Bad Child Psychology in Schools – How to Make Kids Feel like a Big Burden to Resentful Parents

 

Why aren’t many kids seemingly growing up as maturely as they used to any more? Why are mental health problems and suicidal ideation as well as actually suicides increasing? Why are more and more children losing self confidence and feeling defective? 

In a new book by Abigail Shrier, Bad Therapy: Why the Kids Aren’t Growing up, the author blames the mental health establishment. So does the parenting guru I’ve been reading for years, John Rosemond. And psychologists are indeed a big part of the problem. But both miss an important aspect of the phenomenon.

 

The definition of “traumatized” in children has been expanded beyond all recognition by the profession. In the mental health field, consideration of the effects of adverse childhood experiences have gone back and forth from one extreme to the other: the serious ones at times are almost completely ignored. At other times child abuse was thought to be everywhere. And now trauma is seen as almost any occurrence that makes a kid in the least bit unhappy or stressed. 

I described what has been going on at the college level in my review of the book, The Coddling of the American Mind, with students' reactions to “microaggressions,” and political incorrectnesss being equated with PTSD caused by a terrifying combat experience. 

Nowadays, according to Shrier, kids are seen as being unable to put aside even hurt feelings in order to concentrate on the school work in front of them. Resilience is now seen as “accepting” these “traumas” rather than dealing with them in a potent manner. Personal agency has seemed to have “snuck out the back door.”

 

And 40% of the current, rising generation has received psych treatment versus 26% of gen-X’ers when they were younger. More and more phony psych diagnoses are put on kids, often at the suggestion of teachers. More and more children are afraid to be wrong in school laboratories or to test new ideas for fear of making a mistake. Bullies are being suspended less and less frequently for fear of damaging their self esteem. American children are more likely than others to exaggerate all kinds of risks.

 

For those mental health professionals who do recognize all this as a problem, the usual explanation for why it is happening is that when parents and teachers over-protect and over-pathologize their children, they are preventing them from learning social skills which, it is believed, cannot be “taught” in most cases but must be learned through trial and error. 

If a parent always steps in, or even when parents don’t let their children go out to play or walk to school because they believe that something bad will happen to them, the kids are said to never get the chance to learn those things. As the author also points out, sometimes feeling mildly to moderately anxious or moody can be a good thing since it can motivate kids to evaluate their situation and lead them to take action.

 

Now don’t get me wrong. There is much truth to these assertions. What’s missing, however, is the way this sort of treatment by parents and teachers is interpreted by the children themselves. The children start to see themselves as a big burden to their over-anxious, worrying parents. Not only that, but the parents seem angry about it. I believe that if a child feels like too big a burden to their parents, they may start to think their parents would be better off without them. This could increase their risk of suicide.

 

Why? Because, as I have been arguing for years, children are willing to sacrifice their own best interests in order to stabilize their parents. This is due to the evolutionary force called kin selection. It is not just that kids don’t experiment with new behavior in order to figure out how to, say, respond to a bully. Hell, there are TV shows, YouTube channels, and many other sources for suggestions that they could try out at school. But as long as they feel the need to let their parents take care of them, they are not motivated to become independent. "Enabling" parents lead to co-dependent children.

 

Schrier does allude to this aspect of the process involved here, but it is not clear to me that she truly appreciates the extent of the issue. She does say that kids often feel responsible for their parents, and may feel like a “constant burden to their stricken parents.” She also says that there is nothing scarier to them than parents “overmatched and afraid.” She has also noticed that people who make parenting look exhausting do not seem all that fond of the kids they raised. If an untrained observer like the author can see this, then guess what? So can the children. And they will be induced to make any necessary sacrifice.

Book Review: The Body Keeps the Score by Bissel Van Der Kolk

As I stated in my Review of Nadine Harris’s The Deepest Well, every mental health professional should know that adverse (traumatic) childhood experiences (ACE’s) - especially with parents who are abusive, neglectful, are perpetrators or victims of domestic violence, have multiple partners, or have substance abuse issues - are a major risk factor for children developing many different psychiatric disorders, as well as being a risk factor for a variety of physical illnesses. Yet therapists and psychiatrists often ignore this issue in favor of theories about some sort of genetically-caused, pre-existing brain disorder.

