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Minggu, 13 Agustus 2017

My Second Book Finally Available at a Reasonable Price





My second book, "Deciphering Motivation in Psychotherapy" was reissued a while back after going out of print, but was priced in the stratosphere. It's now available on Amazon for a more reasonable price at https://www.amazon.com/Deciphering-Motivation-Psychotherapy-Critical-Psychiatry/dp/0306437902/ref=mt_hardcover?_encoding=UTF8&me=

The book covers the often covert nature of interpersonal communications within dysfunctional families, and helps both therapists and lay readers learn how to dig out hidden meanings in their verbal interactions. The hidden meanings, in turn, reveal the ulterior motives and underlying internal conflicts of the involved family members. 

The book also clarifies the concept of dialectics in a way that I think is way more accurate that the way the concept is used in Dialectical Behavior Therapy (DBT).

Rabu, 09 Agustus 2017

Recognition of the False Epidemic of ADHD by a Major Newspaper Its About Time





Finally, there has been recognition by at least one major metropolitan newspaper, the New York Times, about the phony “epidemic” of ADHD diagnoses among both adults and children. Not that doctors pushing the disorder would ever admit to it. (News to some: a high percentage of these diagnoses are made by non-psychiatrist physicians such as pediatricians).

An e-mail newsletter from the American Psychiatric Association contained the following story on 12/10/2013:

 “The Centers for Disease and Control and Prevention (CDC) reports that there has been a 42% increase in attention-deficit/hyperactivity disorder (ADHD) diagnoses in children aged 4 to 17 from 2003 to 2011. Data were published in the Journal of the American Academy of Child and Adolescent Psychiatry. The study included 2011 data from a randomized, cross-sectional national survey of more than 95,000 U.S. households known as the National Survey of Children's Health. …The results showed by 2011, 11% of children—or 6.4 million children nationwide—had received a diagnosis of ADHD. Among those with a diagnosis for ADHD, approximately 70% were currently taking medication for the disorder—increasing by 28% from 2007 to 2011. Nearly 1 in 5 high school boys was diagnosed with ADHD, compared with 1 in 11 high school girls. ADHD-diagnosis frequency was most prevalent in Kentucky, at 15 percent, and least prevalent in Nevada, at 4.2 percent.

"The authors
[of the study] speculate that 'better detection of underlying ADHD, due to increased health education and awareness efforts' may be the reason for the increase of ADHD diagnoses among American children."

BETTER RECOGNITION?? REALLY?!?  A story in the New York Times by Alan Schwarz on December 14, 2013 had a far more reasonable explanation.  It said that even the person most responsible for recognition of ADHD in children, Keith Conners, questioned the rising rates of diagnosis and called them “a national disaster of dangerous proportions.”
“The numbers make it look like an epidemic. Well, it’s not. It’s preposterous,” Dr. Conners, a psychologist and professor emeritus at Duke University, said in a subsequent interview. “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.”

Keith Connors, Ph.D.

The Times story continues:
“The rise of A.D.H.D. diagnoses and prescriptions for stimulants over the years coincided with a remarkably successful two-decade campaign by pharmaceutical companies to publicize the syndrome and promote the pills to doctors, educators and parents. With the children’s market booming, the industry is now employing similar marketing techniques as it focuses on adult A.D.H.D., which could become even more profitable.
… The disorder is now the second most frequent long-term diagnosis made in children, narrowly trailing asthma, according to a New York Times analysis of C.D.C. data.
Behind that growth has been drug company marketing that has stretched the image of classic A.D.H.D. to include relatively normal behavior like carelessness and impatience, and has often overstated the pills’ benefits. Advertising on television and in popular magazines like People and Good Housekeeping has cast common childhood forgetfulness and poor grades as grounds for medication that, among other benefits, can result in “schoolwork that matches his intelligence” and ease family tension.”
The story was followed by an editorial on 12/18/13, An Epidemic of Attention Deficit Disorder.  Hooray for the New York Times!!  Some of what it said:
“The hard-sell campaign by drug companies to drive up diagnoses of attention deficit hyperactivity disorder, or A.D.H.D., and sales of drugs to treat it is disturbing. The campaign focused initially on children but is now turning toward adults, who provide a potentially larger market…Many of these children, it appears, had been diagnosed by unskilled doctors based on dubious symptoms…

