Meeting the True Needs of Children Diagnosed as ‘ADHD’
By Dan Edmunds
How should one look upon Attention Deficit Hyperactivity Disorder (ADHD) and what is the effective way to aid those who are given this diagnosis? There has been considerable debate as to whether or not ADHD is a genuine disorder. Psychiatrist and professor Robert Hedaya (1996, pg. 140) mentions that an examination by Hartmann in 1993 felt that ADHD is actually normal variant of human behavior that doesn’t fit into cultural norms.
In addition, there is no objective test for this disorder. Hedaya (1996, pg. 140) mentions that a commonly used test is the TOVA (test of variables of attention), a test where the client must use a computer and hit a target at various points. This test is designed to measure the person’s response time and distractibility. However, Hedaya (1996, pg. 140) notes, this tool cannot be relied upon to make or exclude the diagnosis in and of itself. Hedaya (1996, pg. 268) notes that there has been controversy in the use of stimulants for the treatment of ADHD, he states, medications alone do not provide adequate or full treatment in this disorder.
Hedaya (1996, pg. 269) notes that the most serious risk in the use of methylphenidate (Ritalin) for ADHD is that about 1% of these children will develop tics and or Tourette’s Syndrome. Hedaya asks the question,”One might wonder-, why use methylphenidate at all?” Hedaya argues that the side effects involved in the use of methylphenidate are mild. However, he notes that side effects include nervousness, increased vulnerability to seizures, insomnia, loss of appetite, headache, stomachache, and irritability. Hedaya (1996, pg. 271) argues that the causation of ADHD lies in problems in dopamine regulation in the brain and states that stimulants work by stimulating dopamine in the brain and thus the symptoms of ADHD are lessened.
However, previously Hedaya states that Zametkin (1995) noted that stimulants have the same effect in both those diagnosed as ADHD and those who are not (Hedaya, 1996, pg. 139). Dr. William Carey of the Children’s Hospital of Philadelphia commented at the National Institutes of Mental Health Consensus Conference in 1998 that the behaviors exhibited by those considered ADHD were normal behavioral variations. A Multimodal Treatment Study was conducted by the National Institutes of Mental Health in 1999 in regards to ADHD. Psychiatrist Peter Breggin and the members of the International Center for the Study of Psychiatry and Psychology challenged the outcomes of this study because it was not a placebo controlled double blind study. Breggin also argues that that the analysis conducted of behaviors in the classroom of those children studied showed no significant differences between those children receiving stimulant medications versus those who only were utilizing a behavioral management program (MTA Cooperative Group, 1999a, pg. 1074). Breggin notes that there was no control group in the study of untreated children and that 32% of the children involved in the study were already receiving one or more medications prior to the onset of the study. Of those in the study who were the medication management group, they numbered only 144 of which Breggin finds to be enormously small.
Breggin states that in the ratings of the children themselves that they noted increased anxiety and depression however this was not found to be a significant factor by the investigators. Breggin also believes that the study was flawed in that drug treatment continued for 14 months whereas behavioral management was utilized for a much shorter duration. Breggin argues that the behavioral management strategies, which involved mainly a token economy system, were ineffective as well and did not take into consideration family dynamics but regardless, the study still showed that there was no difference between the populations treated with drugs versus those undergoing behavioral management solely. Breggin notes that many of the children receiving medications had adverse drug reactions, which consisted of depression, irritability, and anxiety. 11.4% reported moderate reactions and 2.9% had severe reactions. However, Breggin also states that those reporting the adverse drug reactions were not properly trained, but were rather only teachers and/or parents.
The study, as Breggin concludes, showed no improvement in the children treated with medications in the areas of academic performance or social skill development. Breggin feels that the study was improper in that all of the investigators were known to be pro-medication advocates prior to and after the study. Breggin states that Ritalin and other amphetamines have almost identical adverse reactions and have the potential for creating behavioral issues as well as psychosis and mania in some individuals. Breggin argues that these medications often cause the very behaviors they are intended to treat. He notes that children treated with these medications often become robotic and lethargic and that permanent neurological tics can result.
In his textbook, Attention Deficit Hyperactivity Disorder, Russell Barkley, an advocate for the use of methylphenidate in the treatment of ADHD, notes that there is little improvement in academic performance with the short-term use of psychostimulant medication. Barkley also acknowledges that the stimulant medications can affect growth hormone but at present there is not any knowledge of the long-term effects on the hypothalamic-pituitary growth hormones. Barkley (1995, pg. 122) also states, at present there are no lab tests or measures that are of value in making a diagnosis of ADHD.
Dr. Sidney Walker, III, (1998, pg. 25) a late board-certified neuropsychiatrist comments that a large number of children do not respond to Ritalin treatment, or they respond by becoming sick, depressed, or worse. Some children actually become psychotic – the fact that many hyperactive children respond to Ritalin by becoming calmer doesn’t mean that the drug is treating a disease. Most people respond to cocaine by becoming more alert and focused, but that doesn’t mean they are suffering from a disease treated by cocaine. It is interesting to note Walker’s analogy of Ritalin to cocaine. Volkow and his colleagues (1997) observed in their study, EMP (methylphenidate, like cocaine, increases synaptic dopamine by inhibiting dopamine reuptake, it has equivalent reinforcing effects to those of cocaine, and its intravenous administration produces a high similar to that of cocaine. Walker (1998, pg. 14-15) that in addition to emotional struggles of children leading to ADHD-like behavior, that high lead levels, high mercury levels, anemia, manganese toxicity, B-vitamin deficiencies, hyperthyroidism, Tourette’s syndrome, temporal lobe seizures, fluctuating blood sugar levels, cardiac conditions, and illicit drug use would all produce behaviors that could appear as what would be considered ADHDEhowever Walker feels that these issues are most often overlooked and the person is considered to be ADHD.
F. Xavier Castellanos states at the 1998 Consensus Conference that those children with ADHD had smaller brain size than those of children who were considered to be normal. However, Castellanos reported as well that 93% of those children considered ADHD in the study were being treated long term with psychostimulants and stated that the issue of brain atrophy could be related to the use of psychopharmacological agents. Dr. Henry Nasrallah from Ohio State University (1986) found that atrophy occurred in about half of the 24 young adults diagnosed with ADHD since childhood that participated in his study. All of these individuals had been treated with stimulants as children and Nasrallah and colleagues concludes that cortical atrophy may be a long term adverse effect of this treatment. Physician Warren Weinberg and colleagues stated, a large number of biologic studies have been undertaken to characterize ADHD as a disease entity, but results have been inconsistent and not reproducible because the symptoms of ADHD are merely the symptoms of a variety of disorders. The Food and Drug Administration has noted (Walker, 1998, pg. 27) that ee acknowledge that as of yet no distinct pathophysiology (for ADHD) has been delineated.
There has been concern as well about the addictive component of psychostimulants. The Drug Enforcement Administration (1995c) reports that it was found that methylphenidate’s pharmacological effects are essentially the same as those of amphetamine and methamphetamine and that it shares the same abuse potential as these Schedule II stimulants.
