To Tell the Truth??

A new internet-based survey of 2,020 patients who had received treatment for depression, conducted by a Dr. Sawada and presented at the Annual Congress of the European College of Neuropsychopharmacology, revealed something that I have known about for a very long time.  A lot of patients lie to their doctors. 

About 70% admitted lying at least once!  66% stretched the truth about daily activities such as work while almost 53% were untruthful about their symptoms - on purpose.

That patients can be less than honest should come as not surprise to anyone familiar with the literature on patient compliance with doctors' orders.

In the United States, according to some estimates 20-30% of prescriptions are never even filled at the pharmacy.  According to the World Health Organization, only 50% of people complete long-term therapy for chronic illnesses as they were prescribed. According to the US government's Office of the Inspector General, research indicates that 55 percent of the elderly do not follow the medication regimens prescribed by their physicians.

As described in my post of August 10, 2010, Don't Ask, Don't Tell, I  had an exchange with another psychiatrist that included the following:

Me: Family members will not usually volunteer the whole truth during a superficial visit with a doctor. Anyone who thinks that family members act the same way at home as they do in front of an authority figure, or that they will be totally honest about things like family violence or abuse, needs to get out more.

Other Psychiatrist : This broad statement essentially implies and equates pediatric mental disorders with the family abuse and neglect... The reasoning goes along the line "if child has problems, someone in the family caused them." And if the family does not offer any evidence of maltreatment,they are lying. A fundamental fallacy, in my opinion, that for decades prevented psychiatrists from understanding the nature of mental disorders... Suspecting family members of hiding "the whole truth" is a regrettable statement from a professional. 

It sounded to me like it is the writer who is saying that poor discipline or even child abuse is never an issue in any behavior or psychiatric problem at all! And apparently he believes patients never fib or hide information! And the statement about offering evidence of maltreatment?  First, that implies that this psychiatrist probably never even asks about it in the first place but waits for the parents to "offer" evidence. And since we were talking about children, if the parents had been abusive or neglectful, does anyone think that they would admit this to someone who was legally required to turn them in to the authorities?  REALLY?!?

I pointed out in that last post: Obviously this psychiatrist has never done any serious psychotherapy, or he would know that a patient may not reveal absolutely essential information about their situation until they have been seeing a therapist for months.



I've gotten into similar argument with folks who are against psychiatric meds and who demonize antidepressants and mild sedative/hypnotics by telling tales of people they talk to who claim to have had horrible and never-ending side effects from these drugs.  While some of the people such folks talk to undoubtedly did have very bad reactions to the drugs in question, many are also taking other illegal drugs and/or a concoction of several different prescribed psychiatric and/or somatic medications.

More importantly for purposes of this discussion, they may be scapegoating the drugs for personality and family problems that are the real cause of their "side effects." 

When I make the latter point, the usual response I get is something to the effect that "I've met plenty of people who have none of the additional issues you are talking about."  My answer: And you know this how? Do you think people just advertise all the things they are ashamed of and brag about family dysfunction?

Going back to survey that is the subject of this post, the reasons that the subjects gave for not being truthful to their doctors were very instructive.  Although males often withheld or altered the facts due to a fear that the doctor would recommend that they take sick leave or quit their job, the two most common reasons given for lying to the doctor were:

1. The patients found it difficult to talk to their doctor, particularly about things they were ashamed of or embarrassed about (49%).
2. They thought that the doctor would not take it seriously, even if they they told him or her (36%).  In particular, females said they could not trust their doctor or that "he looked busy."

Both of these reasons concern relationship issues between doctor and patient.  For want of a better term, they concern a doctor's bedside manner.  In therapy circles, these issues are referred to as the therapeutic relationship (or as transference and counter-transference, respectively, if the patient and doctor are reacting to one another subconsciously).



In my experience, A doctor - particularly a psychiatrist who must deal with a lot of skeletons in closets - who is not in a rush, who appears empathic and non-judgmental, and who does not seem uncomfortable with highly emotionally-charged or typically squirm-inducing subjects, is far more likely to get the truth out of a patient than one who lacks these qualities.

If the psychiatrist sees the patient frequently in psychotherapy and maintains these qualities, more of the truth will emerge from the patient.

Many of today's psychiatrists only see patients for a few minutes (thereby appearing to be "busy"), and are only interested in the patient's symptoms and not in the environmental and psychological context in which those symptoms take place).  One can safely assume that in many cases such doctors are getting a highly-distorted picture of the patient's clinical condition.

These problems are magnified in randomized controlled drug studies (RCT's).  In such studies, diagnostic interviews and self-report instruments focus only on symptoms and researchers do not even bother to take a psychosocial-relationship history from research subjects. 

Furthermore, researchers do very little to establish a trusting therapeutic relationship with their subjects.  Many do not know how to establish this type of relationship, but even if they did know how and really wanted to try, doing so would increase the placebo response rate and should therefore not be done in a so-called empirical study!

Since they are not based on lab tests, the data from these studies is almost all dependent on the truthfulness of the subjects, which as I have been arguing is highly questionable in many cases. When lab values are available, such as blood levels of such drugs as lithium, depakote, and tricyclic antidepressants, they are seldom checked frequently if at all. 

And even if they were, they are still subject to manipulation by the research subjects.  Most drug levels should be so-called trough levels - the lowest level that a medicine is present in the body over a 24 hour period.  Levels should generally be drawn 10-12 hours after the last dose of the medication taken and before the next dose is taken.  All a patient has to do to appear to be taking the drug more often than he or she actually is is to take a dose just prior to the blood draw.

This is another big reason why randomized controlled studies should NOT, by themselves, be the gold standard of so-called "evidence-based" psychiatry.

Stats.con



Buy this book!

The current craze known as evidenced-based medicine denigrates widespread clinical experience as a synonym for anecdotal and therefore not really scientific.  Anecdotal evidence in this sense is an individual practitioner's experience using a certain drug or procedure on a certain patient. 

If the drug seems to work or not work in an individual instance, that does not mean that the drug led to the observed results.  The results could be a placebo effect, due to the tincture of time, a fantasy of the observer, or caused by some other factor besides the drug.  A single clinical anecdote may suggest experiments, but by itself cannot be considered good evidence of the efficacy of the drug or procedure.

Of course, if a lot of different practitioners tend to get the same sort of results in a wide variety of different clinical populations, then the differences between that phenomenon and a single anecdote are markedly obvious.

Still, in the evidence-based medicine craze, the gold standard is a randomized, double blind, placebo controlled clinical trial, or RCT.  That is supposed to be the mark of true science.  But not so fast.

A book called Stats.con by James Penston, which I highly recommend reading, makes the case that, while RCT's are important, they are hardly the end all and be all of science.  They have a lot of issues.  And sometimes widespread clinical experience is far better evidence for the efficacy of a drug or procedure than an RCT. 

Lies, damn lies, and statistics.

