Tuesday, March 3, 2015

Book Review: "I, Mammal" by Loretta Graziano Breuning

"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
Despite the protestations of those who like to think human beings are not part of the animal kingdom (What are we then, plants?), we have a lot in common with our fellow furry critters. Our brains have been shaped by thousands of generations of the evolution of both genes and culture.

In this fascinating book, the author focuses on something that we inherited very strongly from our biological past: our tendency to form hierarchical societies based on status. The group, and therefore our genes, survives attacks by predators and shortages of food by allowing the strongest among us to remain strong. Weaker members of the group survive by forming alliances with, and by deferring to, the strongest members of the heard.  

In human beings, because of cultural experiences and the fact that our cortexes can anticipate future consequences more so than any other mammal, status in a particular subculture may not be defined by brute strength against predators, but by a wide variety of status markers - musical talent, scientific discoveries, or even, as illustrated by the quote at the beginning of the post, by who in a group is the least outwardly concerned with what the majority of the herd thinks of status markers.

Hierarchy challenges among primates are relatively rare since the risks are often too high. However, as the so called alphas or dominant herd members - often defined by different parameters in males and females or in different primate species - show signs of weakness, such challenges become more common. Younger members of the group may begin to assert their own dominance through oppositionalism.

The animals that are close to the top of the hierarchy but not at the top - let's call them the betas - often extensively cater to the alphas and cling to their alliance with the alphas tenaciously, often at the cost of being under great stress. They tend to be the most status conscious individuals in the group, because they have the most to lose. As the author wryly observes, they're number two, so they try harder.

The author makes the case that we concern ourselves with status in response to what she calls the "happy" brain chemicals - dopamine, serotonin, oxytocin, and endorphins - which are released in very short spurts under certain environmental conditions, and induce us to do more of whatever activities seemed to promote them in the past. Our impulses to do so are not based on conscious thoughts but are automatic reactions to the activities of the more primitive part of the brain, the limbic system. While the thinking part of the brain, the cerebral cortex, can over-ride these tendencies, doing so feels extremely unpleasant is therefore most difficult.

The author admits that she is oversimplifying the roles of the "happy chemicals," and indeed is doing so drastically. These chemicals not only work together as she points out, but are involved in many different brain and bodily functions besides those to which she attributes to them. Additionally, they regulate one another in highly complicated feedback loops with input from many other chemicals such as GABA, cortisol and glutamate.

However, the simplified view is still helpful because it does provide us with an amazingly plausible understanding of some of the behavior of mammals, including ourselves, that otherwise may seem inexplicable. The author talks about how oxytocin rewards animals for sticking with the herd. Serotonin prods us to take a certain degree of risk in going out and getting our survival needs like food satisfied. 

Dopamine rewards us when we anticipate getting our needs met. Interestingly, it does not reward us after the needs have already been met, which might explain why initially thrilling experiences can suddenly "get old." Endorphins block pain, but only in situations such as when we need all of our strength to flee in order to survive.

The author emphasizes over and over again that she is describing what is happening normally within mammals, and that status behavior is often not based on conscious deliberation. The author is in favor of our endorsing our needs for status as well as being proud rather than overly humble about our accomplishments as a way of avoiding chronic dissatisfaction - which is often then blamed on members of our own status heirarchy who are higher in it than we are. However, she points out that tendency to strive for status is not right or wrong, it just is, and she is definitely not saying that it is what always should be. 

I understand why she feels the need to repeat this, as members of the habitually-offended community will miss the point the first twenty times it is made. Hower, it does make parts of the book repetitive and monotonous. But that is a minor quibble.

I learned some very interesting things from this book that I never knew. Did you know, for example, that there are 10 times more neurons connecting the brain to the eyes than the other way around? Our brain literally tells our eyes what to look for as well as what to look at among the myriad of things surrounding us in our environment.

Did you know that Gorilla fathers in the wild often search for a good family to give their daughters to - just like the people in many cultures who arrange marriages for their offspring?

The author does not discuss "schema" formation per se, but does talk about how past experiences become the dominant mode of responding automatically and without thought to the social environment between the ages of 2 and 3 - during and after the period during which the child is most dependent for survival on getting the attention of the primary caretakers. Nerve tracts formed by observing the behaviors of the parents become stronger and also develop thicker sheathes of a coating made of a substance called myelin, which greatly increases the speed of nerve conduction. 

