Tuesday, November 24, 2015

Depression is a Symptom, Not a Psychiatric Disorder

Lately there have been a slew of articles about "depression" that seem to go out of their way to avoid discussing any specific psychiatric diagnosis listed in the DSM - instead strongly implying that "depression" is itself a disorder. These articles appear in the popular press, but, frighteningly, also in newsletters and newspapers for psychiatrists and psychologists. They explore such questions as "Do antidepressants work?" and "What is better for depression, drugs or cognitive behavioral therapy?"

These types of questions are completely meaningless. Depression is discussed as if it were a single phenomenon that, at best, exists on a continuum from "mild" to "moderate" to "severe." This type of wording is in fact completely ignorant, but does not necessarily reflect real ignorance. In many cases, different entities such as big Pharma have a vested interest in conflating several different psychiatric conditions.

In truth, "depression" is just a mood state, and as a symptom, it can be part of many different psychiatric disorders that are, despite some overlap in symptomatology, as different as night and day when it comes to their clinical presentations as well as their response to various treatments.

To name but a few actual diagnoses, there is major depression (both as part of unipolar and bipolar disorder), dysthymia, adjustment disorder with depression, depression due to a medical condition, and depression due to a substance. Medical conditions that can lead to depressive symptoms include hypothyroidism and some strokes. Substances that can do that include some steroids like prednisone and the "crash" that results when an acute cocaine high wears off.

Furthermore, "depression" as discussed in every day conversation can be a normal mood that is part of chronic unhappiness, or that occurs in response to grief at someone's death or due to any other loss or misfortune.

The most important diagnostic distinction for this discussion is between major or clinical depression and dysthymia. Although we don't know enough about the brain to know the exact causes of either one, and there is some overlap in symptomatology, they appear for the most part with very distinct clinical presentations, especially in their classic forms.

Dysthymia appears to be more of a psychological reaction, while major depression probably involves the more primitive part of the brain called the limbic system. The latter, unlike the former, is accompanied by a whole array of chronic, persistent (lasting all day every day for at least two weeks), and pervasive (coloring all aspects of the patient's mental life) physical symptoms - all at the same time - involving sleep, appetite, ability to experience pleasure, energy level and motivation, and concentration. Sufferers may have an unrelenting and constant sense of foreboding accompanied by inexplicable hopelessness and helplessness. We used to refer to these types of symptoms as vegetative symptoms.

Furthermore, someone in a major depressive disorder episode reacts completely differently to life's every day ups and downs than they do when they are not in the middle of such an episode. It's almost Jeckyl and Hyde territory.

These people stay depressed no matter what life events occur around them. They could literally win the lottery and would not really feel a whole lot better for more than a few minutes.

The most severe form of major depression is called melancholic depression. Most people who have never worked in a mental hospital have never seen a case, but the anti-psychiatry types who have not seen it blather on about depression incessantly as if they knew what they were talking about.

People with melancholic depression exhibit something called psychomotor retardation. People with this symptom move and think at a snail's pace.  It takes them longer to respond to any verbal interactions. They can even appear to have significantly impaired memory, although it is actually a more severe form of concentration impairment. That clinical picture is sometimes referred to as pseudodementia. 

You cannot spend more than an hour with such people without realizing that this condition has next to nothing in common with the type of "depression" people see in their everyday interactions with others, and that there is something seriously wrong with their brain functioning.

In severe major depression, doing any kind of psychotherapy (short of telling them, "take these pills") is a complete and utter waste of time. Sufferers literally do not have the mental wherewithal to deal with any kind of problem solving or other interactions with a therapist. And I say that as a major advocate of psychotherapy.

The symptom of depression in dysthymic disorder, on the other hand, rarely responds to antidepressant medication at all (although the drugs can be useful for other symptoms seen in patients with dysthymia such as panic attacks, obsessive ruminations, and the affective instability characteristic of borderline personality disorder). For these folks, psychotherapy is essential.

