Saturday, February 18, 2017

Portrait of a Personality Disorder, Part 3: Cognitive Distortions in Cluster B Personalities

We all distort things in our heads.  If you're honest with yourself, you know you do.  We all have distorted memories of relationships and disagreements.  We all have distorted ideas about ourselves.  We all have distorted ideas about other people and other people's motives.

But here's the thing . . .  Some people distort more frequently and to a greater degree than others.  Some people cannot or do not acknowledge their distortions and do not even seem aware they might be distorting.  Like all disorders, Cluster B personality disorders are identified, not by unique traits or behaviors, but the frequency, severity and impact of certain traits and behaviors.  The cognitive distortions seen in Cluster B personalities have a direct impact on how an individual relates to other people.

Human relationships are, by and large, reciprocal phenomena.  There is give and take.  And, there is a feedback loop.  I say something nice to you, you say something nice to me, and we both feel good.  Or, I say something mean to you, you return the favor, and we both feel bad.

With Cluster B personalities, the feedback loop is broken.  The short circuit is a defense mechanism in which the individual unconsciously or semi-consciously edits their awareness of their own behavior in such a way to protect their perception of themselves.  The result is an individual who sees themselves as always the victim (as in Borderline Personality) or always the better person (as in Narcissistic Personality).  Perceptions of other people are not anchored in objective observation but, instead, are wildly changeable based on how the other person makes the personality disordered individual feel at any given time.

Lucy's distorted perception of the same interaction?
Lucy of Peanuts provides us a nice illustration of the principle of distortion and the effect it has on relationships.  Now, how about we look at a real life example, say, a recent example?  Here is an excerpt from Thursday's presidential news conference:
QUESTION: . . . You said that the leaks are real, but the news is fake. I guess I don't understand. It seems that there's a disconnect there. If the information coming from those leaks is real, then how can the stories be fake? 
TRUMP: The reporting is fake. Look, look . . .And I'll tell you what else I see. I see tone. You know the word "tone." The tone is such hatred. I'm really not a bad person, by the way. No, but the tone is such -- I do get good ratings, you have to admit that -- the tone is such hatred. . . .But the tone, Jim. If you look -- the hatred. The, I mean, sometimes -- sometimes somebody gets...Well, you look at your show that goes on at 10 o'clock in the evening. You just take a look at that show. That is a constant hit. The panel is almost always exclusive anti-Trump. The good news is he doesn't have good ratings. But the panel is almost exclusive anti-Trump. And the hatred and venom coming from his mouth; the hatred coming from other people on your network. . . I -- I think you would do much better by being different. But you just take a look. Take a look at some of your shows in the morning and the evening. If a guest comes out and says something positive about me, it's -- it's brutal. . . .Tomorrow, they will say, "Donald Trump rants and raves at the press." I'm not ranting and raving. I'm just telling you. You know, you're dishonest people. But -- but I'm not ranting and raving. I love this. I'm having a good time doing it.But tomorrow, the headlines are going to be, "Donald Trump rants and raves." I'm not ranting and raving.Go ahead. . . . 
QUESTION: Just because of the attack of fake news and attacking our network, I just want to ask you, sir... 
TRUMP: I'm changing it from fake news, though. 
QUESTION: Doesn't that under... 
TRUMP: Very fake news. 
QUESTION: ... I know, but aren't you...(LAUGHTER) 
TRUMP: Go ahead. 
QUESTION: Real news, Mr. President, real news.. . . But aren't you -- aren't you concerned, sir, that you are undermining the people's faith in the First Amendment, freedom of the press, the press in this country, when you call stories you don't like "fake news"? Why not just say it's a story I don't like. 
TRUMP: I do that. 
QUESTION: When you call it "fake news," you're undermining confidence in our news media (inaudible) important. 
TRUMP: No, no. I do that. Here's the thing. OK. I understand what you're -- and you're right about that, except this. See, I know when I should get good and when I should get bad. And sometimes I'll say, "Wow, that's going to be a great story." And I'll get killed.I know what's good and bad. I'd be a pretty good reporter, not as good as you. But I know what's good. I know what's bad. And when they change it and make it really bad, something that should be positive -- sometimes something that should be very positive, they'll make OK. They'll even make it negative.. . . as an example, you're CNN, I mean it's story after story after story is bad. I won. I won.

Here, like Lucy, we have an individual who sees himself as a victim and simultaneously better than, a clear sign of a narcissist (more on that later). And, like Lucy, he is seemingly oblivious to his part in any contentiousness. You can see the distortions all serve to bolster, not just the image of the man, but more specifically, his self-image.

This is a clear and beautiful example of a neurotic process expressed publicly and recorded by worldwide news outlets.  It is less an argument than the man's internal process expressed outwardly, for he is not attempting to convince his audience of his greatness and their badness so much as his argumentation serves to reinforce his internal beliefs.  By stating his distortions externally, they become more real for him internally.

And, this is exactly what is so challenging about relating to and attempting to have a reason-based conversation with someone with a Cluster B personality type.  There is no real give and take.  The disordered individual is simply having an argument with himself or herself, and, while you may be the target, you cannot meaningfully take part in the manner you are used to if you are expecting a reciprocal give-and-take relationship.

Portrait of a Personality Disorder, Part 2: What Are Cluster B Personalities?

So, we have ten standard personality disorders and they are grouped into three clusters, A, B, and C.  Here, we are going to focus on cluster B, arguably the most difficult and controversial of the three clusters, but before we dive in, lets take a quick glance at A and C, and get that out of the way.

