Sunday, March 11, 2018

My 10 Part Interview on Borderline Personality Disorder on Internet Radio Available Again

The audio of my 10 hour discussion of 

borderline personality disorder on 

"Free Thinking Voice - The Earth Needs Rebels" 

internet radio show on 

Orion Talk Radio (which became unavailable 

after the interviewer passed 

away), has now been uploaded to my YouTube 


Saturday, March 10, 2018

When Commonly Believed Ideas Turn out to be False

When I list a whole lot of stupid, money-wasting studies "proving" things we already know on my periodic blog posts from my favorite journals, "Duh!" and "No Sh*t, Sherlock," I often hear the argument that we still need to do these studies because at times things thought to be obvious turn out to be wrong.

While that does indeed happen very rarely, most of the time when a commonly-believed proposition turns out to be false, it's because 1 or the other of 2 conditions was operating:

1. Evidence that calls the proposition into question had been systematically ignored or devalued ("Kids with ADHD are able to appear to be able to concentrate while engaged in video games, but that isn't really concentration"), or

2. The proposition was just an old wives' tale that someone pulled out of their ass and that was never based on widespread observations in the first place ("You should drink eight glasses of water per day").  

This issue relates to the widespread use of certain charges made by those in the fields of psychology and psychiatry with various oxen to gore. They pooh-pooh ideas by saying that the conclusions that some of us base primarily on our clinical experience and multiple observations are automatically invalid because they are based on so-called “anecdotal evidence.” I dissected “anecdotal evidence” in my post of March 11, 2014.

I still maintain that you don’t need a scientific study to prove that the sky looks blue to non-colorblind people at the equator at noon on a cloudless day.

Tuesday, January 23, 2018

The Role of the Family Black Sheep – The Hidden Aspects

Are you a black sheep in your family? You know, the one that doesn’t seem to go along with the program and acts in ways that seemingly run counter to the values of the rest of the family? Guess what: you are not nearly as rebellious as you think you are.

A frequent topic on this blog and on my blog on Psychology Today is dysfunctional family roles. Because of the biological phenomenon known as kin selection, individuals are often willing to sacrifice their own needs and desires in order to act in ways which stabilize unstable parents and maintain what family systems therapists refer to as family homeostasis

The latter is a process by which the family operates by rules, strongly enforced by all family members, in which every family member plays a predictable, designated part. Family rules are originally derived from the culture or ethnic group in which the family has operated as well as by family experiences that necessitated certain behavior. In dysfunctional families, the family rules have become obsolete due to rapid changes in the ambient culture (cultural lag).

Many cultural changes have lead to situations in which individuals are much freer to express their own wants and needs separate from those of the family (self-actualization). If the family is stuck in the past, members (especially the older ones) may be threatened by certain aspects of individual freedom. They may be enticing and seductive, but were strongly forbidden to them by the people that raised them in earlier times.

This desire versus fear dynamic is what the Freudians were talking about with their notion of intrapsychic conflict. What they missed, however, was that the conflict is not entirely intrapsychic, but is triggered and reinforced by an entire family. In fact, the “intrapsychic conflict” is actually shared by all of them! It leads to family members giving off mixed and contradictory messages to one another about what is expected of them.

A big source of shared intrapsychic conflict in families that I have not discussed extensively is changing attitudes toward individual satisfaction involving things such as the proverbial sex, drugs, and rock and roll. There has been a marked cultural shift in the propriety of pleasuring oneself with these pursuits. Because of cultural lag, people will often give lip service to such issues as sexual abstinence or reserving sex for procreation only, while at the same time covertly availing themselves of opportunities seemingly at odds with their expressed values.

This is the situation that leads to one member of the family – often but not always a younger child—to volunteer to be the rule breaker, enjoying that which is attractive to but forbidden to all the others. The others, particularly the parents, get vicarious satisfaction of their own secret desires through watching their children indulge themselves. However, the situation is far more complicated. While black sheep may seem to be having a good time so the parents can do this, that unfortunately is not their only job.

If they have too good a time, and end up being happy and content, a parent who was secretly and subtly pushing them to break the family rules starts to become unstable. Vicarious experience, while mildly satisfying, is just not the same thing as actual experience. The conflicted parents start to wonder about their own choices in life and then become depressed, have marital problems with the spouse that has helped them go along with family rules, or engage in self-destructive behavior.