In my experience a very high percentage of the people who do drug and psychotherapy outcome studies, at least in adults, make almost no meaningful effort to differentiate dysthymia from major depression by: 1) Not spending any time making certain that patients understand the pervasiveness and persistence criteria that differentiate the symptoms of the two disorders; and by 2) Not taking a complete biopsychosocial history to distinguish psychological from limbic system factors.

All of the fancy biological research is not being complemented by good old fashioned clinical typing.

Furthermore, with the private Contract Research Organizations that do a lot of the studies, experimenters get paid only if they recruit a subject, and subjects get paid only if they get recruited - giving a financial incentive for everyone to exaggerate symptoms in order to qualify.

And people with suicidal ideation, comorbid (other, co-occurring) conditions, and significant personality pathology are excluded from studies. Those "exclusions" eliminate the vast major of subjects that have any of the psychiatric disorders in which depression is a symptom.

Garbage in, garbage out.

By the way, you can also have something called double depression. Such people are generally dysthymic but every so often can have a superimposed episode of major depression. So they have both conditions.

Once a major depressive episode starts to occur, it takes on a life of its own. However, being chronically unhappy, anxious, or stressed out may be risk factors for triggering a major depressive episode to begin with.  If you are genetically vulnerable to an episode of major depression, being chronically unhappy might make an episode more likely.

This is another reason why the question, "Should you treat these people with medications or therapy" is a really stupid question. It's a bit like asking, "Which treatment should people who have extensive, severe, cardiovascular disease get, bypass surgery or high blood pressure medication?" 

These treatments address completely different aspects of the disorder. In major depressive disorder, drugs should be used during the acute disorder, but psychotherapy should be given later to address personality  and relationship risk factors - in order to reduce the likelihood of subsequent episodes.

Friday, November 13, 2015

Parenting: How Criticisms and Nagging Backfire

Children give their parents what the parents seem to need

Mell Lazarus, the cartoonist who created Miss Peach, writes a very creative comic called Momma. I wish it were in a lot more newspapers. He understands something paramount about family dynamics that it seems a lot of so-called parenting experts do not address or even seem to notice. 

Psychiatrists and pediatricians who prescribe medications for children who supposedly have "ADHD" or "Pediatric Bipolar Disorder" never even ask their teenage patients about it - or inquire in any detail about much of anything that goes on at home between them and their parents.

I've included in this post several of his strips that demonstrate how tuned into this process Mr. Lazarus is. The dynamics can be described quite simply in three sentences:

1. If a parent repeatedly criticizes a child or a teenager about the very same behaviors, the child will not only not stop them, but will continue or even dramatically increase them.

2. If a parent continually nags a child or teenager to do the same things, the child will not only refrain from doing what the parent is ostensibly asking for, but will studiously avoid doing so - or even do the exact opposite.

3. If a parent continually tells children or teenagers they have some trait, or lack some trait, the children will compulsively act out the trait they have been told they have, and/or will compulsively avoid doing anything that suggests they actually have any trait they have been told they lack.

So why is this? Well, if parents obsessively do something, children will conclude that they parents either need to do it and/or enjoy doing it, even if the parents repeatedly deny it. Actions speak louder than words. Far be it for any child to deprive a parent of a cherished role.

So, if the parents seem to like or need to nag or criticize, their children will continue to misbehave. If the parents compulsively state or predict that the child has or will develop a negative trait, their children will continue to prove them right. They do these things so that the parents will feel good about themselves, not because they enjoy have negative traits.

Tuesday, November 3, 2015

Where Psychotherapy Goes Wrong

In my post of November 4, 2014, I discussed something called the fundamental attribution error. As described by Richard Nisbett and Lee Ross, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.” That post discussed how this error results frequently in mistaken conclusions that are drawn based on studies of people with personality disorders.

It is also the main reason why psychotherapy has not really progressed much as a science in the last 25 years or so.  The 1980's and early 1990's were a period of amazing creativity in the field, during which new ways of looking at human behavior and new interventions to help change that behavior seemed to be coming out every day. In particular, family systems thinkers began to realize that the causes of behavioral problems like self-destructiveness, as well as the causes of symptoms like chronic dysphoria and anxiety, do not reside entirely within the heads of the people coming for help.  

