Tuesday, May 10, 2011

Bipolar Paradigm Swings

But seriously folks, there really is a problem with the trauma fad.  Just the other day, I had a therapist tell me, without blinking an eye, that 95% of mental illness is caused by trauma.  And, as you might imagine, coming from a therapist, the statement was made with the upmost in self-important tones with flavor highlights of virtuous condescension.

Yes, obviously, she read it off a brochure, or somewhere in all that blather on the web that has taken the place of brochures.  But where did this “fact” originate in the first place?

Looking back to the mid-20th century, there were any number of theorists who promoted the idea that schizophrenia was caused by trauma, or at least, early childhood events and social environment.  Generally speaking, dating back to this era, we have the idea that a child bonds with a parent (the word “attachment” is quite chic at the moment), the parent psychologically hurts the child’s sense of self—typically through abuse, neglect or ambivalence (this is the basic trauma)—and, the child ultimately develops schizophrenia or just about any other diagnosis you can think of for that matter.  Here we have the infamous “schizophrenicgenic” mother who relates to her child in an ambivalent or abusive manner and causes the child to become insane in adulthood.  The theoretic underpinning is the (now dated) belief that schizophrenia is a result of a weak ego that disintegrates and is overwhelmed by the id when the subject is faced with the challenges and pressures of adult life.

Essentially, childhood trauma perpetrated by an adult (to who the child is bonded) results in the development of a weak ego.  A weak ego results (later in life) in flooding of impulses and internal stimuli emanating from the subconscious.  Hence, insanity.  Neat little theory and it was quite the rage in the 50’s but slowly declined in subsequent decades and by 1990 had very little following in professional circles.

You can dig even deeper into the intellectual history of psychology.  Freud comes to mind and he had his antecedents in previous beliefs about the causes of insanity going all the way back to Plato and Hippocrates.  Hippocrates, as you might imagine, saw insanity as caused by an imbalance of humors in the body, but Plato interpreted it as reason being overwhelmed by emotion (but before you get too excited keep in mind that Plato also advocated that people who were sick and not likely to contribute should simply be killed).  This is just to point out the old nature versus nurture or, more correctly, mind (or spirit) versus body debate goes way back to ancient times and has been with us ever since.

Fast forward:  Prozac was approved by the FDA in 1987.  One of the first atypical antipsychotics, Clozaril, was made available in 1989.  The schizophrenicgenic mother idea had been on the decline for a very long time and the biomedical model was on the rise, driven by pharmaceuticals and helped along by National Alliance for the Mentally Ill, an advocacy group whose core mission was to combat the blame-the-parents stigma resultant from the schizophrenicgenic mother hypothesis.

All this is really to point out the pendulum swing in mental health ideology.  The biomedical approach was on a high in the 1990’s, most famously expressed in the NAMI slogan, “Mental Illness Is a No-Fault Brain Disease.”  At the height of it, you couldn’t use the word trauma without being jumped on and re-educated on the biological basis of mental illness.

My, how things change.  In 15 years, things have more or less reversed, and clinicians are barraged with trademarked treatment models and consumer activists and mental health reform all aimed at eradicating what we were training people in 15 years ago.  Even key players in the designing of the DSM-III and IV are coming out publicly to denounce the very basis of psychiatric diagnosing.   Now the only word that matters is trauma.  Trauma is the cause of mental illness and the only possible cure is to understand and validate the trauma.  We seem to have come full circle.  Attachment theory again finds the source of all psychopathology to emanate from problems in early attachment and early developmental trauma.  We are pretty much back to the schizophrenicgenic mother concept in all but name.*

I exaggerate only slightly for emphasis.

The, I hope obvious, problem with all this is that these bipolar paradigm swings are not based on advances in knowledge so much as fickle swings in popular sentiment.

We are simply replacing one reductionist model (mental illness is a no-fault brain disease) with another reductionist model (95% of mental illness is caused by trauma).  Not that reductionism is all bad.  Even Stephen J. Gould pointed out the crucial importance of reductionism in the scientific process.  Newton described gravity with a simple but elegant formula.  Darwin reduced all that complex biological diversity down to a few core principles of evolution.  But, this is not what we are seeing in mental health.  Although it wears the cloak of empiricism, it looks a lot more like political ideology or hopeful religious beliefs.  It all comes down to wishful thinking.  People build treatment models and cherry pick research results, all in order to bolster what they already believe or what they want to believe.

The mental health field would be a much more healthy and functional endeavor if we all just decided to be honest with ourselves and each other.  We want to help people, but we don’t really know what the hell we are doing.

* Of course, as gender beliefs have changed over the years, it is now more likely that we will see the father as the source of trauma/abuse/neglect/ambivalence as opposed to the mother.