Breggin states that psychiatrist Arthur Green in the Comprehensive Textbook of Psychiatry published in 1989 reported that all commonly diagnosed disorders of childhood can be linked to abuse and/or neglect. Abuse and neglect produces difficulties in school, such as cognitive impairment, particularly in the areas of speech and development, combined with limited attention span and hyperactivity. (Breggin, 1991, pg. 274)
Being that ADHD is a subjective diagnosis and that stimulant treatment has been shown to have risk as detailed above, what is the effective alternative to aiding those who have been diagnosed ADHD and what actually is underlying the difficulties that these individuals may be manifesting? Psychologist and educator Michael Valentine (1988) suggests that it is necessary to love your children, care about them, do as much as possible to have them grow and develop, teach them social skills, and teach them how to identify and express their feelings and to become uniquely human; but at the same time, care about them and love them enough to give them guidance, structure, limits, and control as they need it.
Valentine advocates a psychosocial approach to aiding children and adolescents who would be considered to be ADHD. Psychiatrist Peter Breggin also advocates this approach and feels that it is necessary for parents to feel empowered and for their to be a compassionate therapeutic adult in the lives of these children. Breggin (1998, pg. 308-310) feels it is necessary to examine the effects of institutionalization and placement on children as well as the effects of psychiatric stigmatization (that is, the effects on esteem of receiving the label of ADHD itself). It is necessary to examine the experience of the child and if they have suffered physical, sexual, or emotional abuse from adults, or have experienced peer abuse. It needs to be examined if they have an appropriate educational setting and if any conflicts exist with instructors or if the educational environment is stressful to them.
Psychiatrist William Glasser (2003, pg. 31-32) comments in this regard, Epediatricians are being called in to diagnose schoolchildren who do not cooperate in school because they don’t like it as having attention deficit disorder or attention deficit hyperactivity disorder. Treating them with a narcotic drug is only confirming what many psychiatrists and pediatricians already believe: that it’s better to use drugs than to try to apply their prestige and clout in the community to the real problem: improving our school s so that students find them enjoyable enough to pay attention and learn in an environment where drugs are not needed. This misguided psychiatric effort has created an epidemic of drug treated mental illnessEin the schools.
Breggin continues that it is also necessary to examine the environment the child lives in and the stressors around them. It is necessary to build relationship and collaboratively design structure and limits with the child or adolescent (Breggin, 1998, pg. 318) Breggin feels it is necessary to train parents in relationship building with their children and in working through situations of conflict. He states, parent management training has consistently proven successful in improving parent self-esteem, in reducing parent stress, and in ameliorating ADHD-like symptoms, especially negative attitudes toward parental authority and aggression.
Dr. David Stein (2001, pg. 236-238) has detailed a drug free approach to aiding children who are diagnosed as ADHD who Stein prefers to call highly misbehaving children. In this program, known as the Caregiver’s Skills program, Stein states it is necessary to treat your child as normal and not diseased. He states that the children should not be taking any medications, as they are risky for the child’s health and merely blunt behaviors. Stein argues, if the behaviors don’t occur, we can’t help (them) learn new habits.
The program encourages social reinforcement rather than material reinforcement, encouraging parents to refrain from excessive prompting and coaxing. The program encourages development of target behaviors and consistent encouragement and social reinforcement as well as consistent consequences for misbehavior. The program encourages the self-assessment and evaluation of the child of their own behaviors.
Barkley, Russell, Taking Charge of ADHD, Boys Town, NE, Boys Town Press, 1995)
Breggin, Peter R., Reclaiming Our Children, Perseus, Cambridge, MA, 2000)
Breggin, Peter R., Talking Back to Ritalin,Common Courage Press, Monroe, ME, 1998)
Breggin, Peter R., Toxic Psychiatry, St. Martins Press, New York, 1991)
DuPaul, Barkley, and Connor, Stimulants (article appearing in text Attention Deficit Hyperactivity Disorder, 1998).
Glasser, William, Psychiatry Can Be Hazardous to Your Mental Health, Harper Collins, New York, 2003)
Hedaya, Robert J., Understanding Biological Psychiatry, W.W. Norton, New York, 1996)
Nasrallah, H.J., Loney, S. Olson, M. McCalley-Whitters, J. Kramer, and C. Jacoby, Cortical Atrophy in Young Adults with a History of Hyperactivity in Childhood, Psychiatry Research, 17:241-246, 1986)
National Institutes of Mental Health Consensus Conference Statement, 1998
Stein, David, Unraveling the ADHD Fiasco, Andrews McMeel, Kansas City, 2001)
Walker, Sidney, The Hyperactivity Hoax, St. Martins Press, New York, 1998)
Weinberg, Warren et al., Attention Deficit Hyperactivity Disorder: A Disease or a Symptom Complex, Journal of Pediatrics, 130, 665-6
Dan L. Edmunds, Ed.D.
Article Source: http://EzineArticles.com/?expert=Dan_Edmunds
COMMITMENTS : Cutting the Cord : Saying goodbye to your therapist can elicit bad feelings–unless it’s handled right. Then the parting can be a chance for growth.
That period of wrapping up therapy and saying goodbye is known as “termination,” a word that evokes images of being fired from a job or being stalked by Arnold Schwarzenegger. But mental-health experts consider termination a crucial stage in therapy.
If handled properly, it provides an opportunity to re-examine the issues that led the client to seek help in the first place, to evaluate the therapy itself and to deal with feelings that might bubble up in the face of bidding farewell.
A so-called natural termination, in which the two of you agree to end treatment because your goals have been met, is difficult enough. Who, after all, likes to say goodbye, especially to someone who has helped you so profoundly and so intimately? But a premature termination, where a dissatisfied client leaves without much notice or a therapist departs before the patient is ready, can be downright traumatic.
“It’s always best if people can have time to pay attention to the process of saying goodbye,” says Carl Shubs, a licensed clinical psychologist in private practice in Beverly Hills. “If people leave too abruptly, it interferes with the process–they’re not able to deal with the sadness or anger, the mourning that occurs.”
Adds Sylvia Martin, a licensed marriage, family and child therapist in private practice in Sherman Oaks: “Termination is a time when people start to deal with all their losses. It can trigger feelings about old issues, or issues about the relationship between the therapist and client.
“If there is an old loss they have not grieved, they will tap in and experience the same feelings,” she says. “Maybe they had a feeling of abandonment when they were young and did not understand it. Or maybe they have not had the luxury before now of dealing with a loss–for example, going through a divorce with two kids.”
If it is the patient who says so long, a good therapist will try to determine if he or she wants out because the topics being discussed are becoming too painful. In those cases, the therapist will encourage the patient to remain, so as to work through the discomfort and resolve those issues.
Many times, though, the client is willing to slog through the hard stuff, but feels this particular therapist is less than able. Such was the case last year for Laura, 41, who works in the travel industry in Orange County and sought counseling for marital problems.
“I was therapy illiterate,” she recalls. “I had no basis for comparison. But I never felt I was getting help. I would drive home and think, ‘Why did I just go there?’ I didn’t expect a magic cure, but I was just begging my therapist, ‘Give me some tools to help me.’
“All she said was, I had to divorce my husband, which I wasn’t ready to do. I felt her attitude was, ‘You won’t take my advice, so I don’t know what to tell you.’ ”
Laura–who is still married and on better terms with her husband–found another therapist to her liking. But she stuck with her first counselor longer than she preferred to because, she says, “The last thing I wanted was to look for someone new to spill my guts to, to start over again.”
Indeed, for some people, leaving the current therapist is the easy part; it’s finding a new one that poses problems. Says Studio City writer Catherine Johnson, author of the book “When to Say Goodbye to Your Therapist” (Simon and Schuster, 1988), “Finding a new therapist is not like finding a new dentist. It’s extremely difficult to find a match.