Cluster A is the "odd duck" cluster of personality types.  These are clustered together because they share certain attributes and characteristics.  To a layperson, seeing someone with a Cluster A personality on the street, you might assume that person is seriously mentally ill.  They might keep to themselves, they might be dirty and unbathed with an unkempt look, they might be wearing a heavy coat in the middle of a warm summer, they might act paranoid.  Basically, they look mentally ill.  The only thing is, they aren't.  There are no delusions, no auditory hallucinations, no manic episodes.  This is a person who has separated themselves from society and from normative social standards.  They have made themselves social isolates, and there they stay (unless there is a dramatic change to their personality at some point).  The specific Cluster A disorders are Paranoid Personality, Schizoid Personality, and Schizotypal Personality Disorders.

Cluster C is the anxious and fearful cluster of personalities.  These are people whose personalities and habits have been shaped by lifelong anxiety and fear, resulting in avoidance, dependence on others, obsessiveness and compulsive behaviors.  These are personalities that could be associated with the popularized version of neurosis--bundles of worries with irrational behaviors.  The specific disorders are Avoidant Personality, Dependent Personality, and Obsessive-Compulsive Personality Disorders.  Please note that Obsessive-Compulsive Personality Disorder is distinct from Obsessive-Compulsive Disorder per se, which was categorized as an anxiety disorder in DSM IV but in the 5th edition was placed in the new category of Obsessive Compulsive and Related Disorders.  The very brief explanation of the difference is that OCD per se is more severe and has a higher subjective experience of distress, whereas the personality disorder is characterized by a person who finds comfort in the OCD type behaviors and therefore is not usually motivated to change.

And, now, what we are really here for, Cluster B personalities.  These are your worst nightmares, as a therapist.  These are people for whom everyone else is wrong.  Everyone else is at fault.  They are blind to their own role in the making of their misery.  Their behaviors are motivated to manipulate and use others while seemingly unaware of what they are doing.  They have deep seated defense mechanism and are rarely motivated to change.  After all, why should they change when they're never at fault?  It's your fault.  You made me this way.  You change.

Cluster B personalities are familiar to everyone, but they are notoriously difficult to define and understand.  The characteristics that make up these personalities are somewhat disparate, and yet they appear together as a pattern again and again.  You will rarely find Cluster B defined or described as a whole, because it is so difficult for people to get a conceptual grip on it.  The APA's diagnostic manual, keeping it simple, describes Cluster B thus, "Individuals with these disorders often appear dramatic, emotional, or erratic."  That's it.  That's what the DSM has to say on the subject.  The UK's NHA describes Cluster B thus, "Someone with a cluster B personality disorder struggles to relate to others. As a result, they show patterns of behaviour (sic) most would regard as dramatic, erratic and threatening or disturbing."

I'm sure I can't expect to do better than the APA or the NHA, but here's my best shot . . . (1) thinking is characterized by cognitive distortions in the form of strongly developed defense mechanisms in which the individual fails to recognize the negative impact to them from their own actions and behaviors (more on this next time), (2) excessive use of out and out dishonesty and subterfuge, (3) actions and interactions frequently tied to secondary gains (i.e., attention seeking behavior), (4) excessive emotional reactions, and (5) apparent lack of substantive empathy (but superficial empathy may be expressed).  These personality disorders, besides having some common characteristics, are conceptually tied because there is a fair degree of co-morbidity.  In other words, it is not uncommon to find someone, for example, who has a combination of narcissistic and anti-social traits.  And this holds true for all four Cluster B disorders.

In this cluster, we have Anti-Social Personality Disorder.  This is very broadly defined disorder that accurately describes just about anyone who has found themselves up against the criminal justice system more than once.  It is more widely known by the older term of psychopathic personality.  It's characteristics include lack of empathy, lack of stress reaction to violence, dishonesty, disregard for the safety of self and others (but, especially others), lack of remorse, impulsivity, consistent irresponsibility, etc.  One point I would like to emphasize is that anti-social types often fail to plan or think ahead.  This, of course, is tied to impulsive behaviors, lack of ability to get one's needs met through normative behaviors (e.g., holding a job and budgeting your money to pay rent), and lack of concern about consequences (because cognitively the individual is trapped in the moment, they seem blithely unaware that tomorrow is going to happen).

Then there is Borderline Personality Disorder.  This is the most difficult to understand and relate to, but we see this pattern of behavior quite frequently in the mental health system.  With this personality profile, you often see intense emotional reactions, misunderstandings, the individual frequently attributes negative motivations to others, self harm behaviors (e.g., cutting), suicidal gestures, suicide attempts, intense anger (but often masked), and highly unstable relationships.  Being in any kind of relationship with such an individual can be very difficult due to the constant manipulation and polar emotional swings between clinging and anger.

Histrionic Personality Disorder is the least often diagnosed of this cluster.  Many clinicians and researchers have questioned the validity of this diagnosis, but I think it is more accurate to say it is an anachronism in the sense that it is an idiom of emotional distress that was common in the cultural context of the past but is much less common now.  To give you a sense of the flavor, criteria include (1) Is uncomfortable in situations in which he or she is not the center of attention, (2) . . . inappropriate sexually seductive or provocative behavior, (4) . . . uses physical appearance to draw attention to self, (6) shows self-dramatization, theatricality, and exaggerated expression of emotion.  Et cetera.

And, lastly, we have Narcissistic Personality Disorder.  It's been splashed all over the news, of late.  Most people already have a sense of what narcissism is, but that concept is not necessarily the same as the personality disorder.  Anyway, I'll save this one for a later, dedicated, blog post.

In our next installment we'll try to get a grip on those pesky Cluster B cognitive distortions that are so damn crazy making.

Portrait of a Personality Disorder, Part 1: What Is a Personality Disorder?

Can a personality be an illness?

Well, not exactly.  Everyone has a unique personality.  And, some are more likable than others, I suppose, but when and how is it appropriate to slap the "disorder" label on someone's personality?