Thursday, April 28, 2011

The Trauma Bandwagon

Gee whiz.  Is it just me, or is there a "trauma" jihad going on?  I can't open my eyes without seeing the word "trauma" in bold headlines in newspapers and journals and in 4H newsletters.  Do I see a new line of Hallmark "Trauma Condolence and Get Well" Cards on the way?

Don't get me wrong now.  I fully support the idea that psychological trauma is bad and can lead to bad things, and supporting people who have experienced trauma is a good thing, but let's try to have some perspective here people.  There is a mob mentality going on.  Is it a competition?  Is that it?  That would explain why people seem to think they're going to get a special treat if they use the word "trauma" more often and louder than anyone else.  A kind of self-satisfied glow appears on people's faces every time they use the word.

Maybe I'm just an old stick-in-the-mud Scrooge.  Bah-humbug.

Monday, April 11, 2011

Two New Mental Disorders?

Researchers are forever trying to link existing mental disorders with some kind, any kind, of brain structure “abnormality.”  Even the weakest of links send people into hysterical excitement and soon we see flashy headlines claiming Researchers Find Neurological Cause . . .” for, well, just fill in the blank yourself with your favorite mental disorder.

So, this is just what I was thinking about when I came across this flashy brain structure study, published in Current Biology, which found a significant link between anatomical brain differences and certain identifiable behaviors.  It’s a headline grabber for sure.

Of course, any researcher who has an actual college degree and took Statistics 101, would never, never assume that correlation equals causation, but this doesn’t stop people from doing endless correlational studies that grab headlines and are statistically significant but are of no use diagnostically.

If you don’t know what I’m talking about, you can see for yourself.  Go to Google and do a search for:  “brain structure” +adhd

ADHD happens to be a favorite target for useless correlational brain structure studies that might be interesting but give us no immediately useful knowledge because the differences they find can never be clearly separated out from the background noise of human variation.

But, back to the topic at hand . . . this write-up from Current Biology, found a strong link between brain structure and behavior that gives us a greater neurological understanding of this behavior than we have of many mental disorders.  What I don’t understand is why the authors didn’t make that leap and suggest a couple new diagnoses.  Does it make any difference that the behavior they looked at was political identification?  Honestly, I don’t know why it should make any difference; it seems to me we have two new perfectly good mental illness labels with some statistically significant data to back it all up.  All we need to do now is develop some psychopharmacological interventions and some evidence based psychotherapies.  Then we’re in business.

Kanai, et al., found that people who say they are liberal (gee, does anyone really do that anymore?) have thicker anterior cingulated cortexes.  On the other hand, people who go around using the word conservative in reference to themselves have inflated right (wing) amygdalas.  So, the authors interpret this to mean that liberals are able to cope with conflicting information (in other words, they’re spineless elitist smarty-pants who can’t make decisions) while conservatives are more able to recognize threats (which I interpret just a little further as meaning they are neurologically closer to highland gorillas than they are to homo sapiens sapiens).

Well, that’s all very cute, but let’s turn this into a real money maker.  It’s simple.  All we have to do is turn the glass-half-full language into glass-half-empty language.  Like this:

Liberalism Not Otherwise Specified is linked to smaller than average amygdalas resulting in impaired ability to recognize threats leading to being taken advantage of by freeloaders and traumatized by bullies and obstinate foreign powers.

Conservatism With or Without Paranoid Delusions is linked to withered anterior cingulates resulting in impaired ability to process complex information leading to reactive, bellicose and sometimes violent behaviors when confronted with multifaceted ideas and situations.

See? That wasn’t so hard, was it now?  Is it too late to get them added to the DSM-5?

Reference:  Ryota Kanai, Tom Feilden, Colin Firth, Geraint Rees.  Political Orientations Are Correlated with Brain Structure in Young Adults.  Current Biology, 07 April 2011 DOI: 10.1016/j.cub.2011.03.017

Wednesday, April 6, 2011

There are Psychiatric Diagnoses and Then There is Reality

Reality is a hard thing to pin down sometimes.  Why do the stars spin in a circle overhead?  Why are the people born under the constellation of Scorpio always such jerks?

I suppose the scientific method comes in there somewhere.  But let’s face it, our empirically grounded bodies of knowledge have their limits.  We can be hopeful that we will continue to expand our horizons of knowledge, but knowing what we really know and how we know it is probably a good thing.  I mean, isn’t that part of the whole scientific endeavor?

Well, I know you agree with me, but can someone help me understand how this message got so mixed up in the field of psychology?  In psychology, “scientific findings” and diagnostic labels seem to be thrown around with about as much critical scrutiny as a gibbering glossolalic soliloquy might receive in the midst of a writhing Pentecostal congregation.

Among practitioners, it seems to me, that the diagnostic categories of the DSM are typically taken with several cobblestone-sized grains of salt.  Not so among journalists or among the ubiquitous faceless internet-based free-advice-givers with their pop-up ad business models.  Doubly not so among purveyors of “evidence-based” therapies who use flashy headlines from the world of scientific research to prove their wares (acupuncture, Blood-LettingÒ, Eye Movement Desensitization Reprogramming, etc.).