“It’s a bit like finding a lover, or best friend, or a parent. You don’t just go out and find a new best friend. You have to find a real emotional fit, on top of basic competence.”
Lisa Moore, 34, a West Los Angeles advertising account executive, discovered that last year when she left the marriage and family counselor she had been seeing for 15 months because she thought the therapist had crossed the professional line and was becoming too friendly. After six weeks with a new therapist recommended by her physician, she decided to return to her former counselor.
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When is it time to say
goodbye to a therapist?
Maybe you don’t like your therapist. Maybe you do, but you’ve resolved the
issues that drove you to seek counseling in the first place. Or maybe those
issues remain unresolved, with few signs of progress. Maybe your sessions feel
as if they’ve morphed into very expensive chats with a friend.
For myriad reasons, people come to a point when they wonder if they should
break up with their therapist. And “break up” is the right term for it, because
quitting therapy can spur emotions as painful and complicated as ending a
How do you know if you’re ready to stop therapy? And how should you go about
it? First, any therapy that is abusive or destructive should be stopped
immediately, said Dr. Kenneth Settel, clinical instructor in psychiatry at
Harvard Medical School. Examples of abusive therapists are those who are
disrespectful or insensitive to certain issues; those who violate boundaries;
those who reveal too much about their own problems; and those who insist on
focusing on areas the patient didn’t come in for.
But assuming you’re not dealing with that, patients should approach ending
therapy as a chance to grow, Settel said. Rather than cut and run or avoid the
topic altogether — tempting routes for the confrontation-avoidant — it’s
important that patients, well, talk to their therapist about it.
In therapy, the relationship between the patient and the therapist is a
vehicle for understanding the patient’s issues, Settel said. So the way you end
therapy can be a way of examining how you say goodbye to people, and the
feelings involved in leaving and loss.
Ask yourself why you want to move on. When did you start feeling that the
therapy was no longer helpful or productive? What happened that made it
different? Was there a change in you, in the topics being discussed, in the
therapist? Confronting that tension can be a turning point because it forces you
to work through obstacles, Settel said.
“Ending therapy can be very therapeutic,” Settel said.
Though the patient-therapist relationship can have a weird power dynamic —
you’re paying, but the therapist is the expert and knows your every demon —
patients should feel they have control of the process, said Lynn Bufka, a
psychologist and head of the department of practice, research and policy at the
American Psychological Association. Patients should feel empowered to ask
questions, steer the sessions to focus on particular issues and let the
therapist know what’s not working.
The tricky part is making sure you’re not leaving therapy just because it’s
unpleasant or difficult, which oftentimes it has to be, Bufka said. More than
make you feel better, therapy is supposed to help you understand yourself
On the flip side, therapy shouldn’t be some indefinite appointment you keep
as part of your routine. There should be regular discussions about what you’re
trying to accomplish and whether you’re meeting those goals.
“I hope that I’m going to work myself out of a job,” Bufka said.
There is such a thing as staying in therapy for too long. One warning sign is
if a patient has to run all decisions by his or her therapist, which can signal
dependency, Bufka said. Another concern is if the therapist relationship is
taking the place of building other relationships.
Another downside of staying in therapy for too long is that you don’t have
the opportunity to practice the skills you’re developing independently, Settel
said. If the therapy was aiming to help you build internal skills of
self-observation, stopping therapy can encourage growth because it forces you to
internalize the process.
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How to Figure Out When Therapy Is Over
If you think it’s hard to end a relationship with a lover or spouse, try breaking up with your psychotherapist.
A writer friend of mine recently tried and found it surprisingly difficult. Several months after landing a book contract, she realized she was in trouble.
“I was completely paralyzed and couldn’t write,” she said, as I recall. “I had to do something right away, so I decided to get myself into psychotherapy.”
What began with a simple case of writer’s block turned into seven years of intensive therapy.
Over all, she found the therapy very helpful. She finished a second novel and felt that her relationship with her husband was stronger. When she broached the topic of ending treatment, her therapist strongly resisted, which upset the patient. “Why do I need therapy,” she wanted to know, “if I’m feeling good?”
Millions of Americans are in psychotherapy, and my friend’s experience brings up two related, perplexing questions. How do you know when you are healthy enough to say goodbye to your therapist? And how should a therapist handle it?
With rare exceptions, the ultimate aim of all good psychotherapists is, well, to make themselves obsolete. After all, whatever drove you to therapy in the first place — depression, anxiety, relationship problems, you name it — the common goal of treatment is to feel and function better independent of your therapist.
To put it bluntly, good therapy is supposed to come to an end.
But when? And how is the patient to know? Is the criterion for termination “cure” or is it just feeling well enough to be able to call it a day and live with the inevitable limitations and problems we all have?
The term “cure,” I think, is illusory — even undesirable — because there will always be problems to repair. Having no problems is an unrealistic goal. It’s more important for patients to be able to deal with their problems and to handle adversity when it inevitably arises.
Still, even when patients feel that they have accomplished something important in therapy and feel “good enough,” it is not always easy to say goodbye to a therapist.
Not long ago, I evaluated a successful lawyer who had been in psychotherapy for nine years. He had entered therapy, he told me, because he lacked a sense of direction and had no intimate relationships. But for six or seven years, he had felt that he and his therapist were just wasting their time. Therapy had become a routine, like going to the gym.
“It’s not that anything bad has happened,” he said. “It’s that nothing is happening.”
This was no longer psychotherapy, but an expensive form of chatting. So why did he stay with it? In part, I think, because therapy is essentially an unequal relationship. Patients tend to be dependent on their therapists. Even if the therapy is problematic or unsatisfying, that might be preferable to giving it up altogether or starting all over again with an unknown therapist.
Beyond that, patients often become stuck in therapy for the very reason that they started it. For example, a dependent patient cannot leave his therapist; a masochistic patient suffers silently in treatment with a withholding therapist; a narcissistic patient eager to be liked fears challenging his therapist, and so on.
Of course, you may ask why therapists in such cases do not call a timeout and question whether the treatment is stalled or isn’t working. I can think of several reasons.
To start with, therapists are generally an enthusiastic bunch who can always identify new issues for you to work on. Then, of course, there is an unspoken motive: therapists have an inherent financial interest in keeping their patients in treatment.
And therapists have unmet emotional needs just like everyone else, which certain patients satisfy. Therapists may find some patients so interesting, exciting or fun that they have a hard time letting go of them.
So the best way to answer the question, “Am I done with therapy?” is to confront it head on. Periodically take stock of your progress and ask your therapist for direct feedback.
How close are you to reaching your goals? How much better do you feel? Are your relationships and work more satisfying? You can even ask close friends or your partner whether they see any change.
If you think you are better and are contemplating ending treatment but the therapist disagrees, it is time for an independent consultation. Indeed, after a consultation, my writer friend terminated her therapy and has no regrets about it.
The lawyer finally mustered the courage to tell his therapist that although he enjoyed talking with her, he really felt that the time had come to stop. To his surprise, she agreed.
If, unlike those two, you still cannot decide to stay or leave, consider an experiment. Take a break from therapy for a few months and see what life is like without it.
That way, you’ll have a chance to gauge the effects of therapy without actually being in it (and paying for it). Remember, you can always go back.