Penston points out that surgeons have for decades operated on various organs in the body with the assistance of effective anesthetics and muscle relaxants - "all without a statistician in sight."

In this post I would like to cite several lines from the book that I think are important in evaluating medical "evidence."

"An individual instance may not logically refute a statistical study, but it cannot be dismissed as being irrelevant to the matter."  (p. 4).

"No wonder politicians are rarely fazed by statistical data.  Presented with a study that challenges their position, they simply bring into question the authors or the data." (p. 7).  Because it is very easy to introduce bias into an RCT, and because any study will have weaknesses, they can always be challenged.  And studies often contradict one another.  I notice some of my critics apply their criteria for judging a study far differently for studies they agree with than for those they do not.  You can always cherry pick studies in this manner to prove whatever argument you are making.

"The simplicity of [randomizing patients to active treatment and placebo groups in an RCT] hides the practical difficulties of selecting two groups of patients equally matched in terms of all relevant factors." (p. 13).

"Numerous errors [in technical aspects of a study] may occur that threaten the integrity of the findings yet these are far from easy to detect."  (p. 19). In other words, practitioners reading the study might easily be oblivious to major weaknesses of the study.

The size of a study sample is "inversely proportional to knowledge of the subject matter, the size of the treatment effects, the value of the results to individual patients, and the overall importance of the study." (p. 23).  This has to do with the difference between statistical significance and clinical significance. 

Say that a given drug caused a reduction in the incidence of gallstones by only one percent or in only one percent of patients.  A study may show that this difference is statistically significant, but in terms of its relative value to you when balanced against the cost and/or the side effects, it may be next to worthless.  In order to find such a small statistically significant differences between one drug and another, or between a drug and a placebo, one needs a very large sample.  Significant results in studies with smaller samples tend to be much more dramatic from a clinical standpoint.

"Confounding is present when both the supposed cause and the supposed effect [of a clinical result] are associated with a third factor which is responsible - in whole or in part - for the difference in outcome detected between the groups...no methods are available for correcting for the presence of unknown confounding variables." (p. 30).

"Yet, surprisingly, trials that are being reported as being randomized yield groups with equal numbers of patients more often than would be expected by chance." (p. 63).  This is strong evidence that the randomization process in a lot of studies is being manipulated to influence the results.

In re subjective symptoms - like almost all symptoms seen in psychiatry: "Such changes, even with the assistance of validated scales of symptoms, depend entirely on the account given by each individual patient." (p.69).  There is strong evidence that patients frequently lie to doctors for a variety of reasons.  I will address this issue in more detail in a future post.

On subgroup analysis:  Critics of the literature refer to a process that pharmaceutical companies use called data mining.  If the main result of the study is not to their liking, they will divide the subjects into several different subgroups based on some criteria like gender‎ or age.  The more of these subgroup analyses they do, the more likely they will find a significant result.  Unfortunately, the statistical odds in this situation indicate that the result is most likely just a coincidence:

"[The pitfalls or running analyses on subgroups of subjects in a randomized controlled study was illustrated by one study in which the] ...overall results showed a reduction in mortality from myocardial infarction with aspirin yet subgroup analysis suggested that the drug was of no benefit to those born under the sign of Gemini or Libra." (p. 75).

"Strictly speaking, statistical data apply to groups, not to individual patients.  But clinicians treat individual patients....In every case, we can legitimately ask whether the findings [of an RCT] are applicable to that particular individual." (p. 89).

"Estimates suggest that less than 1% of patients will be recruited to trials. Thus, from this measure alone, it's highly unlikely that participants will be representative of the broader population of patients with the disease." (p.91).

"Patients excluded from [RCT's] tend to have a worse prognosis than those who are recruited." (p. 95) and "Most clinical research is carried out in teaching hospitals by medical staff with both a particular interest in the disease and considerable expertise, supported by nurses with specialist skills and well qualified junior doctors.  Under these circumstances, the standard of care is expected to be ...superior to the average general hospital." (p.96).   [This second point may in many cases not be true in the United States due to the proliferation of Contract Research Organizations or CRO's].  The chances study patients will get better can be much better than for your average Joe, making the results of the study less generalizable to the population of all patients with a disease.

Another big point made by Penston concerns what he calls the relative risk deception.  Let us say that a cancer drug reduces the percentage of recurrences from 5% to 4%.  The authors may then claim they have reduced the chances of recurrences by 1 in 5, or 20%.  That is highly misleading.  This cited rate of risk reduction, as old Albert Einstein might say, is relative.  The absolute risk reduction is only 1% - which may even be within the margin of error of the study - since 95% of the sample would not have had a recurrence regardless of whether or not they took the drug!

And finally:

‎"We may say, for example, that the probability of the clutch [of a certain car] surviving 50,000 miles based on the analysis of a large sample is 0.6, but this hardly applies to the one owned by a driving instructor who, day in and day out, witnesses assaults on the clutch of his car." (p. 120).

Borderline Personality Family Dynamics: The Parents, Part II

In my post of 2/6/11, Dysfunctional Family Roles, Part I: The Spoiler, I opined that the basic problem in the "borderline" family (one that produces offspring with borderline personality disorder [BPD]) is that the parents in such families see the role of being parents as the end all and be all of human existence, but all the while, deep down, they either frequently hate being a parent or see their parental role as being an impediment to their personal fulfillment.

In Part I of this post, I described the one most common major issue - gender role conficts - and the resultant behavior patterns, that I have discovered leads individuals within a family to develop a severe conflict over the parenting role. In Part II, I will describe the other ones.

To repeat a caveat from the previous post: All of these issues may seem very common everywhere, and indeed they are. Most families that face them do not produce emotional conflicts significant enough to create BPD pathology. Rather, the issues in families that do have been magnified significantly by an interacting tableau of historical events impacting the family and the individual proclivities of each and every family member and descendent.

Common issue #2 causing parental ambivalence over being parents: Untimely deaths. The loss of children, in particular, may make someone fearful over losing the others while, at the same time, may lead to parental resentment over the fears and insecurities created by the presence of the remaining ones.

For example, one grandparent of a patient in our clinic had lost 10 out of 11 children to disease; the 11th was the parent of the therapist's BPD patient. The grandmother was overprotective of the mother but at the same time avoided closeness for fear of the pain of losing yet another child. When the mother grew up and left home, the grandmother became depressed. The patient was then given up as a child to the care of the grandmother to help feel the void, and became the new focus of the grandmother's hyperconcern and insecurity. This is also an example of a parent giving up a child as a gift to a grandparent - the subject of my 10/15/2010 post.

Issues #3 and #4: Financial reverses and chronic illnesses - including severe mental illnesses. Because of the financial strains and general chaos caused by these considerations, the joy of raising children may be suddenly turned into a frightful burden, both emotionally and financially, and thereby generate parental ambivalence.