“Shire, an Irish company that makes Adderall and other A.D.H.D. medications, recently subsidized 50,000 copies of a comic book in which superheroes tell children that “Medicines may make it easier to pay attention and control your behavior!” Advertising on television and in popular magazines has sought to persuade mothers that Adderall cannot only unleash a child’s innate intelligence but make the child more amenable to chores like taking out the garbage…

“The potential dangers should not be ignored. The drugs can lead to addiction, and, in rare cases, psychosis, suicidal thoughts and hallucinations, as well as anxiety, difficulty sleeping and loss of appetite…So many medical professionals benefit from overprescribing that it is difficult to find a neutral source of information. Prominent doctors get paid by drug companies to deliver upbeat messages to their colleagues at forums where they typically exaggerate the effectiveness of the drugs and downplay their side effects. Organizations that advocate on behalf of patients often do so with money supplied by drug companies…

“Curbing the upsurge in diagnoses and unwarranted drug treatments will require more aggressive action by the F.D.A. and the Federal Trade Commission, which share duties in this area. It will also require that doctors and patients recognize that the pills have downsides and should not be prescribed or used routinely to alleviate every case of carelessness, poor grades in school or impulsive behavior.”


Sabtu, 27 Mei 2017

If a psychologist makes a joke while all alone in her office


Today, I am ... well, I am nervous. At noon, I'll be giving my first online seminar ever, and it will be the final keynote session for MediaBistro's Literary Festival.

As much as I talk about being shy, I'm actually a good presenter. I love connecting with my audience,  making them laugh and seeing them respond to what I'm saying and all that great stuff. I do a lot of training at work, and the staff seem to enjoy it (apparently I make a lot of funny faces). I've presented at conferences and to rooms full of CEOs. And I don't get nervous, not anymore. Until today!

Because today, as I present "Overcoming Obstacles to Becoming the Writer You Want To Be," I'll be in my office, wearing headphones, talking into a webcam, and trying to be charming even though I AM ALL BY MYSELF.

Heh. So, anyway, to occupy you while I climb the walls, here is something that I find quite lovely ------------------------------------------------------------------------------------>

This, as you might have figured out, is the spine and part of the back of the dust jacket for SANCTUM. I think it is rather badass.

And, because you are here and still reading, I will share with you a bit of news. If you've read any of the first few reviews (there aren't many, but they're *starting* to come in), you may have seen that they mention the ending. I'm thrilled that it's getting that kind of reaction. And if you decide to read it and have that same kind of reaction, this is for you:



YES. The first chapter of the AS-YET-UNTITLED BOOK TWO will be included at the end of SANCTUM! So there's a map, and there's a sneak peek, and oh, yes, a BOOK between those two pieces of awesomeness. I think you might want to pre-order this sexy-fantastic thing (for less than $9 ...). Or, you know, you could enter to win the ARC here (that giveaway ends tomorrow!).

And now, off I scuttle. I won't be around next week, but I'll be back the week after, when I'll be sharing with you bits of the talk I'm giving today, specifically the parts about dealing with writer's block. If you commented on my original post on this topic, your first name/posting name is on my acknowledgments slide. I really appreciated your input, and I will repay it with a little series on writer's block at the end of this month!

Jumat, 26 Mei 2017

Interview at Get Lost in a Story High school fall back plans and love


Today I'm being interviewed by Maureen McGowan (whose fabulous book DEVIANTS will be featured here next Monday) at Get Lost in a Story, where I talk about what I was like in high school, what I'd do if I couldn't write anymore, and what it means to love someone. There will be a giveaway of a signed hardcover of Sanctum there as well, so please enter if you're interested!