In answering this question, it is important to understand that all mental disorders, including severe disorders such as schizophrenia, are defined by behaviors and/or inner states that cause distress or dysfunction for the individual or for people around them.  This concept is true of the larger medical field, as well.  Take for instance the individual with six digits on each hand.  It is an unusual condition, yes, but do we consider it an illness?  No, nor should we (unless of course, having six fingers is excessively distressing and dysfunctional or you simply want to say it is so the insurance will pay for surgical "correction," but that's a wholly different blog post, for another day).  On the other hand, being born with the inability to produce blood clotting components is considered a disease for the simple fact that it will lead to a quick demise unless treated.

Biologically, every individual is unique, and the human population presents a vast range of phenotypes.  Disease cannot be defined by deviation from the norm, alone, but must be defined by impact, dysfunction, pain and death.  This is even more true with mental disorders.  We cannot pathologize based on what looks different or anormative, alone.  We have to limit our determination of disorder to the impact of behaviors and inner states, i.e., distress and dysfunction.  And, this is even more important when discussing the pathology of personalities.  Why?  Because, it is far too tempting for us to label people we don't like or don't understand as disordered.

According to the American Psychiatric Association (APA) in the latest diagnostic manual (DSM 5), "A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" (emphasis mine).

This definition attempts to limit the idea of personality disorder within strict parameters, but let's face it, it's still wide open.  The DSM 5, like its predecessor, the DSM IV TR, then goes on to list 10 specific personality disorders grouped into three clusters, A, B, and C, and an eleventh, "unspecified" personality disorder for personalities that meet the general definition but do not meet criteria for any one of the 10 specific disorders.  Lastly, there is a disorder for personality change due to a medical condition.

Personality disorders carry some controversy in the field and some clinicians simply refuse to acknowledge them or diagnose them, but this is the minority of clinicians, I think.  I too was very skeptical as a new clinician, but over two decades of working with a wide variety of clients, I have come to recognize there really are some distinct patterns of personality dysfunction and pathology, and it does us no good to pretend it does not exist.

Personality disorders are categorically distinguished from major mental illness.  This idea goes back a ways, well before Freud, even.  The personality disorder idea is the intellectual descendant of the concept of moral insanity.  This was a diagnostic category proposed in 1835 by a certain Dr. Prichard.  He defined it as "madness consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses, without any remarkable disorder or defect of the interest or knowing and reasoning faculties, and particularly without any insane illusion [delusions] or hallucinations."  It remains an important distinction that personality disorders are defined by cognitive distortions and aberrant behaviors and emotions as opposed to cognitive impairment or delusions or hallucinations as these are indicative of major mental illness.

Well, there's a nice little overview.  Not too boring I hope.  In the next installment, we will take a big bite into Cluster B types and figure out why they leave such a bad taste in your mouth.  Then, we'll examine what we mean by cognitive distortions and why it leaves you wondering if you're the crazy one.  Finally, we will narrow our focus on narcissists and what you can do when your family member, or your boss, or your president has this personality disorder.

Wednesday, November 6, 2013

Making Our Children Conform Using Mental Trickery

Here is an absolutely excellent article by Elizabeth Weil in the New Republic in which she analyzes the increasing use of various therapeutic techniques to get kids to conform to expected classroom behavior. It is a more subtle but insidious form of pathologizing children who are being normal children.  Much of it is predicated on the now well known delayed gratification studies of young children.  You've heard it before--the test child is told not to eat the marshmallow in order to get two marshmallows in a few minutes.

Everyone who has a child with childhood impulses is immediately struck by inner fear.  Is my child the one who can't wait?  What does this mean for her/his future career?

Now this is the basis for all kinds of behavior modification schemes used in schools.  The problems Weil outlines include that (1) we are telling our children they are mentally sick or wrong, and (2) the empirical evidence does does not support the actual interventions being used.

It is yet another case of wanting to believe this is the right way to do things because it sounds good.

Please take a look, it is worth the read.

Wednesday, October 9, 2013

Seeking Safety from Trauma

Over the last decade we have seen a deluge of spilled ink and sermons delivered on the topic of Trauma (capital letter intended).   Therapists and other clinicians are wont to see Trauma as the cause of all mental/emotional distress and disorder.  Payers and regulators want to see Trauma informed care as the standard for all services.

Please don't misunderstand and think I am about to argue against trauma as a factor of etiology.  I am not.  Please do not think I am going argue against trauma sensitive care.  I am not.

I do, however, have to take issue with a number of things.  One of which, I will briefly introduce here, is an intuitive response to emotional trauma (or the vision of Trauma in the mind's eye of the therapist).  I have noticed a tendency among my colleagues to fix Trauma through the exclusive use of invoking Safety (capital letter intended).

What is Safety?  It is a mythical destination we point people to who we believe are wounded by emotional trauma.  In its simplest and cliched manifestation, it is the "safe place" we tell people to go to inside themselves when they are distressed by Traumas past or current.  In its most Utopian manifestation, it is the construction (socially and physically) of a space (or whole communities) designed to remove all sources of trauma and reminders of trauma.  A Safe place is a place where people speak to each other exclusively in soft and supportive tones.  A Safe place has no rules to remind us we are not in control.  In a Safe place no one tells me I am wrong.  A Safe place is a place without "no".

The idea of creating Safety seems to come to some practitioners by intuition and without need for training.  For other practitioners (e.g., Sandra Bloom) it is a treatment model that is bottled, trademarked and sold, but more than that it is a morally driven world view.  It is true by faith and has to be defended against the unbelieving (read: medical model).

Why do we need to create Safety?  Because Trauma doesn't just hurt in the moment, it continues to harm day after day, year after year.  Life's little annoyances and disappointments are more than they are.  They are reminders of the Trauma.  Triggers and re-triggers.  It harms even when the individual has no idea it continues to harm.  Why?  Because the clinician believes.  Sometimes the individual doesn't even know they were Traumatized.  In those cases, the true believing therapist has to help the individual remember . . . (we know where that leads).

