed as well. 

For post traumatic stress disorder uncomplicated by major personality disorders, in my estimation the most effective psychotherapy treatment is something called prolonged exposure (PE), a type of desensitization treatment. Another treatment that is "empirically validated" - by which some people mean that there are some studies, no matter how pathetic, showing that it is minimally effective - is called cognitive reprocessing therapy (CPT). That in my experience is less effective for a lot of patients than PE.

Commensurate with my experience at the VA in Memphis, an article in the journal Psychiatric Services by Watts and others published in May of 2014 found out that, nationwide, the percentage of veterans who received any sessions of either PE or CPT was six percent. Six percent! But our VA bragged about fulfilling the mandate because the veterans were seen by a mental health professional the correct number of times. Well sort of seen, anyway.

More on looking good rather than doing good in upcoming posts in this series, coming soon to a blog near you.

Cognitive Behaviorists and Big Pharma Demonize Tranquilizers for PTSD

A medical society called the International Society for Traumatic Stress Studies (ISTSS) publishes a set of guidelines for treating those people suffering from post traumatic stress disorder (PTSD), such as soldiers returning from war zones or victims of natural disasters.

Treatments for PTSD generally involve both psychotherapy and psychiatric medications. No psychiatric medication controls two of the primary symptoms of post traumatic stress disorder:  re-experiencing the trauma as flashbacks, and becoming episodically numb or zoned out.  We do, however,  have a medicine that effectively controls the nightmares, believe it or not – an old blood pressure medication called prazocin. I will talk more about medication a little later in the post, but first let me discuss the psychotherapy of PTSD. 

Many types of psychotherapy have been employed for PTSD, with widely varying results. 

In my clinical experience, many chronic PTSD patients have been given group therapy, in which they meet with other PTSD sufferers who have had similar experiences. I have found that this sort of treatment has been next to worthless for a significant percentage of such patients, particularly those patients who have been severely disabled by their disorder and who have been unable to work for years or even decades.

In patients with chronic PTSD (who do not also have severe personality disorders or majorly dysfunctional families), it is generally believed that the most effective type of psychotherapy is something called prolonged exposure therapy (PE), which is an intense form of what cognitive behavioral therapists (CBT) refer to as systematic  desensitization.  

It is a difficult process in which - and I am grossly simplifying it in order to be brief (and since I do not do this sort of work myself) -  the traumatic experiences suffered by the patient are relived under controlled conditions so that the anxiety and other symptoms generated by the memories can gradually be extinguished.  I have read that doctors have even experimented with recreating the traumatic events using virtual reality through computers, projected images, and earphones, to enhance the desensitization process.

In a PTSD treatment facility I know of, I was told that if a patient were taking a benzodiazepine tranquilizer like Klonopin or Xanax, then they would not be a candidate for PE and would therefore be referred to the aforementioned group therapy.  I was told this was the case because, CBT folks believed, that tranquilizers somehow affect the learning process so that the PE therapy was not effective if the patient were on the meds.  I had heard this idea before from other CBT therapists. 

However, since people who take benzodiazepines are almost never intoxicated, I had always thought this idea a bit strange. So I asked the head of the clinic for a reference. He did not know of one.  Interesting, I thought.  So I did my own literature search. 

Well guess what?  I found exactly one study that showed that benzodiazepines might affect learning in rats.  But in people?  All of the studies showed they had absolutely no effect whatsoever. 

Yet another urban CBT psychotherapy myth.

But then things got even stranger. I was also told that I should check out the treatment guidelines from ISSTS, which said that benzo’s were not indicated for the treatment of PTSD, and that  this clinic followed ISSTS guidelines.  On advice from the clinic leader, I looked up said treatment guidelines, which turned out to be pretty amazing.

Here’s what they said:

 “Although [benzos] are effective anxiolytics [anti-anxiety] and anti-panic agents, they are contraindicated [italics mine] for PTSD treatment.  They don’t reduce re-experiencing or avoiding/numbing behavior.  They should not be prescribed in patients with past or present alcohol/drug abuse or dependence.  Finally, they may produce psychomotor slowing or exacerbate depression. [Benzo’s] do not have any advantage over other classes of medications; therefore they cannot be recommended as monotherapy [again, my italics] in PTSD at this time.”

Being the cynical critic that I am, I should not have been shocked how a supposedly scientific document could be filled with so many half truths. (I’ll enumerate them shortly). But I was. And then I remembered that the pharmaceutical companies had been demonizing benzo’s ever since they all went generic and therefore became far less profitable for the companies (See my earlier post). 

The Cognitive Behavioral Mafia folks also has a vested interest in demonizing benzodiazepines, it seems to me, since the drugs are so effective for some symptoms. This leads to a situation in which  patients would rather just take drugs than go to a CBT therapist to go through systematic desensitization, which can be a long, involved process that is sometimes itself quite traumatic in the short run. 

This preference is unfortunately common even though it is probably better to treat chronic anxiety with psychotherapy than with medication alone, because when the therapy is successful, the patient might be  more or less cured. Not so with the medication.  If you stop them, the symptoms often return.  (And no, not because the medications cause the symptoms, but because they stop but do not cure the symptoms).