BUT BEFORE YOU GO:

Congratulations to Ruby97, who won the $20 gift card from last week's "What I used to believe/What I know now" giveaway!

Happy Monday, everyone!

Rabu, 19 April 2017

More Bipolar Disease Mongering in a Respected Journal


“The drug companies learned a while back that the best way to sell drugs was to sell diagnoses… selling the diagnosis is a way of opening up the new market. New diagnoses are as dangerous as new drugs, at least in psychiatry.”~ Dr Allen Frances, chair of DSM IV task force - Selling Sickness conference, 2011.

One of the main themes of both my book How Dysfunctional Families Spur Mental Disorders and this blog has been the incredible expansion of the bipolar diagnosis to anyone who is moody, chronically depressed and irritable, or chronically agitated. 

This has been done predominantly by some egocentric blowhard psychiatrists trying to make a name for themselves in conjunction with a well-documented and highly successful plan by several pharmaceutical companies to enlarge the market for their brand named, so-called atypical antipsychotics.  This marketing plan was documented with the release of Eli Lilly's own company marketing memos as part of a US Justice Department investigation - the so called Zyprexa Documents. These medicines are potentially toxic and do nothing to solve the interpersonal and psychological problems of many of the mental health patients to whom they are prescribed.

My colleague in Australia, Peter Parry, told me,  "Our director of training for psychiatry in our state quipped sarcastically that we may as well subsitute “mental disorder” with “bipolar disorder” and have the “DSM of Bipolar Disorders” and then recategorise subtypes like ‘adjustment bipolar disorder,’‘personality-based bipolar’ etc."  With some of the psychiatrists I know personally, this would actually be considered a good idea!

Many of the adults misdiagnosed with bipolar actually carry the diagnosis of borderline personality disorder and not bipolar. While medication can help these folks with some symptoms, most of these patients are in dire need of good psychotherapy.  Unfortunately, a lot of therapists do not like to work with them, so many end up seeing psychiatrists who use antipsychotics basically to shut them up.

"Disease mongering" is a term used for marketing techniques designed to accomplish what Dr. Frances alluded to at the top of this post.  The ongoing mongering of bipolar disorder by the pharmaceutical companies uses many tricks.  Often so-called researchers and practitioners alike do totally inadequate diagnostic evaluations using highly inaccurate and misleading symptom checklists; others employ the completely unvalidated concept of bipolar spectrum, or b.s. as I like to call it.

Bipolar ver. 4.1

A highly transparent example of disease-mongering was just published in a respected psychiatric journal, the Archives of General Psychiatry.  521 hospital-based or community psychiatrists in 18 countries in Asia, Europe, and Africa between April 1, 2008, and April 30, 2009 were involved in a “research” project which was designed to shape their thinking and diagnosing, and altering diagnostic paradigms in those countries.



The article is titled “Prevalence and Characteristics of Undiagnosed Bipolar Disorders in Patients With a Major Depressive Episode” and was “designed, conducted and prepared” by Sanofi-Aventis. Sanofi-Aventis markets an atypical antipsychotic named Solian, which is the brand name of the drug amisulpride.  It is not FDA-approved in the United States, which is probably one reason why this study was done overseas.

The supposed "results" of the study:

“These results are from a large, 3-continent, culturally generalizable study conducted by practicing psychiatrists. The data indicate that, whereas with application of the DSM-IV-TR criteria, 16.1% of patients with Major Depressive Episodes met criteria for either bipolar I or bipolar II disorder, this rate rose to 47% with application of the bipolarity-specifier criteria.

These results suggest that bipolar features are more frequent in patients with MDE than indicated by DSM-IV-TR criteria. Almost half of the entire 5098 cohort presented the core symptoms of bipolarity (elevated mood, irritable mood, or increased activity), and these symptoms led to unequivocal changes in behavior that were observable by others in a similar proportion of patients.”

What this means is that, if this were true, half of patients who exhibit Major Depressive Episodes are actually bipolar and should  be taking “mood stabilizers.” Not lithium, I suppose, but antipsychotics. 