Interestingly, the presence of bipolar disorder - with which BPD is often confused these day by both incompetent psychiatrists and the public despite the fact that they do not look anything alike - in a parent may lead to the very chaos in families that generates BPD behavior in children. Children in such a family are at risk both biologically and genetically for bipolar disorder and environmentally for BPD.

Issue #5: Ambivalence over religious or cultural values concerning childbearing, child rearing and filial responsibilities may lead to parental ambivalence. Examples include:

• 1.  The Roman Catholic emphasis on large families in a day and age when children cost a small fortune to raise. This may lead parents to follow the church rules but be extremely unhappy about the results.
• 2. Children, often the eldest female in a traditional family, may be called upon to take care of younger siblings in large families. In doing so they are often forced to give up exciting adolescent activities in which their peers at school freely indulge. The result may be that they become identified with the caretaker role yet resentful of it. When they leave home and have families of their own, this history may lead them to resent their own children. 

I     I used to practice in Los Angeles where I saw many Chicano (Mexican American) patients.  I saw several females who had functioned as "mother's assistants" when they were growing up. They were the eldest sister in large families. They had to stay home and take care of their younger siblings, and frequently had to miss important social events in school such as their senior Proms. Their younger sisters, however, got to go to and do everything the olders sisters had missed. When these older sisters grew up and had their own children, this recreated the family of origin issues for them and induced ambivalence in them about their brood.



•  The eldest male in a traditional family, such as seen in some Asian cultures, may be called upon to take over the family business in a career that he may just happen to hate. The costs incurred in raising children may lead to continuing family pressure to keep the business going when he wants out. The anger of Son #1 in such a situation may be displaced onto his children.

Issue #6: Parent-child role reversals. If adults in the family become incapacitated for whatever reason, and the children are therefore called upon to take over heavy adult responsibilities prematurely, the children may become resentful in a manner analogous to the situation of the eldest female in a traditional family described above.

Such individuals often describe this state of affairs with statements such as “I never got to be a kid.” [This is not the reason, however, that Michael Jackson said that]. A similar situation occurs when parents who were infantalized by their own families of origin appear to be unable to take care of themselves. Their children then try to fill the power vacuum and take care of them before they are really equipped to do so.

Issue #7: A couple has a child to “save the marriage.” The child then becomes the reason that the parents must continue in their miserable relationship. The resentment within the marital dyad becomes symbolized by the child whose presence was supposed to make the relationship better, but instead has led to the continuation of the same old marital misery.

The child then begins to believe that the family problems are all his or her fault, and the parents do not seem to try very hard to counter this belief. Children in such a bind usually come to the conclusion that their very existence is the reason their parents seem to hate each other. They may also feel that it is their reponsibility to provide a distraction to the parents' anger at one another by drawing anger on to themselves. This is one of the functions of the spoiler role.

Two or even several of these issues can present themselves simultaneously to a family, thus increasing parental ambivalence over the presence of children almost exponentially. The whole family becomes embroiled in quite a stew, and the abuse and neglect of children that sometimes results from these conflicts becomes more understandable, although still not excusable.

Expressing empathic understanding of the family's behavior, without condoning it, is far more productive in helping a family to stop troublesome behavior patterns than raking them over the coals for their misbehavior.

Pharma Weapons of Mass Seduction: Part II

In my post of August 31, Plausible Deniability, I illustrated how Pharma-tainted psychiatrists are able to subtly make marketing points about various drugs while denying that they are doing anything of the sort.  I commented on some of the tricks that were being used.

This post will be the second in an occasional series that discuss the more subtle and insidious devises used by Pharma-connected "experts" to mislead - or should I say con - practitioners.  These "experts" are called opinion leaders by Pharma and are a major part of their psyche ops.  Their marketing departments have been scrupulously studying physician behavior - especially physician weaknesses - for decades.  I will also discuss in future posts some of the ways they have done and are doing that. 

An excellent discussion of the more obvious and better-known pharma marketing techniques can be found at http://www.abc.net.au/rn/backgroundbriefing/stories/2011/3337618.htm.  This program is from the Australian media, but the situation is much the same in the US.  I will not be focusing on those techniques much in these posts.

Pharma marketing targets all physicians, not just psychiatrists, although psychiatrists have been a leading target.  Of course, I am more familiar with the marketing of psychiatric drugs, so my main focus will be those.

Of course, it is ultimately the fault of the practitioner for not taking the time to challenge misleading ideas and to check them out with unbiased and readily available sources of scientific information such as the Medical Letter.  But that is, in a way, the point.  Pharma knows quite well that many practitioners will not have either the time or inclination to do this.  The average physician works about 60 hours per week. 

Not only that, but many are also suckers who can be easily deceived. 



BTW, did you know that 80% of antidepressant medications are prescribed by non-psychiatrists?

In this post I will discuss how Pharma-inspired or paid-off writers in psychiatric newspapers, throw-away journals, and journal supplements denigrate highly-effective drugs (antidepressants and benzodiazepines) that just happen to have gone generic, in hopes that doctors will prescribe more expensive, potentially more toxic, and less effective brand-named drugs (particularly atypical antipsychotics). 

(And yes, antidepressants and benzo's do not work for everyone, can cause severe side effects in some people, can be habit forming, may cause unpleasant withdrawal reactions, blah blah blah.  [All of these problems can be dealt with by a competent physician who follows his or her patients closely].  And a majority of patients need psychotherapy instead of or in addition to medications. No sh*t! So please don't keep writing to me to point out the obvious).

I am going to use as illustrations two articles that appeared in a newspaper called the Psychiatric Times.  I do this because two very recent articles that clearly illustrate my points appeared there, not because I want to pick on that particular publication.  In fact, Psychiatric Times tends to be rather fair in general and is one of the most pharma-critical of the publications I am talking about.

By way of definition:  Throw-away journals are official-looking medical "journals" that are mailed free of charge to all doctors who might prescribe certain drugs pushed by big Pharma.  Psychiatric Annals (Anals?) and Current Psychiatry are two examples from psychiatry. 

They are heavy on full-page and sometimes multi-page Pharma advertisements, and Pharma probably pays to produce and mail them.  The articles they contain are not peer reviewed (sent out to about three independent experts for review of the adequacy of their science prior to a decision by the journal editors about whether or not they should be published).

Journal Supplements are mini-journals mailed along with more legitimate, peer-reviewed journals (and usually having the same cover design) that consist of multiple articles which claim to review a particular topic in the field.  Most doctors are unaware that the articles in a journal supplement are not peer reviewed like the articles in their accompanying primary journal, and that the supplements are usually sponsored by one pharmaceutical company.

First, an article about anti-depressants.  I submit as evidence for my contention in the Plausible Deniability post (that the article by Sachs and others claiming that antidepressants are ineffective in bipolar depression is being used in the field to push other medications) the CME article "Understanding and Treating Bipolar Depression" by Caleb Adler, M.D. It appeared in the July, 2011 issue of Psychiatric Times. As mentioned, there are a lot more articles like this one in various publications.

