Antipsychotic Medication Used to Dope Up Unhappy Children.

There were two interesting editorials in the September 2015 issue of JAMA Psychiatry, a journal that used to be called the Archives of General Psychiatry and which is published by the American Medical Association. On the surface, the articles seem to address completely unrelated subjects, but on closer inspection, they both involve a common theme.

The first one is entitled "Antipsychotic Use in Youth Without Psychosis: a Double Edged Sword." I have of course railed in many of my blog posts about the use of antipsychotic medication for patients who do not have psychosis, because these agents can have serious drawbacks, and because better alternatives exist. In many cases, the better alternative is psychotherapy that can help the anxiety and mood symptoms that used to considered to be part and parcel of, and caused by, neurosis - behavioral disorders based both on internal ambivalence about one's life choices as well as interpersonal conflicts.

I have been particularly critical of the use of antipsychotic drugs in children who are almost never actually psychotic, and who are being diagnosed with bipolar disorder when they are in fact just misbehaving because of stress and family discord. As the JAMA Psychiatry editorial points out, the long term effects on the brains of developing children of antipsychotic drugs are unknown, although changes in the density of neurons have been observed.

The editorial mentions recent statistics that really do prove that the medications are being used in children primarily to shut them up. I quote: "All signs suggest that [antipsychotic medication use] among children is chiefly in those with aggression and behavioral dyscontrol, ADHD, and disruptive behavior disorders, but not for those with psychosis, bipolar mania, Tourette's Syndrome, or autism spectrum disorders." They are also being combined more and more with stimulants. 

Repeat after me, "Uppers and downers, and bears, oh my!"

Fewer than 25% of the young people in this study had any recorded psychotherapy of any kind. 

These drugs are effective for aggressive behavior - but not because they are specific for that problem, but because they are sedating and at times mind-numbing - as a side effect. Heroin would probably work just as well! After longer term use, however, the sedation side effect diminishes, so the drugs don't seem to work as well any more, which is when second and even third drugs are added.

The second editorial is titled, "Why Are Children Who Exhibit Psychopathology at High Risk for Psychopathology and Dysfunction in Adulthood?" Somebody actually did a study about this question, which should be high on my all time list of studies appropriate for the journals Duh! and No Shit, Sherlock. The study wasted time and money actually investigating the question of whether or not the proposition in question was even true. Turns out it was. Surprise!

Gee, childhood conduct disorder predicted antisocial tendencies. Who'd'a thunk? However, behavior problems in childhood predicted a wide range of different mental disorders, and was therefore a non-specific risk factor for a whole host of problems. 

Even less surprising, "a subthreshold or threshold mental disorder at some time from late childhood through adolescence predicts lower levels of adaptive functioning." So poorly functioning children become poorly functioning adults. I wonder why?

Actually, the question of why childhood behavior problems are non specific in being risk factors for various other psychiatric disorders is addressed in the editorial, and this part is where this editorial touches on the issues addressed by the other editorial discussed above. Three possible "causes" of why disturbed children become dysfunctional adults are listed. 

While there is some truth to the possibilities, which are not mutually exclusive by any means, it is simply amazing to me how the editorial author studiously avoids any clear-cut mention of ongoing family dysfunction as the culprit.

Family dysfunction is often chronic and ongoing and is rather widespread in our culture. To name just a few: parental drug abuse, divorces with multiple lovers coming and going and/or with children being passed around to different relatives, child abuse (physical, sexual, psychological), domestic violence, parenting issues (parents leaving children unattended or neglected for long periods, putting childcare entirely on the backs of older siblings, catering to children's every whim, invalidation, screaming and yelling, undermining the disciplinary efforts of one another), parents having multiple affairs, bad mouthing the other parent in front of the children and enlisting them as allies (triangulation), and general chaos at home. Is the author of the editorial really saying that none of these problems might explain the connection between childhood and adult psychiatric problems? Is that their argument?

If you don't believe that these patterns are common, I have two words for you: country music.

The closest the author of the editorial comes to this issue is reason #3. But notice the wording: ongoing instability is mentioned, but mostly things like poverty and living in bad neighborhoods. The nearest thing to family dysfunction that is mentioned is "lack of stable social support." Vague enough for you?

In reason #1, the authors seem to be blaming the child for the problems of the adults, rather than the other way around! They say, "exhibiting the behaviors that define conduct disorder in childhood may alienate peers and family."