The article  goes on to state: “Major depressive disorder, the most common psychiatric illness, is often chronic and a major cause of disability. Many patients with major depressive episodes who have an underlying but unrecognized bipolar disorder receive pharmacologic treatment with ineffective regimens that do not include mood stabilizers.”

All of the "researchers" recruited received fees, on a per patient basis, from Sanofi-Aventis in recognition of their participation in the study. The key lead authors, all with significant Pharma connections, did not disclose their personal ties. Quite a transparent example of how cultural beliefs are manufactured, and how direct involvement with Pharma is normalised.

So what's wrong with the study?  Well that hinges on the meaning of the term "bipolarity specifier" that was added to the usual, DSM criteria for bipolar disorder.  This assumes that this additional test has been validated as being predictive of actual bipolar disorder, which is a "fact" not in evidence.  It sounds in the study as if this were an established and valid measure.

Here's the defintion:

“This bipolarity specifier attributes a diagnosis of bipolar disorder in patients who experienced an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR associated with at least 1 of the 3 following consequences: (1) unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, (2) marked impairment in social or occupational functioning observable by others, or (3) requiring hospitalization or outpatient treatment. No minimum duration of symptoms was required and no exclusion criteria were applied.”

People sleeping less, talking more, and doing more. This is how mental illness is now being defined in psychiatry’s leading journal.

One of the dead giveaways that this article is bipolar diseases mongering is the sentence:
“No minimum duration of symptoms was required and no exclusion criteria were applied.”
This means that any person who has a suddenly angry, agitated, or elated response to an environmental trigger (like a big fight with a family member or winning the lottery) could be labeled bipolar.

This would also mean that if they had an episode of emotional dysregulation for the same reason, the reaction would be labeled a bipolar episode. This makes almost anyone who has borderline personality disorder suddenly bipolar.

23.2% of their subjects had experienced episodes of elevated or irritable mood triggered by antidepressants and were also defined as bipolar.  This is almost comical. Irritibility is a common side effect of drugs like prozac and has absolutely nothing to do with bipolar disorder (unless tranquilizers cure mania, because they sure do cure that side effect). This incredible nonsense is straight out of Hagop Akiskal’s dishonest playbook. I heard him say once that if someone who is depressed gets agitated on an SSRI, he just “knows” that person is bipolar.

The word bipolar, in the sense advocated by this piece-of-you-know-what study, is showing up in common discourse everywhere, particularly among young people describing their unpredictable and volatile classmates.  You can even hear the word in pop songs used as a synonym for moody (e.g. “Hot and Cold” by Katy Perry).

Someone... call the doctor
Got a case of love bi-polar
The drug companies have really done a masterful job in bastardizing the diagnosis of real bipolar disorder, which is a serious mental illness.  The harm to both the field and to patients alike has been staggeringly immense.


Rabu, 05 April 2017

Guest Post Is Social Media Offering a Safe Haven for Disordered Eating in Teens






Anorexia, bulimia, and other eating disorders are generally frowned upon and discouraged among teens, and skin and bones isn’t attractive to the majority of people, no matter how you cut it. So why are so many teens still engaging in this harmful behavior? Log onto any social media site and you’re bound to see pictures of food, links to weight loss tips, and people complaining about their weight. That’s just normal, everyday life, right? Maybe. But maybe not. While you and I may seem these acts as normal, people who struggle with disordered views of their body may see it as an open door to encouraging eating less and working out more, to the point that they’re battling for their lives, even though they may see it as battling for a better body. 

Pinterest

Pinterest recently came under fire for inadvertently encouraging “thinspiration” for people suffering from anorexia, bulimia, and other disordered eating habits and views on how the body should look. Jezebel recently released an article detailing this “thinspo” phenomenon, showing how women were congregating together  and creating “thinspo” Pinterest boards where they pinned pictures of women who were bare bones to inspire them to be thinner as well.