That's the reasoning for it.  I can't fault the premise (that psychological trauma hurts), but I doubt the conclusions.

So then, does creating a Safe place help?  I feel the need to ask, if only because so many around me seem to take it on faith.

I haven't come across so much empirical evidence apart from the some apocryphal study about mice and cat hairs.  But maybe this Trauma-Safety dilemma has a corollary in Happiness?  Seeking Happiness for the Sad seems like a very similar impulse to me.  And in that realm I think we do have some evidence that tells us it is a fool's quest.  Turning Sadness into Happiness through the power of affirmations, replacing negative self talk with positive self talk, while intuitively sensible, turns out to be the psychological equivalent of trying to catch a rainbow.  Every time I tell myself I'm beautiful and smart and wonderful, the opposites of those things echo in the mind and I have to increase my affirmations louder and louder to myself, but in the end, affirmations in a vacuum do not lead to Happiness.

Could the quest for Safety be a similar fairy tale?  A nagging doubt tells me so.   The fact that no one questions it, makes me worry all the more.
  • Focusing so exclusively on Safety paradoxically highlights an individual's vulnerability.
  • Focusing so exclusively on past Trauma reifies victimhood and takes the person out of the here and now.
  • By focusing on victimhood we take away a person's agency.
  • By focusing on the past we can't change, we forget the here and now where a person actually does have the power to change things.
  • By externalizing cause and effect we have taken all control away from the person.
Considering these things, is it any wonder that we see so many people taking part in this therapeutic approach sink deeper and deeper into dysfunction?

Monday, September 9, 2013

Autism's Tipping Point

Besides being an expert at neuroscience, to the benefit of the greater good neuroskeptic also dabbles in cultural criticism of science and healthcare with an eye toward empirical observation of the ethnocultural processes of those areas.  A bit of armchair social science, but well done.

His latest piece on the phenomenal growth of autism:

Many have observed the unnatural increase in autism over recent years.  In the midst of this apparent epidemic, news stories push "autism awareness" and "promising findings" about the cause(s) of autism.

Among practitioners, among psychiatric naysayers, among the small community of social scientists who make medicine, psychiatry and science their field of study, there has been much conjecture about the sociocultural factors behind the growth.  The usual conclusion based on observation and/or conjecture, is that the incidence of the underlying condition has probably not changed dramatically, but instead we are seeing an expanding practical definition of autism as interpreted by clinicians in the field.  You can add to this the fact of heightened awareness of the diagnosis resulting in people (clinicians, parents, teachers, etc.) seeing it where they didn't see it before (rightly or wrongly).  This, in the context of a loosely defined spectrum disorder that (like all mental health diagnoses) is determined by a check list of behavioral signs and indicators allowing for broad differences of interpretation and understanding.

Sadly the places and people with money to pay for research don't seem particularly interested in putting resources into resolving this question.

Lucky for us we have a guerrilla social science researcher in neuroskeptic who counted the number of research papers (via PubMed) on the subject of autism, relative to several other disorders.  He found that autism research has increased eight fold in 12 years, about twice the rate of ADHD (the next highest growth disorder) and maybe 4x (about) the growth of schizophrenia research.  It is hugely out of proportion to the 4% growth in science (as a whole) per year.

I might take it a step further and just state what has been clear over the last 150 years or so of psychology and psychiatry--the field, popular and professional, is driven by fads.

Monday, August 12, 2013

Peers of the Mental Health Realm

The last decade has seen a flood of peer counselors in the public mental health system in the U.S., the basic idea modeled, if loosely, on the the practice of recovered addicts becoming counselors in the alcohol and other drug (AOD) treatment field.  In mental health it has the added gain of making public mental health treatment a more humane and understanding place.  Psychiatric survivor activists have long called for this move.  If services are provided by counselors who have themselves experienced mental health problems and have been on the receiving end of services, then services will inevitably be rendered in a more sensitive and user-friendly manner.

These things are true as intended, but I feel the need to point out there is also a dark tangled mass of contradictions, uncertainty, and politics that inhabit the practice of peer counseling like a hidden cyst threatening to break open and poison the entire initiative.  As always, I find myself the voice of doom and gloom in the fantasy land of Mental Health where fake positivism, false prophets, and general quackery goes hand in hand with unicorns, pixies, and evidence base practices.

Peer counselors come to the public mental health field like faerie-activists waving their magic "recovery" wands.  They go to the dark places of mental health--think Shutter Island, Sucker Punch, One Who Flew Over the Cuckoo's Nest, and hundred other examples--and these peers turn the dark places into sunlit gardens of recovery with doors broken open to let the sunlight in and to let the inmates out to discover they were never mentally ill to begin with--it was all a lie made up by psychiatry and Big Pharma.

The only thing is, it’s just another lie really.  Let me give you a smattering.

1. Peers do not necessarily have special insight into the experience of individual mental health system users.

Mental health peers are self defined.  It has to be so for simple legal reasons.  A prospective employer is not permitted to ask about an applicant’s disability.  It is contingent upon the applicant to decide if she or he is or is not a mental health peer.

In the AOD field, addiction disorders are a straightforward set of behavioral categories that are bound by a single phenomenon: addiction.  Straightforward, relative to mental health anyway.  By contrast, mental health disorders cover so vast an array of human behavior patterns so as to be absurd.  What does it mean to be a mental health peer?  Does someone who experienced adult attention deficit have some kind of special insight into what it’s like to experience schizophrenia?  Or vice versa?  If that seems like a stretch, it’s because it is.