Of course, it is also a perfectly good idea to treat anxiety issues with medicine for the quick relief and therapy for the eventual cure. You might then be able to stop the drugs after therapy is completed.  Remember, there is no evidence that medications interfere with systematic desensitization. Still, the CBT folks (and many psychiatrists as well) seem to think of drugs versus therapy as some sort of competition or zero sum game, so their prejudices just happen to coincide with the interests of drug companies: demonizing benzodiazepines. 

It is well documented by several news organizations that drug companies have insinuated themselves into scientific committees that draw up treatment  guidelines to make sure that their interest in making higher profits from their brand-named medication is advanced.  I do not have any proof, of course, but might this have been what happened with the ISSTS treatment guidelines for PTSD?

So let us return to the subject of the half truths in the ISSTS guidelines.  Most of the misleading ideas in the paragraph reproduced above have to do with the misconception implied in the guidelines that PTSD generally exists in some sort of psychiatric vacuum in which PTSD patients show no other symptoms of any other psychiatric disorders as well (Comorbid conditions). In fact, comorbidity is the rule rather than the exception.

For patients suffering from PTSD, I find clinically that the most important common co-morbid condition is panic disorder. In this disorder, sufferers experience severe anxiety attacks with physical symptoms that mimic those of a heart attack.  People who have been traumatized are especially vulnerable to developing panic attacks. 

I found it difficult to find information about exactly what percentage of chronic PTSD sufferers also have panic attacks, but in one study it was 35% and in those patients who sought treatment, 49%! (Cougle et. al., Anxiety Disorders 24(2), p. 183, 2010.)  In another study  (Falsetti & Resnick, Journal of Traumatic Stress 10, p. 683, 1997) the percentage was 69%. More than two thirds!

Yet another study (MacFarlane and Papay, Journal of Nervous and Mental Disorders 180 (8) p.498, 1992) showed that comorbid panic disorder is an important predictor of PTSD turning in to a chronic disorder.

People who have panic disorder also often develop agoraphobia - the fear of being out in crowded places.  Agorophobia is particularly likely to develop in combat veterans who have comorbid PTSD and panic disorder because of another symptom of PTSD: hyper-vigilence. It is as if these veterans have to remain constantly on guard for enemy soldiers, rocket propelled grenades, and improvised explosive devices – even though they are now back home in a safe environment. Being hyperalert in a crowd will often bring on panic attacks. 

This is probably one reason why patients with chronic PTSD and panic disorder may do not do well in group therapy. They are deathly afraid of groups.

Supposedly the first line treatment for panic disorder is an SSRI antidepressants like Paxil or Zoloft, but in my clinical experience benzodiazepines tend to be far more effective. The SSRI’s often only decrease the frequency and severity of panic attacks, but do not stop them completely as certain benzo’s often do. In fact, many victims of PTSD are already on SSRI’s when I first see them, and their panic symptoms and agoraphobia are not under any semblance of control whatsoever. 

So I add a benzo. The combination of an SSRI and a benzo is probably the most effective pharmacologic treatment of panic attacks of all, but you will never find a study that shows that.  In fact, you will never find a study using them in combination for the treatment of any disorder. The drug companies won’t fund such studies, because they don’t want doctors to think that benzo’s are good drugs.

Interestingly, the clinic I have been discussing allows patients who are on SSRI’s to get PE, whereas not so for those on benzo’s or the combination.

Back to the ISSTS guidelines.  They correctly point out that benzo’s do not help the PTSD symptoms of flashbacks and numbing - but no one has said that they do.  I agree that they should not be used as monotherapy for PTSD, as the guidelines say, for that very reason. But why would they be contraindicated (which means they should never ever be used under any condition)? The guidelines themselves start out by admitting that they are very effective for panic disorder, which as I have shown is highly comorbid with PTSD.

Well, maybe it’s because, “They should not be prescribed in patients with past or present alcohol/drug abuse or dependence. Finally, they may produce psychomotor slowing or exacerbate depression.” 

Well first of all, the first statement is not at all true for all patients, particularly those patients who have been sober for a significant period of time. Two different studies have shown that ex-alcoholics do not abuse benzo’s at a higher rate than anyone else. Also, some alcoholics are drinking only because they are, in fact, medicating themselves with alcohol for their panic attacks. They often STOP drinking when put on a benzo.

And even if a chronic PTSD sufferer becomes dependent on benzo’s, so what?  Is that somehow worse that being nearly housebound and completely disabled from work because of panic disorder with agoraphobia?  I think not. And the drugs have almost no side effects. The worst thing about being addicted to a benzo is that you are addicted to a benzo.

Ironically, a lot of the PTSD patients I see are never taken off SSRI’s. Essentially, they are dependent on them. But somehow that’s different. How?  Beats me.