Since then, when you search Pinterest for “thinspiration” a warning message will come up saying “Eating disorders are not lifestyle choices, they are mental disorders that if left untreated can cause serious health problems or could even be life-threatening.For treatment referrals, information, and support, you can always contact the National Eating Disorders Association Helpline at 1-800-931-2237 or www.nationaleatingdisorders.org.”

Twitter
A quick Twitter hashtag search for #proana will bring up everyone discussing any and all things related to pro-anorexia. Girls and guys alike post pictures of bones jutting out, siting this as #thinspiration and being #proana. There are tweets showing what #proanas do at restaurants, with a picture of coloring books. And there’s even a new pro-ana Twitter account that offers tips for those wishing to engage in a pro-anorexia lifestyle.
Facebook
Not to be left out, the largest social media site definitely has its place in the disturbing world of encouraging disordered eating and helping people strive for thighs that don’t touch and collar bones that stick out. One search of “thinspiration” and “pro-ana” brings up fan pages and support groups, giving people a place to swap stories and tips, and post goal pictures and (what is deemed to be) success pictures when they achieve a certain amount of thinness.
Encouraging Thinspiration
In our quest to eliminate obesity and encourage healthy habits, there is always the risk of people, teens especially, taking advice too literally and too far, especially with the extreme focus in the media of stars sporting unattainable bodies and going on crazy crash diets. However social media has given these type of people a new outlet and even community that encourages these views. It’s not necessarily the fault of social media, but it is definitely one of the consequences of connecting people around the world.

Author  Byline:
Monta the mother of three children serves as an Expert Advisor on multiple household help issues to many Organizations and groups, and is a mentor for other “Mom-preneurs” seeking guidance.  She is a regular contributor of “gonannies.com”.  You can get in touch with her at montafleming6Atgmail dotcom.

Jumat, 24 Februari 2017

I Shall Never Live With a Female Again Part Two




Wrench not pictured.