Some of it can be a normal and adaptive response to a very abnormal interpersonal environment. The "attachment" literature, which is fairly strong, shows that kin behavior has a huge effect on the psychological stability and the relationships of all human beings.  Much more so, I always say, than the food pellets and electric shocks favored by behaviorists.

Due to the wide variety of independent factors listed in the masthead of this block, family systems ideas have, unfortunately, been left behind to a significant degree, and therapists are back to looking at people as if their problems were "all in their heads."

Critics blasted systems ideas by focusing disingenuously on areas about which family systems theorists were completely wrong - like the genesis of such real brain diseases as schizophrenia (and yes, the evidence that schizophrenia is truly a brain disease is overwhelming, so spare me the "myth of mental illness" bullcrap). They pulled the usual slick ploy of making arguments based on black and white thinking: if family systems theorists were wrong about some things, then they must have been wrong about everything.

Because the effectiveness of psychotherapy interventions meant to change interpersonal behavior are hard to prove in a treatment outcome study, the systems people were also accused of being unscientific. As if observation were not the first step in the scientific method! (So much for much of what we know about astronomy). "Outcome studies" were touted as definitive proof of various treatment methods, despite the fact that they are extremely limited in their overall validity because there are almost an infinite number of variables that cannot be controlled. And they cannot be double blinded. And the therapists who are participating are not all doing exactly the same thing.

And the studies that are touted show only exceedingly modest effects in those subjects who do improve, as well as showing that a significant percentage of subjects did not get better at all.

Then there is another important fallacy that psychologists discuss: confusing an inference about an observation with the observation itself. Or, in other words, jumping to conclusions, and then acting like the those conclusions are facts. Andrew C. Papanicolaou, Ph.D, a neurobiologist at the University of Tennessee Health Science Center where I used to work, observes,  "Scientific discourse is unique in that it aims to maintain clear distinctions among assumptions, hypotheses and facts and treat each of them appropriately. Although this aim is often attained, it is rarely attained fully and occasionally is not attained at all."

Especially in psychiatry and psychology.

There's this rather big issue of what is really going on with patients, as opposed to what looks like is going on.  If you do not think people have hidden ulterior motives for their behavior, secrets about themselves that they don't want to share, and lack a complete understanding of the behavior of all of those around them who affect their lives, then I am afraid you are living in an alternate universe.

But still, therapists observe their client's performance, and confuse it with ability, as described in a previous post. Even when therapists look at what is basically interpersonal behavior, they make this error. Good examples of this are two of the current "evidenced-based" therapies for borderline personality disorder (BPD), Schema Therapy and Mentalization-Based Therapy. Both posit that people have mental models of how to behave in the interpersonal world, as well as of the motives and intentions of other people in their world. 

In schema therapy, the theory correctly asserts that these mental models or schemas are built up in childhood through interactions with primary attachment figures. It then goes about trying to change those schemas that it identifies as "maladaptive."  Surely, they are maladaptive in some ways, but that they serve no adaptive purpose at all is just assumed.

Although these therapists have started to look at how the primary attachment figures of their patients are behaving in the present , I have not seen much about the fact that schemas are continually updated (through the Piagetan process of assimilation and accomodation) during a person's ongoing interactions with those attachment figures. To understand what is really happening, you also have to look at the schemas of those other people.  The schemas of the various players in the family drama interact with one another!

Mentalization therapy also deals with a person's mental models of the motivations and intentions of other people, but just assumes that the mental models of their patients with BPD are distorted. This is based entirely on the way the patients respond to others, while completely ignoring the motivations and intentions on which that behavior is based. Maybe the patient wants other people to think they have distorted mental models. Why? Because they are playing the role of spoiler. The incorrect assessment of the accuracy of the patient's mental models is confused with the feigned actions of that patient.

Sorry, but we cannot read minds. You have to look at both the behavior and the history of everyone involved, and even then you can get a highly distorted picture yourself. So therapists should quit accusing their patients of what they themselves are doing - distortion.

People who have a history together base their behavior on that entire history, not just what is going on at any particular moment.  And when they talk, they can leave a lot out (ellipsis) and still understand each other, because they both already know what both of them already know. An outside observer does not know these things, and therefore their conclusions based entirely on what is said in front of them can be way off.