After they are formed, these tracks then begin to function as if the individual were on autopilot. We only notice our behavior when it no longer seems to "work" on those around us. This is partly why parental behavior is so powerful in triggering our automatic repetitive behavioral responses.

Another aspect of our powerful urges to create status hierarchies is basic to the formation of neurotic (confused, conflicted, and amibivalent) behavior. This is easiest to see in dogs, but I believe it applies to kids as well. It was discussed extensively by Cesar Millan, TV's "dog whisperer."

Dogs will presume that they are the alpha animal in a household  - unless the owner acts like he or she is the alpha, and acts that way consistently. To create a neurotic dog, treat them as if they are the pack leader by catering to them, but then punish them when they act out the normal response to being a pack leader: aggression. Then follow the punishment with lots and lots of affection, which again causes the dog to feel like the alpha. Repeat over and over. The dog becomes neurotic "because it can't make sense of the social reward system" (p. 91). Readers of this blog may recognize a similar pattern that I describe when I write about problematic parenting styles.

In general, the ideas in the book apply somewhat more to automatic behaviors within a group than they do to automatic behavior between groups. As evolutionary biologist David Sloan Wilson points out, "Selfishness beats altruism within groups. Altruistic groups beat selfish groups. All else is commentary."

Evolution has also been shaped by kin groups and ethnic groups as well as by the evolution of human culture, in which the balance between collectivism and individualism has gradually evolved to favor the latter more than in past generations, as first described by Erich Fromm. These often competing forces comprise the evolutionary theory of  so-called multilevel selection.

Once again, however, oversimplifying reality can nonetheless help us understand important ideas that might otherwise be too murky.

Tuesday, February 24, 2015

Conventional Wisdom that Seems Obvious Once Again Found to be Actually True

As I did on my posts of November 30, 2011,  October 2, 2012, September 17, 2013, and June 3, 2014, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of No Sh*t Sherlock. My comments in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.


5/28/14.  Physical activity program may reduce mobility disability in seniors.

USA Today (5/28, Painter) reports that for seniors, “losing the ability to walk a short distance often means losing independence.” Now, “researchers say they have found a treatment that, for some, can prevent that loss of mobility,” and that is “a moderate exercise program.” The Washington Post (5/28, Bahrampour) reports that the study, “called the Lifestyle Interventions and Independence for Elders and funded by the National Institute on Aging and the National Heart, Lung, and Blood Institute, was the first of its kind to test a specific regimen of regular physical activity for sedentary older people.” The Boston Globe (5/28, Kotz) “Daily Dose” blog reports that the study, published online May 27 in the Journal of the American Medical Association, “found that elderly people who walked and did basic strengthening exercises on a daily basis were less likely to become physically disabled compared to those who did not exercise regularly.” The study control group consisted of people who were instructed to take health education classes. 

I guess it's still OK for seniors to sit very, very still while posing as nude models for art students.

6/17/14. Study Shows Association Between Mental Illness Severity and Employment and Income.

More severe mental illness appears to be associated with lower employment rates in recent years, and people with serious mental illness are less likely than people with no, mild, or moderate mental illness to be employed after age 49, according to the report, “Employment Status of People With Mental Illness: National Survey Data From 2009 and 2010,” published in Psychiatric Services in Advance.

We now know for sure that employers are not always hot to hire people who are too mentally impaired to perform the work.

6/20/14. Brain Injuries Linked To Higher Risk For Headaches.

HealthDay (6/20) reports that research scheduled to be presented at the American Headache Society meeting suggests that “U.S. veterans of the Iraq and Afghanistan wars who suffered brain injuries are at a much higher risk for headaches, especially migraines.” This “study included 53 veterans who had suffered a traumatic brain injury during deployment and...53 veterans without brain injuries.” Investigators found “that all of the veterans in the brain injury group said they experienced headaches, compared with about 76 percent of those in the control group.” Eighty-nine percent of the headaches in those with brain injuries were migraines, while just 40 percent of the headaches in the control group were migraines.

Now just a minute. Bodily injuries produce pain?? Since when?

9/1/14. The relationship between premorbid body weight and weight at referral, at discharge and at 1-year follow-up in anorexia nervosa

European Child and Adolescent Psychiatry, 09/03/2014: Focker M, et al.  In this study, the relationship between pre-morbid body mass index (BMI) percentile and BMI at admission was solidly confirmed. In addition to pre-morbid BMI percentile, BMI at admission and age were significant predictors of BMI percentile at discharge. BMI percentile at discharge significantly predicted BMI percentile at 1–year follow–up. An additional analysis that merely included variables available upon referral revealed that premorbid BMI percentile predicts the 1–year follow–up BMI percentile.