The Prozac Jitters
 
I had worked at the same company with S about a year when we decided to live together. She seemed a nice enough person, with a good sense of humor.
     She had been engaged, but the fiance had inexplicably moved out one day and canceled the wedding plans. She was distraught and, paying too much rent for a Brooklyn floor-through, wanted something more economical. I sympathized with her over the disappearance of the boyfriend. 
     "How could he abandon you like that?" I asked, indignant. It seemed capricious and cruel; later, I thought it showed a discerning nature and more than a lick of sense. He had legged it, and fast. When he broke up with her, S had idly threatened to stab him with a kitchen knife. 
     When S left her old apartment, I took the opportunity to let an apartment-hunting couple of mine know about it. They visited, approved, and agreed to take it. After S arrived with bags and boxes to our new apartment, she asked if I would accompany her back to her old place to "pick up a few things,"  such as her bedding, and a few pairs of shoes. Odd that she left them out of the moving truck, I thought, but agreed to help. When we arrived, I received my first harbinger of doom. S waded right into the apartment, through piles of wrinkled clothing, bags of half-eaten potato chips, cat toys, sponges, utensils, and sacks of garbage. I stood there, appalled, as she scooped up a few pairs of shoes. A couple of them spilled out of her arms as she shuffled back toward the door.
     S, you see, was the kind of girl who always appeared impeccably dressed, ironed, and accessorized. I had never had a hint of the chaos under the veneer.
     "Things got out of control while I was packing," she confessed. Very well. I had visited her in the apartment a few months before, but remembered nothing like this. Perhaps it was just an aberration.
     She gathered up whatever she could carry and gave me the garbage bucket and a mop to tote back to the new apartment. They looked suspiciously unused.
     "I guess you're going to come back and clean up this stuff?" I ventured.
     "Not at all." she replied. "The landlord will take care of it."
     A few days later, I received a phone call from my friends who had moved in. The apartment was supposed to have been left "broom clean." They had spent a full day, along with the landlord, toting sacks of discarded possessions and rotten food to the street. The refrigerator was filled with half-eaten bags of stale Cheese Doodles. Not only that, but S had left two big cardboard boxes stuffed full of her personal diaries. My friends were kind enough to hang onto them. (About two years later, when S still had not made a move to reclaim them, my friends cracked a couple and read a couple of tiresome, whiny entries. They were then chucked unceremoniously in the trash.)
     S, however, had brought plenty to our new apartment. Three cats, with all their accessories, moved right in. The place was lousy with cats. Her former fiance, a poet, had abandoned a full library of books in his haste to escape her. About 30 boxes of them sat in our living room. And her clothes collection was astounding. It came in big black garbage bags, on clothing racks, on hangers stuffed into boxes. Everything was impossibly wrinkled and, I soon discovered, would be summarily dry cleaned--at what enormous cost I can't fathom.
     After a couple of weeks in the new apartment, S still had not made a single effort to put away any of her belongings. They filled the common rooms from floor to ceiling, spilled out into the hallways, glutted the exits. The whole place was one goddamn fire trap. Over the piles, the three cats prowled about, yowling and urinating wantonly.
     Enraged, I demanded that S raise herself off the couch and do some work. She would tote a load of clothes up to her lair, then collapse on the sofa and smoke languidly, watching me under half-lidded eyes as I strained with more of the load.  After about 3 months of steady work, all the materials were contained. Her own room was a study in chaos: great, black garbage bags of clothes were piled around her bed like a barricade, and the clothing racks sagged under the weight. S had become so enslaved by fashion that it had literally imprisoned her; she lay in there like some troglodyte harpy, cawing out demands and complaints. She was so doped up on Prozac and other unidentified substances that she never got out of bed before 11 a.m.--especially on work days. Around her bed, an alarming supply of prescription bottles lay opened and half-spilled, presumably so she could snack on them in the night. I also noticed what I thought was a crusty old vibrator lying amongst the detritus, but I won't speak of that.
     Sometime early in our relationship, we acquired a third roommate. G moved in , full of good will. During his first week, one of the wretched cats urinated on his new leather jacket, which he had been unfortunate enough to leave on his floor.
     Despite the enormous number of feline presences in the home, S cleaned their litter box sporadically, at best. The cats rebelled. Occasionally, we would find little cat doody surprises on the kitchen floor. G and I made a pact--we would not clean the things up, no matter how terrible, because it would set a bad precedent. As a result, sometimes the poo would remain on the linoleum until it encrusted into a kind of awful museum piece. When we tactlessly mentioned the "little accidents," S would mutter and growl under her breath.
     S spent most of her evenings sprawled on the couch, a cigarette in her lips, the remote in hand. I seemed destined for weak-willed, pasty roommates with no hope of social life. A nimbus of cigarette ash and food products formed on the carpet--my carpet--under her head; the stain is there still. When I returned home from a night out with friends, S would fix a lazy, lizardlike eye on me from her recumbent position. The effect was downright creepy.
     Pretty soon, we began to notice that a pervasive odor of cat urine was infecting the entire place. The cats seemed to favor a dank, brown rug that had been laid down over the stairs and in the front hall sometime in the 1960s. One afternoon, G. and I tore up the entire carpet, picking out nails with a pair of pliers, and hoisted the sodden mass outdoors. The wood floor that was revealed was in decent shape. During our labors, S returned home, and fell into a foul humor as we had not asked her "permission" before the undertaking.
     Money also became an issue. S and I had initially agreed to share the grocery shopping. This changed after I got wise to her little scheme. At the store, she always seemed to have an empty wallet. I was constantly asking her to reimburse me for food, cleaning supplies, and other household necessities. So jittery with Prozac that she could barely write, S would grudgingly pen a check after some weeks of requests.
     During this time, she was set up by a sympathetic coworker on a blind date. On only their second time out, her purse was stolen. The date, acting as a gentleman, offered her his credit card until she could get her cards replaced. During the next few weeks, S engaged in a maniacal spending frenzy. She returned home with pairs of new shoes to add to her growing pile, and wallets stuffed full of cash-advance money--none of which, I noticed sourly, went to repay me for all her past debts. After at least $1,000 of madcap spending, S went to the bank machine and discovered she had maxed out the poor fellow's card. She explained to us, without a trace of remorse, that as his mother had recently died, he had a number of expenses on the card for the funeral and the gravestone. She seemed slightly put out that her ready cash flow had dried up. By this time, the poor man was so repulsed by her that he insisted she get out of his life--and forget about the money.
     For some time, S had taken to applying her makeup and dressing in my room after I left for work in the mornings. Her room was such a disaster that such actions were impossible. Although I kept my door bolted shut to keep the infernal cats out, S would often forget and leave it open behind her. After a weekend away, I returned home and headed for my room. Something was wrong. Terribly wrong. I patted the bed, and realized that it was a sea of cat piss--soaked through right down to the mattress. G returned home to find the sheets, featherbed, and blankets cascading down the stairs, while my tortured screams echoed through the house. To add fuel to my fire, I discovered that S had eaten a large portion of my prescription allergy medication. She must die.
     S, when confronted, suggested that perhaps the cats were angry because I had abandoned them for the weekend. She also recommended that I kept my door locked. With that, she slouched out of the room, forgetting to offer to clean my bedding. I did eventually wrench a check out of her to pay for the exorbitant cost of cleaning the featherbed (no dry cleaner within a 50-mile radius would touch it), but the situation led to the final dissolution of our friendship, as it were. After accusing G and I of a cruel collusion against her and the cats, she elected to move out. I made myself scarce while she packed. Afterward, G and I cleaned every trace of her foul presence from the apartment. I noticed that the little toad had somehow managed to pack all my music notebooks and my entire box of tools--two things which she would never use in her lifetime. She claimed she didn't have them, but I think the real reason is that she never unpacked at her new apartment. I can picture her there now, surrounded by cardboard boxes and piles of faeces.
     After she was gone, we did find one more memento of S: we made an odd discovery of a collection of giant x-rays of her skull and pelvis, stuffed behind the couch. Sadly, there was no silhouette of a metal wrench to be found that might explain the mystery of her troubled nature. Somewhat terrified, we pried up the cheap wooden boards in the dining room wall and hid the x-rays there, where they will no doubt be found by some future archaeologist.  