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Why Mental Health Professionals Don’t Help
Are you unsatisfied with mental health care? Do you get the feeling that professionals just don’t care about you and would rather you just went away and left them alone? Do you get disappointed or angry when clinicians ignore your tears or tantrums. Have you ever wondered why?
Mental health professionals deal with all sorts of psychological, emotional and behavioral problems every day. They’re trained to assess and react appropriately to many different situations and are often confronted by violence, manipulation, ridicule and sometimes even honest distress. They’re also human.
Not all psychiatric patients have an illness. Many are just trying to manipulate the system. They may want to escape a court judgment or perhaps they’re keen to get more benefits from the state. Sometimes they want to manipulate a family member and are pretending to be depressed to get their own way. There are lots of reasons why some people will get themselves into the mental health system. Mental health professionals are interested in treating illness. They’re not generally too interested in spending a lot of time and energy ‘treating’ someone who’s healthy but trying to use the system for their own ends.
Some patients are genuinely ill but use their illness as an excuse for unacceptable behavior. Just because you’re anxious doesn’t give you the right to hurt others. If you have a drug habit or alcohol problem staff can help you with that but don’t expect to intimidate them as well. Caring does not mean being fooled by a manipulative threat to injure self or others and mental disorder will not always protect a person from the consequences of their actions. After all, ill or not most people still have choices and can choose to abide by the law just as easily as they can choose to break it.
Very often staff will ignore a client’s threats simply because they believe them to be a manipulative technique. Common examples include:
Threats of suicide if staff don’t dispense or prescribe inappropriate medication;
Threats of violence, including veiled threats such as ‘I don’t think I can control myself much longer’ (a common one from people awaiting trial for violent assault as they think a diagnosis of anger problems will mean a reduced sentence);
Emotional blackmail such as the suggestion that the professional is making things worse by not letting them have their own way and thus is a ‘bad’ practitioner.
When faced with manipulation the usual course of action will be to ‘disattend’. This means effectively to ignore the threat and so demonstrate the pointlessness of manipulation. Often clients learn this lesson very quickly and then real work can begin on the actual problems. This does not mean that the manipulation isn’t a symptom of the disorder – often it is but focusing too much upon threats of self-injury or whatever just clouds the issue.
Of course any one of these threats could also be a statement of fact from a genuinely distressed client. In these cases the reaction from staff is often very different. As a rule mental health professionals are so used to manipulation that they can quickly tell the difference. For example the drunken young man who breaks up with his girlfriend, takes an overdose of aspirin and then calls her to get the ambulance is more likely to want her to feel guilty than to end his life. Most psychiatrists resent getting out of bed at three in the morning to interview such cases.
Some people come into contact with services with impossible expectations. For example they may expect to sit back and wait while the clinicians sort out their marriage difficulties or change their apartment for a state owned house. They may have themselves admitted to a ward for detoxification so that they can sell drugs to patients already there – sometimes they even sell drugs prescribed to them by the unit they’re in. It’s surprising how often these people claim a mental illness defense when the hospital authorities call the police. Mental health units generally take a very hard line where drugs are concerned because many drugs, when combined with psychiatric medications can cause major problems and even kill.
Inpatients are often very vulnerable and the effects of other patients upon their mental health can be devastating. Clients admitted to psychiatric hospitals who set about exploiting, ridiculing or otherwise distressing their fellows are generally ‘moved on’ very quickly by the ward team. It’s not a good way to get help for yourself and it can be very damaging to the care of your victim. This is also why those patients who demand a lot of staff time and attention will only get it if the staff think it’s because of genuine need. Time spent with one patient is also time taken away from another. Many people are surprised to learn that this is also considered an abuse as it prevents other patients from getting the care they need.
Bear in mind that this does not mean that inpatients are expected to sit quietly and wait for their medication like good little girls and boys. Mentally ill or not adults are adults and have a right to express their needs, fears, distress or whatever. They’re also entitled to friendly conversation and many clients do strike up friendships with professionals as a result. It’s simply that attempts to monopolize staff time for non-genuine reasons cause problems for patients and staff alike.
Some clients have an expectation that mental health staff are there to be assaulted. They too become surprised at the reaction they receive. Staff who are attacked by florid schizophrenics as a result of a genuine delusional state tend to be quite philosophical about it. Staff attacked by people who simply want to prove a point or by those who just enjoy hurting people tend to press charges.
Mental health professionals are not anywhere near so stupid as many of their clients believe them to be. It’s true that they are often deeply cynical but that’s different. As a rule, however, they will work hard to help the genuinely ill so long as the client is also prepared to help themselves. It’s often impossible to help a mentally disordered person to move on without co-operation and so people who spend their time trying to justify their illness instead of working to overcome it tend not to do very well. Shortage of professional resources often means that after a while professionals stop trying to treat those who would prefer to manipulate them and move on to those they can help after all.
The concept of ‘treatability’ is very important to mental health clinicians. In any other job or profession people would not be expected to spend time trying to do the impossible. Much can be done to alleviate or even cure mental disorder but this is rarely possible if the client doesn’t play their part. Sometimes of course the client doesn’t know how to behave appropriately or isn’t able to in which case practitioners tend to do the best they can. Often teaching appropriate coping skills is the first step. The person who can control their actions and chooses not to however is a very different proposition.
This does not (or at least should not) mean that clients are written off. It’s simply that clients aren’t always ready to change. Often they are so bogged down with secondary gain issues that no amount of therapy will help. The response from services is often to stop trying and wait until the client is actually ready to change. That’s why many clients who begin drinking or using substances immediately after an inpatient detoxification program will not be admitted until six months or a year has elapsed. The client needs time to come to terms with their situation and build some motivation before trying again.
This concept of ‘readiness’ is valid for many types of mental disorder from neurosis to depression. It does not mean that medication won’t help in the meantime and very often medication is all that is necessary but for those who need to make other changes the will to do so must be present.
It’s often very difficult for professionals to know exactly what is going on. Patients tend to tell their doctors, nurses or social workers what they think the professional person wants to hear. The obvious result of this is that professionals are generally very wary and regularly find themselves ‘second-guessing’ their patients. This is not usually helpful for either patients or staff but it does explain why professionals are so used to spotting manipulation. Usually professionals will ‘see through’ the deceit to the distressed person beneath and hopefully will always begin from a position of trust but it doesn’t take long for that trust to disappear in the face of obvious and persistent lies.
Professionals are also very aware that a client who lies to one staff member will usually be just as ready to lie to all the others. That’s why playing one member of staff off against another often results in the whole team’s mistrust. Mental health staff are ordinary people who do their work in order to help people – not to be treated as fools. Neither do they take kindly to verbal or physical abuse and will respond with criminal charges if necessary.
Of course not all mental health service users are trying to manipulate their careers. In many cases they genuinely want help but don’t know what to do. Some of these people use manipulation because it’s a part of their culture. They may not even realize that it’s a problem. Many people genuinely believe that everyone manipulates others and are just doing what they think is appropriate. Until recently mental health services have not been good at understanding this distinction. Psychiatry is a relatively young science and there is still much to be learned.
The process of learning, like the process of helping is always hindered by deceit however and clients in contact with mental health services generally do better by being honest in their dealings with professionals. If you genuinely want help with your problems it’s important to trust clinicians to do what’s right. Given the chance they generally will although giving you what you need isn’t always the same as giving you what you want.