Imagine, if you will, a world in which medical peers--people who have experienced medical problems and have received medical treatment in their lifetimes--replace nurses in your doctor’s clinic.  Will a medical peer who has experienced medical treatment for eczema have some special understanding, gleaned from experience, into the medical needs of a patient with necrotizing fasciitis?  Sound preposterous?  Why then is the idea of mental health peers any less preposterous?

2. In mental health, recovery is a word without meaning.

One of the basic rationalizations for peer counselors is that a peer is a living example of recovery, a person with a mental health condition who has persevered, and met their therapeutic goals, and now can work productively as a peer counselor.

It stands to reason.  This rationale works very well in AOD services where peer counselors are the norm.  In that field, peer counselors have beat their addiction--they are in recovery--and they can help other addicts on the path to recovery through the wisdom of their experience.

Okay, that’s all well and good.  But.  In the AOD field, recovery is black and white.  You are either using, or you aren’t.  Recovery is tested and assured by urinalysis.

If you think mental health has a standard of recovery, you are mistaken.  Recovery, like the peer identity itself, is entirely self defined.  Anyone, and I mean anyone, can walk through the door and proclaim they are a peer and they are in recovery.  There is no testing and such claims are accepted at face value, at least at time of hire.  This literally true.

Sadly, I have seen peer counselors (and therapists and psychiatrists for that matter) with untreated axis II disorders do great harm.

3. The sudden, poorly thought-out growth in peer services is driven by feel-good politics.

This true statement does not discount the possibility of benefit from having peers working in the system, but, it does tell us something about the process that led to the current situation and can illuminate how preventable problems were allowed to fester.  The peer counselor initiative may have a grassroots origin in the consumer/survivor movement, but it came to fruition because of state legislatures and state level department heads made the decision that peer delivered services is a good thing and made it so through law and regulation that, if not mandates, at least incentivises the practice in many states.

System changes driven at the state level are seldom well considered.

4.  And it is powered by cost cutting.

Medicaid reimbursement for services delivered by a peer counselor is considerably less than reimbursement for services provided by bachelors and masters level clinicians.  This impacts state budgets.

Need I say more?

Sunday, February 24, 2013

The Folly of DID

Not that I've been there myself, but I understand if you travel through England you might come across some of these apparent medieval towers or castles in various states of ruin.

Except that they aren't medieval and they aren't ruins.  They were built to look like ruins.  Many of them were constructed in the 18th and 19th centuries by persons with excess wealth and imagination.  A little bit of deception for someone's amusement.  They refer to them with the term folly.

That brings us to Dissociative Identity Disorder, AKA multiple personalities . . .

I just came across this good review of the DID controversy by Dr. August Piper:

The Persistence of Folly: A Critical Examination of Dissociative Identity Disorder. Part I. The Excesses of an Improbable Concept

Here is an excerpt:

With the recent appearance of several critical articles and books, the concepts of dissociative amnesia and dissociative identity disorder (DID) have suffered some significant wounds (1–5). Between 1993 and 1998, the principal dissociative disorders organization lost nearly one-half of its members (1). In 1998, Dissociation, the journal of the dissociative disorders field, ceased publication. A paper published in 2000 examined the weaknesses in the dissociative amnesia construct (6). Various dissociative disorder units in Canada and the US (for example, in Manitoba, Illinois, Pennsylvania, and Texas) have been closed down. US appellate courts have repeatedly refused to accept dissociative amnesia as a valid entity (6), and several ardent defenders of dissociative disorders faced criminal sanctions, malpractice lawsuits, and other serious legal difficulties.

Nevertheless, despite the significant harm these concepts have wrought in North America, some Canadian and US practitioners continue to support, and practise according to, dissociative disorder concepts (7–9). Further, these North American countries export the concepts. In India, for example, the cinema has influenced the production of dissociative signs (10), and 4 recent papers demonstrate a recurring interest in spreading awareness of DID to other countries (11–14).

and on it goes.

Like the follies built by the idle rich of the romantic period, DID is not simply wrong, it is a fantasy people want to believe and proliferate.

Saturday, December 29, 2012

Mental Illness and Danger: The Data

Yet again, Neuroskeptic delivers well vetted empirical data on topic and, as if, on cue.  In this case a massive study in Australia exploring the statistical links between crime and mental illness.

Sunday, December 23, 2012

Mental Health or Gun Control?

[accidentally deleted this post, so I'm reposting]

Public discourse, political, media, whatever, likes to frame things in dichotomies, false or otherwise.  No wonder that in the wake of yet another tragedy we seem to hear we have a choice with two options.  Limit access to military style weaponry or provide more mental health services.

I don't like forced choice questions.  Usually makes me feel like I'm being railroaded.  Usually is the case too.

Just a few thoughts on the mental health side of the equation.  People on both, or all, sides of the political spectrum are generally supportive of increased mental health services when something like this happens, but few people are aware of what that means or the issues involved.

Here is just an outline of a few things people should be aware of.
  • Not every mental health problem can be resolved by talk therapy (an understatement)
  • Not every mental health problem can be resolved by medication (another understatement)
  • Except under very legally circumscribed circumstances, we, as a society, cannot make people visit and talk to a therapist.
  • Even where we can legally compel someone to see a therapist, we can't compel individuals to care or to want to change or to benefit from therapy they don't want.
  • Likewise, we cannot compel most people to take medications even if we think they are very not sane.
  • When we can compel someone to take medications, it may not actually help much, and may have severe repercussions for the individual (side effects up to and including death, psychological and physical trauma from restraints and forced injections).
  • Civil commitment laws (or interpretation of them) have drifted toward the individual liberty side of the equation.  This is in no small degree a result of historical abuses in the mental health system.  It likely also reflects shifts in the overall sociopolitical zeitgeist.
  • We generally cannot civilly commit, and thus compel treatment and seclusion, unless someone has already engaged violently or they have made credible threats.  There are times when individuals with mental health problems plan violent actions and choose not to broadcast their intentions to mental health professionals.  In these cases it is very hard to predict and even where we have concerns there is often very little we can do.
This continues to be the state of the field when it comes to extreme mental states and available interventions
It saddens me deeply every time I talk to some parent who has come to me believing I will be able to intervene with their adult son or daughter with a psychiatric disability and I see the relentless disappointment on their faces as I explain to them the limitations of what we can do to intervene with an adult who does not want help.