It bothers me, not a little, that DSM labels are thrown around the way they are and it troubles me that so many researchers build their research designs as if these committee-written categories are unquestionable real-world phenomena.  Does anyone really believe that there is a discrete Major Depressive Disorder that is a distinct and separate process from Dysthymia?  Even that most archetypal of mental disorders, Schizophrenia, is quite fuzzy around the edges, and there continues to be some question as to whether we are dealing with a single disease process or multiple phenomena with similar and overlapping symptoms.

It is a truism that, in young disciplines, where there is a dearth of causal understanding, we tend to fall back on simple categorization of observable phenomena.  That, in fact, accounts for every single mental health diagnosis now in use.  These are loose categories based on our sad attempts to group complex human behaviors into digestible and palatable portions that we can pretend to understand and try to get the insurance companies to swallow without puking all over us.

With the upcoming DSM-V we are going to realign our categories by shifting our bullet-item-symptoms from one list to another and rebranding our labels, but still we will end up with somewhat arbitrary diagnostic descriptions authored by compromising, wordsmithing  committees and deeply confounded by cultural assumptions, political correctness and insurance driven language games.

Some day, maybe, we will have our grand synthesis of psychology, neurology and genetics, but we are not there yet people.  Please let’s stop playing pretend.

Friday, March 4, 2011

More on Borderlines and Crime

In January I posted on Borderline Personality Disorder, Crime and Responsibility.  More recently, I came across an interesting literature review on the topic of BPD and its association with crime and incarceration.  “Borderline Personality and Criminality,” by Randy and Lori Sansone, was published in Psychiatry in 2009.

In this paper, the authors review multiple studies that have looked into the rates of Borderline Personality Disorder among the incarcerated and the criminal.  They acknowledge that it is not a comprehensive review and they did find a wide discrepancy in findings probably related to differences in methodology as well as peculiarities of different sample populations drawn on from penitentiaries.

Their overall conclusions:
According to the findings of the majority of studies in this area, compared to rates expected in the community, BPD is over-represented in prison populations.  This finding may be particularly evident among female prisoners.  Rates vary, depending on the methodology, but generally appear to be in the range of 25-50 percent.
This is a considerable difference from the rate in the general population that has been measured at between two and six percent. 

They continue:
Factors that may be associated with the presence of BPD among criminals include being female, having a history of childhood sexual abuse, committing an impulsive and violent crime (e.g., murder), having antisocial personality disorder traits, and perpetrating domestic violence.  given this association, clinicians in both mental health and primary care settings need to be aware of the possibilities of such histories in their patients with BPD.
It is well known that BPD has a higher rate among women than men.  This holds true in prison populations as well.  Rates among incarcerated men range around 5-6%, very similar, but maybe slightly higher than men in general.  Now where it gets interesting is with women.  Studies varied significantly in their findings.  On the low end, one study found 11.5% of incarcerated women to have BPD but another study found as many as 42.9%!  This last study was conducted in Germany using structured interviews.  Overall, not only do imprisoned  women have a higher rate of BPD than men, but also significantly higher than women in general.

It has often been speculated that the overall gender imbalance is due to biases in the formulation of the disorder criteria or biases in the act of diagnosing.  The authors mention this question in passing but do not offer any speculations.  (In my own, non-scientific, observations from the world of practice, I believe that because we expect to see BPD in women it leads to over-diagnosing among women where any kind of Axis II behavioral problems tend to result in a BPD label while, in contrast, BPD traits in men often go unnoted or misinterpreted as anti-social features.)

Childhood sexual abuse:
As with the general population, incarcerated people with BPD had a higher rate of childhood sexual abuse.  Not surprisingly, history of childhood sexual abuse was even higher for incarcerated women who were both sex offenders themselves and met the criteria for BPD.

Violent offenses:
Overall, data supports an association between BPD with higher rates of violence (toward others) when comparing prisoners with and without BPD.  One study found that women prisoners who had committed crimes related to major violence were four times more likely to meet criteria for BPD than women who had committed minimally violent crimes.  Another study of men in British prisons for murder found 49% of their subjects had BPD traits.

Some studies looked at violence in association to subtypes of BPD.  One study found serial murderers to be associated with a strongly manipulative subtype of BPD.  Another study relates rage-based murder with an “over-control” subtype of BPD.  The authors conclude that “the majority of current data and impressions indicate an association between BPD and the impulsive, rage-fueled murder."

Antisocial personality:
Both BPD and Antisocial Personality Disorder are associated with higher rates of violence.  Antisocial individuals tend to engage in more property crimes and are more calculating and planned.  Borderline individuals tend toward episodes of aggression and violence.