Oh, I did not see it before, but I get it now. More severe disorders have a worse prognosis.

11/25/14. Talk Therapy May Prevent Suicide in High-Risk Patients

Talk therapy may decrease risk for future suicide attempts and completions in patients who have already made a previous attempt, new research suggests. 

God, I should hope so, or I'm in the wrong business!!

1/13/15. Self-injurers experience greater negative emotionality, particularly self-dissatisfaction, compared to individuals with no NSSI history.

Self-injurers also reported less positive emotion, but these effects were smaller. The pattern of results was similar when controlling for Axis I psychopathology and borderline personality disorder.

And here I thought cutters and burners did so because their joy was just soooo unbearable.

1/30/15. Repeated Blows To Head In Boxing, Martial Arts May Damage Brain.

HealthDay (1/30, Preidt) reports that research published in the British Journal of Sports Medicine “supports the notion that repeated blows to the head in boxing or the martial arts can damage the brain.” Investigators studied “93 boxers and 131 mixed martial arts experts,” as well as 22 individuals who had never suffered a head injury. “MRI brain scans and tests of memory, reaction time and other intellectual abilities showed that the fighters who had suffered repeated blows to the head had smaller brain volume and slower processing speeds, compared to non-fighters.”

So I guess I should quit beating my head against the wall trying to get researchers to actually look into things we actually do NOT already know.

1/30/15.  The US Food and Drug Administration (FDA) has approved lisdexamfetamine dimesylate (Vyvanse, Shire) to treat binge eating disorder (BED) in adults.
The drug is the first FDA-approved medication to treat this condition. "Binge eating can cause serious health problems and difficulties with work, home, and social life," said Mitchell Mathis, MD, director of the Division of Psychiatry Products in the FDA's Center for Drug Evaluation and Research. "The approval of Vyvanse provides physicians and patients with an effective option to help curb episodes of binge eating." The efficacy of Vyvanse in treating BED was shown in two clinical studies that included 724 adults with moderate to severe BED, as reported by Medscape Medical News. In the studies, participants taking Vyvanse experienced a decrease in the number of binge eating days per week and had fewer obsessive-compulsive binge eating behaviors compared with patients in a placebo group.
Shocking new finding: appetite suppressants reduce eating.
January 2015.  Alcohol, Depression potent risk factors for suicide.

BERLIN– Alcohol dependence and major depressive disorder are similarly potent yet independent risk factors for suicidal behavior, according to Dr. Philip Gorwood. Although alcohol use disorder and major depression are extremely common and often comorbid, the mechanisms by which they boost the risk for suicidal behavior are very different, he said at the annual congress of the European College of Neuropsychopharmacology.

Insert your own joke here. No prize will be awarded for best gag, but let's see what you got!

And yes, it is OK to joke even about suicide. Black humor often helps us all to squarely face up to very serious issues, and is therefore to be encouraged. 

Tuesday, February 17, 2015

The Sacrifice of One's Own Children: Abraham and Isaac

In my blog post from 1/2/2011, Of Hormones and Ethnic Conflict, I described a biological rationale for why, under some circumstances, people are not only willing to sacrifice their own lives for their kin or ethnic group, but to sacrifice the lives of their children as well. How else to understand such diverse phenomena as mothers gladly sending off their sons to war or even to be suicide bombers, female infanticide in China, and so-called honor killings in the Middle East?

The later is especially strange - fathers or brothers kill their own daughters/sisters because they have besmirched the family honor, usually through some sexual transgression - even if involuntary! Women who have been raped can suffer this fate.

The mass appeal of the Jesus story, in which God sacrifices His only son in order to save mankind from the fires of hell, is probably due to this characteristic tendency of human beings. 

In the Old Testament, there is another widely cited story of the willingness of a parent to sacrifice a child. It is the story of God ordering Abraham to sacrifice his son Isaac as a test of his faith. He is about to do the deed when God tells him he does not have to.

An interesting sidelight to this story is that in almost all artwork that depicts this incident, Isaac is portrayed as a little boy. This can be seen in the painting at the top of the post. Not so! I was surprised to recently learn that, in fact, most Biblical scholars believe, from other things in the Bible happening around the same time, that Isaac was about 37 years old!