Which do you think is more powerful and important: adults' behavior negatively impacting children, or children's behavior negatively impacting adults? This reminds me of a speaker touting Adderall at a grand rounds in our department who said, "If you had kids with ADHD, you might drink too much too!" In other words, he was saying that rambunctious children are a cause of alcoholism.

In reason #2, the authors do refer to environmental factors, but over-emphasize early ones. I guess the authors think either than family dysfunction ceases miraculously by virtue of a child turning 18, or that adults are not affected much any more at all by what their family members are doing to and with them. Sorry, but those assumptions are just plain nuts.

Before I quote what they listed as the three reasons, what is the connection I am implying to the issue of antipsychotic use in kids? It is this: instead of recommending family therapy, the doctors are just drugging the kids who act out in response to these problems.

Anyway, here are the reasons as they described:

1. Child psychopathology and adult psychopathology could have different causes, but experiencing mental health problems in childhood may directly or indirectly increase the risk for adult psychopathology. For example, exhibiting the behaviors that define conduct disorder in childhood may alienate peers and family, lead to curtailed education and incarceration, and increase the risk of brain and spinal cord injuries. In turn, these adverse consequences of childhood conduct disorder may place the individual at increased risk for later psychopathology and compromised adaptive functioning during adulthood.

2. It is possible that some or all of the causes of psychopathology across the life span operate early in life. That is, childhood psychopathology could predict psychopathology and compromised functioning in adulthood because they are both influenced by at least some of the same genetic and early environmental factors. Although there may also be later age specific causal influences, such enduring effects of early causal influences would foster the observed predictive association. At the level of mechanism, child and adult psychopathology would at least partly share atypical functioning in the same neurobiological processes in this case.

3. The predictive association between child psychopathology and adult psychopathology could reflect chronic or intermittent exposures to conditions that give rise to psychopathology when encountered across a life span. For example, psychopathology at all ages may be fostered by chronic economic instability, pollution, living in disorganized and violent neighborhoods, and lack of stable social support. To the extent that these causal environmental factors are stable across a person’s life, childhood psychopathology would reliably predict adult psychopathology even in the absence of a shared causal or mechanistic link between them. 

How to Fail at Family Problem Solving

In prior posts, I have discussed what I call the principle of opposite behaviors as it applies to repetitive behavior in personality disorders as well as in recurring dysfunctional family behavior. It is related to an idea that I call the net effect of behavior: that if someone always gets the same results from their actions, and they keep doing it anyway, then the result they get is the result they are trying to get.

The principle of opposite behaviors applies in those cases in which someone repeatedly does the exact opposite of what another person is doing, yet repeatedly gets the same results anyway. Or those cases in which a person goes from one extreme to the other, and still always ends up in the same place.  Prior examples discussed in this blog: Parents who let their kids do anything they want versus those who try to control their every move; those who never ask anyone for anything versus those who ask people for the moon.

This post is about how the principle of opposites applies to metacommunication — family members discussing both their mutual interactions and the family dynamics over several generations. As readers of this blog know, I believe that doing so is the most effective way to solve problems and put a stop to ongoing dysfunctional interactions which trigger psychological symptoms and troublesome behavior. It is the "curative" part of my psychotherapy, which I call Unified Therapy.

When I discuss this idea on either this blog or on my blog on Psychology Today, I am usually besieged with comments saying that readers have tried this and it just doesn't work, or that I cannot appreciate that their family members are totally incapable of stopping abusive, distancing, or other provocative behavior.

I always reply that I do not blame anyone for not believing what I say about how metacommunication is both possible and effective in any family in which members are not fragrantly psychotic or a victim of brain damage or Alzheimer's disease. In fact, when I first broach this ideas with my own psychotherapy patients, I frequently get this response. Patients tell me that I couldn't possibly know how impossible their particular family can be.

Oh, but I do. In fact, I've almost always seen families that are far worse. And it is true, I add, that metacommunication done poorly can make a family problem even worse. Then I go on to say that doing it well is extremely difficult and that if it were easy, the patients would have already done it. 

In order to do it well, they have to become aware of things about their family and its members that they could not possibly have known before. Last, every family is different, so I can't just tell them right off how to proceed. Therapy is a complex process by which the right interventions are devised prior to any actual attempts at implementing them.