Where BPD and APD co-occur, there are significantly higher rates of anger, impulsivity and aggression resulting in a higher score of psychopathy.  (Personally, I've often felt there is a significant overlap between these two categories but the authors do not give any additional insight on the topic.)

Domestic Violence:
Multiple studies have found a very solid association between BPD and both male and female batterers.  Many batterers have a history of experiencing trauma themselves, and this, in turn, is also associated with development of BPD.  One study found that 27% of women arrested for domestic violence met the criteria for BPD.

Overall it seems there is a very clear link between BPD and both violence and criminality in general.  The strength of that link varies quite a bit from study to study, however.  The authors offer no causal speculations.  Make of it what you will.

Reference:  Sansone, Randy; Sansone, Lori (2009).  “Borderline Personality and Criminality.”  Psychiatry; 6(10):16-20.

Wednesday, March 2, 2011

Drug Money and Scientific Objectivity

A study published in the Canadian Medical Association Journal (CMAJ) confirms what we all suspected.  Drug money sullies the objectivity of medical journals.

Medical journals run the gambit from purely funded by subscription to those that are funded solely by advertising.  Some journals have both kinds of revenue.  The ad-supported journals get most of their business from pharmaceutical manufacturers.  These drug money supported journals are typically sent free to doctors around the world and have much larger circulation than the subscription supported journals.  These free journals are also less likely to be peer reviewed.

The CMAJ study examined 11 medical journals with distributions in Germany in 2007.  In addition they surveyed Canadian general practitioners to find what journals they rely on for up-to-date data.  The write-up states, “Our study shows that the tendency to positively recommend the use of a drug depends on the source of a journal’s funding . . . Free journals almost exclusively endorse the use of the selected drugs, whereas journals that rely exclusively on subscription fees for their revenue are more likely to recommend against the use the same drugs. . . . More than half of the doctors surveyed had used free journals as a source of information during the previous months.”

This kind of bias can be critical when adverse reaction to prescription medication is the sixth leading cause of the death, at least in the US (reported in JAMA several years ago).  This study was not specific to psychiatric drugs but it certainly has salience in the psychiatric field where many medicinal treatments have questionable benefit.  If the risk-benefit calculation is skewed, then neither doctors nor patients are making truly informed decisions.

We now know that people with severe mental illness have life spans that are 20 years shorter than the general population.  How much of that is a result of our pharmaceutical treatments?

Reference: Becker, Anette; et al.  Canadian Medical Association Journal (2011, March 1).  The influence of advertising on drug recommendations.