Jumat, 20 Januari 2017

Depression is a Symptom Not a Psychiatric Disorder




Lately there have been a slew of articles about "depression" that seem to go out of their way to avoid discussing any specific psychiatric diagnosis listed in the DSM - instead strongly implying that "depression" is itself a disorder. These articles appear in the popular press, but, frighteningly, also in newsletters and newspapers for psychiatrists and psychologists. They explore such questions as "Do antidepressants work?" and "What is better for depression, drugs or cognitive behavioral therapy?"

These types of questions are completely meaningless. Depression is discussed as if it were a single phenomenon that, at best, exists on a continuum from "mild" to "moderate" to "severe." This type of wording is in fact completely ignorant, but does not necessarily reflect real ignorance. In many cases, different entities such as big Pharma have a vested interest in conflating several different psychiatric conditions.

In truth, "depression" is just a mood state, and as a symptom, it can be part of many different psychiatric disorders that are, despite some overlap in symptomatology, as different as night and day when it comes to their clinical presentations as well as their response to various treatments.

To name but a few actual diagnoses, there is major depression (both as part of unipolar and bipolar disorder), dysthymia, adjustment disorder with depression, depression due to a medical condition, and depression due to a substance. Medical conditions that can lead to depressive symptoms include hypothyroidism and some strokes. Substances that can do that include some steroids like prednisone and the "crash" that results when an acute cocaine high wears off.

Furthermore, "depression" as discussed in every day conversation can be a normal mood that is part of chronic unhappiness, or that occurs in response to grief at someone's death or due to any other loss or misfortune.

The most important diagnostic distinction for this discussion is between major or clinical depression and dysthymia. Although we don't know enough about the brain to know the exact causes of either one, and there is some overlap in symptomatology, they appear for the most part with very distinct clinical presentations, especially in their classic forms.