I pointed out in the previous post that drug companies did not need the folks who authored the Sachs article to recommend anti-psychotics for bipolar depression. They have a lot of other people to do that particular job for them. ("Opinion leaders" is the term Pharma uses for such people), like the authors of articles like these.

The Times article lists a variety of treatment options for bipolar depression including various atypicals and mood stabilizers, and even mentions neurontin and lamictal - both of which have both been shown to be particularly ineffective - before mentioning, at the very last, standard antidepressants.

After focusing on the red herring of antidepressants causing switching into mania - which even the author grudgingly admits can be easily prevented with drugs like lithium that true bipolar patients should be taking anyway - it speaks of the use of antidepressants as "fairly controversial," even though they have been used successfully for over fifty years.

Then the reference to the Sachs et. al. article come in: "Nonetheless, the large STEP-BD analysis did not observe improvement in patients receiving standard antidepressants. Other meta-analyses that have purported to observe an effect may be methodologically flawed."

I do not see any mention that this part of the STEP-BD study was a study ONLY of treatment-resistant subjects, or that it used only two antidepressants for that matter.

And what is the unspoken implication of that last statement about the meta-analyses, even though it may be literally true for any given study? (The reference cited for this statement, by the way, was just another article in Psychiatric Times!) It is this: that any study which purports to show that antidepressants work is probably methodologically flawed, that's what.  There are no similar caveats attached to any of the other drugs mentioned in the review.

A lot of plausible deniability built into the wording though. Brilliant marketing.

The second article concerns benzodiazepines and is titled, "Anxiety Disorders: the Anxious Bipolar Patient" by MD's Khavital Lohano and Rif S. El-Mallakh in the September 2011 issue of Psychiatric Times.  The article correctly points out that many bipolar patients also have severe co-morbid anxiety disorders like panic disorder, which often require additional meds (an instance in which polypharmacy may sometimes be legitimate and necessary). 

In one study, 21% of bipolar patients had panic disorder - a 26 fold higher incidence than in the general population. 

Interestingly, the panic attacks in manic-depressive patients do not occur when a patient is in the manic state.  They occur when the patient is in the normal (euthymic) mood state or, more frequently, in the depressed phase of the illness.

Certain benzodiazepines are, in my experience, far and away the most effective medications for panic disorder, whether it is comorbid with something else or not.  The second most effective drugs are antidepressants. 

Of course, just as with the last article, in discussing treatment options this one goes out of its way to stress that antidepressants can induce mania, without mentioning that anti-manic drugs prevent this from ever happening.

At least antidepressants were the first class of drugs mentioned.  The second?  Antipsychotics, of course.  They are actually stated to be the second line drugs for this indication!  Without FDA approval, I might add.  And the FDA happens to be absolutely right in not approving them for this indication.

Listed third was anticonvulsants like depakote.  Interestingly, the article admits, "There are no randomized controlled trials that examine the use of anticonvulsants for the anxiety component in bipolar patients."  But, naturally, it goes on to state, "However, anticonvulsants appear to have a small effect in reducing anxiety."  Side effects were not even mentioned about either antipsychotics or anticonvulsants anywhere in this article.

Next, under "alternative agents," the article discusses the anticonvulsant gabapentin, which in my experience has very mild tranquilizer-like properties but is not FDA-approved for anxiety. 

LAST, the article finally and very briefly mentions benzodiazepines.  Get this: and I quote:  "Benzodiazepines are clearly effective in many types of anxiety disorders.  However, their use is problematic, and these agents must be prescribed cautiously."  

So what, the fact that antipsychotics can cause diabetes is not problematic and did not need to be mentioned in the article like the problems with benzo's were? Or the fact that depakote can cause polycystic ovaries in females?  No caution needed in prescribing those agents, I guess.

Even in mainstream publications and in the APA Treatment Guidelines, whenever benzodiazepines are mentioned, one almost always also sees a phrase added that is something similar to, "But of course they can be addictive."  On the other hand, when antipsychotics are mentioned, one almost never sees a phrase like, "But of course they can cause diabetes, massive weight gain, higher cholesterol, and an irreversible neurological disorder called tardive dyskinesia."

How to Disarm a Borderline: Last Part

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), Part VI (March 2), Part VII (April 30), Part VIII (June 5), and Part IX (August 2). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

This post, the last one in this series, will continue to describe specific countermeasures to the usual strategies in the BPD bag of tricks used by them to distance and/or invalidate you, as well as to induce you to feel anxiously helpless, anxiously guilty, or hostile.

Today's subjects are what to do when none of the previous interventions seem to decrease the angry responses of the family member with BPD, and what to do when you yourself blow your cool and react with a nasty comment that might kick off a variable intermittent reinforcement schedule than can undo all the fine work you have done until this point..

When all the suggestions in these posts fail

The next suggestion is useful in cases in which, no matter what you say, the family member with BPD continues to escalate with more and more outrageous accusations or oppositionalism. It only works when all others have failed, and not before.  It probably can be used only once or twice. The reason for this is, in order for you to be confident in the assumption you are about to make, the Other's negative patient behavior must have already persisted in the face of your consistent efforts to be conciliatory.

The Solution? Inquire, "Why are you picking a fight with me?"  Once again, you have to refuse to get sucked into a debate about whether or not the family member with BPD is indeed picking a fight.  It will have by this point become damn obvious, and therefore you do not have to prove it.

In response to this question, people with BPD will usually do one of two things.  First, they could conceivably stop the behavior, admit that they are picking a fight, and begin to explain why they feel it necessary to do so.  In the unlikely event that this happens, hear them out!  You will probably learn something important about your relationship.  Try not to be defensive but look for the kernal of truth in what they are saying, as described in Part IV of this series.

More usually, they may suddenly stop the provocative behavior and go on to talk about some other, completely different subject, and nicely proceed as if the fight had never even happened! In this scenario, the family member with BPD suddenly drops whatever he or she was complaining about right in the middle of a heated interaction. 

This maneuver is a lot trickier than you might think.  Because of the abrupt nature of the change in subject, you may feel drawn back into continuing the previous angry discussion yourself.  This happens because the interaction that preceded the switch feels unfinished.  You should remind yourself that the Other's goal may just have been to keep an argument going, not to settle any actual complaint or win an argument.  In other words, the actual content of the argument may be something that is somewhat unimportant.

The feeling that one gets after an argument is suddenly dropped is somewhat akin to the way one feels in the following situation: you have repeatedly tried to get a talkative friend off the telephone.  You know, those conversations when you've said several times that you'd love to talk longer but you have to go, and your friend says OK after each time, but then keeps on talking as if you had not said anything at all. Finally, you raise your voice and firmly say, "I really have to go!" In response, the friend angrily says, "OK, GOODBYE!" 

The natural response is "No, wait!" even though ending the conversation had been one's goal in the first place! 