Friday, February 4, 2011

Crime, stupidity and responsibility among mental health professionals

I in no way want to promote the Church of Scientology nor am I in the fan club of Dr. Thomas Szasz.
I don’t have much to say about Scientology other than the fact that it gets pretty annoying to be accused of being a Scientologist simply because I question the validity of a diagnostic category like Attention Deficit Disorder and maybe I’ve suggested that giving amphetamines to young children might not be the best solution to this non-disease.
On the other hand, I could say a lot about Szasz who is something like the father of the anti-psychiatry movement.  I certainly think that he has done a lot of good by questioning the assumptions and practices in the mental health field going all the way back to the 1950’s.  Unfortunately, his discourse and that of his anti-psychiatry disciples is just as ideological and lacking in factuality as the worst drivel coming out of NAMI and from pharmaceutical marketers and the APA for that matter.  But, we’ll save that discussion for a later post.
Today, I just wanted to share about their Psychiatric Crimes Database, a rogues' gallery of badly behaved mental health professionals.  It makes for a, maybe not exactly fun, but perhaps amusing at times and otherwise disturbing read.  It is part of a website presented to the world by the Citizens’ Commission on Human Rights (CCHR).  CCHR is a joint effort by Szasz and the Scientologists dating back to 1969.  Its mission is to ”investigate and expose psychiatric violations of human rights and to clean up the field of mental healing.”
They claim to have aided in increasing prosecutions of mental health professionals of all kinds and to have promoted improved ethical and legal standards in the industry.  As to the later of these claims, I cannot vouch for the activities of CCHR itself, but I can say from my experience in mental health that the consistent pressure from the psychiatric survivor and anti-psychiatry movements, which have at least symbolic if not real leadership and impetus from Szasz, have had an actual and positive impact in the industry by increasing awareness and respect for things like informed consent and patient/client choice.  Yet, that being said, I do have to question what they seem to want to imply about themselves and the industry with their database.
Carrie Denbow, social worker, had her license suspended, according to the CCHR site, due to accusations she had sexual relations with a minor client in a motel room with two other students while drinking and smoking marijuana.  The client was an adolescent to whom she was providing counseling.  It is further alleged that Ms. Denbow took the client to her office three or four times a week where she performed oral sex followed by intercourse.  It is also alleged she broke confidence by seeking relationship advice from her minor client's peers.  Ms. Denbow was let go from her job in 2009.
The Psychiatirc Crimes Database is, very simply, a list of prosecutions and licensing censures against mental health professionals.  It appears to be updated quite frequently; there are eleven items in the database for January of 2011.  If CCHR had a role in any of these investigations, it is not evident and seems unlikely.  It appears to simply be a list of items gathered from the news and public records.  Items span a gambit of crimes and ethical violations.  Just in the last couple of months we see everything from a psychologist having his license placed on probation due to DUI to a psychiatrist charged with attempted murder for stabbing a patient twice in the chest with a sword.
My non-scientific cursory look at the database leads me to the conclusion that the most common category is the big no-no of sexual relationships between providers and clients, in some cases with minor clients.  This appears to be followed by billing and documentational faults leading to charges of fraud.  A third category is providing excessive prescriptions of controlled substances, sometimes for a payoff, sometimes without medical examination (as in being handed out in a public park in one case).  Otherwise, items are a miscellany of misdemeanors, violations and serious crimes.
The website explains its purpose:
The following database is being presented as a public interest service to law enforcement agencies, health care fraud investigators, immigration offices, international police agencies, medical and psychological licensing boards, and the general public.
And claims to impact larger issues:
Many psychiatrists have an intimate knowledge of criminality-one which has nothing to do with the professions involvement in the expert witness field.
  • Between $20 billion and $40 billion is defrauded by the American psychiatric industry in any given year.
  • At least 10% of psychiatrists admit to sexually abusing their patients: In America, that's at least 4,500 rapes and, internationally, more than 15,000 rapes.
  • Psychiatrists, psychologists and psychotherapists have the dubious distinction of having laws specifically designed to curtail their tendency to commit sex crimes against those in their charge.
  • A 1992 study of Medicaid and Medicare insurance fraud in the U.S. showed psychiatry to have the worst track record of all medical disciplines.
They don’t indicate how they came up with the specific numbers (e.g., 10% of psychiatrists admit to sexually abusing patients), but it is also true that both Szasz and the Scientologists share an overall denouncement of the very concept of mental illness and this database has to be seen as part of their larger pogrom against all things psychiatric.
Psychiatrist Douglas Rank who, according to CCHR, was charged with stabbing a woman in the chest twice with a sword in front of his office.  The wounds were life-threatening, but she survived after hospitalization.   She was apparently both his patient and in a "personal relationship" with him.  Rank was sentenced to 15 years after plea bargaining down from attempted murder to first-degree assault.  He had previously been investigated for over medicating and having sex with a patient.
Speaking to that implied intent, I have to feel that simply listing every kind of crime and stupid behavior of individual mental health providers cannot be taken as a condemnation of the industry as a whole.  There is plenty of room to criticize the mental health field and all of its tenuous assumptions and cherished beliefs, but, in my opinion, the fact that a particular California psychologist had his license placed on a probationary status, for instance, according to the CCHR site, because he was found awakening from unconsciousness in a department store after hours with a pocket full of methamphetamine, has no real bearing on the field of mental health other than the fact that it is peopled by human beings who are capable of addictions, errors, criminality and stupidity as humans are in any profession.  
Furthermore, the fact that professionals are censured, placed on probation, suspended and prosecuted, if anything, indicates that the industry does in fact have good safeguards and oversight by which to protect consumers and the public.
Yet, the database does have an impact on the reader, and if you haven’t yet, I suggest every one take a look at it who has an interest in mental health whether as a provider, consumer, family member or interested bystander.  If nothing else, it serves as a reminder that it is always a good idea to be cautious and do a little research before accepting a particular professional as the mechanic of your mind, so to speak.

Friday, January 28, 2011

Borderline Personality Disorder, Crime, and Responsibility

On the topic of mental disorders and responsibility—of late, I’ve been hearing several therapists repeat a couple things that bother me:

1) Borderline Personality Disorder is just as serious as Schizophrenia and sufferers of BPD should be given just as much clinical attention and services.

I have to say, no, BPD is not the same as schizophrenia and should not in fact be treated the in the same manner.  Should medical professionals be told they need to treat sunburn the same way they treat cancer?  I think not.  Furthermore, I don’t know why we treat so many people whose primary presenting problem is BPD in the public mental health system intended for people with severe disabilities.  The bulk of the empirical research seems to show that BPD is best treated in the community with an established and effective therapy such as Dialectical Behavioral Therapy or similar.  Placing people with BPD in residential facilities for the severely disabled will only be detrimental for both the client and everyone else who lives or works at the facility.

2)  People with BPD who behave manipulatively should not be blamed or expected to change because their behavior is avolitional.