Permission by Anonymous Person
Seven-year-old Gabriel Meyers didn’t want soup for lunch one Thursday in April, 2009. When his 23-year-old foster brother sent Gabriel to his room for dumping his soup in the trash, Gabriel threatened to kill himself. He kicked his toys around his room, then locked himself in the bathroom.
Police reports say Gabriel was home sick that day from his elementary school in Margate, Florida, under the care of Miguel Gould, his foster father’s son. Around 1 p.m., city police responded to Gould’s frantic 911 call and found Gabriel had hanged himself.
A troubled child who had previously suffered from neglect, sexual assault and abusive parenting, Gabriel spent the previous year shuttling among several foster parents while taking a constellation of anti-psychotic medicines, including Lexapro and Vyvanse, to control his depression and attention deficit hyperactivity disorder. Like most children in Florida foster care, Medicaid paid Gabriel’s medical expenses.
Just one month before his suicide, Gabriel’s doctor prescribed him Symbyax, an anti-depressant restricted for treatment of children. The medication’s FDA-required label features a warning that use of the drug by children or teenagers can lead to suicide.
Symbyax does not meet criteria established by Congress for Medicaid reimbursement, so it is illegal for Medicaid to pay for a prescription of the drug to a child. Sohail Punjwani, the doctor who prescribed Symbyax for Gabriel, received a stern letter from the FDA about his history of over-prescribing mental health drugs.
According to a number of foster care experts who spoke with Politics Daily, children in foster care, who are typically concurrently enrolled in Medicaid, are three or four more times as likely to be on psychotropic medications than other children on Medicaid. Alarmingly, many of these drugs are medically prohibited for minors and dangerous to the children taking them. Often young patients under state supervision are also prescribed three or four high-risk drugs at a time — all paid for by Medicaid.
State foster care programs and child protective services have had mixed success addressing the pervasiveness of dosing their clients with prescription psychotropic drugs. Using federal Medicaid money to purchase dangerous prohibited prescriptions for children, which cost the government up to $600 per dose, is technically a violation of the law.
Now, the Senate Subcommittee on Federal Financial Management, chaired by Sen. Tom Carper (D-Del.), has asked the Government Accountability Office to look into the drugging of foster care children. The investigators will attempt to account for estimates in the hundreds of millions of dollars of possible fraud arising from prescriptions for drugs explicitly barred from Medicaid coverage. The GAO is collecting data from Oregon, Massachusetts, Florida, Maryland, Minnesota and Texas, to search for patterns of abuse. This effort marks the first time suspicion of Medicaid fraud related to psychotropic drugs has been examined at the federal level. According to Senate staffers working on the investigation, the committee will likely hold hearings on the matter later this year.
Psychotropic medications act on the central nervous system and alter brain function, mood and consciousness. The GAO investigation is chiefly focused on anti-depressants, widely used in foster care in dangerous combinations, and for so-called “off-label” uses to treat symptoms for which they have not been medically approved. Anti-psychotic medications have been a factor in a number of children’s deaths.
Statistics on psychotropic drugs in foster care have until now come out in scattered reports, mostly from investigations of foster care failures by individual states. For example, in 2003 a Florida Statewide Advocacy Council study found that 55 percent of Florida’s foster children were being administered psychotropic medications. Forty percent of them had no record of a psychiatric evaluation. Another Florida report also indicated anti-psychotic medication use increased an astonishing 528 percent from 2000 to 2005.
A Texas state study in 2004 revealed that 34.7 percent of Texas foster children were prescribed at least one anti-psychotic drug — and 174 children aged 6-12 in the care of the state were taking five or more psychotropic medications at once.
Last April, an investigation by the Atlanta Journal-Constitution exposed several companies operating foster care homes in Georgia repeatedly used anti-psychotic medications to “subdue” children in their care. Despite being cited repeatedly, none of the agencies were fined more than $500.
According to child care experts and assessments by both advocacy groups and state government agencies, many states lack efficient records management and adequate oversight of foster care, contributing to a pervasive lack of medical continuity for the children. Social workers have oversized caseloads of foster children, who are often shunted between families and prescribed anti-psychotics from doctors unfamiliar with their medical histories. Without a case history, experts and foster care alumni say, doctors are more likely to add medications than take them away, resulting in record numbers of children dispensed several anti-psychotic medications at once. In many cases, the drugs are prescribed off-label to youngsters with behavior problems.
Julie Zito is a professor of pharmacology at the University of Maryland who conducted a 2008 study of the Texas foster care system that found 41 percent of the children prescribed psychotropic drugs received three or more different medications. She told Politics Daily what little research has been done suggests children in foster families are rarely assessed properly, a failure leading to serious effects. There has been no research on multiple-drug regimens, Professor Zito explained, and “blitzes” of medication have become a pervasive way of dealing with behavior problems in foster care. “We’ve expanded the medication practice in response to children not getting better,” she said, and children who fail to improve, “are getting more medication.”
Pharmaceutical companies manufacturing psychotropic drugs have played a major role in encouraging their increased use on foster care clients. Drug companies participate in aggressive marketing, conduct misleading research about efficacy and safety, and in some cases, “bribe” psychiatrists to prescribe their drugs, according to Zito and Jim Gottstein, an Alaska lawyer and founder of the Law Project for Psychiatric Rights, who has mounted several lawsuits against pharmaceutical corporations.
For example, last year the St. Petersburg Times reported that a psychiatrist in Jacksonville, Florida, was paid for speaking engagements to encourage her to prescribe Seroquel, a drug used to treat bipolar disorder and schizophrenia, and a neurologist in Tampa received free trips to Spain and Scotland from AstraZeneca, the drug’s British manufacturer, for her innumerable prescriptions of the drug for headaches. Seroquel is the top-selling anti-psychotic drug in the United States, with more than $4 billion per year in worldwide sales. AstraZeneca recently paid $520 million to settle lawsuits — some brought by doctors who had been offered swag in exchange for prescriptions — over its illegal promotion of off-label uses for Seroquel.
According to Jim Gottstein, the increase of anti-psychotic use in foster care amounts to “drug companies sacrificing children’s lives on the altar of corporate profits.” Gottstein recently filed a citizen’s suit on behalf of the state of Alaska against several doctors, drug companies and insurance companies, claiming that they knowingly promoted Medicaid fraud.
In response to the devastating study of the Texas system in 2004, that state’s top health agency introduced a new set of guidelines stressing specific treatment goals for medication and “informed consent” of parents and guardians. That effort led to decreased use of psychotropic drugs relative to the number of children enrolled in foster care from 2002 to 2009, according to data from the Texas Health and Human Services Commission.
In May 2005, Florida expanded foster parents’ rights to reject psychotropic treatment for the children in their care. Four years later, however, a review found that the new requirements were being flauted, and the panel that investigated Gabriel Meyers’ suicide concluded that every level of the Florida system had missed “warning signs” that Gabriel’s care was inadequate. Thirteen percent of Florida foster children were on one or more psychotropic drug, and 16 percent of those were not approved by parents or guardians.
In 2008, Rep. Jim McDermott (D-Wash.), the only psychiatrist in Congress, introduced a bill titled Invest in KIDS Act, which included stronger oversight for prescription medications in foster care. McDermott held a hearing on the use of psychotropic drugs in foster care, but the bill died in committee. Near the end of George W. Bush’s second term, Congress passed a law, co-sponsored by McDermott, that included increased oversight for “mental health” in foster care, but did not specifically mention psychotropic drugs.