 

In this fascinating book, the author also makes the case for the importance of ACE’s, especially in the case of pediatric psychiatric conditions, by examining the physiological effects of trauma on brain development. There is an extensive literature on this, although most of it neglects the fact that a continued relationship with an abusive or formerly abusive parent is usually continuing in some form throughout much of these patients’ adult life. 

In any event, the author points out that organized psychiatry in 2011 refused to acknowledge that “…childhood adverse experiences lead to substantial developmental disruptions” and added that the idea that it is is “more clinical intuition than research-based fact.” They then added, “There is no known evidence of developmental disruptions that were preceded in time in a causal fashion by any type of trauma syndrome.” (From the American Psychiatric Association rejection of a Developmental Trauma Disorder diagnosis, as quoted in the book).

 

That last part is misleading if not an outright lie. We don’t have high caliber causal evidence on the causes of just about any diagnosis in the DSM. Van Der Kolk has a list of references from an extensive literature on the enduring negative effects of early maltreatment. ACE’s are a major contributor to a variety of psychiatric symptoms that are part and parcel of the genesis of many different psychiatric disorders. Especially the childhood ones like ADHD, conduct disorder, and oppositional defiant disorder, as well as many of the mood and anxiety disorders.

 

This blindness by the psychiatric community has led to what is called “malignant polypharmacy”  – the tendency of some psychiatrists and psychiatric nurse practitioners to confuse symptoms that appear in different forms within a variety of different psychiatric diagnosis as instead being co-morbid (co-occurring) conditions. When I was in practice, I would find new patients who were on several different psych medications – sometimes including both uppers and downers simultaneously – because new drugs were added whenever the practitioner noticed additional, seemingly untreated symptoms. 

Clinicians had misinterpreted these symptoms as being due to their being indicative of other psychiatric disorders that were not being addressed by the existing drug regimen. As the author points out, what was really not being addressed is the underlying issue – the history of abuse.

 

As mentioned, and as with the Deepest Well, this book unfortunately ignores the question of whether brain changes caused by ACE’s are at least partially reversible - were it not for continuing reinforcement of the trauma throughout the lives of the subjects of this literature. This question lurks in many of the book’s case examples and within the literature that the author quotes. 

For example, he talks about a case where a woman continued to blame herself for her father molesting her despite her rational mind knowing full well that this was nonsense. He describes traumatized firefighters who were “desperately trying to protect the system.” As part of a suggestion for criteria for a proposed diagnosis of developmental trauma disorder, he included,  “Intense preoccupation with the safety of the caretaker or other loved ones.” He even describes himself as mistakenly thinking that his own parents no longer had a major influence on him!

 

In the numerous, highly interesting case examples, Van Der Kolk omits mention of whether or not the patient still maintained contact with abusive parents. The closest he comes is a statement on page 210 about a perpetrator "hopefully" not still being around to hurt a traumatized individual.

 

Nonetheless, this well-written and almost entertaining book is a good introduction to the consequences of ACE’s on psychological and brain development, as well as introducing some possible therapeutic ways to treat traumatized patients. Van der Kolk is a master story teller.

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.

The Concept of Resilience - Another Way to Marginalize the Effects of Family Dysfunction on Children?

Some people are just born hardier and tougher than others. Such individuals are better able to process, handle, and bounce back from stress and can handle more of it - on the average - than other people. They are said to be more resilient. No denying it. 

However, it is also true that at least some of any apparent resilience does not come from having been born with a better innate temperament, but results from having had at least one supportive and nurturing adult family member who buoyed up the person's coping skills as a child. Dysfunctional families may contain some of these folks in addition to other adult members who are more, shall we say, problematic. This helps to reduce the adverse consequences created by the latter.

Adverse Childhood Experiences, or ACE's, are clearly shown by a variety of research methodologies to be, overall, the most important risk factors for the development of personality dysfunction (as well as being major risk factors for a wide variety of other health problems). Somehow, however, in reading the personality disorders literature, you might think that defective brains were instead the biggest factor. 