To prevent this and keep the parents stable, the black sheep must also demonstrate the folly of engaging in the “rebellious” behavior. They do so by, in a sense, finding ways to make themselves miserable because of it. In a sense, they fail at it, so the parents can become once again secure in the knowledge that they made the right decision in sticking to the old prohibitions.

In the process of indulging themselves in sex, drugs, and rock’n’roll, black sheep may develop an addiction, contract a sexually transmitted disease, have an affair and destroy their marriage and their relationships with their own children, have multiple divorces, or become deadbeat dads. The rest of the family can then hold them up as examples that “prove” that the forbidden impulses are forbidden for good reason. The old family rules against self indulgence simply must continue to be followed. 

If they want to redeem themselves, black sheep may have to join a 12 step program and denounce their own willfulness. They need to go back to that old time religion – and the group that they join, in order to maintain itself, also needs someone to do just that. Just like their families need them to do.

Wednesday, December 27, 2017

Family Dysfunction and Gene Expression: Effects on Personality and Behavior

Jenny Macfie, Ph.D., Department of Psychology, University of Tennessee Knoxville

It’s amazing what you can discover if you actually look

When it comes to the “scientific” literature about what causes borderline personality disorder (BPD) and other forms of self-destructive and self-defeating behavior, readers of my blogs know that I think genetic influences are way overemphasized and the effects of dysfunctional family dynamics and child abuse ignored as much as possible.

In my clinical practice, I see dramatic evidence that the effects of the family dysfunction on behavior are often passed down from one generation to the next.  A few studies have also looked at this, and in every case supported this viewpoint.

Two more recent studies support my views in general about what creates the disorder.

Jenny Macfie and others, following the work of Karlen Lyons-Ruth described in a previous post, actually watched the interactions between children aged 4-7 and their mothers with BPD (“A Mother’s Borderline Personality Disorder and Her Sensitivity, Autonomy Support, Hostility, Fearful/disoriented Behavior, and Role Reversal with her Young Child,” Journal of Personality Disorders 31(6):  pp. 721-737, 2017).  

The pairs were given a task with the following instructions: “This puzzle is for your child to complete, but feel free to give any help your child might need.” A researcher presented one puzzle at a time in order of increasing difficulty.  Mothers who did not have the disorder and their child were also given the task. All interactions were observed and scored.

Mothers who had BPD “demonstrated significantly less sensitivity and autonomy support [supporting the child’s efforts to solve the puzzles without the assistance of the parent], more hostility, more role reversal, and more fearful/disoriented behavior in interactions with their children than did comparison mothers.

“Role reversal” is the child taking care of the mother instead of the other way around. In this study they specifically looked at mothers deferring to their child’s demands, the pair acting like playmates (for example, child abandons task and the two run around the room rather than the mother setting limits), and mothers taking the child’s attention away from the task by demanding signs of affection from the child.

There was no group of mothers with other personality disorders so we do not know if the researchers results are specific to mothers with BPD.

In a second, unrelated study, Pierre Eric-Lutz and his colleagues looked at the effects of child abuse on the expression of genes that control the development of the brain (“Association of a History of Child Abuse with Impaired Myelination in the Anterior Cingulate Cortex: Convergent Epigenetic, Transcriptional, and Morphological Evidence,” American Journal of Psychiatry 174 (12), pp.1185-1194, 2017).

Epigenetics refers to the process by which environmental influences turn genes on and off. Most genes in a cell are not operating at all at any given time. Epigenetics ties environmental and genetic influences together in ways that a lot of people in the various mental health field either seem to be unaware of, or consciously ignore. The anterior cingulate cortex is a part of the brain heavily involved in making decisions regarding what to do in various social situations.

Without going into the authors’ methodology, which was quite sophisticated, the study found that individuals abused during childhood showed significantly decreased expression of a large collection of genes involved in myelination of cells in that part of the brain. Myelination is process which markedly changes the level of functioning of brain cells that are part of so-called white matter.

Once again, we find that one of the main purposes of the genes that create the brain in human beings is to make humans exquisitely sensitive to the social environment.

Tuesday, December 5, 2017

Sleep, Discipline and Childhood Behavioral Disorders

A couple of news stories about some new “studies” recently caught my eye. They illustrate the downright ungodly lengths certain segments of the mental health industry, as well as dope-dealing drug companies like Shire Pharmaceuticals, will go to distract both the field and the public from the real cause of many childhood behavioral problems: family interactions. They do so in order to justify their mostly ineffective and potentially toxic treatments. 