Just so everyone knows.  Increasing availability of mental health support may be a good thing and it may help, but it will never be a complete solution to protect us and our children from rampages and violence.

addendum -- Oregon is now looking at increasing civil commitment from six months to two years after a Eugene police officer was gunned down by a woman in a psychotic and paranoid mental state.  I happen to think this is the wrong approach.  Lengthening commitment would have made no difference to the death of the officer.  The real rub is what it takes to place a hold and then commit someone.  If the legislators want to make a difference, they will need to look at that issue instead.

Tuesday, August 21, 2012

A Buffet of Childhood Diagnoses

I just want to promote this very good post on Neuroskeptic on the North American epidemic of diagnosing young children with the adult disorder of Bipolar and the American Psychiatric Association's attempt to fight this problem by writing yet another childhood disorder into the DSM-V.

Psychiatrists: Does Fire Put Out Fire?

What is it about North America that we want to believe all our children are mentally sick?

Monday, August 20, 2012

Dissociation, DID, Culture, and Empirical Evidence

Dissociation is some kind of human phenomenon that crosses time and place in the human experience.  Most forms of dissociation occur in the context of religious ecstasy.  There are many many examples.  Umbanda in Brazil.  Indigenous Taiwanese healers.  Balinese ritual trance (people have been know to go into spontaneous trance states even working in factories in Indonesia).  Pentecostal direct experiences with the Holy Spirit.  Speaking in tongues.

Umbanda trance

The list goes on.  But, we find that dissociation manifests differently in different cultural contexts.

Dissociation itself is not what is in question, but Dissociative Identity Disorder (DID), previously known as multiple personalities, is.

In North American culture, dissociation generally manifests, if not in a tent revival, than in the context of hypnosis or with the patients of certain therapists with proclivities for the promotion of DID.

Does DID occur universally or is it a product of the North American culture of psychopathology?  We already know that mental health disorders can be a product of cultural place and time.  Hysteria in Victorian Europe and America is one well known example.  Neurasthenia in China is another example that has been written on extensively.

Is DID another disorder that is not universal but tied to the Zeitgeist of a particular place an time?  Right now the field of mental health is in an intellectual tug of war on the topic.  We have the historical record that gives us some insight.  The concept of multiple personalities appeared early on in the development of the field of psychology, but it was an extremely rare diagnosis up to a certain point.  That point was the publication of "Sybil" in 1973 and the subsequent film adaptation.  This was the story of Shirley Mason, AKA Sybil Dorsett, who claimed to have multiple personalities, (and later said she made the whole thing up to please her therapist, and then changed her mind again).  After the popularization of multiple personalities by "Sybil" it became a mainstream diagnosis and has benefited from several waves of popularity since.
Sally Field acting
Shirley in youth
"Sybil" acting?
Dr. Richard J. McNally, et al., has now provided us with an empirical window on the topic.  He crafted a controlled study to test a fundamental basis of the DID construct, the amnesic barrier.  The amnesic barrier being the concept that as a DID identified individual transitions from personality to personality, the one personality has no direct memory of the other personality or personalities.

These researchers used a concealed information task that consisted of flashed words on a screen in which subjects were instructed to push "yes" or "no" based on whether or not the word was on a list.  What DID identified subjects did not know is that some of the words flashed on the screen were taken from surveys conducted with at least two of each of their personalities.  The words were specific to the personalities, such as the name of a friend or a favorite food, for instance.

The crux of the study was on a microsecond lag in pressing the button related to words autobiographical to the personality.  This occurred as expected.  Unfortunately for the construct of DID, the same delay occurred for words related to alternate personalities (not currently present/aware personalities), showing that knowledge crosses alternate personalities, undermining if not disproving the amnesic barrier.  It also implies, if not deception, at least an attempt on the part of the subjects to conform to the cultural model of DID.

McNally concludes that "Cultures provide envelopes for people to express suffering or psychological pain and DID is one such cultural trope. . . . I don't think much would be lost if the diagnosis were eliminated from the Diagnostic and Statistical Manual."

Source:  "A story that doesn't hold up" in the Harvard Gazette

Original paper is on PloS ONE here

DID in defense of crime: the case of William Bergen Greene and his therapist

mugshot of William Bergen Greene
William Bergen Greene was a troubled man who started with a troubled childhood.  He apparently suffered severe abuse as an early child until he was made a ward of the state at age eight.  He suffered further abuse in foster homes and institutions.  At age 17 he escaped from his institution and started his adult life of chronic criminality.  He was so frequently convicted of sexual offences that he spent the vast majority of his adult life in prison.  He remains incarcerated today in Washington State.

He became a prison sex offender patient after a 1988 conviction.  His prison sex offender therapist, known to the public only by the initials M.S. (because she later became another victim of Mr. Greene's many sex offenses), was the first to diagnose him with Dissociative Identity Disorder (DID) otherwise known as multiple personalities.

Her course of therapy started with hypnosis.  With this extremely questionable (if not negligent) technique she proceeded to draw out (or co-develop) some 24 personalities in her patient, not the least of whom were "Auto," a non-human robot personality, and "Smokey" the dragon.  Yes, a dragon personality.