Dysthymia appears to be more of a psychological reaction, while major depression probably involves the more primitive part of the brain called the limbic system. The latter, unlike the former, is accompanied by a whole array of chronic, persistent (lasting all day every day for at least two weeks), and pervasive (coloring all aspects of the patient's mental life) physical symptoms - all at the same time - involving sleep, appetite, ability to experience pleasure, energy level and motivation, and concentration. Sufferers may have an unrelenting and constant sense of foreboding accompanied by inexplicable hopelessness and helplessness. We used to refer to these types of symptoms as vegetative symptoms.

Furthermore, someone in a major depressive disorder episode reacts completely differently to life's every day ups and downs than they do when they are not in the middle of such an episode. It's almost Jeckyl and Hyde territory.

These people stay depressed no matter what life events occur around them. They could literally win the lottery and would not really feel a whole lot better for more than a few minutes.

The most severe form of major depression is called melancholic depression. Most people who have never worked in a mental hospital have never seen a case, but the anti-psychiatry types who have not seen it blather on about depression incessantly as if they knew what they were talking about.

People with melancholic depression exhibit something called psychomotor retardation. People with this symptom move and think at a snail's pace.  It takes them longer to respond to any verbal interactions. They can even appear to have significantly impaired memory, although it is actually a more severe form of concentration impairment. That clinical picture is sometimes referred to as pseudodementia. 

You cannot spend more than an hour with such people without realizing that this condition has next to nothing in common with the type of "depression" people see in their everyday interactions with others, and that there is something seriously wrong with their brain functioning.

In severe major depression, doing any kind of psychotherapy (short of telling them, "take these pills") is a complete and utter waste of time. Sufferers literally do not have the mental wherewithal to deal with any kind of problem solving or other interactions with a therapist. And I say that as a major advocate of psychotherapy.

The symptom of depression in dysthymic disorder, on the other hand, rarely responds to antidepressant medication at all (although the drugs can be useful for other symptoms seen in patients with dysthymia such as panic attacks, obsessive ruminations, and the affective instability characteristic of borderline personality disorder). For these folks, psychotherapy is essential.

In my experience a very high percentage of the people who do drug and psychotherapy outcome studies, at least in adults, make almost no meaningful effort to differentiate dysthymia from major depression by: 1) Not spending any time making certain that patients understand the pervasiveness and persistence criteria that differentiate the symptoms of the two disorders; and by 2) Not taking a complete biopsychosocial history to distinguish psychological from limbic system factors.

All of the fancy biological research is not being complemented by good old fashioned clinical typing.

Furthermore, with the private Contract Research Organizations that do a lot of the studies, experimenters get paid only if they recruit a subject, and subjects get paid only if they get recruited - giving a financial incentive for everyone to exaggerate symptoms in order to qualify.

And people with suicidal ideation, comorbid (other, co-occurring) conditions, and significant personality pathology are excluded from studies. Those "exclusions" eliminate the vast major of subjects that have any of the psychiatric disorders in which depression is a symptom.

Garbage in, garbage out.

By the way, you can also have something called double depression. Such people are generally dysthymic but every so often can have a superimposed episode of major depression. So they have both conditions.

Once a major depressive episode starts to occur, it takes on a life of its own. However, being chronically unhappy, anxious, or stressed out may be risk factors for triggering a major depressive episode to begin with.  If you are genetically vulnerable to an episode of major depression, being chronically unhappy might make an episode more likely.

This is another reason why the question, "Should you treat these people with medications or therapy" is a really stupid question. It's a bit like asking, "Which treatment should people who have extensive, severe, cardiovascular disease get, bypass surgery or high blood pressure medication?" 

These treatments address completely different aspects of the disorder. In major depressive disorder, drugs should be used during the acute disorder, but psychotherapy should be given later to address personality  and relationship risk factors - in order to reduce the likelihood of subsequent episodes.