The stories were:

1    1. Poor Childhood Sleep May Lead to Behavior Woes in Adolescence by Molly Walker, Staff Writer, MedPage Today, December 04, 2017: Study suggests bidirectional association for some problems

“Young children who had greater sleep problems were more likely to have certain types of behavioral problems years later, Australian researchers found…There was a bidirectional association between sleep problems and externalizing difficulties, such as attention deficit-hyperactivity disorder, oppositional defiant disorder, and conduct disorder, in children when measured at particular time points through early adolescence, reported Jon L. Quach, PhD, of the University of Melbourne in Australia…Quach's group said that the directionality of the associations between sleep problems in children and later behavioral problems are "poorly understood," but argued that "addressing this knowledge gap will provide valuable information to inform the focus and timing of interventions aiming to improve children's sleep and behavior during the elementary school years...Sleep problems were defined by parent report. 

Of course they relied on parental reporting - to make use of parental denial to the maximum extent possible. 

The directionality of the associations between sleep problems in children and later behavioral problems are ‘poorly understood?’” Poorly understood, my ass. See below.

       2.  ADHD and insomnia appear intertwined By: Bruce Jancin, Clinical Psychiatry News, November 30, 2017  (

“Converging evidence suggests that attention-deficit/hyperactivity disorder and sleep difficulties share a common underlying etiology involving circadian rhythm disturbance, J.J. Sandra Kooij, MD, PhD, declared at the annual congress of the European College of Neuropsychopharmacology…Having built the case for circadian disruption as an underlying cause of both ADHD symptoms and the commonly comorbid sleep problems…Multiple studies have shown that roughly 75% of children and adults with ADHD have sleep-onset insomnia.”

Shared etiology for sleep problems and certain childhood behavioral disorders like ADHD? Well, duh. Both are caused by parents who don't know how to discipline their kids. In the case of ADHD, they let them stay up half the night playing video games. And then the kids are too sleepy to concentrate the next day. 

This sleep pattern leads to the circadian rhythm disturbances (getting days and nights mixed up, in a way) described by Kooij. Of course, the discipline problems in the houses of these kids are hardly limited to bedtime. Inconsistent, abusive, and/or just plain absent discipline lead to children acting out. You know, “oppositional defiant disorder” and “conduct disorder.” Like I said, acting out.

Tuesday, November 7, 2017

A Psychiatric Diagnosis: Behavioral Problem or Brain Disease?

When the first edition of the DSM (the manual of psychiatric diagnoses published by the American Psychiatric Association) came out in 1952, it listed about 100 different psychiatric diagnoses. By the time the fifth edition was published in 2013, it listed over 550 separate ones! One has to wonder if early psychiatrists were just missing a bunch of them, or if normal but repetitive everyday problems in living due to trauma, stress, and interpersonal dysfunction have been turned into diseases. I vote for the latter.

At any rate, the DSM uses the word “disorder” to fudge this question somewhat, leaving a “to be determined” answer as to whether any of the diagnoses are brain diseases or just psychological or behavioral problems experienced by normal brains. So how do we go about making an educated guess as to which it is?

The question is complex because the phenomena under discussion are very complex. While our understanding of the brain is increasing by leaps and bounds, it is still very rudimentary. That is because the brain is literally the most complicated and complex object in the entire known universe, with about a trillion constantly changing connections between nerve cells. Remember when computers would go crazy and produce the infamous “blue screen” when two programs would conflict, and you would have to restart it? Imagine what might happen if the computer were not hard wired!

A lot of people, including many in the various mental health professions, seem to be prone to highly simplistic “either-or” thinking. If even one of the 550 DSM diagnoses is a brain disease, then they all must be. Or if one is a behavioral/psychological disorder, then they all must be. That is just stupid. But throughout the history of psychology and psychiatry, the field has often lurched back and forth between brainlessness and mindlessness (as described in Chapter One of my last book), incorporating what turned out to be ridiculous or misguided theories.

Autism is caused by refrigerator mothers. Schizophrenia is just a different way of experiencing the world or due to being placed in a double bind by your family. Sexual promiscuity is a genetically determined trait, and certain races are genetically inferior to others. Acting out by children is caused by underlying bipolar disorder. Obsessive compulsive disorder is caused by harsh toilet training. A central part of women’s psychology is penis envy. The list of nonsensical and grossly mistaken theories like these is nearly endless. I’m surprised that no one ever theorized that the memory deficits in Alzheimer’s disease are really a result of the defense mechanism of repression.