Abraham was supposedly over 100 years old at this time, so Isaac could have undoubtedly overpowered him. What this means is that Isaac must have been just as willing to be sacrificed as his father was willing to sacrifice him. Self sacrifice and the sacrifice of children often go hand-in-hand.

The idea from evolutionary biology that covers this willingness, kin selection, is often criticize by many in that field due to what I believe to be a misinterpretation of the phenomenon. Indeed, it is quite true that many people are not willing to sacrifice themselves or their children at those times when most of the people within their peer group are. The willingness to follow the herd into sacrifice is an inherited biological tendency, not a mandate.

Group pressure to be willing to sacrifice can indeed be very powerful - often leading resistant individuals to an almost overwhelming sense of terror known as existential groundlessness or anomie as described in this post. This does not mean, however, that everyone simply must go along. The thinking parts of the brain can choose to ignore their fears and can override the biological tendency to follow the kin group.

People who resist the herd are often in danger of being attacked or even killed themselves from others from within their group who condemn their independent ways. People may give in to these threats, but they can also stand up to them even at great peril. 

Where does such courage come from? That is an interesting question, and I do not think we know the answer.

Tuesday, February 10, 2015

Dumb Hidden Assumptions in Drug Abuse Research - An Update

And do not forget the private prison system and racist people in positions of power who want to ruin the lives of as many African-American youths as possible.

In my post of November 21, 2014, I reported on a study that showed that regular adolescent marijuana use was associated with a reduced likelihood of finishing high school, among other things. The authors of the study attributed these results to marijuana essentially causing brain damage, rather than to the fact the kids who feel the need to get stoned all the time have other problems which could easily account for their poor performance. Almost none of these other problems were controlled for in the study.

I asked, "What on earth makes people who draw the conclusion that the drug was the primary cause of the lower achievement become so stupid that they don't see that frequent drug use is a sign that the teens already had emotional problems before they even started smoking - and that it was these problems that predate the drug use that were the real cause of both the drug use AND the poor performance?"

Well guess what? Two new studies show exactly what I was talking about.

First was a new, ongoing study funded by the U.K. Medical Research Council, the Welcome Trust, and the University of Bristol, whose authors had no financial conflicts of interest. It's key clinical point: Previous research findings showing poorer cognitive performance in cannabis users may have resulted from the lifestyle, behavior, and personal history typically associated with cannabis use rather than the cannabis use itself.

Occasional to moderate cannabis use at a young age was not found to be associated with detrimental effects on cognition or educational performance. It was true that adolescents with heavier use – defined in the study as self-reported lifetime use of cannabis 50 times or more by age 15 – had a modest 2.9% decrease in educational performance on a compulsory school exam given at age 15 or 16, compared with never-users. However, heavier use had no impact at all on IQ scores measured at age 15 after adjustment for potential confounding factors.

"Previous research findings showing poorer cognitive performance in cannabis users may have resulted from the lifestyle, behavior, and personal history typically associated with cannabis use rather than cannabis use itself,” said Claire Mokrysz, of University College London.

She reported on 2,612 children who had their IQ tested at ages 8 and 15. Adolescents with heavier cannabis use by age 15 had a nearly a 3-point lower IQ at that age than did never-users, after adjustment for IQ at age 8. However, upon further adjustment for maternal education, pregnancy, and early-life factors, and use of tobacco, alcohol, and other recreational drugs, the difference in IQ between heavier and never-users vanished.

Heavier users of cannabis scored an initially impressive 11% lower than never-users on the standardized educational performance exam in an unadjusted analysis. After adjustment for the potential confounders, however, the difference shrank to a modest 2.9%. 

Performance, by the way, is not the same thing as ability. Even in this study, no effort was made to control for the motivation of test subjects, or for whether they were being distracted by ongoing problems such as family chaos at home.

The authors added that the belief that cannabis is particularly harmful may detract focus from and awareness of other potentially harmful behaviors. Not to mention other more important psychological and family issues.

The second study was done by neuroscientists at the University of Colorado at Boulder and published January 28, 2015 in the Journal of Neuroscience. Its major finding: Daily marijuana use is not associated with brain shrinkage when using a like-for-like method to control for the effects of alcohol consumption on those who both drink and toke up.

Kent Hutchison, a clinical neuroscientist at the University of Colorado, Boulder, and the senior author of the study, said his team reviewed a number of scientific papers that showed marijuana causes different parts of the brain to shrink, and his team found the studies were not consistent.