So why do folks who have tried to talk about family issues get into trouble? Well, again, every family is different, but we can discuss some general issues. It is much easier to talk about what does not work than trying to predict what will work in a given family or with a given relative. 

For this post, I invoke the principle of opposite behaviors: talking too much about something— especially if one always goes about it in the same way—is as futile as not talking about it at all. In either event, nothing gets resolved.

Obviously, trying to ignore an issue might work for a short time, but the issue will continue to hang over the heads of the participants like the proverbial Sword of Damocles, and things will eventually blow up. Or there will be an emotional cutoff in which family members try to divorce one another. But even that does not prevent the issues from continuing to contaminate the participants' other relationships, particularly between them and their lovers and children.

So what "doesn't work?" Here is a short list: blaming, accusing, and saying some variant of "You're bad (or evil, or stupid)," "You hate me," or "You did this to me." Getting angry rather than trying to hear the other person out, and/or becoming defensive rather than being thoughtful about what might be the kernal of truth in what the other person is saying. Not giving the other person the benefit of the doubt no matter what they say.

Another big one is invalidation. There are several variants of this. One of the most obvious is denial of events such as child abuse when both parties to the conversation know very well what happened. 

Telling the other person what they are feeling rather than asking them what they are feeling is another well known example.

A less well-known pattern is when each party is so keen on making their own points that they do not address the points that the other person is making at all. They steamroll any exchange by talking over each other, by completely ignoring what the other person has said in response to something they said, or through other ways of refusing to acknowledge the other person's point of view at all as they continue to make their own additional points.

Interestingly, people talking about a family problem can move on to discuss a related issue without ever having come to any agreement on the initial issue that was broached - so that neither of the issues is addressed fully. Sometimes people make a big circle, bringing up one related or tangential issue after another without achieving any resolution of any one of them, and then at long last returning to the initial issue. And then starting the whole circle all over again from the beginning!

Last is the best illustration of how talking too much leads to the same results as talking too little. After achieving some resolution of an issue, the parties continue to bicker incessantly about it, refusing to drop it even though, if they followed up on their initial plans, the problem would have been solved. In a commonly discussed example, some members of couples are well known for repeatedly bringing up an old grievance even decades after the problematic event took place.

There are a lot of ways to fail.

Book Review: Madness and Memory by Stanley B. Prusiner, M.D.

I thought I'd take a short break from the main themes of this blog to focus on another subject on which I have been working (getting together an edited volume by multiple contributors): How scientists may block important, transformative ideas from gaining prominence because of group biases and prejudices. 

I will review the book Madness and Memory, which is an amazing first-person account of the trials and tribulations of one scientist who somehow managed to keep getting his research funded, and who continuously did very careful studies despite mass skepticism about his discoveries from other scientists as well as from the lay press.

Strangely enough, the skepticism from infectious disease doctors, particularly those who specialize in viruses, continued even after the scientist, author Stanley Prusiner, was awarded the Nobel Prize in medicine for his work!

In this case, I do understand the reasons for the skepticism. Dr. P. discovered an entirely new form of seemingly self-reproducing infectious agent that did not contain either DNA or RNA. These nucleic acids were reasonably thought by almost all biologists to be required for any biological agent to reproduce itself. The new agents are called prions (pree-ons), and consist entirely of proteins. 

They are the definite cause of some obscure neurological degenerative diseases such as Kuru, Scrapie, and Creutzfeld-Jakob disease. (In medical school I knew it as Jakob-Creutzfeld disease - the name reversal has a rather silly story which the author relates in his book. Despite the ramblings of memory "expert" Elizabeth Lofton, my memory that the name had been different when I was in medical school 45 years ago was entirely accurate).

You may also have heard of another important prion-caused entity, dubbed by the press as "mad cow disease." People could get it from eating meat from infected cattle.

Most importantly, prions are quite likely the cause of the more common types of neurodegenerative disorders: Parkinson's Disease, Lewy Body Demetia, and Alzheimer's.

As best as I can understand prions from the descriptions in the book, they are once-normal proteins that had been encoded, as one might expect, by chromosomal DNA in various organisms, but which somehow later changed shape and became almost more of a toxin than an infectious agent. The altered proteins then somehow lead to a chain reaction in which other normal proteins of the same chemical makeup change shape as well, and therefore seem to multiply. 