In many previous posts I have discussed several different ways in which this latter idea is falsely argued - such as by looking at how a normal brain processes trauma physiologically and declaring, ex cathedra, that those processes represent some sort of abnormality. I have also discussed one of the major reasons this sleight-of-hand is employed: to avoid holding parents responsible for their problematic parenting and chaotic family interactions. 

It's just not popular to discuss the role of dysfunctional parenting in creating psychological problems in their offspring. The poor dears just cannot take it! Better to blame the victim.

Of course, it is also true that bashing parents and making them feel guiltier, more defensive or angrier than they already do is counterproductive, as doing so often causes them to double down on whatever dysfunctional interactions they had been routinely engaging in previously. Nonetheless, pretending that their behavior has nothing at all to do with their child's problems is just a big fat, ugly lie.

The blog Aces Too High is devoted to discussing the effects of childhood trauma. It usually puts the family environment in the proper perspective in discussing the relative effects of children's inherent, genetic capabilities, the problems their child's innate tendencies present to parents, and the effects on children of ongoing interpersonal trauma and dysfunction.

A recent posting in the ACES blog by Christine Cissy White contains a highly informative and wide-ranging discussion about how vague a concept resilience actually is, as well as about how difficult it is to measure. I recommend reading it. 

She also points out how the concept of resilience can be used as another device for the purpose of blaming the child victims of severe family dysfunction for their predicament and pretending that the parents' behavior is hardly important at all, if not completely irrelevant:

"Many trauma survivors, with experiences that are often minimized, marginalized or medicalized, are often frustrated by what seems like excessive funding for or fascination with resilience. It can seem as though resilience and protective factors can get overemphasized while the prevention and treatment of ACEs ends up sidelined – as though human suffering might be optional if it’s served up with enough resilience." 

Well said.

Do Antidepressants Cause Suicide?

Readers of comments to this blog may have noticed that I have had frequent discussions with readers who question all use of psychiatric medications. They know that I believe (actually I know) that medications can be extremely useful in some properly diagnosed patients with disorders known to respond to the medications who are also monitored for the emergence of side effects.

I have had some interesting conversations on the back channel with people who are absolutely convinced that loved ones committed suicide directly because of having taken an antidepressant. Psychiatrists counter that antidepressants prevent suicide because they treat depression, which is itself - obviously - a cause of suicide.

There is some data that indicates that antidepressants can increase suicidal ideation (but not necessarily completed suicides) in teens and young adults who take antidepressants. So what gives?

Before I answer that, I would like to point out that anti-depressants take two to six weeks to work, and often we have to increase the dose or change drugs which makes this period of time much longer, so people are at risk for suicide because of the underlying depression before the drugs have kicked in. Frequent follow up and a good suicide evaluation usually can prevent tragedy. Also, as I have posted before, there are different types of depression. The less severe type, dysthymia, will often not respond to meds at all, while significant major depression usually does.

But yes, antidepressants per se can indeed cause increased suicidal ideation, suicidal behavior, and completed suicides. However, I believe this only happens in three very specific situations, all of which can be managed by a competent psychiatrist.

The first situation is when a patient develops a side effect known as akisthesia, which is extreme agitation in which a patient can barely sit still. Milder agitation can also be a side effect. Studies clearly show that a mix of depression and anxiety greatly increases the risk for suicide. The psychiatrist can warn patients about this side effect and tell them to call the doctor if it develops. Tranquilizers usually take care of this problem, but some patients must be switched to a different antidepressant, which may or may not cause that particular side effect.

Second, if a patient has bipolar disorder but has not yet had a manic episode or has been misdiagnosed, an antidepressant can unpredictably cause them to switch into mania. Some mania is not characterized by euphoria as it is in most typical mania, but can instead be "dysphoric mania" in which the patients are miserable rather than elated. Suicide risk is high in this condition. Again, family members can be warned to look for signs of this and stop the patient from taking any more antidepressant until the doctor is reached.