"So far, there's not a lot of evidence to suggest that you have these gross volume changes" in the brain, Hutchison said. 

I wonder how often Nora Volkow and other leaders of the National Institute on Drug Abuse will discuss these two studies or even mention them in their public presentations opposing marijuana legalization. Probable answer: NEVER.

Tuesday, February 3, 2015

Book Review: Unhinged by Anna Berry

I breathe you in again just to feel you
Underneath my skin, holding on to
The sweet escape is always laced with a
familiar taste of poison
~ Halestorm

In female patients with borderline personality disorder (BPD), a behavior pattern is sometimes seen in which the woman quickly gets involved with a seemingly charismatic but at base highly narcissistic male. At the beginning of the relationship, it's love at first sight. There is a whirlwind romance in which both partners seemingly have found their soul mates, and love is professed - occasionally with even a hasty marriage proposal, sometimes within just a couple of weeks. The couple spends all their free time together and can not seem to get enough of each other either physically or mentally.

Before too long, however, the man reveals his true nature. He usually becomes extremely controlling, hyper-jealous and possessive. He wants to know where the woman is every second, and tries to isolate her from her friends and family. All the while, he may lie about his own whereabouts and compulsively cheat on the woman. Not infrequently, he becomes physically abusive to her.

Alternatively, the seemingly exact opposite may happen. Without warning, the man seems to lose interest in her entirely, but nonetheless continues to string the relationship along for a considerable period of time.

In many such cases, after the couple finally breaks up, the woman repeats a nearly identical pattern with another man. She never seems to learn from her mistakes, and denies that she has ever seen any red flags that indicate that things might go awry.

What on earth is going on in the mind of such a woman?  In her new book, author Anna Berry  (a pseudonym) does a marvelously detailed, brilliantly written, and entertaining job of describing her experiences with instances of her involvement with three such men. The memoir is an excellent introduction to the inside of the head of someone like her.

In another part of the book, she describes an experience in which she sort of toys with a psychiatry resident serving as her therapist, demanding that he help her to get back a guy who has treated her like crap and then dumped her. The therapist persists in gamely confronting her about how obviously ill-advised and self-destructive such a course of action would be, if it were even possible.  

As described by the author, the resident seems to be following the suggestions of James Masterson, one of the early psychoanalytic pioneers in the treatment of BPD, to confront, confront, and confront some more. Such confrontations are supposed to be done empathically, however, and in this the therapist falls short, at least in the descriptions of the author.

At some point he even tells her she is a hopeless case - something a therapist should never say to a patient even for effect. She is often snide and sarcastic to him in therapy, yet she continues to see him and even feels abandoned when he has to move away.

The author eventually got herself out of her self-destructive lifestyle and then does pretty well for herself. So what is her explanation for her earlier, crazy-sounding behavior?  

Well, she says it was because she was (and still is) both mentally ill herself, and comes from a crazy family. She at times uses the word delusional to describe herself, and also states categorically that she had brief psychotic episodes - although as I will discuss, from what she describes in her writing, she never once says anything that would clearly illustrate a delusion, hallucination, or any other evidence of psychosis. What she describes so well is something else entirely. So why, even though she does things that seem crazy, does she insist on labeling herself psychotic?

Having never evaluated the author myself, I can only guess, although I certainly can speculate and offer a possible hypothesis. More on that later.

The confusion about whether the author is mentally ill or just self-destructive arose when I was approached by the publisher to write this review.  Initially, it sounded like the book was about the difficulty in growing up in a family with a parent who was chronically and persistently mentally ill, possibly schizophrenic. 

While having a psychotic parent can certainly create family dysfunction and personality problems in offspring, it also sounded like the author herself was struggling with psychosis, and psychotic illnesses per se are not the main focus of this blog. When I asked them for clarification on this, the answer I got did almost nothing to clearly answer my question.

In the book, the patient discusses her own diagnosis, and implies that BPD was the closest thing in the diagnostic manual, the DSM, to what she had. Nothing in the book would cause me to doubt that proposition. She also discusses how she was also diagnosed by different mental health practitioners with a different psychiatric disorder almost every time she saw a different clinician - clinical depression, bipolar disorder, bipolar II, multiple personality disorder, episodic depression, seasonal affective disorder, dysthymia, cyclothymia, anti-social personality disorder, histrionic personality disorder, schizotypal personality disorder, and post traumatic stress disorder.

