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:

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?