Third, in a severe form of depression called melancholia, patients have a lot of clear-cut biological symptoms like thinking in slow motion and having no energy for anything. When treated with an antidepressant, their energy tends to come back well before they felt better subjectively. They suddenly develop the energy to kill themselves whereas before they did not. This is well known to psychiatrists - or should be well known - as a very dangerous time for suicide attempts.

We warn patients and families about this, and tell them to get guns and other possible means of suicide out of the house during this crucial time, as well as to keep an eye on their depressed family members. We are not seeing as much melancholia these days as we used to probably because patients usually get an antidepressant before their illness develops to the point where it is that severe - indirect evidence that the drugs are effective, by the way.

Readers of this blog also know I am highly critical of both pharmaceutical company marketing tactics and "biological" psychiatrists who think that pills can cure every human foible, that psychotherapy is a bunch of bull that has never been validated in randomized controlled studies (totally not true), and who tend to exaggerate the benefits of drugs in those conditions in which they are indicated.

I have not had many comments from these latter type of folk on the blog. So, in the spirit of being an equal opportunity critic, I thought I would post a debate I had on another blog called Medscape with other psychiatrists. Parts of the debate are somewhat technical, so I will put explanatory material in brackets and italics. I am not including every post on this particular thread, but only the ones that I respond to or that respond to me, and I've edited out some comments that are not relevant to the points I am trying to make.

The debate was started by a posting by the blogger, Nassir Ghaemi, MD about the finding that antidepressants may increase suicidal ideation in teens and young adults.

Dr. Ghaemi, MD: ...In reviewing the published FDA meta-analysis [combining the results of several different studies, often using different methodology, and running statistics on the combination] of the randomized clinical trials (RCTs) of antidepressants, [a researcher] summarized the rather clear finding that antidepressants seemed to have an age-dependent effect on suicide risk: In children and young adults below age 25, they increased the risk ...in later adult years they were neutral ...and in middle age and in the elderly they were protective... When all these age groups are summarized, antidepressants have a small protective benefit for suicide ...In all these analyses, suicidality (defined as actual suicide, suicide attempts, or notable increase in suicidal ideation) is being assessed, one should say, rather than completed suicide. There were only 8 suicides in 77382 subjects, though 2 were on placebo and 6 on antidepressant.

Predictors of antidepressant-related suicidality with antidepressants were interesting: Suicide attempts (i.e., actual behavior) were more associated with antidepressants rather than increase in suicidal ideation (thoughts without behavior). Also, non-depressed persons (e.g., studies of antidepressants in other conditions such as anxiety disorders or PTSD) were more likely to be suicidal with antidepressants than those diagnosed with clinical depression (major depressive disorder).

[The researcher] also addressed the common critique that adolescent suicides increased after the FDA warning, which led to a decrease in antidepressant prescriptions in children. He reviewed data showing that suicides per 100,000 population for adolescents occurred at rate of 7.3 in 2003, 8.2 in 2004, 7.6 in 2005, and 7.2 in 2006. The FDA warning came out in 2004, but that increase in suicide rates occurred before the decline in antidepressant prescription rates for adolescents, which happened more in 2005 and 2006, corresponding to a decrease in adolescent suicide rates.

It is a not entirely appealing aspect of our profession that we wish to criticize, but not be criticized: Many of us are critical of the pharmaceutical industry, or of diagnosing mental illnesses like bipolar disorder in children, and yet we react angrily when asked to restrain our use of drugs. Instead, we should think seriously about the clear question arising from these data: Why are antidepressants preventive of suicide in later adulthood, and causative of it in younger age?

MD #1: "Why are antidepressants preventive of suicide in later adulthood, and causative of it in younger age?"
The qualifier there is in RCTs for FDA drug approval. There are many reasons these days why clinical populations are different.

My only criticism of the pharmaceutical industry is that they have not found many safe and effective drugs. I would like to be able to prescribe a mood stabilizer to a bipolar patients where I did not have to warn them that in 20 years there is a small but substantial risk of kidney failure. I would be quite happy to provide psychotherapy alone to bipolar patients if it prevented them from killing themselves or otherwise destroying their lives. In fact, it would be much easier to provide therapy than obsessing about lithium toxicity.