Her conclusion from having had these different diagnoses was that people just don't fit neatly into the DSM diagnostic boxes. While that is somewhat true, and while it is also true that people can have more than one psychiatric condition (comorbidity), it seems that in her case these labels were applied to her when she in fact did not actually meet the diagnostic criteria at all. She cannot be bipolar if she never had anything resembling a manic episode, or be histrionic when she is primarily an introvert who usually hates to be the center of attention, or have seasonal affective disorder and be depressed at any time of year.

The diagnosis of the author's mother is rather obscure in the author's descriptions. Her brother clearly has severe schizophrenia, and in the beginning of the book it sounds as though the mother did too.  She clearly had psychotic episodes. At one point she throws a lot of the possessions in the house out because voices are telling her that the objects are dirty and if she doesn't throw them away, everyone in the family will get sick and die.

As the book progresses, it eventually becomes clear that the mother's psychotic episodes are episodic and accompanied by her talking non stop and staying up without any sleep for days at a time. Her psychotic episodes would be exacerbated by prescription drug abuse and alcohol - she would often get large quantities of benzodiazepines and other controlled substances from three different free clinics that never communicated with one another. Again, without examining her myself, true bipolar disorder would be the most likely diagnosis if these descriptions are accurate and complete.

Clearly growing up in a chaotic household had a bad effect on the author's mental stability, particularly as she was neglected quite a bit. There often was no food in the house. Dad was apparently too busy having sex with his mistresses openly in the house, with the kids there, to go to the grocery store.

But has the author ever been delusional? Well maybe, but not by her own descriptions in the book. What she describes as being delusional is really a description of her lying to herself while knowing the truth deep down. A real delusion is believed totally and without any doubt, and is certainly not shared by anyone else like a manipulative boyfriend. This is an essential distinction.

In describing her rush towards involvement with one of the problematic men, she says she "could have seen the warning signs a mile away" (p.29).  Although she does not explicitly say that she did not see them, it sounds like she made a concerted effort not to.  On page 74, she writes, " I still didn't have the insight to recognize my destructive relationship patterns, but I can feel the impending doom approaching deep in the pit of my stomach, the way a seasoned sailor can feel approaching storms in his very bones."

That clearly sounds like it was not insight into her relationship patterns that was lacking, but rather that she had decided not to think too much about them. Last time I checked, stomachs can't really think.

On page 87, she describes red flags going up in her brain, but then shrugging her concerns off.  Again, not a psychotic process. She also peppers the book with phrases such as "passive aggressive cry for help and state of denial." Not a psychosis.

She describes her "voices" as almost psychotic hallucinations, but they sound a lot more like the "tapes" we all have running in our heads left over from childhood that tell us what to do and not to do. They are not described as completely external voices like the ones we all hear every day coming from other real people. The hallucinations of psychosis are more like real external voices than inner thoughts.

The first clue that she had never been psychotic was actually a beautiful description of a person with BPD's inner experience - way back on page 5: "...the day-to-day torture of having to create inner and outer selves simultaneously, and maintaining both convincingly...perfect real world training for a professional actor."

So why does she keep telling herself how mentally ill she is? Well, one possibility is that, coming from a family where mental illness is sort of the norm, these thoughts provide her with a sense of belonging and familiarity. Those are powerful needs for most people. Again and again, she uses the same words to describe both herself and her mother, as if their psychiatric experiences were actually far more similar than they really were.

But of course she would be conflicted about thinking herself to be crazy, because, deep down, nobody really wants to be or thought of by others in that way. The author often lived in fear that someone would find out how crazy she was - before demonstrating it to them in spades.

On page 200, she indicates that one of the most important lessons she learned from her psychotherapy was "I am not my parents." More accurately, she probably learned she did not have to be like them. Her mother and brother would never have recovered the same way she did with just the treatment she eventually received that was helpful to her. 

Tuesday, January 27, 2015

If All the Docs are Doing it, is it not Malpractice?

Part of the legal definition of malpractice includes the idea that the treatment provided falls below the accepted standard of practice in the medical community.  In other words, it must be shown that the practitioner was acting in a manner which was contrary to the generally accepted standard operating procedures that are currently being widely used by other physicians in the city in which the doctor practices.

For a malpractice case to be successfully pursued in court, the treatment must also be shown to be negligent and of course result in some quantifiable harm to the patient. But what happens if certain harmful procedures were being widely performed by almost all of the other doctors in the community? Even if the harms are predictable and significant, is a doctor protected from liability just because "everybody's doing it?"