I advise you to resist the temptation to re-ignite whatever fight had been taking place before you asked the question concerning why the family member was picking a fight, and move on to whatever new and friendlier topic the Other has chosen.  Just like your partner in conversation, act as if the earlier argument had never even taken place.

The fine art of apology

The last bit of advise on disarming someone with BPD concerns the situation in which the family member with BPD gets the best of you and you react with a statement or action that invalidates or insults the patient.  Despite being well versed in the kinds of interventions described in this series of posts, you may still find yourself responding poorly to a family member's provocations. 

The person with BPD, after all, has a lifetime of experience in creating these reactions.  Unfortunately, intermittent emotional overreactions from another tend to make such a person try even harder and longer to illicit said reactions. This is due to the variable intermittant reinforcement process desribed in Part I of this series of posts.

Solution:  After you and your targeted other have calmed down, own up to your mistake and apologize for it!  Be a person of integrity. Be someone who is responsible, has a sense of right and wrong, and is the sort of person other people can look up to.

Having said that, however, an effective apology in this situation should not have the slightest hint of self-denigration attached to it.  If you put yourself down in some way, the person with BPD may then go for your jugular in response.  Basically, there are two characteristics this kind of apology should always have:

First, be good-natured about your error.  After all, you are only human.  Be able to laugh at yourself.  Say, "Gee, I sure did get frustrated with you that time."

Second and most important, apologize only for what you actually said or did, but not for the feelings that led to it.  Example: "I am sorry for sounding so critical, but I just had the feeling that you were dismissing everything I said out of hand."

This sort of statement frames the former explosive interchange as a mutual problem that the two of you need to work on solving in a constructive manner.   And after all, solving interpersonal problems is what effective metacommunication is all about.

Some Suggestions for Avoiding Bad Psychiatrists

"Letters, we get letters

We get lots and lots of letters"

(Apologies to the producers of the old Perry Como TV Show, if any are still living.  Damn I'm old!)



A blog reader sent me a very interesting e-mail with some important questions about the treatment one psychiatrist was providing her daughter.   Maybe I should start a newspaper advice column.  Or maybe not.  Anyway, I'll try my hand at it this one time.

The behavior of the doctor that she describes, assuming that the description is accurate, seems to be typical of the way a lot of bad psychiatry is administered these days. I thought readers might appreciate some tips on how to avoid it.

You can find many additional tips on how to pick a psychiatrist or a psychotherapist who deals effectively with family dysfunction in Chapter Ten of my book, How Dysfunctional Families Spur Mental Disorders.

The names in the letter have been changed to protect the innocent - or in this case, the name of a doctor who is perhaps guilty:

Dear Dr. Allen,

I just recently ran across your blog and became distressed because I fear my daughter is a victim of the over diagnoses of bipolar II. I took her to Dr. XXX because she was nearly suicidal after her father threw her out of her apartment (which he owns) because of her drug and alcohol use. She had no money saved to get an apartment, she wrecked her car and had no vehicle to go back and forth to college and work, and she was on a downward spiral. I told my daughter that I would help her get on her feet financially if she saw a psychiatrist (fearing she was suicidal). She found Dr. XXX’s name in the yellow pages and off we went.

Within 10 minutes he had her diagnosed as BP II. Perhaps we were relieved that there was a medical explanation for her state or perhaps his insistence that “of course this is BP II; I am an expert in the field and should not be questioned” but we did not get a second opinion. After 11 months of ‘treatment’ she is still not ‘normal’ which he blames on her not being compliant in his instruction about when to take medication, eat, sleep, etc. She does not want to continue with the treatments as the drugs are messing her up with extreme tiredness, swelling up like a balloon on the face and extremities, hypothyroid, there are constant blood tests, and on and on.

Dr. XXX refuses to help her wean off the medications stating that he can not do that when he knows she needs the meds and he took an oath. Who can help or how can we proceed to get her safely weaned off the numerous drugs she is currently taking (Equatro, lithium, lyrica, synthroid, zyprexa) to see if now that she is no longer abusing drugs and alcohol, if she can function normally? Should we get a second opinion? What should we do? Please help!

Best regards,

Mrs. ZZZ

Hi Mrs. ZZZ,

Obviously I can not make a diagnosis of your daughter or fairly evaluate her treatment based on an e-mail, but I can make some generalizations that relate to some of what you said. The following should in no way be interpreted as medical advice, but of course that does not mean you need to discount what I say.

First of all, if any psychiatrist makes a diagnosis with certitude after just ten minutes, it is not only time to get a second opinion, but to completely ignore the first one.

If a doctor does not really address a patient’s or the family's concerns but instead just says, “Trust me, I am an expert,” ditto.

The medications you describe would be for bipolar I, not II, and fibromyalgia, which is a wastebasket diagnosis for pain we do not understand. Also, your list includes two mood stabilizers (lithium and carbamazepine [“Equatro” – a brand named drug when a much cheaper generic is available]), as well as an anti-psychotic.

Whenever I see patients on such a bizarre mix of medications, some of which are for symptoms such as psychosis which they do not in fact have, the odds are extremely good that the patient has been highly overmedicated and misdiagnosed, and the doctor has been just throwing meds at the patient willy-nilly to see what sticks.

Blaming the patient for a failure of medications, while possibly true if the patient is not taking them as prescribed, is usually counterproductive. If a patient is not compliant, maybe it is because the meds are creating more problems than they are solving.

A doctor can not make a legitimate diagnosis of a mood disorder if a patient has been using drugs throughout the entire period in which symptoms occur – because the effects of the drugs can and often do mimic the symptoms of a mood disorder.

If a patient with a diagnosis that has been made under the above circumstances needs to be weaned off meds, he or she may have to consult with several psychiatrists before being able to find one that is willing to help the patient do that. But it is definitely worth the effort.

Last, I think that bipolar II is not a legitimate diagnosis to begin with, but I am in a distinct minority of psychiatrists on that point. 

Sincerely,

David Allen

Let the buyer beware!

Antipsychotics Are For Psychosis, Not Insomnia Redux



In my post of February 16 of this year, Antipsychotics Are For Psychosis, Not Insomnia, I reported on the increasing off-label (non FDA-approved) prescription of so-called atypical antipsychotic medication for insomnia and anxiety, despite the risk these drugs pose of causing metabolic syndrome (diabetes, obesity, and increased blood cholesterol and triglycerides [blood fats]) as well as an irreversible neurological problem called tardive dyskinesia. 

Somehow doctors - mostly primary practitioners but many psychiatrists as well - have been brainwashed into thinking that this risk is somehow much less than the risks posed by addiction from sedatives and hypnotics  - the old fashioned tranquilizers and sleeping pills. (Tranquilizers and sleeping pills are actually one and the same thing, by the way.  What's the difference?  Marketing.  Some of these drugs are marketed for sleep and some for anxiety, but they all do both of these things).