Tissue with the prions can then be transferred to another organism and then start to destroy the nervous systems in the new beast over extended periods of time. The time before animals become symptomatic can be years. (Before it was found that prions contained no DNA or RNA, these diseases were assumed to be caused by a "slow virus"). It is this property, I surmise, that makes them "infectious."

The fact that Prusiner did not get discouraged when he was being attacked by all sides is very impressive. His networking skills must have been substantial, as every time someone threw a road block in the way of his research, he was able to find someone else who could provide him with an alternative. 

He would literally call up the editors of the most prestigious journals like Cell and Science and discuss his research results before even submitting an article for publication. (When I was an academic, I had no idea that you could even do that! And I probably wouldn't have gotten away with it anyway). He was also able to manage to find help from academics in several seemingly unrelated disciplines who would be key in his discoveries.

At least he didn't have to worry about the privacy rights of his rats and hamsters. Psychiatrists like me who work with subtle and pretext-laden human interactions have to be concerned about that.

The pressures he faced were enormous. In academia, if you don't get enough publications, you don't get tenure, and if you don't get tenure, you no longer have a job. You also live in constant fear that some other scientist somewhere else will beat you to a confirming experiment and publish it before you do, or that someone else will make a discovery that will bring your ideas into question ("A few pages in a reputable journal can render another scientist's years of toil virtually worthless"). 

You get feedback from "peer reviewers" of your submitted work than can be absolutely vicious. Dr. P. had to suddenly find new places to house his rodents due to concerns about animal rights activists who were more concerned with rats than people. The press, always looking for a sexy story, quoted his critics to publicly attack him.

I am envious of anyone like Dr. Pruisner who was so skillful at negotiating academic politics, because I was not. I unfortunately had minimal guidance from those around me. I found it impossible to get funding for researching the phenomena that I was witnessing first hand every day in my practice with my patients with personality disorders and their families, and which only one other author was even writing about. 

Prusiner quotes someone named Maurice Maeterlinck about this type of problem: "At every crossway on the road that leads to the future, tradition has placed, against each of us, then thousand men to guard the past."

He also quotes Hilary Koprowski on the "Four stages of adopting a new idea:"

1. "It's impossible, it's nonsense, don't waste my time."

2. "Maybe it's possible, but it's week and uninteresting. It's clearly not  important."

3. "It's true and I told you so. I always said it was a good idea.

4. "I thought of it first."

For anyone interested in understanding what doing science is really like, and what scientists can be up against, I recommend this book.

More Great Quotable Quotes from People Who Agree with Me About Stuff

Today's post is the second of a series of two containing some of my favorite recent quotes that center around themes discussed in this blog. 

As mentioned, I have been collecting the quotes and putting them on my Facebook fan page at http://www.facebook.com/pages/David-M-Allen-MD/80658565761?fref=ts. The ones posted here started in January of 2014, and are loosely organized by topic. 

Family Dysfunction

"Taking responsibility for something and self-blame are horses of two entirely different colors. The former is empowering; the latter is paralyzing." ~ John Rosemond, Ph.D

Chronic Mental Illness

Our prison population is bigger than Slovenia
Cause we put people in jail instead of treating schizophrenia 
        ~ John Oliver

On trying to find the cause of schizophrenia: "30 wasted years of looking for bad mothers followed by 30 wasted years looking for bad genes." ~ E. Fuller Torrey, M.D.

Psychiatric Practice, Electronic Medical Records, and Managed Care

"The shift from benzodiazepines [for anxiety disorders] to antidepressants is one of the most spectacular achievements of propaganda in psychiatry." ~ Giovanni Fava, M.D., clinical professor of psychiatry at SUNY in Buffalo.

"You're complaining about a Freudian slip? Freud should be able to wear whatever he wants." ~ Tony Kreitzberg

"Why would anyone want to teach me to tolerate my pain? My only interest is in removing it!” ~ Cynthia Mueller, a blog reader, when first exposed to the DBT treatment model for borderline personality disorder.

"Methadone and Buprenorphine [suboxone] should be our first line opiates for use in the treatment of severe acute pain. That way, if patients become addicted to them, they would already be taking the appropriate treatment for their addiction!" ~ Steven A. King, M.D.

"The current EHR has destroyed the narrative, especially in psychiatry, and converted the basis of care to a checklist." ~ George Dawson, M.D.