MD #2: It's a peculiar to read criticism of pharmaceutical industry for "not found[ing] many safe and effective drugs" along with favorable (at least the way I read it) mentioning of psychotherapy which failed to provide anything substantial and replicable for suicide prevention whatsoever. While pharmaceutical limitations are measurable and evident, psychotherapeutic shortcomings are hidden behind self-congratulatory process. It's de rigueur in psychiatric narrative nowadays to insert reverences toward "psychotherapy" together with BigPharma admonitions (a form of psychiatric PC, I suppose) without any critique of the former or balanced view about the latter.

The response to the criticism 'why the pharmaceutical industry have not found many safe and effective drugs' is unprecedented, enduring assault on the industry from angry psychoanalysts, greedy selfish government, opportunistic politicians, and many busybodies. I am surprised BigPharma stayed in business this long - there are less vexing ways to make a buck.

Me: What a bizarre conversation! Talking about "drugs" or "psychotherapy" or even "depression" as if they were monolithic entities is insane.

Treating a melancholic depression with any type of psychotherapy is indeed a waste of time, as is treating most cases of dysthymia with just drugs alone.

As to suicide with antidepressants, [I list the clinical situations mentioned earlier in this post].

And of course we need better drugs. With all current antipsychotics, for instance, you get to pick between a significant risk for metabolic syndrome and a significant risk of tardive dyskinesia [a long-term neurological side effect]. What a wonderful choice. And of all the things one can choose to criticize big pharma for, I don't think that problem is one of them.

MD #2: It would be nice if one could comfortably tell one type of depression from another and expect at least half of his colleagues to agree. But your dysphoric mania is another man's agitated depression and the third one's depression with ADHD. And someone else's frontotemporal dementia. Before we start claiming superiority of one treatment over another shouldn't we first sort out the nomenclature?

The irony about "wonderful choice" is misdirected. Consider oncological drugs and their side effects. I don't see oncologists mocking BigPharma. Psychoanalytic/dynamic psychiatrists, OTOH, do. They are still convinced that the world is flat and if you keep moving ahead you can fall from the edge of the earth.

Me: I agree there is a lot of diagnonsense around, but if a psychiatrist can't tell a severely melancholic depression from a typical dysthymia, he or she needs to go back to medical school. While the DSM contains a lot of b.s., much of it is also highly consistent with both clinical presentation and treatment response.

About the "wonderful choice," what I said was that should NOT be blamed on big Pharma. However, if you think big PhARMA science is so honest, perhaps you should read The Truth About the Drug Companies by Marsha Angell, former editor of the New England Journal of Medicine, and see if you still think so. Or check out the Zyprexa marketing documents on FuriousSeasons.com, or the US Justice Department settlements with FIVE different big Pharma companies, available on the DOJ website, for a description of highly misleading and pervasive marketing of psychotropic drugs - including ghostwriting journal articles and paying big name "experts" to sign on as authors. Get your head out of the sand!

By the way, I'm not a psychoanalyst in the least. I agree that old line psychoanalysis was wrong about a lot of stuff, but not everything, and hardly any therapists practice it anymore anyway. I mean, biological psychiatrists have stopped doing insulin shock, so I don't continue to hold that against them now.

MD#2: I see the fine line separating constructive criticism from vilification is permanently erased by critics. Even if we dispense with objectivity, slamming BPharma is plain impractical. We see several leading manufacturers exiting the stage. Another Pyrric victory?

It was refreshing to see your trust in the US DOJ as a pillar of fairness. When thugs put on suits and badges, does it make shake-down palatable? One can grudgingly accept governmental thuggery but applauding would be a bit exuberant, wouldn't it? Any other gov organization in line for blind love and trust? BTW, the data on Zyprexa side effects were available from the get go for anyone who cared to check, but laziness and ignorance of our colleagues found excuses in pharma bashing.

And why shouldn't pharm co's aggressively advertise and market? Are there laws against it?

After descending from planet Utopia to our sinful Earth, maybe misdeed of E Lilly & Co won't look so evil and the US government so white and fluffy.