What about benzo’s causing depression?  They sometimes do.  Rarely. The studies that led to FDA approval of the various benzo’s show that this happens in the range of 2-6% of cases. Not much different than placebo!  Sometimes one benzo will have this side effect on a given patient, while another will not. And if they all do in a given patient, they can be discontinued. Or an SSRI can be added for the very effective combination therapy, which prevents this side effect as well as the panic attacks.

The treatment guidelines do not say that SSRI’s are contraindicated because some people might develop side effects, so why should benzo’s be? This is particularly nonsensical in light of the fact that one common side effect of SSRI medication is increased agitation. PTSD is an anxiety disorder!!  (This side effect can also be treated with – you guessed it – a benzo).

More B.S. About Bipolar Spectrum

A psychiatrist who works at the University of Texas Medical Branch in Galveston occasionally writes for a newspaper for psychiatrists called the Psychiatric Times, which is usually relatively unbiased in its coverage of the field despite heavy advertising from pharmaceutical companies. Dr. Wagner is, however, one of those “experts” who advocate labeling children who exhibit behavior problems with what I believe to be phony brain diseases like ADHD and then drugging them.

We know that true bipolar disorder is a real brain disease that has a significant genetic component. Earlier studies indicated that if you have a bipolar parent, your odds of developing the disorder are 5 to 10 times higher than the general population. Since the prevalence in the general population is about 1 percent, that means you have a five to ten percent chance of developing the disorder yourself. True bipolar disorder usually manifests itself in the late teens or early 20’s, most frequently with a depressive rather than a manic episode. Although rare, I saw one patient who had his very first manic episode in his 80’s!

Doctor Wagner wrote a column about a study by Birmaher and others (Archives of General Psychiatry 2009, vol. 66, pp 287-296) that allegedly studied the children of bipolar patients. Birmaher’s data is already suspect in my mind because a third of his sample of parents was diagnosed with something called “bipolar II” disorder rather than actual manic-depressive illness. In over thirty years of practice and teaching residents in both the public and private sector in two states, I have seen only two or three patients that actually meet the DSM criteria for this supposedly common disorder, and I suspect that these patients were all just mild cases of Bipolar “I,” because they all responded to lithium.

Bipolar II as described in the literature is said to rarely respond to lithium, most likely because it is not bipolar disorder at all. In my experience, many patients seem to endorse some of the criteria for bipolar II when asked about them by a psychiatrist because they really do not understand what the doctor is getting at. This becomes readily apparent if the doctor follows them closely for an extended period of time. As I discussed in a previous post, many patients with borderline personality disorder are misdiagnosed as bipolar II by doctors who use symptom checklists.

The children in Birmaher’s study, according to Wagner, were studied when they were on average about 12 years old. In truth, we rarely have any idea whether a 12 year old is going to eventually have a manic episode. Yet supposedly 10% of the children in the sample were diagnosed as bipolar! This means that they had to have some version of a manic episode, because you cannot tell if a depressed adolescent will turn out to have bipolar disorder or unipolar depression.

Of this group, the rate of Bipolar I in the children was stated to be about 20% of the supposedly bipolar sample. Some 12 year olds actually do have mania and are psychotic, but they are extremely rare. I doubt that the diagnoses of these young children were accurate. Another hint that the diagnoses might be bull was that about three quarters of the allegedly bipolar children were diagnosed with “bipolar NOS.” NOS means “not otherwise specified,” and is now used by those who believe that any moody, difficult or temperamental child has bipolar disorder. Bipolar NOS can be and often is applied to kids with “mood swings” or even temper tantrums that last for only a few minutes! The authors in the study toss out the “Bipolar NOS” term in the paper as if it were a well-validated and well-accepted psychiatric diagnosis.

The authors of the study claim at the beginning of the article that they evaluated the “family environment” of their subjects, but in the study methodology section of the paper, the only environmental factor mentioned as having been evaluated was the family’s socio-economic status. Nothing was said, of course, about the disciplinary practices of the parents.

Interestingly, the rate of post traumatic stress disorder (PTSD) from physical abuse, sexual abuse, witnessing death, or family violence was significantly higher in the “bipolar” children in the study than in the “normal” controls - 16% versus 3%. Now why would children with a supposedly biogenetic disorder like bipolar disorder have a higher risk of being abused? Could it be that a high percentage of the children in this study who were diagnosed bipolar came from dysfunctional families, and the source of their apparent mood swings was family dysfunction? Many of the parents were diagnosed with bipolar II after all, and could instead have severe personality disorders. Furthermore, family dysfunction has to be pretty severe to lead to clear-cut PTSD in a child, so perhaps the 16% feature was just the tip of the iceberg.

Some who want to explain this all away have argued that bipolar kids, being difficult, often create the very chaos that leads to both child abuse and marital conflict. Parents who are frustrated and cannot agree upon what to do with their child frequently do have angry interchanges, and punishment can get out of control. Talk about blaming the victim! Still, I must admit that it is probably true that a difficult child is somewhat more likely to be “punished” with physical abuse than an easy one. But how do the folks advancing this sort of explanation account for the childhood sexual abuse? How do we blame that on a rambunctious child? “She was driving me crazy, so I raped her.” I don’t think so.