"It's not just about doing the right thing for your patients, it's about proving to someone else that you've done the right thing, and sometimes "I can't quite remember if I'm an underpaid physician or an overpaid data entry clerk!" ~ Dr. J.D., Family physician.

"The proving [that I did right by a patient] takes longer than the doing." Chrisitine Sinsky, M.D.

"You don't need any research to show that if you are cycling people with serious mental illnesses in and out of short stay psychiatric units in 3 - 5 days and basing their stay there on whether or not they are "dangerous" and using treatments that take weeks to work that by definition you are appearing to treat many more patients but providing adequate treatment to very few. You don't need any research to show that when you shift mental health care from psychiatric units run by psychiatrists to county jails that the outcomes will be worse. You don't need any research to show that when people do not get research-based psychotherapies in the manner that they were designed and instead get a few crisis oriented sessions that do not address their basic problems that outcomes cannot hope to be better. When your attitude is that all mental health treatment can proceed by treating common problems with definite social etiologies with medications as fast as possible and not having an intelligent conversation or working alliance with the person affected - it is logical that treatment outcomes will not improve. Treatment outcomes do not improve if you do not provide effective treatment and that is the mental health landscape at this time." ~ George Dawson, M.D.

"I don’t know if anyone has ever not tensed at being told to relax." ~ Carolyn Hax

"Health care systems that allow patients to rate their doctors on satisfaction ratings without considering that patients might be dissatisfied with reality should be held to task." ~ George Dawson, M.D.

"You want a tale of two cities...look how the financial services industry has captured regulation to their advantage vs. how doctors have been battered by regulation. But it's based on the mind-set of Goldman Sachs vs. the mindset of the family practitioner...who politically shows up for a gunfight with a butter knife." ~ James O'Brien, M.D.

"Managed care has done an expert job of cost shifting by developing business friendly treatment criteria, abandoning the social and community mission of treating difficult problems associated with mental illness and addiction, and removing the element of humanism from psychiatric treatment. When I first started to practice, discharging people from a hospital when a psychiatrist had serious concerns about whether or not they could make it or whether they would be safe was very uncommon. Today those discharges are the rule rather than the exception largely due to the imaginary dangerousness criteria. "~ George Dawson, M.D.

Drug War

"When we talk about marijuana as a gateway drug, we have to remember that the last three occupants of the White House have smoked marijuana. We can very well say marijuana is a gateway drug to the White House” ~ Carl Hart, Ph.D

Psychiatric Diagnosis

"Then there’s the matter of testing a child to determine if he has ADHD. The plain fact is that none of the published diagnostic criteria depend upon test results. They refer to behavior, period." ~ John Rosemond, Ph.D.

"A [mental] disorder does not operate with [social environmental] discrimination. If something was “wrong” with [your child], she would be obnoxious in front of friends, their parents, teachers, and the people in white coats who came to take her away (tra la, for those who appreciate the reference)."
~ John Rosemond, Ph.D.        

            ("Actually, "Ha Ha" and not "Tra La" ~ Napoleon XIV)

A reader writes that her friends 'recently spent around $300 on their daughter’s birthday party—her first. They bought lots of stuff to entertain their young guests and extended family. The child, a baby, obviously had no clue what was going on. I should mention that the parents are struggling to make ends meet.' As my readers know or should know, I am a psychologist. That qualifies me to determine and assign psychological diagnoses. As such, it seems obvious to me that these parents suffer from a now-commonplace parenting malady known as just plain nuts." ~ John Rosemond, Ph.D.

"One symptom does not make a diagnosis " ~ John Rosemond, Ph.D.

"Test anxiety is frequently not an aberrant psychological response - it is instead the normal anxiety anyone would feel in facing a situation for which they were inadequately prepared." ~ Barbara Oakley, Ph.D.

"Under the influence of intense affects, EVERYBODY becomes an idiot."~ Otto Kernberg, M.D.

"Only in America does 'gotta' substitute for 'wanna' so we can avoid the guilt. " ~ The Last Psychiatrist

ADHD

"An often trivialized cause of irritability, difficulty concentrating, reduced vigilance, distractibility, decreased motivation, lack of energy,and disturbed mood: insufficient sleep syndrome. People with this syndrome, common in our 24 hour society, intentionally curtail sleep for work, social, family, or other reasons. According to the International Classification of Sleep Disorders, a practical and effective remedy does exist: more sleep." ~ Psychiatric News.