Anyway, a class of drugs called benzodiazepines are the most commonly used drugs indicated for insomnia and anxiety.  These include drugs like Valium, Librium, Ativan, Klonopin, Dalmane, Restoril, and Xanax.  They replaced the far more addictive and dangerous barbiturates several decades ago.

A newer (and of course much more expensive) group of drugs (Ambien, Lunesta and Sonata) were marketed as being "different" from the other benzodiazepines, so many doctors are much less afraid of prescribing them than the old drugs. 

In truth, these drugs work almost exactly the same way as the older benzo's.  They also cause sleepwalking. And they are every bit as addictive.  In fact, according to my prime source for all things concerning drug abuse, Rolling Stone magazine, the latest fad in D.C. is staying awake while on Ambien. Apparently, you can get really high if you do that. (Now that you know, please don't go out and do it!)

Of course, mild and moderate anxiety and insomnia can often be treated without any medication at all, but don't even get me started on that.

Actually, benzo's (with the possible exception of Xanax, which is very short acting), are not abused by themselves very much at all by addicts.  When was the last time you read a horror story in the news about valium addiction? It is also almost impossible to die from a benzo overdose if no other drugs are taken with them.

The drugs can create trouble, however, when they are combined with opiates - in which case one can overdose on the combination and die.  Unfortunately, this has been happening with increasing frequency lately.  But I digress.

Not only are benzo's by themselves pretty safe, but they have almost no side effects at all except in the elderly.  Compare their risks with the risks of atypical antipsychotics, and it is absolutely no contest at all.  Personally, if I had to choose, I would much prefer to be addicted to a benzo than be addicted to insulin shots!

Despite this obvious discrepancy in the risks, the problem of the misuse of prescriptions for antipsychotics by physicians to treat insomnia and anxiety continues to worsen.  In the September 2, 2011 issue of Psychiatric News, an American Psychiatric Association newspaper, there were two headlines side by side:  "Antipsychotics Increasingly Prescribed for Anxiety" and "Concern Raised Over Antipsychotic Use for Sleep Problems."

Even well known drug company apologist Charles Nemeroff was quoted as bemoaning the use of antipsychotics for anxiety disorders like panic disorder.

For insomnia, the biggest seller is the drug Seroquel (Quetiapine), which is second only to Zyprexa (Olanzepine) in causing metabolic syndrome.  Indeed, Seroquel is probably the most sedating atypical.  The article in the paper pointed out that a lot of physicians who prescribe this medication do not even bother to monitor the patient for increases in weight, blood sugar, and serum fats. 

The article about insomnia was prompted a large increase in prescriptions for this drug for insomnia in military personel.  According to the Department of Defense, in 2001 20-30 soldiers per ten thousand were treated for insomnia.  By 2009, the figure had soared to 226 per ten thousand. 57% of all prescriptions of Seroquel were for insomnia! 

Soldiers reported gaining an average of 6.3 pounds each on the drug.  Only 61% had a check of their blood sugar within six months of starting the medication.  Fortunately, no actual cases of diabetes were found.  The author of the study that generated these statistics agreed with my theory that these drugs were being used by physicians instead of benzo's because of fear of addiction.

That reasoning is a bit like the reasoning of people who will not fly in a commercial airplane for fear of a crash, but refuse to use seatbelts when they ride in a car.  These doctors apparently are completely clueless when it comes to evaluating relative risks.

Borderline Personality Family Dynamics: The Parents, Part I

In my post of 2/6/11, Dysfunctional Family Roles, Part I: The Spoiler, I opined that the basic problem in the "borderline" family (one that produces offspring with borderline personality disorder [BPD]) is that the parents in such families see the role of being parents as the end all and be all of human existence, but all the while, deep down, they either frequently hate being a parent or see their parent role as being an impediment to their personal fulfillment.

I also explained how the person with BPD develops the Spoiler role in response to the double messages that this emotional conflict leads such parents to give off to their children.

It's all well and good to try to understand the behavior of the individual with BPD in terms of a response to parental problems, but that just kicks the question of an explanation for the disorder back a generation. In order to fully understand BPD, we have to ask, "What on earth makes these parents so damn neurotic that they compulsively have children and then covertly resent them?" 

If the parents are not patients themselves, the only way for a therapist to get to the bottom of this is by helping the patient with BPD to construct a special type of family genogram.  A genogram is sort of an emotional family tree, and is a mainstay of the type of family systems therapy designed by family therapy pioneer Murray Bowen.

Murray Bowen

Using historical figures and geneology records as illustrations, the book Genograms: Assessment and Intervention by Monica McGoldrick and Randy Gerson describes how genograms can be constructed .

Monica McGoldrick

The genograms described by Bowen therapists are, in my mind, incomplete.  They concentrate on which relatives were overinvolved or underinvolved with which other relatives, and whether these relationships were hostile or friendly.  IMO, this leave out an awful lot of important information.  Two individuals may easily have a hostile and enmeshed relationships with each other over one area of functioning, say work or love, and yet still be very distant, friendly and uninvolved with each other over a different area of functioning. 

In other words, these genograms omit the content of the family squabbles.  When the content is added to the genogram, one can then look for the historical experiences of the family that may have created the picture that is taking place in the present.

While I have indeed seen the parents of adult children who exhibit BPD in therapy and traced their genograms, I have also coached patients with the disorder themselves to construct their family's genogram.  We try to go back as far as we can to figure out what family experiences led to the parents' conflicts.  Sometimes the story goes back more than three generations and we may lose the historical scent, so to speak, in that no one alive knows what happened way back whenever.  Usually, however, certain patterns come to the fore.

In Part I of this post, I will describe the one most common major issue, and the resultant behavior patterns, that I have discovered leads individuals within a family to develop a severe conflict over the parenting role.  In Part II, I will describe some other ones.

All of these issues may seem very common everywhere, and indeed they are.  Most families that face them do not produce emotional conflicts significant enough to create BPD pathology.  Rather, the issues in families that do have been magnified signficantly by an interacting tableau of historical events impacting the family and the individual proclivities of each and every family member and descendent. 

I will not describe the details of the magnification process here, but a full explanation can be found in my book, A Family Systems Approach to Individual Psychotherapy.

The most common cause of conflicts over the parenting role stems from cultural rules regarding gender role functioning.  Over the last century the opportunities open to women to explore their interests and ambitions have gradually expanded, and having a lot of children certainly put a damper on their ability to do this.  If a woman came from a family where the women were very bright and had a natural proclivity for being ambitious career-wise, this would often create difficulties for them since they lived in a male-dominated culture that was at best unfriendly to female career ambitions. 

To demonstrate how this might play out in a hypothetical family, I often discuss the evolving role of women in the United States since World War II. During the war, when all the men went off to fight, women in the United States entered the workforce in large numbers for the first time - in order to build the airplanes and tanks.  This phenomenon was known as "Rosie the Riveter." 