PS I am curious what entails "not everything" that "old line psychoanalysis were wrong about"? In regard to psychiatry, I mean.

Me: I am not out to vilify the drug companies. We need them. I'm a capitalist myself. I have no objection to marketing if it's even relatively honest. Make your best case. Buy me lunch, even. I don't care. However, the horrendous tactics described in the DOJ agreements go far far beyond that, and they can readily be observed every day at sponsored promotional talks, in regular and throw-away journals, and in DTC advertising. I don't have to make it up. The so-called science behind sponsored clinical trials has become almost comically biased.

You think the government has been too hard on big business? I'd say they're more often partners in crime. We all know that unrestrained big business never does bad things - just look at those paragons of virtue, Enron and BP. And don't big insurance companies always give both patients and us physicians a fair shake?

You're right about the side effects of Zyprexa being (or should have been) common knowledge a long time ago. I actually wasn't concerned about that. What I was concerned about was that, according to the company own memos (which were not even supposed to be released according to the agreement with the "thugish" DOJ, but a journalist got a hold of them), there was a conscious marketing decision to deceive doctors into expanding the definition of bipolar disorder to include any patient who was both anxious and depressed, without regard to any duration criteria, in order to sell more atypicals [expensive brand named anti-psychotic medications].

I have to admit I'm shocked by how many doctors fell for this, but if all you have is medication to offer, everything looks like a brain disease. There's an excellent study by Zimmerman and others that showed that in his sample, 40% of patients who had seen a previous psychiatrist and who clearly met DSM criteria for borderline personality disorder, and who did not even come close to meeting DSM criteria for bipolar disorder, had been diagnosed as bipolar by the previous doctor. Argue with the DSM definitions if you will, and I often do, but I think they got a lot things right.

There's plenty of b.s. in the psychotherapy literature as well. Your question about what is right and wrong about analytic theory would take a book to answer, so I won't even try. What I will say is that any neuroscientist can tell you that the brain is plastic and is literally shaped by interactions with primary attachment figures and other social influences on an ongoing basis. There's a ton of hard science available to back up that assertion.

MD #3: What a profoundly dispiriting exercise reading these comments has been. With one or two exceptions the desire to make a point has created only a painful experience of heat and smoke with precious little light.
Let's face a few facts:

What we don't know is enormous, for all of us. What we don't know we don't know is even greater. Therefore it behoves us all, myself included, to have humility in the face of our ignorance....

I am saddened to see that the arguments which rage for and against Big Pharma, necessary but venal, and psychoanalysis, unpalateable and frequently misused, are just infantile. They each have a place and each have contributed to where we are today. The exciting findings of today in neurophysiology in relation to infant attachment and trauma confirm the prescience of early psychoanalysts, their other failings not withstanding.

The absence of healthy doubt is dangerous. Let's have more doubt.

MD #2: It's unusual to see anyone to be so emotionally perturbed with tepid professional discourse and experience pains while reading opinions different from his/her own. "Let's have more doubts" appeal might work for dogmas (psychoanalytical and others), not for emerging, vibrant, and already highly controversial field like biological psychiatry..

"The exciting findings of today in neurophysiology in relation to infant attachment and trauma", IMO, are not exciting, specific, replicable, practical, and measurable. They serve a purpose, though, - resurrection of fading psychoanalytical orthodoxy. Good luck with that.

Suicide is too serious problem to trifle with psychoanalytic nonsense. There was steady, linear increase in teenage suicide rates for more than half a century during heydays of psychoanalysis in absence of other viable treatments until 1990, when (as some might remember) SSRI’s was introduced. Then, there was a 15 years of suicide decline (first time in recorded history). The decline reversed when first reports of suicidal thoughts related to SSRI treatment initiation emerged in the literature accompanied by sharp decrease in prescriptions

http://www.emaxhealth.com/1/22/24448.html
http://www.sciencedaily.com/releases/2007/09/070907221530.htm
http://www.infoplease.com/ipa/A0779940.html
http://teenadvice.about.com/b/2008/09/05/teen-suicide-rates-growing-in-us.htm
http://www.afsp.org/index.cfm?fuseaction=home.viewpage&page_id=050fea9f-b064-4092-b1135c3a70de1fda

We ought to talk about suicidality (i.e. suicidal thoughts) only in conjunction with discussion about protective role of medications contrasted with measurable (!) impact of other treatment modalities on suicide. Otherwise the discussion turns into fear mongering and emotional plea for "healthy doubt".