"The maps of child obesity in the U.S. look suspiciously like those of the ADHD epidemic, with the highest rates in the deep South." ~ Psycritic

"It’s truly surprising how many parents have been told that if their child did not have ADHD the child would not respond to stimulant drugs. In the blitzkrieg of World War II, German bomber pilots took a stimulant drug with a chemical structure similar to that of Adderall. When the American military discovered how much the stimulants helped German pilots, they put stimulants in the kit of every American and British bomber pilot to improve their concentration and alertness on long-haul missions. Surely not all these pilots had ADHD." ~ Marilyn Wedge, Ph.D.

"...after taking the [drug company-designed screening] ADHD quiz, I've realized that both I and my cat have the dreaded disease. I'm off to get us both the treatment we need." ~ Anonymous comment on one of my blog posts.

Evolutionary Psychology

"Selfishness beats altruism within groups. Altruistic groups beat selfish groups. All else is commentary." ~ David Sloan Wilson, Ph.D.

"We mammals are curiously preoccupied with social hierarchy. You may say you don’t care about status, but if you filled a room with people who said that, they’d soon form a hierarchy based on how anti-status each person claims to be." ~ Loretta Breuning, Ph.D.

Some Great Quotable Quotes from People Who Agree with Me About Stuff - Part I

Some people just naturally have a way with words, and succinctly summarize ideas using comments that I wish I had come up with. 

Today's post, the first of a series of two, contains some of my favorite recent quotes that center around themes discussed in this blog. Many of them come from three of my favorite sources of great quotes: advice columnist Carolyn Hax, parenting advisor John Rosemond, and fellow blogger George Dawson.

Of course, the authors of these quotes and I do not agree about many other things, but so what?

I have been collecting the quotes and putting them on my Facebook fan page at http://www.facebook.com/pages/David-M-Allen-MD/80658565761?fref=ts. The ones contained in this post and the next started in January of 2014, and are loosely organized by topic.

You may find a hidden joke or two among the mayhem.

Psychiatric and Psychotherapy Research

"A significant p value does not specify the probability that the same result can be reproduced in another study." ~ Prof. Gerd Gigerenzer, Max Planck Institute for Human Development.

"If being cited [as a reference in another published study] meant being read, citation statistics might well be a useful criterion. Yet a study estimated that of the articles cited, only 20% had actually been read... For instance, the most important publication in 20th-century biology, Watson and Crick’s paper on the double helix, was rarely cited in the first 10 years after its publication. Innovative ideas take time to be appreciated."
       ~ Prof. Gerd Gigerenzer

It's all in how you look at it, Department:

Medscape News Story about a Study: "Individuals with a neurotic personality type may have reduced brain plasticity during the performance of working memory tasks that may affect their ability to store memories, say US researchers in findings that show the opposite effect in people with a conscientious personality."

         Said one commenter in response: "It is nice to have documentation what those of us who have hired office help have known for years. Personnel with personal problems that occupies their minds continuously are unable to perform satisfactorily in the office."

" I have lost count of the number of papers [that "study" what is supposed to be major depressive disorder] I have read where the depression rating scores were what I consider to be low to trivial." ~ George Dawson, M.D.

In a PTSD study comparing CBT to psychodynamic therapy: "The so-called psychodynamic therapists were also forbidden to discuss the trauma that brought the patient to treatment. Imagine that—you come to treatment for PTSD because you have experienced a traumatic event, and your therapist is forbidden from discussing it with you. When patients brought up the trauma, the therapists were instructed to change the topic." ~ Jonathan Shedler, Ph.D. 

"Evidence based data' is suggestive but typically based on group data, hence only suggestive when working with a single patient. Other sources of suggestions are also available." ~ Thad Harshbarger, Ph.D.  

"The notion that biological changes going on during early adolescence predispose the young teen to all manner of difficult behavior is a myth belied historically, cross-culturally, and by the fact that plenty of young teens are respectful, obedient, and hard-working. That last fact is conclusive evidence to the effect that despite hype to the contrary, there are no changes going on in the young adolescent brain that make inevitable any sort of problematic behavior." ~ John Rosemond, Ph.D.

"When every study reported by a particular group of researchers just happens to reinforce their shared belief system, it makes me skeptical." ~ Loretta Graziano Breuning, Ph.D. 
         Are you listening, CBT and bipolar II researchers?