“Some children in foster care may need and benefit from psychotropic medication,” McDermott told Politics Daily. “But these drugs should not be used as a shortcut to treat foster children when more effective treatments, including counseling, might provide long-term benefits.”
Federal and state agencies have pursued drug companies that illegally market their drugs for off-label uses, a practice that experts say heavily contributes to the overuse of psychotropic drugs in foster care.
Last year, a Justice Department action against Pfizer led to a $2.3 billion settlement, the largest in the department’s history. Companies convicted of major health fraud are barred from participating in Medicaid and Medicare. But worrying that a conviction would cause Pfizer to fail and cost its employees their jobs, the government allowed Pfizer’s shell company, which exists solely to plead guilty in lawsuits, to be charged instead, and the drug company paid a fine. Pfizer maintains that it did not break the law.
In 2006, The New York Times obtained a batch of internal documents that showed Eli Lilly, the maker of Zyprexa, a medication approved exclusively for treating the severe mental illnesses of schizophrenia and bi-polar disorder, was suppressing information on the drug’s harmful side effects and advertising it illegally. Lilly paid $62 million to settle lawsuits with 32 states and the District of Columbia, and agreed to ensure that its marketing complied with the law.
How to Fix It
The problems that lead to drug abuse in foster care are complex and deeply entrenched, but activists and advocates have proposed a number of solutions for limiting the overuse of anti-psychotics. Foster care experts, including a current task force of the American Academy of Pediatrics, believe that getting foster children a “medical home” — one physician who manages their care over the long term and has access to relevant records — would reduce the overprescription of psychotropic medications.
“Having a drug to take the edge off the pain and fear and sadness saved my life a time or two, but it’s not a lifestyle.” said Misty Stenslie, a former foster child who is currently the deputy director of Foster Care Alumni of America. Children under the protection of government agencies deserve the assurance of safe and decent health care. Especially, as Stenslie points out, “We can’t give kids what they really need, and that’s a family and love.”
- The Failure to Protect Foster Children and Children on Medicaid (madinamerica.com)
- 12. A HORRIBLE SECRET – What the US Government does to Foster Care Children (12160.info)
- Ending Misuse of Anti-Psychotic Medications in Long-Term Care (pattidudek.typepad.com)
- Making a Killing: The Untold Story of Psychotropic Drugging – Full Movie (Documentary) (newsworldwide.wordpress.com)
- Making a Killing: The Untold Story of Psychotropic Drugging (Full Version) (undergrounddocumentaries.com)
Can the label “brain disease” be applied to a cluster of willful, irritating, often manipulative behaviors—from aggressiveness to roller-coaster emotional attachments—that may cause even psychiatrists to dismiss a patient as simply “impossible”? Impossible or not, these behaviors are part of a syndrome that psychiatry has consigned to the borderland between neurosis and psychosis, a gray area where more than one in ten psychiatric outpatients may be wandering, often without appropriate professional care—and where thousands will commit suicide.
Psychiatrists Larry J. Siever and Harold W. Koenigsberg argue that the complexity of borderline personality disorder may stem from the interaction among genetic vulnerabilities (such as extremes of temperament), early experiences, and vast differences in patients’ coping patterns. Patients must be held responsible, they argue, but so must the mental health professionals whose role is to understand and help them.
For the young psychiatrist in training, the term “borderline personality disorder” conjures up images of that angry young woman who regularly calls the emergency room at midnight, telling him that she has swallowed rat poison but refusing to reveal her name or whereabouts.
For the boyfriend of the young woman who reacts to their arguments by slashing her arms, the term sums up a series of perplexing, profoundly disturbing behaviors.
For the wife of the real estate developer, it evokes images of her husband’s angry tirades after an evening of heavy drinking with his cronies.
For the person suffering from the disorder, the term may epitomize the bewilderment, bitterness, and sense of helplessness at the swirl of shifting emotions and insistent impulses that roil daily life.
Ask even the experts about borderline personality disorder and you will get an array of theories and interpretations different enough to remind you of the proverbial blind men examining the elephant, each convinced that a part is the whole. The psychoanalyst will talk of “splitting” and distorted “object relations,” the cognitive behaviorist of “faulty schema” and “an invalidating environment.” The psychopharmacologist may refer to imbalances of brain chemicals such as serotonin and dopamine, and the sociologist to “identity diffusion” promoted by a culture rapidly losing its cohesive social norms. Probably they will agree only on certain observations of behavior: that the person with borderline personality disorder experiences rapidly shifting emotions, is highly reactive to surrounding events, and has a short fuse for irritability, anger, and impulsive behavior.
At a time when psychiatry is grounding one severe mental disorder after another in brain biology, borderline personality disorder confronts us with an enigma—and a clinical dilemma. We have little trouble understanding how a man with a tumor impinging on his frontal lobes may become irascible and display poor judgment, or how someone with an abnormal organization of her brain may hear voices and act out of touch with reality. But we resist seeing the moody, irritable, apparently manipulative and willful behavior of “borderlines” in terms of the biology of the brain; it seems to absolve them of responsibility for their aggressive, antisocial, or even outright criminal acts. Thus we may dismiss them as “impossible” without comprehending the extent of their inner turmoil and pain.
Partly for these reasons, many people, among them many mental health professionals, think borderline personality disorder is far less common than it really is. Primarily manifested in irritating behaviors rather than signs more commonly associated with mental illness, the disorder frequently goes undiagnosed or misdiagnosed. The prevalence of borderline personality disorder has not been established systematically, but estimates are on the order of 2 to 3 percent of the general population and more than 10 percent of psychiatric outpatients. One in ten people with the disorder commits suicide. People with borderline personality disorder are frequently treated for conditions—such as major depression, anorexia or bulimia, or substance abuse—that can coexist with it. Also, many people with the disorder are in nonclinical settings, such as prison. The disorder is implicated in other public health problems, such as domestic abuse and compulsive gambling, in addition to suicide and substance abuse.
THINKING IN TERMS OF VULNERABILITIES
One way to think about psychiatric disorders of this kind is as neurobiologic vulnerabilities. Just as each of us differs in hair color, height, or eye color, we differ in subtleties of brain structure and function. These differences are genetic in origin, but they are elaborated by early biologic inﬂuences (starting in the womb) and all the experiences that mold us as infants and children. The end result is our own particular disposition, ways of behaving, and patterns of coping that are called our personality.
Sometimes, however, these individual differences are extreme enough to lead to signiﬁcant psychological and social problems. Then we begin to think of them as potential vulnerabilities. A person’s consistently extreme emotional reactions to simple daily disappointments and frustrations may make rational coping seem impossible. Where differences in temperament are modest, they can be either an asset—for example, the sensibilities and emotional reactions of an artist or writer—or a liability, such as a tendency toward “emotional storms” that disrupt relationships or even the continuity of sense of self. For example, it is counterproductive consistently to react to frustration with aggression rather than reﬂection on how to respond. The person who speeds, gets intoxicated, plunges into a promiscuous relationship, or recklessly gambles to drown out painful, desperate feelings of abandonment following the loss of a relationship may ﬁnd temporary relief but is getting into some serious long-term problems. What in a milder form was a propensity for assertive action has become, in these extreme forms, a serious vulnerability.
Before we examine the evidence for the origins of these dispositions in the biology of the brain, how brain biology may shape an individual’s development (and be shaped by it), and the resulting complexities of treating the patient with borderline personality disorder, let us share a clinical vignette to illustrate the complexity that clinicians face in drawing the line between willful behavior and biologically determined vulnerability.