Me: No dogmas in biological psychiatry? How about every difference found between diagnostic groups and normals on an fMRI [a brain scan] being automatically labeled as an abnormality when it might instead be a conditioned response or even an adaptation? London taxi drivers have more grey matter in their posterior hypothalamus [part of the more primitive section of the brain] than controls. I suppose that driving a taxi is a disease?

How about the complete ignorance by biological psychiatrists of the vast literature in social psychology, which shows that, given the right environmental context, most people can be induced to do almost anything?

The effect of trauma on the hypothalamic-pituitary axis [the part of the brain that is responsible for regulating the release of stress hormone in the body] not specific or replicable? That's factually incorrect.

I agree that antidepressants, properly prescribed and in patients who are closely followed for the emergence of side effects, do reduce the suicide rate in some patients. Unfortunately they don't work for a significant number of suicidal patients.

Following epidemiological trends is suggestive but proves nothing, however. There are unfortunately almost no drug OR psychotherapy outcome studies that directly involve suicidal patients (for obvious ethical and practical reasons), so I think making overly broad statements about which treatments are most effective in preventing suicide (without regard to the evaluation of the individual patient) is both naive and extremely premature.

MD #2: Let's sort out confusions and contradictions. First paragraph is critical of "every difference found ... on an fMRI being automatically labeled as an abnormality when it might instead be a conditioned response or even an adaptation."

Third paragraph categorically refutes any suggestion that "the effect of trauma on the hippothalamic-pituitary axis" is not specific and replicable.

When a biopsychiatrist finds correlation then it is fatuous, unless it's convenient finding. Then it's alright.

The studies, BTW, found certain degree of ASSOCIATION - not cause-effect relationship, as implied, - between trauma and "dysregulation" (!) of HPA (blunted HPA-axis reactivity ) which was neither indicative nor specific for the type of trauma or associated diagnoses. Similar "dysregulations" were found in physical trauma, chronic disease, maternal undernutrition, substance abuse, and every mental disorder in DSM). It is a nonspecific finding in medicine, akin elevated sed rate, that don't demonstrate, less so proof, anything. There might be confusion btwn HPA studies and hippocampal volume decrease (cell death and cell atrophy )and corresponding increase in amygdala size and activation associated with chronic abbuse (http://www.isps-us.org/koehler/trauma_brain.html)

These studies indeed demonstrated that CHRONIC repetitive trauma in certain (not all) vulnerable individuals might produce anatomical and physiological changes. But these do not explain psychiatric disorders in children who were never abused and lack of mental disorders in many chronically abused.

Some biopsychiatrists my not be familiar, as was suggested, with "vast literature in social psychology" (this particular biopsychiatrist is an exception) but why should they if this literature, as interesting as it might be, has little to do with diagnosis and treatment of debilitating mental disorders. From social psychology viewpoint, hypothalamus and hippocampus are just two Greek words. Biopsychiatrists would disagree.

Another quote: "...given the right environmental context, most people can be induced to do almost anything". Not to develop a psychiatric disorder, they don't.

Now, back to our suicidal patients. It is irresponsible, IMO, not to consider the role of medications in suicide prevention. We may not know to what extent if any medications protect from suicide, but we can convincingly assume that psychoanalysis is as good as useless in these cases.

Me: Good point about my inconsistency on the hypothalamic-pituitary axis example. What I should have said was that this finding was found frequently in, as you say, chronic repetitive trauma, and of course not everyone is genetically susceptible. My bad. This finding has been replicated, however.