"Neuroscientist: someone who knows how little we know about the brain." ~ Neuroskeptic

“Maybe sometimes it’s the questions that are biased, not the answers,” ~ John Ioannidis, Ph.D., on bias in medical research - for example,drug companies comparing their new drugs against those already known to be inferior to others on the market.

"Blaming personality disorders on brain pathology due to bad genes is like "blaming badly written software on the hardware." ~ "SwissCheese," who commented on a post on my Psychology Today blog and says he's a computer scientist married to someone with borderline personality disorder.

"The NIMH devotes almost all of its enormous research budget to glamorous, but very long shot, biological research that over the past four decades has contributed exactly nothing to the treatment and lives of the severely [mentally] ill." ~ Allen Frances, M.D.

"The trial result generally depends on rating scale or clinician global rating scale results that grossly oversimplify the condition and measure parameters that are irrelevant in clinical settings. The best example I can think of is depression rating scales that list DSM criteria for depression and then apply a Likert dimension to those symptoms. In clinical practice it is common to see hundreds of patients with the same score on this scale who have a full spectrum of disability from absolutely none to totally disabled. Which population might be more likely to exhibit an antidepressant effect? " ~ Richard Dawson, M.D.

"Published' and ‘true' are not synonyms" ~ Brian Nosek, Ph.D., a psychology professor at the University of Virginia in Charlottesville

"Laboratory studies of social attention have largely focused on the extraction of social information from images (e.g., photos and videos). However, in the natural world attending to real people involves both the reading of social cues and the sending of social signals. ... the influence of another individual on human behaviour is so pronounced that the implied social presence of another person is enough to have a profound effect on where people look, what they say and do, and even modify their willingness to cheat or to engage in prosocial behaviours." ~ Alan Kingstone, Ph.D.

"The hypothalamus is involved in the body's centrally important "Four F's:" fight, flight, feeding, and sex." ~ Otto Kernberg, M.D.

"No man should escape our universities without knowing how little he knows." ~ J. Robert Oppenheimer

"The biggest misconception here seems to be that patients are accurate reporters and they have no unconscious agenda." ~ George Dawson, M.D.

Relationships

"No one can help you if you’d rather be safe than brave.” ~ Carolyn Hax

"Hiding how you feel is how love dies. You think he backed the wrong horse here? Then say so. A grown-up won’t make you pay." ~ Carolyn Hax

"You want a spouse who wants to meet your needs, as part of a commitment to mutual support." ~ Carolyn Hax

What to say to a spouse who refuses to see a marriage counselor when you request it, because he or she doesn't have a problem, it's all just you: "But you do have a problem: Your marriage is in trouble." ~ Annie's Mailbox

"You either aren’t up to this challenge or you don’t want to be, and that’s all you need to know, because choosing a life partner isn’t about being open-minded or fair or noble. It isn’t just about loving or being in love, either. It’s about an unflinching estimation of what works." ~ Carolyn Hax

"One problem that recurs more and more frequently these days, in books and plays and movies, is the inability of people to communicate with the people they love: husbands and wives who can't communicate, children who can't communicate with their parents, and so on. And the characters in these books and plays and so on, and in real life, I might add, spend hours bemoaning the fact that they can't communicate. I feel that if a person can't communicate, the very least he can do is to shut up." ~ Tom Lehrer

"If people are determined to be insulted, they will find a way to be insulted." ~ Amy Dickinson

Parenting

"An adult who enters into a power struggle with a child is no longer acting like an authority figure; therefore, the only person with any power in an adult-child power struggle is the child." ~ John Rosemond, Ph.D.

Letter to advice columnist Carolyn Hax: I am happy he is sharing his interests (in rap music) with me and I have explained to him my perspective that the material makes me uneasy for all of the above reasons. His interest continues unabated. Do I set certain limits on what he can listen to (he is 14) or do I just let it be and hope he grows out of it?

          Ms. Hax's answer: You omitted (c) Raise him, then trust him, to be one of the millions of people who are able to distinguish between an art form and an instruction manual for the treatment of others.

"I, too, am skeptical of the 'Oh you’ll love them when they’re yours' line. Some people regret having kids and just know they can’t say that out loud, and I’d wager there’s a bigger population who don’t even let themselves think that." ~ Carolyn Hax

"Helicopter parenting now seems to have blossumed into Apache Blackhawk parenting." - John Rosemond, Ph.D.