Many mothers back in my day used to answer their kids' protestations that "other kids get to do it!" with, "If everyone jumped off a bridge, would you do it too?" I can't speak for others, but mindlessly following the herd was not something that was encouraged in my family system.

I do not know off hand what the answer is to the question above. Perhaps some malpractice attorney who happens to read this might write in with the answer. The reason I thought of this question was something I recently read in the psychopharmacology (psych drug) newsletter Biological Therapies in Psychiatry (July 2014) about how often kids are monitored for side effects when they are prescribed psychiatric medications.

Regular readers of this blog know that I think that the diagnosis of pediatric bipolar disorder is in the vast majority of cases a scam, and that prescribing antipsychotic drugs to children to control their behavior is a reprehensible activity. Kids should not be sedated into being less affected by family dysfunction.   

That would be bad enough, but what is worse is that antipsychotic drugs have potentially dangerous side effects. Particularly with the newer, "atypical" antipsychotics, there is a significant risk of causing weight gain, type II diabetes, and high cholesterol. These risks may be higher in children and adolescents than they are in adults.

If a patient is psychotic, the benefits of these medications generally outweigh the risks, especially if the patient is monitored for the emergence of these side effects. And there are few other options. (Sometimes one drug in a class will do it in a given patient, but not another drug in the same class). If patients are not psychotic, and very few kids are, the benefits decidedly do not outweigh the risks.

At the very least, the doctor should take blood tests periodically to see if these side effects are developing. You would think that doing that would be the standard community practice.

Well, if you thought that you would be wrong. 

In a retrospective study by Delate and others (JAMA Pediatrics, 2014 May 5) of pediatric patients started on an atypical antipsychotic within the Kaiser Permanente system HMO in Colorado, the authors found that only 1 patient out of 1023 received the full recommended panel of baseline and follow-up blood monitoring!

That's right; you read correctly. 1 out of over 1000, or one tenth of one percent. Of course we don't know if kids in other health plans are being treated this negligently, but I would not be surprised.

So if almost all of the doctors in a community are making little kids jump off bridges, does this mean that they are not going to be held liable if they are sued for malpractice?

Tuesday, January 20, 2015

Family Communication: Countering Relatives Who Go Off on Tangents

In my blogposts about family metacommunication, one issue I discussed is the tendency of people to change the subject when discussing anything touchy. When a person is afraid to or does not want to go into depth in discussing a particular repetitive interactional pattern with a family member, for whatever reason, a subtle switch from the issue under discussion to some other matter is often a successful strategy for avoiding further dialogue about it.

This is particularly easy to do if there are a whole bunch of similar issues that are all inter-related and intertwined with one another. As I wrote in the previous post: 

Another related misdirection strategy is to mix several separate but highly interconnected issues so that none of them is ever completely discussed. For example, one woman was in a complex family system in which her husband would find ways to distract her from her anger at her parents and vice versa. Whenever she expressed anger at one of her parents, the husband would do annoying things to draw away her anger from her parents towards him Similarly, when she was ready for war with hubby, one of her parents would act out and draw her wrath towards them.

The woman's genogram revealed that the problems in this system were related to gender issues (whether men should take care of women or women should pursue independence), concerns regarding the adequacy of males in the family to take care of their women (her husband felt that he was supposed to protect his wife but felt inadequate to do so and angry about "having" to shoulder the responsibility) and even class (how much money was being brought in).

The discussion would change from one of these aspects of the problem to another at the drop of a hat. Because the aspects were all so interconnected it was indeed difficult to talk about any one of them without talking about the others. For example, when the issue of the husband's adequacy came up, the issue of why he was like that would also arise. Because the subject of any conversation jumped around, however, any conversations about the issue would end up going in circles with nothing being resolved.

In this post, I want to discuss another useful strategy under these circumstances for keeping family metacommunication on track in order to get to the bottom of a single issue. Another way to look at the problem of subject changes is that the mix-up of issues allows people to go off on a tangent that is related to - yet different from - the main theme the metacommunicator is trying to clarify.

The trick here is to remember the definition of a tangent from your old geometry class in high school. Tangents are related to circles, and look like this:

If you go to the tangent line and trace it backwards, it always goes right back to the circle. Analogously in metacommunication, the "circle" is the main theme that ties all the different tangents together.

Any tangent someone goes off on can be thought of as just another example of the main theme - the circle in the diagram.