There are NO necessary or sufficient "causes" for almost any psychiatric diagnoses, only risk factors. No matter what biological, psychological, or social risk factor you look at, there will always be a lot of people who have a lot of it but don't develop any disorder, and a lot of people who have very little of it that do develop a disorder. And almost all risk factors like child abuse or the short allele of the MAOI [An enzyme that degrades chemicals in the brain] gene are risk factors for any number of different disorders. Totally non-specific.

Looking for necessary or sufficient causes in psychiatry is for the most part a fool's errand, and as statisticians (e.g. Cook & Campbell) will tell you, any study results that suggest otherwise are in most cases presenting a statistical artifact generated by where continuous variables were dichotomized [coded as present or absent].

I would also fault social psychologists who are not aware of biology. If one is going to truly understand human psychology, one needs to include ALL sources of information. Yes, there were horrendous historical mistakes made by the analysts with schizophrenia and autism. There were also horrendous historical mistakes made by the biological psychiatrists - i.e., eugenics [the theory that weaker members of society should be prevented from reproducing or even eliminated to improve the human gene pool]. Brainlessness versus mindlessness, as Eisenberg pointed out.

Not all psychiatric diagnoses are created equal - and many of them are probably not brain diseases in the way schizophrenia is. (and yes, even that dichotomy is simplistic).

I agreed with you, by the way, that NOT considering the role of medication in suicide IS irresponsible.

And please, everyone, quit conflating all psychotherapy with orthodox psychoanalysis. I personally think DBT [dialectical behavior therapy, a type of psychotherapy that does not directly involve psychoanalytic theory or technique] is an incomplete treatment for borderline personality disorder, but replicated randomized controlled studies do show it is quite effective for reducing suicidal and parasuicidal behavior in that population, at least for the first year after therapy. That's more than I can say for almost any drug study you care to look at.

[I did not mean to give myself the last word on purpose; MD #2 never responded to my last post, and it's been over a week].

Attachment: the Latest Dirty Word in Biological Psychiatry

The crowd that wants to substitute the “bio-bio-bio” model for the bio-psycho-social model in psychiatry apparently freaks out if anyone brings up the wealth of studies that look at the effects of attachment behavior and attachment trauma on human behavior.

Attachment phenomena are those interactional variables that are present in the relationship between babies or children with their primary caretakers. These patterns affect the child’s psychological development as well as his or her adult intimate relationships.

Attachment patterns are loosely classified as “secure” or “insecure.” Insecure attachments are further subcategorized as “avoidant/dismissive,” “ambivalent/preoccupied,” or “disorganized.”

Clear evidence ties parental behavior problems and parenting styles with subsequent behavioral and interpersonal relationship problems in their children. Those children with disorganized attachments, for example, become overcome with anxiety, confusion, and paralysis whenever they are involved in intimate relationships. The literature shows that the best predictor of how a mother will bond with her child is the nature of the attachment bond the mother had with her own mother.

At the recent meeting of the American Academy for Child and Adolescent Psychiatry in Hawaii, some of the so-called researchers who have been diagnosing bipolar disorder in young children were presenting their material. Peter Parry, an Australian academic psychiatrist who is, to say the least, highly skeptical about pediatric bipolar, relates the following:

“They had no answer to attachment and trauma. Melissa DelBello, when I asked her about her presentation on neuroimaging in Pediatric Bipolar Disorder (PBD) - which was incredibly detailed and actually quite well put together and I complimented her on that – I said that the findings presented seem to have considerable overlap (a phrase she'd kept using about findings with PBD and ADHD) to the neuroimaging findings presented by Alan Schore etc re attachment trauma.

She initially said she didn't understand my question; after repeating it she twice said that there are some differences with ADHD. I eventually had to again repeat that I wasn’t talking about ADHD - I was talking about the amygdala and right frontal changes she was showing with PBD which they also find in the attachment/developmental trauma literature - at which point she conceded they hadn't looked at that population.”

This interchange is typical of the way some researchers who are overly tied to a pet theory attempt to avoid looking at or talking about any data that would call their theories into question. Usually they just avoid answering any questions that would do this, and subtly change the subject. I admire Dr. Parry’s persistence in not letting her get away with that.