Some Suggestions for Avoiding Bad Psychiatrists

"Letters, we get letters

We get lots and lots of letters"

(Apologies to the producers of the old Perry Como TV Show, if any are still living.  Damn I'm old!)



A blog reader sent me a very interesting e-mail with some important questions about the treatment one psychiatrist was providing her daughter.   Maybe I should start a newspaper advice column.  Or maybe not.  Anyway, I'll try my hand at it this one time.

The behavior of the doctor that she describes, assuming that the description is accurate, seems to be typical of the way a lot of bad psychiatry is administered these days. I thought readers might appreciate some tips on how to avoid it.

You can find many additional tips on how to pick a psychiatrist or a psychotherapist who deals effectively with family dysfunction in Chapter Ten of my book, How Dysfunctional Families Spur Mental Disorders.

The names in the letter have been changed to protect the innocent - or in this case, the name of a doctor who is perhaps guilty:

Dear Dr. Allen,

I just recently ran across your blog and became distressed because I fear my daughter is a victim of the over diagnoses of bipolar II. I took her to Dr. XXX because she was nearly suicidal after her father threw her out of her apartment (which he owns) because of her drug and alcohol use. She had no money saved to get an apartment, she wrecked her car and had no vehicle to go back and forth to college and work, and she was on a downward spiral. I told my daughter that I would help her get on her feet financially if she saw a psychiatrist (fearing she was suicidal). She found Dr. XXX’s name in the yellow pages and off we went.

Within 10 minutes he had her diagnosed as BP II. Perhaps we were relieved that there was a medical explanation for her state or perhaps his insistence that “of course this is BP II; I am an expert in the field and should not be questioned” but we did not get a second opinion. After 11 months of ‘treatment’ she is still not ‘normal’ which he blames on her not being compliant in his instruction about when to take medication, eat, sleep, etc. She does not want to continue with the treatments as the drugs are messing her up with extreme tiredness, swelling up like a balloon on the face and extremities, hypothyroid, there are constant blood tests, and on and on.

Dr. XXX refuses to help her wean off the medications stating that he can not do that when he knows she needs the meds and he took an oath. Who can help or how can we proceed to get her safely weaned off the numerous drugs she is currently taking (Equatro, lithium, lyrica, synthroid, zyprexa) to see if now that she is no longer abusing drugs and alcohol, if she can function normally? Should we get a second opinion? What should we do? Please help!

Best regards,

Mrs. ZZZ

Hi Mrs. ZZZ,

Obviously I can not make a diagnosis of your daughter or fairly evaluate her treatment based on an e-mail, but I can make some generalizations that relate to some of what you said. The following should in no way be interpreted as medical advice, but of course that does not mean you need to discount what I say.

First of all, if any psychiatrist makes a diagnosis with certitude after just ten minutes, it is not only time to get a second opinion, but to completely ignore the first one.

If a doctor does not really address a patient’s or the family's concerns but instead just says, “Trust me, I am an expert,” ditto.

The medications you describe would be for bipolar I, not II, and fibromyalgia, which is a wastebasket diagnosis for pain we do not understand. Also, your list includes two mood stabilizers (lithium and carbamazepine [“Equatro” – a brand named drug when a much cheaper generic is available]), as well as an anti-psychotic.

Whenever I see patients on such a bizarre mix of medications, some of which are for symptoms such as psychosis which they do not in fact have, the odds are extremely good that the patient has been highly overmedicated and misdiagnosed, and the doctor has been just throwing meds at the patient willy-nilly to see what sticks.

Blaming the patient for a failure of medications, while possibly true if the patient is not taking them as prescribed, is usually counterproductive. If a patient is not compliant, maybe it is because the meds are creating more problems than they are solving.

A doctor can not make a legitimate diagnosis of a mood disorder if a patient has been using drugs throughout the entire period in which symptoms occur – because the effects of the drugs can and often do mimic the symptoms of a mood disorder.

If a patient with a diagnosis that has been made under the above circumstances needs to be weaned off meds, he or she may have to consult with several psychiatrists before being able to find one that is willing to help the patient do that. But it is definitely worth the effort.

Last, I think that bipolar II is not a legitimate diagnosis to begin with, but I am in a distinct minority of psychiatrists on that point. 

Sincerely,

David Allen

Let the buyer beware!

Some Questions Answered About Family Dynamics in Borderline Personality Disorder

"Letters, we get letters

We get lots and lots of letters"

I had an interesting exchange with a reader who asked me some questions about my ideas about the family dynamics of people with borderline personality disorder. I thought other readers may have similar questions, and she gave me her permission to reproduce the exchange in a blogpost. So here t'is, with my answers in blue:

I think my mother has BPD. I am trying to make sense of it, and I am digging into my family's history, to see if I can find a possible cause for her BPD.

The mother of my mother seems to be like the mother in the movie Thirteen, that you commented on in your article. She is always stating she would do anything for her children, but at the same time she sometimes drops things like, 'I sacrificed my life for them." Which pretty much sounds like playing the victim, to me.

It is new to me, that parents who are not physically or emotionally abusive, can also provoke BPD in their offspring. Thank you for attracting my attention to that.  Researching more about this, I read an article that stated that parents who are 'over-involved' can do the same, because they don't allow their children to grow into beings with clear boundaries. Do you agree on this statement? If this is true, than the hypothesis, that BPD patients always have poor attachment to their primary care givers, doesn't stand? 

One last question is: Can patients who have BPD get cured without professional help? I am asking this question, because I realize that I also have had several traits of BPD during the course of my life - although they never co-occurred. Coming to a point where I am realizing that my mother probably has BPD, I am also evaluating my own personality, and if I am honest, I can see that, especially during my twenties, I have had several symptoms, though never more than one at the same time.