Some women found the experience of a career exhilerating, but when the war ended, they had to go back to just being wives and mothers once again.  The US govenment even made propaganda films thanking the women for their important work, but then encouraging them to go home and get barefoot and pregnant once again.  I have seen some of them; by today's standards they are positively jaw dropping. But effective. The Rosies did what they were told, and that is why we had the baby boom.

Rosie the Riveter

The daughters of this generation came of age in the sixties, when the women's liberation had started in earnest.  Women were more and more torn between the earlier gender role requirements and the new cultural opportunities expectations, and some women (as well as some men) did not make the transition very smoothly at all - for a variety of reasons.  One common reason: the Rosie the Riveters, having had a taste of the career world, would vicarioulsy live through the career aspirations of their daughters, but at the same time be extremely frightened by them.

Having children could easily bring the whole craziness to a head for some families.  Even today, parents feel very guilty about not spending as much time with their children as they would like, and they are often criticized at every turn by their own parents as well as the Phyllis Schlafly's of the world.  (Phyllis Schlafly was a career woman who made a career out of bashing career women).

Phyllis Sclafly

In doing genograms, one can often see just how far a family's operating rules lag behind the current cultural norms .  In anthropology, this problem is called cultural lag.  The cultural progression in Western nations, which is mimicked within certain families, was thus:  First, women really could not have careers at all.  Then, they could have careers, but only when they were single.  Then - and here is where many families with BPD members are stuck - they could only have careers when they had not yet had children.  Then, they could have careers even if married with children, but they had to give priority to the husband's career.  Last, both men and women were entitled to the same freedom.

Gender role confusion and conflict can, given the right combination of ingredients, create a nasty intrapsychic conflict over the very act of procreating. 

In Part II of this post, I will look at the rest of the historical factors and patterns that can create such a conflict: Deaths and illnesses, financial reverses, religious demands, parent-child role reversals, being the eldest child in a traditional family, and having children to "save the marriage."

Why Do Some Siblings From Troubled Families Turn Out Fine, While Others Flounder?

Tag - You're It!

One nice thing about Google Blogs is that Google provides blog authors like myself with the search terms used in search engines that have led potential readers to find our blogs. 

One recent search term leading a reader to one of my posts struck me.  It was "Five children.  One BPD [borderline personality disorder].  Why?" 

What an excellent question!

Unbelievably, I still occasionally hear the argument that this or that behavioral disorder could not possibly be shaped primarily by dysfunctional relationships with parents, because other children of the offending parents turned out quite different.  That fact proves the disorder is biogenetic?  Of course, in addition to growing up in the same household, siblings also happen to share many of the same genes - but that point is seldom brought up by people who make such claims. 

Anyway, neuroscientists already know for certain that complex behaviors in human beings are not determined by single genes or even by groups of genes.

That siblings turn out different is quite true.  In fact, they can and often do turn out to be polar opposites!  In some families, for example, one son may become a workaholic and the other a lazy freeloader who refuses to keep a job.  I have difficulty imagining a genetic mechanism that would lead to an outcome like that, but it can be easily explained by looking at family dynamics and psychology.

The ridiculous assumption implicit in the sibling argument is that parents treat all of their children the same. 

Do you have siblings?  Do you have more than one child?  Tell me if the siblings are all treated exactly the same by your parents or in your family.  Come on, be honest.



The Smothers Brothers comedy duo in the sixties and seventies made an entire career out of feigned sibling rivalry summed up by Tommy Smother’s catch phrase, “Ma always liked you best.”  Clearly this theme resonated with a lot of people.  Does anybody really treat all of their children in a nearly identical manner?  How could they?  Children are born with major differences from one another that force parents to react differently even if they try not to. 

"Ma always liked you best."

Even more important, anyone who thinks that some parents do not pick out some of their children to treat like Cinderellas and others to treat like princesses has his or her head in the sand. 

In some ethnic groups, contrasting and seemingly unfair treatment of siblings because of their birth order is actually mandated by the culture.  For example, in some Chinese families the oldest son is groomed to inherit the family business, while his younger brother inherits much less if anything.  In many Mexican American families, the oldest daughter has the duty to look after her younger siblings.  She may have to forego her own high school social life in order to do so, while her younger sister has far fewer family obligations and gets to party on. 

Of course, parental behavior is hardly the only influence on how children turn out after they grow up, but it remains one of the most important and potent ones.

Indirect evidence that children are responding to environmental contingincies in the family and not to genetics is also provided by a phenomenon I have occasionally seen that I call sibling substitution. 

I derived this term from a similar term, symptom substitution, which is a subject that was a bone of contention between psychoanalytic therapists - who thought psychological symptoms were caused by an individual’s internal emotional conflicts - and behavior therapists - who thought that symptoms were caused by environmental rewards and punishments impacting certain behaviors. 

The behaviorists claimed that if they just taught patients new and better habits and reinforced them, then they would be completely cured. The analysts said that would not work because the patient’s underlying conflict would still be present, so the patient would therefore develop a new and different symptom.  The behaviorists claimed to have proof that their side won the argument, but that might be because they cured things like phobias that were not caused by internal conflicts in the first place.  Neither side had any evidence for their argument when it came to dysfunctional personality traits.

What I noticed was that if I somehow successfully helped patients to significantly change a dysfunctional role that they were playing within a family of origin, they often did not develop any new dysfunctional behavior, just as the behaviorists would have predicted.  Unfortunately, a previously unaffected brother or sister would suddenly step into the role they vacated!  Hence, no symptom substitution.  Sibling substitution.  While as a patient's therapist I did not owe anything to his or her sibling, I still found this result less than satisfying.  I helped a patient, but in the process I helped screw over his brother!  What good is that?

To illustrate, say that one sibling is the “Chosen One” who has agreed to fulfill a dysfunctional role: He's the one who never gets married so that he remains free to never leave home - in order to keep an eye on an ailing mother after a father runs off.  Let us further suppose that the Chosen One suddenly says to Mom, “I can’t do this any more.  I’m moving out so I can have a life of my own.  You need to find someone your own age to take care of you!” and actually moves out (Mind you, this is something most people playing such a role are highly unlikely to ever do). 

If he follows through, he will usually first suffer universal condemnation from every relative he has.  If that powerful family maneuver does not get him to change his mind, as it usually will, a brother may then move in with Mom and take his place.  The brother may even develop marital problems that lead to a divorce so that he can free himself up to do so.

As an aside, this sequence of events might seem to indicate that all the siblings in such a family had, until this point, been perfectly willing to let one of their number stay in the unhappy position of Chosen One so they could selfishly go off and lead their own lives.  However, selfishness may not be the complete reason they had stayed out of Mom's problems. 

They may pressure the Chosen One to stay in the role, not just to let themselves off the hook, but because they think their mother actually prefers the Chosen One in the role, and wants no one else to play it.  The Chosen One was, in a sense, picked out by Mom specifically to play the role. The Chosen One is treated by the siblings in the way they do for Mom's benefit, not just their own!