"Parents help their kids with homework, often downright doing it for them; they help their kids study for tests; and they demand of educators that their kids’ school experience be immaculate. I don’t believe that pouring more money into education has worked or is going to work, but I do believe that teachers should be duly compensated for putting up with this garbage. " ~ John Rosemond, Ph.D.

"Parents who are not on the same parenting page will not get on the same page by regarding and treating their differences as a parenting problem. It's a marital problem." ~ John Rosemond, Ph.D.

To be continued.....

A New Kind of Twin Study and the Heritability Fraud

In my post on Psychology Today, "Scientific Fraud in the Nature versus Nurture Debate," I discussed the disturbing tendency of psychiatric researchers to use the term heritability as a synonym for genetic, which it certainly is not. The heritability statistic is a measure of phenotype, not genotype, meaning it is a measure of the final outcome of the influence of the interactions between genes and the environment on such things as certain personality characteristics or psychiatric symptoms.

The statistic is derived from twin studies in which fraternal and identical twins who were raised together are compared to each other and to those raised apart on various traits. It is not a measure of purely genetic influences but instead a measure of a mix of purely genetic influences plus gene-environment interactional influences. 

There is no way to tell how much of each is present in the statistic. The determination of heritability can also be manipulated in a number of ways, such as by setting the bar for saying that a symptom is present or absent at different levels.

Interestingly, a recent study employing a very different type of twin study has been getting a fair amount of press (Thalia C. Eley, Tom A. McAdams, Fruhling V. Rijsdijk, et. al., "The Intergenerational Transmission of Anxiety: A Children-of-Twins Study," American Journal of Psychiatry, 172 [7], pp. 630-637, 2015).

Rather than comparing twins with each other, the authors compared the children of twins with one another. The subjects were anxiety and a dimension of normal personality known as neuroticism - a measure of emotional reactivity. People with higher neuroticism scores tend to get more anxious and/or depressed in reaction to negative environmental stimuli, and remain dysregulated longer, than those with lower scores.

By comparing the extent to which correlations between children and their twin uncle/aunt (avuncular correlations) differ for monozygotic (identical) and dizygotic (fraternal) twin families, the authors were able to infer the extent to which genetic and environmental factors influence transmission from one generation to another. Children share a greater level of genetic influence with their uncle/aunt when in monozygotic families than when in dizygotic families.

Thus, if children resemble their uncle/aunt to a greater extent in monozygotic families than in dizygotic families, this implies a genetic influence on transmission of the trait of interest. In contrast, if these two sets of correlations are similar, and are significantly lower than the parent-child correlations, this is indicative of an environmental mode of transmission.

The results of the new study showed almost the opposite of the usual results of heritability studies on neuroticism: environmental factors came out very much more important than genetic ones! Living with one's parents was found to be far more influential than merely inheriting 50% of their genes.

It appeared that children and adolescents learned anxious behavior from their parents rather than inheriting a tendency towards it from their parents genetically.

Now, I must say that the authors used a statistical technique to come to their conclusion called "structural equation modeling"—of which I know absolutely nothing. So I am not able to say if the methodological techniques used in traditional twin studies yield more accurate results than those found in this type of study. This may, in fact, be a case of scientists being able to get the results they want to get through statistical manipulation of their study data.

And surely neuroticism must have some significant genetic component. Clearly, some people are naturally more high strung than others.

Nonetheless, I do know from the observation of blatantly obvious behavioral patterns within families and other social groups that anxiety can be highly contagious. Since as of now mental health professionals can't fix your genes but we can fix your relationships, I know on which factors therapists should focus the majority of their attention.

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.

Dr. Allen's Second Book Back in Print

My second book, Deciphering Motivation in Psychotherapy (which was originally going to be titled Ulterior Motives) is now available in paperback at a reasonable price on Amazon for the first time. It is actually my favorite of the ones I've written, but by far the least read.

It was out of print for a time, and then back out but at a ridiculous price. (A different publisher had bought out the original publisher, then re-published the book without even letting me know!)

It was meant for therapists but is written so lay people can understand it.

This book explains some basics about the theory behind Unified Therapy, including the core concept of dialectic causality.

The main topic is the use of language in dysfunctional family interactions, and how the true intentions and meanings of individuals who are being ambiguous or misleading can be discovered. If you want to see things that have been said to you repeatedly by difficult relatives in a whole new and surprising light, this is the book for you!