Two friends had to carry Melanie into the emergency room. She kept dozing off from the overdose of sleeping pills she had taken. The psychiatrist on call noticed bandages on her left arm that barely concealed dried blood. Her eyes were baggy, the lids droopy, her complexion pale.
Her friends had found her in her apartment, unconscious but able to be aroused, and ﬁgured out that she had overdosed several hours earlier. They said Melanie had broken up with her boyfriend, a man often abusive to her, the previous night. She had called each of them in tears, feeling desperate and abandoned; they made plans to meet for coffee the next morning. Her friends became alarmed when she did not show up and went to her apartment. Melanie was admitted to the hospital for observation and a brief stay.
She was often moody and had had several episodes of depression, but more prominent was her emotional volatility, rapidly shifting from feelings of abandonment to rage. Her outbursts of temper made her personal relationships stormy.
The resident physician who admitted her heard her story the next day, when she was more alert. She looked rested. She was fully made up and even cheerful. He elicited a long history of self-destructive behaviors that included drugs and alcohol, suicide attempts, cutting herself, and outbursts of temper, particularly with boyfriends. Her father was an alcoholic; her mother had been depressed. Growing up, Melanie had been sexually abused by an uncle and verbally abused by her father. As an adult, she had had a series of relationships with men she initially idealized, but who inevitably abused her. She was often moody and had had several episodes of depression, but more prominent was her emotional volatility, rapidly shifting from feelings of abandonment to rage. Her outbursts of temper made her personal relationships stormy and interfered with her effectiveness as a public relations consultant, although she showed a ﬂair for her work when she was not irritable and easily offended by colleagues or clients.
In her episodes of despair, usually after a relationship broke up, she would abuse sedatives and alcohol or behave promiscuously. She often ended up unconscious, sleeping off drug-induced somnolence until she had to get up the next day for work. On some of these occasions, overwhelmed with rage and self-hatred, she cut her arms with a razor blade until she felt a sense of relief. This was not the ﬁrst time such behaviors had led to admission to the hospital.
Melanie had pursued many treatment options, but would inevitably become disillusioned and abruptly end treatment. She had seen several psychotherapists and, at one time, a psychiatrist who met with her twice a week. She explored her feelings about her parents and childhood experiences and examined her rage, which frequently was directed at her psychiatrist. Her feeling of being exploited and abused by the psychiatrist (for example, when he went away on his planned vacation at times she felt she needed him) seemed to echo her feelings about her father’s abuse and neglect. While at times she could see that anger at her psychiatrist was a distortion, based on her past experiences, rage ultimately overwhelmed her and she left treatment.
She then sought the advice of a psychopharmacologist, who suggested she might have a rapid-cycling affective disorder because her intense emotions changed so frequently. He prescribed mood stabilizers, which she abandoned because of the weight gain they caused. Next she sought treatment in a day program that offered cognitive/ behavioral therapy, but she soon found daily attendance too demanding and also disliked being in the company of people who had “serious mental illnesses.” She tried outpatient psychotherapy again, but abandoned it when her therapist showed up ﬁve minutes late for a session. The next counselor felt that her problems arose from repressed memories of sexual abuse at the hands of her father, and spent sessions talking about her childhood traumas.
During this odyssey of treatments sampled and abandoned, Melanie heard seemingly discrepant explanations of her condition. Although the psychiatrist did not offer a direct explanation, his comments seemed to suggest that she had difﬁculty separating from her mother, whom she experienced as being inconsistently available to her, leaving her feeling furious. He suggested that much of her behavior was intended to make other people experience the rage that she found unbearable. The psychopharmacologist explained that low serotonin levels might underlie her propensity to anger and aggression; he prescribed a selective serotonin reuptake inhibitor (SSRI), an antidepressant that made more serotonin available in the brain. He later prescribed a mood stabilizer that he explained might help with her irritability. The cognitive/behavioral therapist emphasized that her parents had not validated her feelings, contributing to her difﬁculty in regulating her emotions and developing interpersonal skills that might temper her impulses. The last counselor traced her problems to her early abuse and suggested that she talk through those experiences. This catalog of explanations left her depressed and disillusioned.
SEEKING A WHOLE ELEPHANT
How do we make sense of Melanie’s symptoms? Does she have a brain disorder to be treated with medications? A disorder arising from faulty learning? Are its symptoms a direct consequence of the trauma or abuse many people with borderline personality disorder have experienced? Are these explanations mutually exclusive, or do they all contribute to a full understanding of her problem?
Although the propensity to act without foresight in an irritable or aggressive way is not unique to borderline personality disorder, it is integral to it.
The circuitous history of the concept of borderline personality disorder reﬂects these complexities. In the 1940s and 1950s, the earliest diagnosis that employed the term “borderline” was “borderline schizophrenia,” a diagnosis that located the patient’s problem somewhere between chronic schizophrenia and normality. (Today people with these mild psychotic-like symptoms and the social withdrawal characteristic of schizophrenia are diagnosed with “schizotypal personality disorder.”) The psychiatrist Roy Grinker referred to a “borderline syndrome,” which included the emotional turmoil and impulsiveness that we associate with borderline personality disorder, but also the psychotic-like symptoms associated with schizotypal personality disorders. Otto Kernberg used the term “borderline organization” to describe a psychological organization somewhere between psychotic, with fundamental alterations in reality testing, and neurotic, characterized by conﬂict and anxiety more than the tendency to behave impulsively. John Gunderson and Margaret Singer tried to deﬁne “borderline personality disorder” more precisely in terms of speciﬁc interpersonal characteristics such as unstable relationships and behavior such as suicide attempts and self-injuring. Their deﬁnition eventually was adopted by the American Psychiatric Association, with some modiﬁcations, for their Diagnostic and Statistical Manual-III (DSM-III), the handbook of psychiatric diagnoses, in 1980. While the term “borderline” has been criticized for not clearly reﬂecting the actual speciﬁc behaviors associated with the disorder, it remains in wide clinical use.
The complex personalities of people with borderline personality disorder cannot be reduced to a single, simple formula. It is more useful to parse the disorder into its components. When we do so, we see vulnerabilities of temperament that may well be rooted in the variations being discovered in key brain systems that regulate emotions and aggression. These individual differences, underlying and inﬂuencing a person’s development, go a long way toward explaining the disturbed behavior and altered psychology associated with borderline personality disorder. Here we will examine the neurobiology of the two essential components of the disorder: impulsive aggression and affective (emotional) instability.
THE NEUROBIOLOGY OF IMPULSIVE AGGRESSION
Although the propensity to act without foresight in an irritable or aggressive way is not unique to borderline personality disorder, it is integral to it. Studies of identical and fraternal twins and adopted children show that this propensity may be inherited. The genetic potential may be triggered by parents or peers who act aggressively; conversely, it may fade in a more supportive, caring environment. The threshold for aggressive acts is more easily crossed in a person of highly changeable emotions and moods—the other essential characteristic of the borderline patient.