Of course, it is true that a therapist can never be absolutely certain of anything. For that, you would not only need a movie camera with sound on all participants 24 hours a day like in the Truman Show, but this equipment would have to be in place throughout the entire lifetime of the patient since birth!  

Still, the more information therapists can gather on the whole picture, the more likely it will be that they will better understand what might be going on and figure out what can be done to change it.

But first, they have to stop their myopic focus on that which is going on entirely in the patient's head.

Friday, October 23, 2015

Double Standards for Brand Named vs. Generic Drugs in Literature Reviews: Use of Medication in Borderline Personality Disorder

In the free psychiatric "journal" Psychiatric Annals (Psychiatric Anals?) of August 15, 2015 - no doubt financed by PhARMA - one article correctly points out that studies on medications used for symptoms of Borderline Personality Disorder have been very small, extremely infrequent, very short-term, poorly controlled, and of limited usefulness. (And done without ANY consideration for comorbid disorders like panic disorder, which is seen in about 40% of subjects, I might add).

It also points out, again correctly, that there are no medications for the disorder itself, and that psychotherapy is the treatment of choice for that. Nonetheless, most of these patients do take medications for certain symptoms of the disorder: most usually the mood instability, irritability, and impulsivity that lead to such other problems such as self-injurious behaviors like cutting.

The review of the studies that have been done is fairly complete, although I notice that they left out an extremely important article on the use of Prozac for the symptom of "impulsive aggression" by Coccaro and Kavoussi from 1997.

During its rather limited review of studies of the use of antidepressants in the disorder, it says things like, "The authors found a reduction in anger among the fluoxetine (Prozac) recipients," "Fluvoxamine (Luvox) improved rapid mood shifts," "Sertraline (Zoloft) was more effective in decreasing symptoms of depression, hypersensitivity in interpersonal relationships, and obsession," and "superior efficacy for phenelzine (Nardil, and MAO inhibitor) on measures of depression, borderline psychopathologic symptoms, and anxiety."

In the summary of this part of the review, it nonetheless says, "No statistically significant effects were observed for the selective serotonin reuptake inhibitors (SSRIs) or phenelzine." So what on earth were those that they had just listed?

Yet, after discussing similar weak data for mood stabilizers, it makes the following summary: "RCT's (randomized controlled studies) involving the mood stabilizers were limited by low statistical power. Divalproex sodium (Depakote) shows an effect for anger and interpersonal sensitivity. Topiramate (Topamax) and lamotrigine (Lamictal) were found to have an effect on anger."

And for atypical antipsychotics, after reviewing even weaker evidence, the summary says: "Olanzapine (Zyprexa) has the most supporting data of the antipsychotics; studies have shown its use can lead to reductions in anger, paranoia, anxiety, and interpersonal sensitivity. Effects were found for aripiprazole (Abilify) on impulsivity, anger, anxiety, psychosis, and interpersonal problems."

Misleading double standard for summarizing the effect of brand-named versus drugs available as generics, ya think?

Tuesday, October 13, 2015

Antipsychotic Medication Used to Dope Up Unhappy Children.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anyway, here are the reasons as they described:

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

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

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

Friday, October 2, 2015

How to Fail at Family Problem Solving

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

There are a lot of ways to fail.

Tuesday, September 22, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. "It's impossible, it's nonsense, don't waste my time."
2. "Maybe it's possible, but it's week and uninteresting. It's clearly not  important."
3. "It's true and I told you so. I always said it was a good idea.
4. "I thought of it first."

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

Friday, September 11, 2015

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

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

As mentioned, I have been collecting the quotes and putting them on my Facebook fan page at The ones posted here started in January of 2014, and are loosely organized by topic. 

Family Dysfunction

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

Chronic Mental Illness

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

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

Psychiatric Practice, Electronic Medical Records, and Managed Care

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

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

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

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

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

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

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

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

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

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

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

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

Drug War

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

Psychiatric Diagnosis

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

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

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

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

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

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

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

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


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

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

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

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

Evolutionary Psychology

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

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