Another therapist at the prison disagreed with M.S.'s diagnosis.  Instead he diagnosed Greene with Malingering.  Incidentally, malingering is listed and described in the psychiatric diagnostic manual and is designated with code V65.2.  V-codes generally indicate a diagnostically important factor or condition that is not itself a disorder.  Malingering, of course, is not a disorder that is treatable under Medicaid but is described as "the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives."  Typically, external incentives have to do with financial gain, or avoidance of responsibilities or consequences.  In this case, Greene was already convicted and incarcerated.  The dissenting therapist warned that Greene's malingering was motivated by his life-long pursuit of sexual victims.  He warned that Greene was setting his therapist, M.S., up for a future assault.  The dissenting therapist's assessment proved to be prophetic, but sadly failed to influence M.S.  Not only did she continue her work treating Greene's purported DID, she seemed to become increasingly close to her patient.

Greene was released from prison in 1992.  Within days of his release, M.S. quit her job at the prison and took Greene on as a private patient.

Was it coincidence that she quit immediately after his release?  I can't say, but it is suggestive of a therapist who was severely enmeshed with her patient.

She met him for therapy on a routine of bi-weekly sessions, but if so, they must have been extremely long sessions, because by the end, when he finally assaulted her in 1994, she had racked up over 2000 hours of therapy with this single patient.  By comparison, standard out-patient therapy is generally in the range of 12 to 54 hours of therapy per year.  Yet more evidence of enmeshment if not outright obsession on the part of the therapist.

M.S. received a phone call from a distressed Greene on April 29, 1994.  She knew he was under stress from several things and she was worried he might be suicidal, so she went to meet him at his apartment.  He was talking very slowly with a childlike voice.  He kept referring to himself as "we."  I will add here, the "royal we" is a common trait or affectation among DID patients and it seems unlikely it was the first time he used it in M.S.'s presence but later, in court, she would use it as one of the evidences of his personality fragmentation at the time of the crime.

At some point, as M.S. tried to console the oddly behaving Greene, alone with him in his apartment, she figured out that he was on cocaine.  In a moment of good judgment, she chose to leave.  Unfortunately for her, he barred her way out.  They struggled and M.S. fell.  He ripped off her shirt and bra and touched her, ignoring her protestations and clear statements for him to stop.  He took her to the bathroom and held her there for two hours.  He continued to molest her there, taking breaks only to shoot up a drug, presumably cocaine.  Throughout this incident, Greene's behaviors were later described by M.S. as childlike with frequent but brief bouts of crying. Near the end he removed his own pants and touched himself but failed to achieve a result and soon after said she could go, but when she tried, he changed him mind, tackling her and left her bound and gagged as he removed himself from the scene in M.S.'s car.

Once Greene had fled, M.S. was able to remove her bonds and escaped to a hospital across the street where she called the police.  Greene was soon apprehended and charged with kidnapping and indecent liberties.

Greene plead not guilty by reason of insanity, but in his first trial, Judge Thorpe ruled that DID could not be used in an insanity defense due to lack scientific consensus on the existence of the disorder.  The defense attorney, David Koch, was not permitted to even mention DID.  Greene himself assisted his defense attorney, telling his attorney that one of his alter personalities was trained in law.  Without DID as a defense, the case rested solely on whether or not Greene had committed the deeds.  He was quickly found guilty on both counts.

In 1998, Greene and Koch appealed to the Washington Court of Appeals.  Appeals continued back and forth up to the U.S. Ninth Circuit Court and, in the end, he was granted a retrial.

A pre-trial hearing was held to determine if DID could be used as an insanity defense.  The defense team brought in expert Dr. Robert B. Olsen who testified that DID was generally accepted in the field but conceded after interviewing Greene, he could not say who Greene really was much less determine his sanity due to the number of alter personalities.  The prosecution brought in their own expert, Gregg J. Gabliardi who failed to challenge DID, stating that he agreed it was generally accepted.  His only contribution to the prosecution was to testify that it would be impossible to determine the sanity of each separate personality or determine which personality was responsible for which of the actions Greene had taken.

This was clearly a low point in the field of psychiatry when two psychiatrists under oath fail to mention any controversy related to this diagnosis.  One wonders if Olsen or Gabliardi had in fact believed they could determine guilt and responsibility of one specific personality out of 15, what the criminal justice system would be expected to do with that information?  How do you incarcerate one personality out of many?

With the given experts, it is not surprising in the retrial the defense was allowed to use DID as an insanity defense to claim that Greene was not legally responsible for his actions.  He had two new public defenders in the second trial, Teresa Conlan and Marybeth Dingledy.  The second trial took place over five days in September 2003 in Snohomish County courthouse.

In one of the strangest twists in the history of DID being used to avoid truth and consequences, Greene's victim, his former therapist, the now 53-year-old M.S. demanded to testify in his defense.  In the retrial she was permitted to do so.  She claimed that only she could explain the impact of his terrible disorder, DID, on Greene and its role in causing his behavior on the night of his attack on her.  M.S. testified before the court that it was not Greene himself who had attacked her but actually three of his alter personalities:  Sam; Tyrone, a three or four year old; and Auto, a robot.  She explained to the jury it was not Greene, but Auto the robot who grabbed her and held her down.  It was not Greene who molested her for two hours, but Tyrone the child.  The personality Sam appeared for only a moment and tried to save her, but was quickly taken over by the other two personalities.  M.S. testified her belief that the chronic sex offender Greene was not responsible for the attack because he was not present during the attack and had no awareness of it until he was informed of it later when he was in police custody.