But even without such simplistic thinking, determining which diagnoses are truly diseases and which are primarily behavior problems caused by problematic learning and stress is not easy. You cannot just do an fMRI brain scan, as I described in an earlier post, because that test alone does not distinguish an abnormality from a normal conditioned response to a particular social environment.

And even if something is a brain disease, family stress and dysfunction can make it worse – just like with many physical diseases. Then there’s this: having a parent who gets manic and runs naked through the streets creates huge stresses for a child who observes it. Such children are at risk both genetically and environmentally.

Not only that, but you get into a chicken and egg situation: does having a controlling family create anorexia nervosa, or is having a child who is starving herself to death lead parents to become overly controlling? A child who is more temperamental is often somewhat more difficult to raise than one who is not, leading some parents to engage in problematic parenting practices with one of their children but not others.

The whole question of “what causes” a disorder is further complicated by the fact that with the vast majority of psychiatric diagnoses, there are no necessary or sufficient causes of any sort – only risk factors that increase the odds someone will develop a disorder, and mitigating factors that decrease those odds. And there are usually hundreds of these factors operating over time.

So what standards do I use in forming my opinions about various disorders? To me, by far the most important metric is whether the symptoms of the disorder only appear under certain social conditions, and disappear when the social conditions change. Real brain diseases like schizophrenia do not do that; they are present almost all the time. You see victims “responding to internal stimuli” whether you are talking to them one-on-one or observing out of the corner of your eye on a ward in a state hospital them when they don’t realize they are being observed by staff. They show them no matter who is talking to them, or even if they are put alone in a room in a psychiatric ER with a hidden video camera keeping a watchful eye on them.

Someone with, say, a melancholic depression reacts at a snail’s pace compared to the way they usually react (psychomotor retardation) every waking moment no matter where they are or who they are with, and stay in that state all day every day, sometimes for weeks at a stretch. Luckily, when I trained we could keep patients in the hospital that long so we could see this; today’s trainees do not get to do that any more, so are more easily fooled.

On the other hand, borderline personality disorder symptoms are not like that at all. I would see patients with the disorder acting out with staff in a psychiatric hospital, but behaving completely appropriately with the other patients when they didn’t know I was observing them. In fact, they are famous for acting one way in the presence of certain staff members and exactly the opposite when in the presence of others, leading the two groups to fight with each other (the staff split)!

I’ve seen people I know who have the disorder out and about at music festivals and theaters acting as normally and appropriately as anyone else. In therapy, certain emotional reactions and provocative behavior would come out of them if the therapist did one thing, but would disappear quickly if the therapist changed to doing something else.

In looking at neuroscience evidence, an important metric in distinguishing disease from mere dysfunction is the sheer number of different types of brain anomalies and other neurological findings. As I said, a single fMRI finding alone tells you nothing. But a whole bunch of different fMRI abnormalities with some of them completely unrelated to the symptoms of the disorder suggests a brain disease. For example, people with schizophrenia tend to have a lot of different abnormalities, many of which have nothing to do with delusions or hallucinations. One cannot be certain, of course, but I would be hard pressed to explain many of these neurological findings in terms of conditioned responses to particular social environmental stimuli.

Wednesday, October 25, 2017

More Stories from the Journal of Obvious Results

As I did on my posts of  November 30, 2011,   October 2, 2012September 17, 2013,  June 3, 2014,  February 24, 2015,  December 15, 2015,  September 13, 2016 and March 15, 2017, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of the later. 

The journals honor the tradition of The Golden Fleece Award, an award given to public officials in the United States for their squandering of public money, its name sardonically derived from the actual Order of the Golden Fleece, a prestigious chivalric award created in the late-15th Century, and a play on the word fleece, as in charging excessively for goods or services. The late United States  Senator William  Proxmire  began to issue the Golden Fleece Award in 1975 in monthly press releases.

My comments are in bronze.

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

3/17/17. Because substance abuse is an indicator of being satisfied with your life. US Veterans With Substance Abuse Problems May Have Higher Risk Of Suicide Than Veterans Without Such Problems, Study Suggests. HealthDay  reported, “US veterans with substance abuse problems have a higher risk of suicide than veterans who don’t,” researchers found after examining data on “more than four million veterans.” The findings were published online March 16 in the journal Addiction.