I will agree that “blaming” the client is in no way helpful, nor will expecting someone with BPD to instantly change result in anything but frustration.  However, it is simply false to say that someone with BPD has no ability to modulate mood or behavior.  No human behavior short of reflexes or seizures are avolitional.  Making false statements of this kind, even in apparent defense of people with serious disorders, only serves to increase the divide in understanding.  It also takes away from the agency and empowerment of the client that we are trying to help.  Someone with BPD is not helpless to change.  Change can happen with trust and support as long as there is a real desire in the person to make a change.  Setting clear but respectful limits helps too, because we all know that, like it or not, life has limits.  It is not at all helpful to give the BPD patient the message that anything they do is okay just because they have a diagnosis.  Such a message can be devastatingly harmful.

It might help to illustrate this issue.  Take a look at this excerpt from a recent news article (well, it's news-ish, I guess, it's from The Sun):
A WOMAN has been jailed for cruelly imprisoning three young children in a disgusting room without clothes, food or water.
Jan. 25, 2011.  Sick Daniella Henderson left the youngsters in the squalid conditions and their ordeal only ended when the kids were seen hanging out of a window desperate for help.
When police arrived at the house they found the bedroom they had been left in all day stank of urine, had no beds or furniture and had a bucket as a toilet.
The grandfather of one of the children today slammed sick Henderson's 15-month jail term as too lenient. . . .
Penny Moreland, defending, said: "Most people will find this shocking and distressing. This has not borne out of pure malice or badness.
"She was deteriorating mentally and has a borderline personality disorder [sic]."
The defense attorney here is presenting what a certain ilk of therapists are trying to put out there, that someone with BPD cannot be held responsible for their behavior. I would say, yes, it is distressing.  The defense states that the behavior was not malice or badness and seems to imply that the behavior cannot be malice or badness as long as the behavior is “explained” by a mental health disorder, in this case BPD.  It seems to be an underlying tacit assumption that the categories of malicious behavior and symptomatic behavior are mutually exclusive. At the risk of blaming people with BPD for their own behaviors, I have to question the validity of this assumed dichotomy.  Is it possible that someone’s behavior might be driven by BPD and that person is acting with malice?

Tuesday, January 25, 2011

Yet another opinion on mental illness, violence, and responsibility

I am hesitant to add to the din about mental illness and violence in the wake of Jared Loughner, but I’d like to make a few small points on the topic.

First of all, I have to say, I find it a little creepy that someone describing himself as a forensic psychologist, would so quickly put up a full website, complete with domain name, dedicated to this suddenly infamous young man: loughner.info

It feels a little exploitative, but probably not anymore than traditional journalism I suppose. The posts seem thoughtful and informative in any case.

a smiling less crazy Jared Loughner
But, to the real point, the consensus seems to be that our Mr. Loughner was coming down with a nasty case of schizophrenia. As more details come out, the more this seems likely. I wouldn’t dispute it, but I'm not going to diagnose him via media reports, either.  Still, I think it's fair to acknowledge there is a mental health component and this ties into larger social concerns about mental illness, danger and responsibility. 

The next questions are, (1) what then is the personal/moral responsibility of a person with mental illness in regard to their behaviors, and (2) are people with schizophrenia dangerous?

As to the first, well, maybe it’s a question for the philosophers, but that won’t stop the lawyers and pundits from opining. I won’t bother to answer such an expansive question myself, but I do want to make note of the fact there is a very large population of people with schizophrenia who suffer from paranoid delusions who chose not to act out violently toward others. This interesting fact touches on both of the above mentioned questions, I think. From my own experience, I’ve known quite a few individuals who believed very strongly that they were being persecuted by specific others in some way and in some cases the belief systems included threats to their lives. Very often this involves poison but there can be any number of creative delusory devices.

So why is it that people who believe they are being poisoned, attacked and persecuted, are so often non-violent even in the face of an overwhelming belief that their own life is being threatened?

This is something like a key question and the answer(s) touch on both personal responsibility and risk assessment. But, this question tends to get overshadowed in the immediate aftermath of a spectacular psychiatric failure as we saw recently in Tucson and not so long ago at Virginia Tech.

The somewhat simplistic explanation is that most people who suffer from schizophrenia have an intact moral capacity and it is only a small subset of people with schizophrenia who also fit an anti-social profile in which there is a lack of compassion or concern for others. I do think this is true in a general sense even if the categories of schizophrenia and anti-social personality suffer from fuzzy boundaries and arbitrariness.

The other important clinical factor is severity of delusions (along with other symptoms). For someone with schizophrenia, delusions seem to follow a sort of hydraulic principle. That is, as the severity of symptoms fluctuate, there is a shift in the psychic pressure of the delusional system (metaphorically speaking). As an episode increases in severity, the delusions shift in two ways, (1) strength of belief, and (2) amount of mental time and energy given over to ruminating on the delusions. With increasing severity there is an intensifying obsessional quality in the person and an increasingly aggressive reaction to reality checks or questioning of the delusory beliefs. Severity comes into play with violence and responsibility because the greater the severity of the symptoms, the harder it is for the individual to ignore the direction of delusory thought and the harder it is for the person to receive any form of feedback or external redirection.