In an odd about face, the expert witness, Dr. Olsen, who had originally testified for the defense, switched sides and testified for the prosecution in the actual trial itself.  He now said he believed Greene was malingering.  In the trial, the prosecution also brought in a new expert witness, psychologist Richard Packard who testified that Greene did not have DID at all.  Packard diagnosed the chronic sex offender with antisocial (AKA psychopathic) personality disorder and a sexual paraphilia disorder.  Packard further stated his doubt about the veracity of DID as a legitimate disorder.  Packard firmly believed that Greene had simply been faking DID from the beginning.  Greene's cellmate, a certain Eric Fleischmann, testified that he too attempted to fake DID with Greene's coaching but had failed.

Defense witness, Dr. Marlene Streinberg, then vice president of the International Society for the Study of Dissociation, testified that DID was real and that Greene fit the profile.  In spite of Dr. Streinberg's rather weak assertions and in spite of the frantic testimony of an enmeshed and obsessed therapist, Greene lost his second trial and was again found guilty on both counts.  The jury deliberated for five hours and were done in time to go home for dinner.  Greene was sentenced to life as a three-strike felon

Now in prison, Greene has since been charged with the 1979 rape and murder of a 25 year old woman by the name of Sylvia Durante in Seattle.  Greene's DNA from his sperm was found on Ms. Durante's body.  He was convicted of her murder in 2005.

Not everybody is a believer in DID.  No matter how self important and self righteous the tone of its promoters like Streinberg, jurors, and most people with any level of critical thought or common sense, remain unconvinced.  Juror, Jim Camp, from Greene's retrial, stated the jury "just didn't believe it."

Sullivan, Jennifer; Insanity defense fails for attacker; The Seattle Times; Nov. 21 2003; as viewed on web 8/2012. 
Fersch, Ellsworth; Thinking About the Insanity Defense: Answers to Frequently Asked Questions; iUniverse, Lincoln, NE: 2005

Monday, August 13, 2012

Multiple Personalities and Responsibility

Multiple Personalities, now known as Dissociative Identity Disorder (DID), is the single most controversial diagnosis in the diagnostic manual.  Most would agree with that statement I think.

One of the most bizarre aspects of this diagnosis and its promoters is the wish to have their cake and eat it too.  Let me give you a few examples of what I am talking about.  These are composite examples that have been slightly altered, not pertaining to any individual patient, but the comments attributed to therapists essentially express comments I have heard at one point or another.

Patient A signed a legal contract and later wanted to back out.  Patient A's therapist states, without any sign of misgiving or embarrassment: "People just don't understand that [Patient A]'s part [alternate personality] signed the contract and [Patient A] can't be held responsible."  Why is this having and eating cake simultaneously?  Well, let me explain.  Both the patient and the therapist believe and strongly advocate for Patient A's right to live and act in the community as a fully fledged adult citizen, and yet, they both want the world hold Patient A free of all agreements and obligations that Patient A has selectively decided some other personality inhabiting her body is responsible for.  This sort of undermines the basic social contract doesn't it?  Either Patient A is mentally competent to make agreements and sign contracts and be held responsible for her obligations, or if she really cannot competently sign contracts and be held responsible due to her psychiatric condition she should not be allowed to and her her therapist needs to be working to develop a legal guardian who can actually make binding decisions on behalf of Patient A who is apparently not competent to do so on her own.

Patient B is granted Social Security Disability for a psychiatric condition.  His primary diagnosis is DID.  He then enters university and goes through to complete a graduate program.  Throughout, he continues to receive monthly disability payments intended for individuals who are too disabled to work.  Both he and his therapist maintain that Patient B is both entitled to disability and able to legitimately complete a graduate program in the field of economics because his parts switch only when he is at the school and he can temporarily maintain his "host personality."  When returning home or out in the community he "switches" to different personalities and is therefore disabled.  After receiving his degree in economics, he continues to receive monthly disability payments and his therapist continues to be paid by Medicaid.  Patient B is both disabled and yet he is not.  It seems to me an ethical and competent therapist would be working with Patient B to utilize his graduate degree in a productive manner to his own personal and financial benefit.  Instead, the therapist continues to promote the idea that in spite of earning a graduate degree Patient B is too disabled to work and must continue in therapy indefinitely.  It may be no coincidence that if Patient B earns wage income, he will ultimately lose both Social Security Disability and Medicaid and the therapist's cash cow with dry up.

Patient C commits a felony crime of posing as a property owner (which she is not), collecting deposits and rents from multiple prospective renters and then flees the scene.  She spends the money on a car, clothing and a purebred Pomeranian dog for herself.  When tracked down by detectives and arrested, Patient C, her therapist and her defense lawyer all maintain that Patient C cannot be held responsible for the crime.  None of them dispute that her physical body was present at the time of the crime and in fact committed the crime, but they claim her body was inhabited by a personality who believed it was the property owner, therefore person/body of Patient C (the only legal and biological entity in this case) cannot be held responsible.  The "host personality" of Patient C cannot be held responsible because she was dissociated and was not aware of what occurred and had no control over it.  Furthermore, the "property owner" personality cannot be held responsible either because he/she/it really believed it was a property owner and did not realize it was committing a crime.  What does the therapist and defense attorney request?  That Patient C be freed and allowed to continue the same therapy (that failed to prevent her criminal behavior in the first place) because this is what Patient C "needs."

Dr. Jekyll and Mr. Hyde

DID patients, therapists and promoters seem to have a problem with responsibility.  Basically they can disavow responsibility for anything with negative consequences for the patient/client/consumer but otherwise expect the world to treat the DID patient as a completely competent and responsible citizen.  Does that sound just a little too convenient?  Most jurors find it pretty fishy, that's why it almost never succeeds as a legal defense, but that doesn't stop people from trying.

Here are some interesting facts about DID and crime.  A small study published in 1989 (Putnum, Diagnosis and treatment of multiple personality disorder) found that 35% of female DID patients reported committing crimes including 7% of which were homicides and 47% of men with DID reported committing crimes of which 19% had committed homicide.

In the end, you can't have your cake and eat it too.