So how does it happen that only one sibling among many is chosen to be and volunteers to be (almost always both)  the Chosen One in a situation where a role is not determined culturally by sibling position or gender?  For simplicity’s sake, lets call that person “It,” like in the game of tag. Before I give my opinion on that question, I want to describe a recent journal article that attempted to look at why siblings turn out so different from one another when they allegedly grew up in the same environment.

In an article in the Journal of Personality Disorders entitled, “Psychopathology, Childhood Trauma, and Personality Traits in Patients with Borderline Personality Disorder and Their Sisters,” Lise Laporte, Joel Paris and others studied the sisters of female patients with BPD.  They state in the abstract: "Most sisters showed little evidence of psychopathology [mental problems]. Both groups reported dysfunctional parent-child relationships and a high prevalence of childhood trauma.

Dr. Joel Paris, my colleague in the Association for Research in Personality Disorders

They concluded that the psychological traits of “affective instability” [high reactivity and emotionality] and impulsiveness predicted the degree of borderline pathology over and above the effects of childhood trauma or adversity.  They do not claim that these traits are genetic or inborn exactly, but that seems to be the implication.  Of course, inborn traits do affect the likelihood of the development of borderline personality disorder, but perhaps not in the way that the authors of this study imply.  More on that shortly.

On closer look at the actual numbers, however, a somewhat different picture emerges.  True, only three of 56 sisters in the sample had the disorder themselves, and parental neglect was equally prevalent among the patients and their sisters. However, 76.8% of patients with BPD reported emotional abuse, while only 53.4% of sisters did.  The severity of this type of abuse was also higher for the patients.  Differences in sexual abuse were even more pronounced, with 26.8% of patients and only 8.9% of sisters reporting such abuse.  In this case, however, the severity of the abuse suffered was similar.

As the authors point out, we know that childhood trauma alone does not lead predictably to any specific psychological disorder, but seems to be a risk factor for almost all of them. 

So is resilience in the face of severe family dysfunction primarily genetic?  The short answer is that we do not have the foggiest notion.   In order to really find out, we would have to genotype babies and then do prospective studies lasting all the way through childhood in which the family was filmed twenty-four hours a day – an impossible task.  Maybe the focus of maladaptive parenting was greater on one child than another, and the difference in focus is what leads to the affective instability and impulsivity in the affected sibling – although genes clearly might make one sibling somewhat more prone to these traits than another. 

The authors discount the idea that the dysfunctional parenting was differentially applied  to the sisters in their study, despite the significant differences in some of the numbers.  The sisters, they wrote, reported “equally impaired” relationship with the parents.

But this conclusion may be due to the fact that the important differences in parenting between siblings are far more subtle than studies of this type can possibly measure.  The number of beatings by the father, for example, may be the same for the two girls, but what about everything else that takes place in the father's separate relationships with the two daughters?  Was the father nicer to one than the other at those times when he was not being abusive?  What was said to each girl during the beatings?  I find that details such as these are of crucial importance in understanding patients with BPD.

As I said in my blogpost of Sept 15, Childhood Sexual Abuse Taken Out of Context: “Studies that examine psychological and social variables in child sexual abuse (CSA) tend to focus on factors such as who the perpetrator was, what type of abuse was suffered (penetration vs. fondling, for example), the severity and frequency of the abuse, and whether the social welfare or criminal justice system became involved. Rarely, the response of non-abusive relatives to CSA victims, usually the mother, is examined. ..

Clearly, most of the victim’s interactions with perpetrators and bystanders alike occur at times when abuse is not occurring, and these other parts of such relationships may also have profound effects on the victim’s later relationships and self image. Again, due to their staggering complexity and intermittent nature, they are difficult to study using statistical techniques.

Contextual factors include the entire history of the relationship between the victim and the perpetrator: what is said during, before, and after the abuse; what the relationship between victim and perpetrators is like when the abuse is not taking place; what other people in the family are doing at the time of the abuse and at other times; how each family member relates to the victim; who if anybody knows what is going on and whether or not they intervene; and a whole host of other characteristics of the interpersonal environment of the victim.

Even during abuse, a victim’s interactions with a perpetrator is not limited to the sex act alone. Words may be spoken; other activities may occur right before, right after, and even simultaneously.”  

These considerations are, while of vital importance, are almost impossible to quantify.

“So get to the question of why one child is singled out already,” I hear you complaining.  “Why would parents focus their conflictual behavior on one or perhaps two of their children, leaving the others relatively unscathed?"  OK, OK, I'll tell you why I think that happens. 

In families with several children, which child or children become the primary focus of the parents’ conflicts and problems depends on a variety of factors.  Certainly a child’s innate temperament plays a role, so we cannot leave genetics completely out of the equation.  A parent who really does not fully want to be a parent but who feels guilty about this impulse (something commonly seen in families that produce a child with BPD), will react more problematically to an innately difficult child than to an easy child.  The latter simply requires a lot less attention, while the former requires much more time. 

Additionally, the problems exhibited by a difficult child may feed into a parent’s guilt over wishes to be free of family burdens.  The parents may become concerned that perhaps their unacknowledged dislike for taking care of children is the cause of the child’s problems.  Hence, parents who are already feeling overburdened yet guilty will often feel guiltier with difficult children.  In response, they often try to overcompensate by getting more involved with those children, which may then further increase their resentment over the parenting role.  The difficult temperament of the child and the internal conflict of the parents feed off of one another, leading to more family conflict and chaos, and so forth.

I will describe how the parents may develop such an internal conflict in my next post. 

Another major factor which determines which child or children become “It” has to do with the natural similarities between particular children and the parents themselves, or between the children and other family members with whom the parents may have had a conflictual or problematic relationship.  Parents are well known to both identify and counter-identify with their own children. 

Say, for example, the mother is the oldest sister in a traditional Chicano family and had been required to give up her social life or college as a young woman in order to take care of her younger siblings.  She then grows up and has children of her own, thrusting her back into the exact same, conflictual position. Because of identification, she might feel sorry for her oldest daughter and envious of her youngest daughter.  Conversely, depending on the extent and severity of her resentment and her conflict over it, she might be harshest on the eldest daughter, who reminds her most of herself.

Either way, the manner in which she interacts with each daughter will be completely different. 

In a similar fashion, light skinned vs. dark skinned children in black families may be the seed of subconscious differential treatment by parents.

Yet another major factor in one child becoming “It” is that parents may often subconsciously displace conflicted feelings about their own parents or other family members on to children who have a physical resemblance or a similar innate personality to the problem parent. That child may then become the focus of the parent’s anger, guilt, or a variety of other problematic feelings, thereby creating a special bond (be it positive or negative) with that particular child and not with any of the others.

Because of the multiplicity of factors involved, determining the exact reasons why one child is the primary focus in any particular family is a speculative and difficult endeavor.  Luckily, in psychotherapy an absolutely accurate and precise identification of these factors is not necessary for planning strategies for altering dysfunctional interactions.  An educated guess will usually suffice.