There can be a number of ameliorating factors however. One factor, in some cases, is life experience. After going through a number of episodes, some individuals learn from very difficult experiences (homelessness, hospitalization, loss of family support, etc.) that their beliefs can be problematic and with time this can aid an individual in developing coping and self-management skills. The reverse is also true, that a young person who is first developing schizophrenia does not have the benefit of those life experiences and the first emergence of delusory beliefs can have a seductive, intoxicating quality and are very difficult to challenge from the outside.

Aside from clinical analysis, I think it is very important to know that people with schizophrenia are individuals. I do not mean this as a slogan, but in a very real way. As overwhelming as the effects of schizophrenia may appear to be on the personality, it does not in fact do away with it. People living with psychosis and schizophrenia continue to hold and express values and morals and a full range of human motivations both good and bad, just like the rest of us. More so than any other label in mental health, the term “schizophrenia” too often overshadows the person.

These kind of catastrophic events, as in Tucson, tend to trigger the latent fears in the public and inevitably lead to calls for greater controls on the mentally ill and stronger commitment laws to allow the mental health system to more easily intervene with involuntarily measures. All this puts the focus on the illness while de-emphasizing personal volition. In this round, by and large, I think the media response has been a little better informed than after Virginia Tech and mostly I see calls for increased mental health services, which is a safe and reasonable position to take, although, I think people need to be better informed about the limits of what mental health services can do. Simply throwing more money at the problem is not necessarily going to help, and there is a good chance the resources will be diverted to other people and other agendas.

Even where a wide array of mental health services are available, the people who need them most often have no interest in them (while there are plenty of other people who don't really need all that care but are willing to accept social security checks and get all kinds of counseling--but that's a whole different story). There really is no way to force therapy and treatment on someone who absolutely doesn't want it, not unless they can be placed under civil commitment, and that is determined by presentation of immediate and believable danger to self or others. Assessing danger has elements of best and customary practice, but in the end it is educated guesswork based on past history, stated intentions and a range of known risk factors. How do you know their history? Well, unless you get past clinical data, it comes down to what the client is able or willing to tell you. For someone who doesn't have an established history, assessing danger is quite tricky and there is a certain amount of intuition and personal judgment involved. There simply are no guarantees or simple solutions.

Monday, January 10, 2011

Is that Thorazine in the Baby's Bottle?

One of the most disturbing trends in mental health today is the increasing use of powerful antipsychotic medication to treat behavioral problems in children, even very young children. According to a 2009 report by the Food and Drug Administration, there are 500,000 children in the United States being administered regular doses of antipsychotics. Medicaid data shows public health monies spent on antipsychotic drugs for children exceeding $30 million in New Jersey and topping $90 million in Texas. It is a trend that has built relentlessly for the past ten years and continues unabated.

I find the use of these drugs on children to be appalling almost beyond words. Having worked as a mental health professional for many years, I am well acquainted with these medications. This class of drugs, sometimes referred to as neuroleptics, are major tranquilizers and are primarily used and intended for controlling hallucinations and delusions in cases of psychosis and schizophrenia. For an adult with severe schizophrenia, these medications may be a glimmer of hope, but it is always a difficult risk-benefit analysis because there are potentially severe side effects and reactions. Depending on the individual, these medications can cause tremors, involuntary spasms and movements, severe sedation, muscles of the face become rigid, and loss of pleasure sensation, just to name a few. Permanent neurological damage can occur in the form of tardive dyskenisia, and sudden death can occur from a reaction called neuroleptic malignancy syndrome. With newer forms of antipsychotics, these type of side effects are less frequent and less severe, but continue to be a risk depending on the reaction of the individual’s body. However, newer, “atypical,” antipsychotics present new dangers to the patient, metabolic changes that result in a dramatic increase in the instances and severity of diabetes and heart disease. The result is that adults on antipsychotic medications have a life span that is 20 years shorter then the average person.

We know these medications have the potential to cause permanent harm to an adult’s brain, but they are still used because it is considered by many to be worth the risks to control just some of the symptoms of debilitating disorders, and, except in the most severe cases, where a person’s legal rights have been taken away due to impairment, it is ultimately up to the patient to decide whether or not to take that risk.

What then will these medications do to a child’s developing brain? The jury is out, but it can’t be a good thing. Who makes the decision and why? Certainly not the child who will live the rest of his or her life with the consequences of that decision.