5/24/17. Because having a potentially fatal illness is so exhilarating. Lung Cancer Diagnosis May Increase Suicide Risk, Study Suggests. HealthDay (5/23, Mille) reports that research suggests individuals “with lung cancer have a strikingly higher-than-normal risk of suicide.” Investigators looked at “data from over 3 million patients during a 40-year period.” The research indicated “that a lung cancer diagnosis raised the odds of suicide by over four times compared to people in the general population.” The findings were presented at the American Thoracic Society meeting.

5/30/17. Because most people adjust instantly when uprooted from their entire way of life by a bloody war. Syrian Refugee Children Living In The US Reported High Levels Of Anxiety, Small Study Suggests. MedPage Today (5/28, Visk) reported, “Syrian refugee children living in the US reported high levels of anxiety,” researchers found. Specifically, “based on self-reported test scores, more than half of children had a probable anxiety diagnosis, and more than 80% had probable separation anxiety,” the 59-child study revealed. The findings were presented during a poster session at the American Psychiatric Association’s annual meeting. Healio (5/26, Oldt) also covered the study.

8/17/17. Cheaters are prone to cheat? Will wonders never cease? Serial Infidelity Across Subsequent Relationships (Arch Sex Behav; ePub 2017 Aug 7; Knopp, et al ).  Prior infidelity emerged as an important risk factor for infidelity in next relationships, according to a recent study. Researchers addressed risk for serial infidelity by following adult participants (n=484) longitudinally through 2 mixed-gender romantic relationships. Participants reported their own extra-dyadic sexual involvement (ESI) (ie, having sexual relations with someone other than their partner) as well as both known and suspected ESI on the part of their partners in each romantic relationship.

9/6/17.  And I thought most elderly people who fall fall out of bed. For nursing home residents, mobility increases risk of fracture. Reuters (9/5, Rapaport) reports a new study published in The Journals of Gerontology: Series A found that for nursing home residents, “risk factors for fracture included the ability to walk independently, wandering the halls, dementia and diabetes.” The study was based on data from “419,668 nursing home residents, including 14,553 who experienced hip fractures.” Lead author Sarah Berry, MD, of the Institute for Aging Research and Harvard Medical School in Boston said, “Frail nursing home residents that are still mobile and independent have opportunity to fall.”

9/6/17. People prone to diseases get them more often than those who are not? Genetic variants linked to health problems appear less frequently in people who live longer, study indicates. Newsweek (9/5, Osborne) reports genetic research published in PLOS Biology used data from over 200,000 people to show humans “appear to be evolving to hit puberty later and those who start at an older age live longer.” Researchers also discovered that “genetic variants linked to heart disease, obesity and high cholesterol appear less frequently in people who live longer.”

9/8/17. Because major depression has a genetic component, and depressed mothers may have attachment issues or altered parental behavior, ya think? Children Whose Mothers Took Antidepressants During Pregnancy May Be At Increased Risk For Psychiatric Illnesses Themselves, Research Indicates. HealthDay (9/7, Preidt) reports, “Children whose mothers took antidepressants during pregnancy may be at increased risk for psychiatric disorders themselves,” researchers concluded after reviewing “data from more than 905,000 children born in Denmark between 1998 and 2012,” whose “health was followed for up to 16.5 years.” The findings were published online Sept. 6 in the BMJ. According to Medscape (9/7, Brooks), the authors of an accompanying editorial “say that reporting absolute risks, as the researchers do in this study, is important to facilitate communication between clinicians and pregnant women.”

9/8/17. Maybe cuz they’re the ones who are eating again? Young Women With Anorexia Nervosa Who Resume Menstruation By End Of Treatment May Experience Greater Improvement In Psychological, Physiological Well-Being Than Those Who Do Not, Small Study Suggests.

Medscape (9/7, Davenport) reports, “Young women with anorexia nervosa (AN) who resume menstruation by the end of treatment experience greater improvement in both psychological and physiologic well-being than those who do not,” researchers found after studying 39 women with AN and 40 women with bulimia nervosa. The findings were presented at the European College of Neuropsychopharmacology Congress.

9/8/17.  Why would you need doctors for people to have healthcare? I just don’t understand. ACA Plans With Narrow Networks May Provide Less Access To Mental Healthcare, Study Indicates. Reuters (9/7, Rapaport) reports that according to a new study conducted by researchers at the University of Pennsylvania Perelman School of Medicine in Philadelphia, “narrow-network insurance plans created by the Affordable Care Act (ACA) offer only limited access to mental health care.” The article says these plans seem to have substituted lower costs for less access to mental healthcare.