Can you please provide me with some clarity ? I would be most grateful. I however will understand if you don't have the time to answer.

In answer to your questions as they apply in general - I am not able to speculate about your situation in particular without having seen and extensively evaluated you and your family situation:

1. The family dynamics of BPD involve the parents being conflicted over the role of having kids. They go back and forth between hostile under-involvement and hostile over-involvement. In a given family, one of these sides may predominate most of the time, but if one waits long enough, the other side shows up.

2. BPD is not a "disease" but a combination of traits by which someone adapts to the above family behavior. Some people have a lot of these traits, some many fewer. The traits can range from very mild to very severe, and severity levels can change dramatically in a short period of time. They can also appear and disappear depending on what is going on in a person's family life at any given moment.

Even in people who show these traits most of the time, many of the traits may start to get better on their own as the person gets older, although certainly not in all cases. Their relationships may continue to be poor, however.  Professional help can be very useful, but whether it's absolutely necessary in every case , the answer is that it depends on a lot of different factors.

Family-oriented psychotherapy is hard to find.  The models I recommend are listed at the end of the post:  http://www.psychologytoday.com/blog/matter-personality/201205/finding-good-psychotherapist. I'm not sure which ones might be available where you are. In England, the most common one is cognitive-analytic therapy (CAT).

What if no other siblings had symptoms while living in this 'borderline producing family?' Does it make sense to develop symptoms only after having left the parental nest? (Because in this case, the 'spoiler' doesn't develop his behavior to balance the mother's moods: instead she only starts to be a spoiler once married, like my mum ... Then this behavior is of no use? (only to act out own frustrations maybe .. but it is not in the interest of balancing the family system). Does this make sense then ?

(Going to a family therapist in my/my mother's case is a non-option for my mother, so unfortunately I have to kind of figure these things out by myself.)

Again, many possible explanations, so I can't say anything about your situation in particular.

In general, in the type of situation you are describing, the person's spoiling behavior with the new spouse stabilizes his/her parents in some way, but is only needed by those parents when the adult child is in the context of a marriage. Often gender role conflicts and repressed anger are at the root of such a pattern - for example, a daughter might act out the mother's repressed rage about having to cater to her (the mother's) own inadequate husband (the daughter's father or step father). Through the daughter's behavior, the mom experiences vicarious satisfaction of her own rage as she watches her daughter frustrating the daughter's husband efforts to "take care" of her.

If a mother acts in a way that produces BPD in her offspring, is it always the case that the child will become a spoiler? In the particular case of my mother, everyone from her family of birth tells me how "good, quiet, well behaved..." she was. It is like she only started to have BPD symptoms when she got married and had kids. Does that make sense? 

No, not always. In fact, family dynamics are like the proverbial true-false test: nothing happens "always" or "never." There are an almost infinite number of other factors which may alter the developmental course of a child - especially other relationships including the other parent, other relatives, or supportive mentors. There is what they call a "chaos" effect - small differences in initial conditions can multiply into big differences later on. Also, in some families, only one sibling will volunteer and/or be chosen to be "it," while the others remain relatively unaffected. If the "it" child stops playing the spoiler, one of the other siblings may suddenly step into that role ("sibling substitution").  The more severe the parental internal conflict, the more additional siblings will be affected or recruited at the outset.

If BPD is not a disease, how is it that the amygdala in people with BPD seems to be different ?

The amygdala is subject to neural plasticity like many areas of the brain, which means that it normally changes in size and activity as it adapts to the environment - especially the social environment.  It's one of the bases for conditioned responses. See http://www.davidmallenmd.blogspot.com/2014/05/borderline-personality-disorder-why.html and http://www.davidmallenmd.blogspot.com/2013/02/neural-plasticity-and-error-management.html

Why do almost all of the experts state that BPD is as good as is incurable, even if the patient is willing to cooperate?

"Cure" is a strange word to use since it's not a disease. Borderline traits absolutely can go away, and the relationships of someone with BPD can change for the better, especially with treatment that focuses on family-of-origin behavior.

You say that the traits of BPD sometimes disappear with aging, as they are not needed anymore. But I thought that BPD primarily stems from a fear of abandonment. So I don't see how someone can get rid of this deeply rooted feeling, even when he doesn't live with his parents anymore / is not being abused by them anymore / or maybe they even died. If there is a 'hole' inside you because of non-attachment with your parents, I thought that this emptiness will always be there, and it will just manifest itself by clinging to - pushing away spouses instead of the parents, or the same behavior towards offspring.

The issue of what happens after the parents die is still somewhat of an open-ended question for me.  For some people, they are freed up for the most part, although the "emptiness" never completely goes away. Other people get worse than ever after the parents die, even if other family members do not seem to be feeding into their problems. I think it has something to do with PTSD-like effects. The more obsessive a patient starts out, the more likely they are to obsessively recreate conversations with their parents in their heads. 

I had one patient who got a lot better after seeing the movie A Beautiful Mind. She realized that even though she couldn't stop hearing those conversations in her head, she didn't have to believe them. She discovered the secret of "Acceptance and Commitment Therapy" (ACT) before it had been "discovered" and written about - although I don't think ACT really works if the parents are still feeding into the problem, as they are more powerful in shaping a person's behavior than any therapist.

Are there cases in which a person with BPD manifests traits towards her spouse, but not towards her children? What does it mean?

There are all kinds of different permutations and combinations, and plenty of traits of other personality disorders that can co-exist and come and go with any patient. The family issues that the patient's behavior is designed to solve determines this, and every family is different. The details matter.  The stuff I write about only represents prototypes or the most common patterns.