As an example, let us take a hypothetical situation in which there is a highly conflicted relationship between a mother and a daughter who come from a typical highly dysfunctional family - one characterized by many examples of major gender issues common to many members: the females getting involved with men who are drunk, abusive, and/or cheating; whether or not they should leave relationships with such men; expressing anger at such men; mothers who do not protect their children from abusive men or from witnessing domestic violence; conflicts over being tied down by children leading to neglect and invalidation of them; enabling children who don't take care of themselves; depending financially on either unreliable men or good providers who mistreat women, and so on and so forth.

There are indeed families characterized by all of the above conflicts- over several generations. If there are several sisters, aunts, great aunts and female cousins acting out several of these themes, one can see how easy it would be to subtly avoid focusing in depth on any one theme, or for that matter, on any one relationship.

So what might tie all of these gender-related themes together as they play out in metacommunication about problematic behavior patterns between a mother and her adult daughter who has children of her own?

Here we can make use of the concept described in a previous post: intrapsychic conflict leading to ambivalence leading to mixed and/or contradictory messages. Anything the mother says to her daughter regarding any of the above behaviors can be translated into a message to the daughter to either "act (or relate to the issues) like me" or "do not act (or relate to the issues) like me." Usually both within the very same conversation!

In this case, a good strategy might be for the daughter to express confusion about what the mother is trying to tell her in terms of following or not following mom's example no matter which aspect of the gender dysfunction is brought up. She might say something like, "Gee Mom, sometimes it sounds like you are criticizing me for doing the same things you do, while at other times it sounds like you are criticizing me for not doing them. I'm confused about what you think is the right strategy when, for example, my ex-husband keeps calling me on the phone several times a day."

A typical dysfunctional conversation might go something like this:

Mother: "I told you to block his phone number and stop talking to him."

Daughter: "But you let Dad keep bugging you all the time."

Mom: "Well, I do that for your sake 'cause I know you still care a lot about him, so it's better if we are civil to each other."

Daughter: "But wouldn't that also apply to my sons from my ex?"

Mother: "Well you don't seem to want to be bothered with your kids' feelings half the time anyway."

In this example, the mother has subtly changed the subject from how to handle an ex-husband to the daughter's parenting practices. If the daughter were to engage the mother on that issue, the mother might then talk about how the daughter is still financially dependent on her ex and needs to support herself better so she can get rid of him. Nothing would ever be resolved.

The counter-strategy is to take each tangent the mother goes off on and reconnect it to the circle or main theme. Any criticism the mother makes of the daughter on any of these inter-related subjects can be used as yet another example of how the mothers statements confuse the daughter in regards to whether or not she should follow her mother's example.

If the daughter starts with the statement above describing her confusion about whether or not mother thinks the daughter should emulate her, and the issue of the stalking ex comes up, the daughter would not say, "But you let Dad keep bugging you all the time." She would instead say, "I'm confused when you say that, cause that sounds like you are saying I shouldn't let my ex keep bugging me like you put up with Dad."

If mother then brings up her having put up with Dad for the patient's sake, that of course contradicts mom's initial advise for the daughter to cut off her ex when there's a child involved there. The daughter might then bring up that seemingly contradictory advice as a way to get back to the circle once again. 

The daughter would be ill-advised to come right out and accuse her mother of being hypocritical, as that would usually lead to the mother becoming defensive. Instead, she could blame her own confusion about what the mother is trying to say:

"Well I'm again kinda confused now. Are you saying I should handle it like you did for the sake of my sons, or that I should do the opposite of what you did and cut off my ex?"

Of course, this strategy could have good results, but it could also backfire.

The mother might at that point be struck by how she is giving the daughter double messages, which might then allow her to take pause and start to discuss why she herself might be confused on these issues - a good result. On the other hand, the strategy might also make her feel guilty and want to change the subject yet again. 

Mom might try the strategy of saying that her situation with the daughter's father is somehow different than the daughter's situation with her ex. Naturally, in some ways every situation is somewhat different, but in doing this she would be ignoring all the ways in which their situations are similar.

Figuring out the next move on the daughter's part would probably require the services and advice of a knowledgeable therapist. A therapist can tailor a counter-move for the daughter, using his or her knowledge of several different things: 

Knowledge of the mother and daughter's prior interactions; the therapist's own experience successfully countering the daughter's having done the very same thing to the therapist as her mother does to her within the context of psychotherapy; and information from the genogram about the source of the mother's ambivalence that can be use to empathically advance their conversations toward problem resolution.