9/11/17. Self destructive kids study less? High school students with poor grades more likely to have unhealthy behaviors, CDC study indicates. The Atlanta Journal-Constitution (9/8, Hart) reported, “There’s a link between unhealthy behavior and bad grades, according to a new study of high school students by the US Centers for Disease Control and Prevention.”  HealthDay (9/8, Preidt) reported the study suggests US high school students with poor grades are “much more likely to have unhealthy behaviors – including illegal drug use – than teens at the top of the class,” researchers concluded after “analyzing data from a 2015 government survey.” The findings were published in the CDC’s Morbidity and Mortality Weekly Report.

9/15/17. Because as we all know the incidence of health problems decreases with age. Risk For Health Anxiety May Be Increased In Older Adults, Study Suggests. MD Magazine (9/14, Warren) reports, “The risk for health anxiety...a disorder characterized by a preoccupation with physical health and/or somatic/body symptoms, is increased in older adults,” researchers found after assessing “538 primary care patients” ranging in age from 18 to 90. The findings were published online June 24 in the Journal of Anxiety Disorders.

9/29/17. They thought infectious disease occur spontaneously, I guess. Babies with older siblings may be at higher risk of hospitalization for influenza, researchers say. In “Well,” the New York Times (9/28, Bakalar, Subscription Publication) reports, “Having older brothers and sisters puts infants at higher risk for being hospitalized” for influenza, researchers concluded after studying “1,115 hospital admissions of children under two born in Scotland from 2007 to 2015.” The findings were published in the European Respiratory Journal.

10/2/17. Because listening to people talk about the voices in their heads is so relaxing. Caregivers of Individuals With Schizophrenia Experience High Levels of Distress, Study Finds. Psychological distress among family or friends who provide unpaid support to people with schizophrenia or schizoaffective disorder is much higher than the general population, reports a study published today in Psychiatric Services in Advance


10/4/17. I didn’t know PTSD had anything to do with being traumatized. PTSD Particularly Common Among People Exposed To Mass Shootings, Studies Indicate. The AP (10/3, Tanner) reports that people who survived this week’s shootings in Las Vegas may be at risk for post-traumatic stress disorder (PTSD). Also at risk for “psychological fallout” are first responders, medical staff, eyewitnesses, and bystanders. Studies indicate “PTSD is particularly common among people exposed to mass shootings versus other types of trauma, with rates as high as 90 percent reported” by some researchers.

Because being abused as a child is good for your mental health. Young Adults Who Recall Being Maltreated May Have A Particularly Elevated Risk For Psychopathology, Researchers Say.   A study to be published in the January issue of the Journal of Psychiatric Research (10/24, Newbury, Arseneault, Moffitt, Caspi, Danese, Baldwin, Fisher) “explores the validity and utility of retrospective self-reports versus prospective informant-reports of childhood maltreatment.” Study data “were obtained from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative birth cohort of 2,232 children followed to 18 years of age (with 93% retention).” Researchers evaluated “childhood maltreatment” through “prospective informant-reports from caregivers, researchers, and clinicians when children were aged 5, 7, 10 and 12,” and via “retrospective self-reports of maltreatment experiences occurring up to age 12, obtained at age 18 using the Childhood Trauma Questionnaire.” The study revealed that “young adults who recall being maltreated have a particularly elevated risk for psychopathology.”

Sunday, September 24, 2017

Cognitve Behavioral Therapy "Evidence-Base" Grossly Exaggerated

In my post on my Psychology Today blog on November 21, 2011, I discussed how the purveyors of today’s most predominant psychotherapy methodology, cognitive behavioral therapy, grossly exaggerate the strength of their research evidence base in the psychotherapy outcome literature.

My opinion was recently confirmed in a review of meta-analyses of the CBT literature in the Journal of the American Medical Association, published online September 21, 2017 (“Cognitive Behavioral Therapy the Gold Standard for Psychotherapy:  The Need for Plurality in Treatment and Research” by Falk Leichsenring and Christiane Steinert).

They reported that a recent meta-analysis using criteria of the Cochrane risk of bias tool reported that only 17% (24 of 144) of randomized clinical trials of CBT for anxiety and depressive disorders were of high quality. The “allegiance factor”—study authors were CBT therapists themselves and often designed the studies to make their treatment look better than it was, and opposing treatments look worse that they were—was rarely controlled for.