The New York Times ran a recent article on the subject, highlighting the case of one child who was started on an antipsychotic at 18 months old. This helps to highlight the human side of this tragedy:
At 18 months, Kyle Warren started taking a daily antipsychotic drug on the orders of a pediatrician trying to quell the boy’s severe temper tantrums.
Thus began a troubled toddler’s journey from one doctor to another, from one diagnosis to another, involving even more drugs. Autism, bipolar disorder, hyperactivity, insomnia, oppositional defiant disorder. The boy’s daily pill regimen multiplied: the antipsychotic Risperdal, the antidepressant Prozac, two sleeping medicines and one for attention-deficit disorder. All by the time he was 3.
He was sedated, drooling and overweight from the side effects of the antipsychotic medicine. Although his mother, Brandy Warren, had been at her “wit’s end” when she resorted to the drug treatment, she began to worry about Kyle’s altered personality. “All I had was a medicated little boy,” Ms. Warren said. “I didn’t have my son. It’s like, you’d look into his eyes and you would just see just blankness.”
Today, 6-year-old Kyle is in his fourth week of first grade, scoring high marks on his first tests. He is rambunctious and much thinner. Weaned off the drugs through a program affiliated with Tulane University that is aimed at helping low-income families whose children have mental health problems, Kyle now laughs easily and teases his family.
Ms. Warren and Kyle’s new doctors point to his remarkable progress — and a more common diagnosis for children of attention-deficit hyperactivity disorder — as proof that he should have never been prescribed such powerful drugs in the first place.
As to what’s driving this latest treatment fad?  I think there are a number of factors.  The easiest and most popular target is Big Pharma.  The pharmaceutical industry has the largest profit margin of any major industry, and do you know what their most profitable line of drugs are?  Yes, that’s right, antipsychotics.  This class of drugs brought in a staggering $14.6 billion in 2009.  Antipsychotics are marketed as heavily as any other product line, and the marketers are always looking for new markets.  Antipsychotics have been marketed for depression, for instance, and they are actively promoted to pediatricians for use on children, but, for the most part, marketing efforts keep within the limits set by the FDA and the risk-benefit decisions made industry lawyers.  The FDA approved Risperdal for use on children as young as 5, but most antipsychotics are only approved for children 10 or older.

Yet, in spite of the FDA guidelines, these drugs are being given to much younger children. Who then is to blame? The other popular targets of finger pointing are the parents (and, I would add, teachers and childcare workers). Perhaps it is helped along by marketing campaigns, but the fact is, parents are increasingly choosing to pathologize and medicate their children in lieu of other, more traditional, parenting strategies. Childcare and educational professionals add to the stampede by pressuring parents to go to the doctor when the child’s behavior puts a strain on the professional. I think we can objectively state, unequivocally, the nature of childhood needs and behaviors has not changed in recent generations, yet more and more parents go to their pediatricians insisting there is something wrong with their child and demanding some pill they can give the kid to fix the problem. Parents just want to do right by their child, I’m sure, but they fail when the don’t take the time to research what they are doing and the possible consequences.

The final responsibility, however, rests on the shoulders of the professionals who prescribe these medications. Physicians are free to prescribe off label use of drugs and are under no legal obligation to stay within FDA approved guidelines, and some physicians seem more then willing to exercise this discretion in spite of the very serious risks they are exposing the child to. Regardless of shameless marketing by drug manufacturers and the irrational pressures of frustrated parents, the physician is supposed to be the final gate keeper and is responsible to safeguarding the health and wellbeing of the young patients. Physicians who push antipsychotics on children clearly fail in their responsibilities.

The issue is further complicated by shifting diagnostic categories. Schizophrenia is a disorder of adulthood. Age of onset is typically late adolescence or early adulthood. There is no defined criteria and very little in the way of scientific data to justify giving this diagnosis to younger children, yet we are seeing it, now, younger and younger, usually tied to a prescription. Another expanding diagnosis is bipolar. This disorder is very loosely defined and as a result, unscrupulous or simply confused professionals can see it everywhere. It too used to be a disorder of adulthood but has mushroomed as a child diagnosis in the last decade. The other big diagnosis linked to antipsychotics is autism. This is a very serious and real childhood disorder and children who suffer from this take a lot of care and present a lot of challenges. However, the autism diagnosis has become hugely popular and its working definition has expanded infinitely. As in the case of Kyle Warren, just about any child can get the diagnosis at this point. It is now virtually meaningless, yet it is the justification for giving these very serious drugs to young children.

The big picture is we have an expanding culture of psychopathology in which more and more facets of human behavior are being defined as disorders and sicknesses. This extends even to the point of defining childhood tantrums as a sickness that we have to treat with a powerful drug. The pathologization of childhood started probably in the 1980’s with attention deficit disorder and this became hugely popular in the 1990’s. In the first decade of the new millennium, we saw a significant expansion of clinical depression, bipolar and even schizophrenia into younger and younger populations with related drug therapies. Additionally the autism diagnosis has been opened up into a “spectrum” disorder so now parents of children with any kind of perceived interpersonal or behavioral challenges can have an autism label slapped on ‘em at bargain basement prices.
The bottom line is that young children are being harmed by antipsychotic drug treatment and it’s no laughing matter. The trend line is very disturbing. I hope I am not one of a few lone voices in the wilderness. Is anybody listening?