Compared with "treatment as usual" —letting subjects get whatever other treatments outside of the study treatment that they chose to have, allowing good therapists and bad therapists, and good therapies and bad therapies, to essentially cancel each other out—the sizes of treatment effects were only small to moderate and might eventually even be found to be due to the allegiance effects.

In panic disorder, CBT was not more effective than treatment as usual but only to being on a waiting list.

Even with these amazing biases, for depressive disorders, response rates of about 50% were reported. This was true for anxiety disorders as well. “Response” just meant there was some significant improvement in symptoms, not that the symptoms of the disorders actually went away. Rates for actual remission from the disorders were even smaller. Conclusion: a considerable proportion of patients do not sufficiently benefit from CBT.

Last but certainly not least, there was no clear evidence that CBT was more effective than other psychotherapies, either for depressive disorders, anxiety disorders, personality disorders or specific eating disorders.

Personally, my biggest beef with CBT and other psychotherapy outcome studies has less to do with symptom relief than with actually changing maladaptive interpersonal behavior. The latter is almost never even looked at, let alone measured in these studies.

CBT’ers seem to think anxiety, depression, and self-destructive behavior are all due to screwed up thinking by individuals rather than being normal reactions to stress-inducing environments. In experimental psychology circles, this is known as the fundamental attribution error. Telling people with these particular symptoms that their problems are basically “all in their heads” in this manner is very invalidating for them.  Ironically, an ‘invalidating environment” is one of the two primary factors these very same therapists cite as the main causes for borderline personality disorder.

Tuesday, July 18, 2017

Book Review: "Behave" by Robert M. Sapolsky

For anyone who wants to understand all of the huge number of factors that influence human behavior, as well as counter overly pat, simple, or downright mythological explanations for it, I cannot recommend a book more highly than this one. Every page – and there are almost 700 of them - is just packed with enlightening information on the role of almost everything you can think of. 

These factors include genes, gene regulation, epigenetics, neurotransmitters, hormones, brain structures, neural networks, unconscious cuing and sensory triggers, stress responses and protective factors, neural plasticity, peers and social acceptance, attachment figures, brain development in childhood and adolescence, socioeconomic and hierarchical status, collectivist vs. individualistic cultures, gender, reactions to “them” vs. “us,” heritibility  vs. inheritance of traits, gene/environmental interactions,  population density, evolution (individual, kin, and group selection), reciprocal and pathological altruism, obedience vs. resistance, cooperation vs. competition, and empathy. And a whole lot more.

Can one book really be that encyclopedic?? Yes! I have no idea how he accomplished writing this. 

If you do not understand some of the scientific concepts that are under discussion, he conveniently includes three appendices in the book to help explain them. Not that the main body of the book is dry and overly technical. It is laced throughout with witty jokes, stories, and ironic observations that kept me thoroughly entertained.

Does he leave anything out? Well, yes, he does not seem to know about the effects of rapid cultural change on families which may create shared intrapsychic conflicts leading to parents giving mixed messages to their children which then trigger and reinforce their repetitive self destructive behavior. But I haven’t yet seen anyone else write about that besides me – at least not in the way I have conceptualized the process - so I wouldn’t expect that. He also doesn’t discuss the effects of chaos theory on the amazingly multi-factorial “causes” of behavior he goes into - a minor quibble.

Sapolsky shoots down behavioral and neuroscientific myths believed by health care professionals, some scientists, and the lay public alike (what mirror neurons actually do, for example) with the abandon of someone armed with an Uzi facing off against people armed with swords. Amazing.

Some of his important points: 

1.       Brains and cultures co-evolve.

2.       We haven’t evolved to be selfish or altruistic, but to behave in particular ways in particular settings. Context is everything.

3.       Genes are not about inevitabilities, but about potentials and vulnerabilities, and they do not determine any behavior on their own.

4.       Evolution has been most consequential when altering regulation of genes, not the genes themselves.

5.       Saying a biological system works well is not a value judgment – it can function equally well for those who do something wonderful or in those who do something horrific.

6.       Nothing seems to cause anything - everything just modulates something else within a specific environmental context. And changing one thing often changes ten other things as a byproduct.

7.       Any causative factor within any specified population of individuals within any specific environmental context has an average effect on behavior that may or may not apply to any given individual. There are always exceptions.

What an accomplishment.