Brain systems that suppress aggressive or socially inappropriate behaviors may be less effective in people with borderline personality disorder. The level of serotonin in their brains is a good place to begin an investigation because serotonin is a “modulatory neurotransmitter”: a brain messenger-chemical that regulates emotion, feeding, temperature, and appetite and can suppress aggressive or antisocial behaviors. The analogue of these human behaviors in animals, such as rats’ aggression toward mice, makes these animals promising models for testing the modulatory effects of serotonin. Rats with lesions of the serotonin system display markedly increased aggression in behavior such as killing mice, compared to rats without the lesions. Furthermore these rats have a hard time suppressing behavior once it has been punished. They continue pressing a bar that had been associated with a reward (food pellets) even after the pressing produces a shock instead of a reward. Their problem is not with discriminating between the reward and the shock but rather with suppressing behavior that previously led to reward. It is tempting to extrapolate from animals to humans, but the vast differences between them precludes direct comparisons. What we need are clinical studies of impulsive, aggressive people.
One method of studying the function of serotonin in humans involves measuring a breakdown product (or metabolite) of serotonin, 5-hydroxyindoleacetic acid (5HIAA), in the cerebrospinal ﬂuid (CSF) that bathes the brain. The concentrations of this waste product of serotonin give us an idea of the activity of the serotonin system in the brain. Concentrations have been found to be low in patients who are depressed, particularly those who seriously attempt suicide. Concentrations have also been found to be low in violent criminal offenders and armed services personnel (and others) with histories of aggression. All this suggests the possibility that low serotonin activity may be associated more with aggression, whether directed against oneself or others, than with depression or suicide per se.
Both suicide attempts involving direct physical violence toward oneself and self-destructive acts, such as cutting oneself or burning oneself, represent self-directed aggression.
Measurements of CSF 5-HIAA, the serotonin breakdown product, cannot tell us the responsiveness of brain cells that are affected by serotonin, but another study uses chemical agents that release serotonin near its targets of action—the receptors— and then measures responses by these receptors, such as the blood levels of hormones whose secretion they control. For example, the chemical fenﬂuramine causes release of the hormone prolactin, and the degree of prolactin release following administration of fenﬂuramine may give us an index of the responsiveness or capacity of the person’s serotonergic system. Studies using this strategy suggest that the serotonin system’s activity has been blunted in patients with borderline personality disorder compared to normal controls, or even patients with other personality disorders.
This blunting is associated with angry outbursts, impulsive behaviors, and self-destructive behaviors—that is, impulsive aggressive symptoms—rather than with emotional instability. Blunted prolactin responses to fenﬂuramine also correlated with suicide attempts (particularly serious ones, involving injury) in both personality disorder patients and depressed patients. Personality disorder patients who had attempted suicide and engaged in self-destructive behaviors showed the most blunted responses. This is consistent with the hypothesis that both suicide attempts involving direct physical violence toward oneself and self-destructive acts, such as cutting oneself or burning oneself, represent self-directed aggression. Blunted prolactin responses to fenﬂuramine were also associated with high irritability and aggressiveness, as reported directly by the people affected. This result has been replicated several times and observed with other chemical agents that test serotonin system activity.
Measuring hormone responses, however, cannot help identify the speciﬁc brain circuits modulated by serotonin that are involved in inhibiting or releasing aggression. Imaging techniques such as Positron Emission Tomography (PET) scanning offer the possibility of studying the serotonin response of brain regions believed to be involved in controlling impulsive behavior. PET measures the activity of radioactively tagged glucose molecules, producing a picture of metabolic activity throughout the brain. Thus changes in brain activity can be seen directly following administration of chemical agents that enhance serotonin activity. Two such agents, fenﬂuramine and chlorophenylpiperazine (mCPP), the latter acting directly on serotonin receptors, cause increases in metabolism in the cortex— the part of the brain responsible for higher cognitive function, including modulating or inhibiting more primitive aggressive and sexual urges. The front of the brain behind the forehead and just above the eyes (called the orbital frontal cortex) is of particular interest. Lesions here can result in less inhibition of aggression.
A perfect example was found in Phineas Gage, a mild-mannered 19th century railroad worker who was injured in a miraculously speciﬁc way that destroyed much of his orbital frontal cortex but left him otherwise functioning. After the injury, Gage underwent a marked personality change, becoming irascible and impulsive and displaying poor social judgment. This famous historical case is consistent with other reports of people with injuries or lesions in this area who develop poor social judgment and antisocial traits. It appears that the orbital frontal cortex plays an inhibitory role, serving as the “brakes” for limbic regions involved in generating aggression. Since this region is heavily modulated by serotonin, one might think of serotonin as the ﬂuid that keeps these brakes working properly. When the ﬂuid is low, the brakes malfunction and impulses toward aggression are not inhibited. Indeed, people with borderline personality disorder who are notably impulsive in their aggression do not show the normal increases in metabolism following serotonin agents that normal volunteers do.
People with borderline personality disorder are often very sensitive to the side effects of these medications. This sensitivity, or the likelihood of their not complying with the requirements, has meant that they often do not give the medication an adequate chance to work.
We do not know what is responsible for individual differences in serotonin system activity, but the differences are likely to be partly genetic. (Remember, there is good evidence for heritability playing a role in impulsive aggression.) One approach to identifying genetic factors involved in a trait or disorder is to select candidate genes: that is, genes that are likely, based on other evidence, to be associated with that disorder. For example, genes that modulate the breakdown or synthesis of serotonin might be logical candidate genes. Thus we ﬁnd that the gene controlling the enzyme tryptophan hydroxylase, which is responsible for the rate at which serotonin is produced, has been associated with suicide attempts in criminal offenders and impulsive behavior in personality disorder patients. Another candidate is a variant of a gene that controls the serotonin transporter, which inactivates serotonin by taking it back from the cleft between the neurons (the synapse), where it does its job, to the inside of the neuron, where it is broken down. Genes coding for other receptors that act like thermostats in modulating serotonin release have also been associated with suicide attempts in personality disorder patients.
There is evidence that trauma or abuse may modify serotonin system activity. People with borderline personality disorder often have histories of sexual or physical abuse. While this experience is not unique to them, it may help shape their personalities and leave its imprint on the brain. The serotonin system itself may be modiﬁed by these traumas and, of course, this plays a critical role in developing brain systems related to habits and coping skills. Complex relationships have been found among responses to serotonergic agents, cortisol (a major stress hormone), and a history of trauma.
The relationship between serotonin activity and impulsive aggression raises the possibility that drugs enhancing the activity of the serotonin system could alleviate impulsive aggression. The SSRIs, such as ﬂuoxetine (Prozac) or sertraline (Zoloft), increase concentrations of serotonin at the juncture between nerve cells. These medications have helped in depression, and there is increasing evidence that they may help in impulsive aggression as well. Studies suggest that they reduce irritability and anger in patients with borderline personality disorder. Indeed, the effects on anger are more pronounced than the effects on depression itself. Unfortunately, people with borderline personality disorder are often very sensitive to the side effects of these medications. This sensitivity, or the likelihood of their not complying with the requirements, has meant that they often do not give the medication an adequate chance to work. This is particularly problematic because people who have reduced serotonergic capacity appear to require more SSRIs than others to achieve therapeutic affects. If used carefully, however, with incremental increases in dose, SSRIs can be brought to levels that reduce impulsive aggression.
THE NEUROBIOLOGY OF AFFECTIVE INSTABILITY
In addition to vulnerability to impulsive aggression, people with borderline personality disorder are unusually emotionally reactive. They may be content for a while, then become intensely angry or hopelessly depressed or unbearably anxious—each state, although intense, lasting only a few hours or a day. Contrast this with classic mood disorders like depression, in which the emotion, although it may wax and wane during the day, endures for weeks or months. Even in bipolar disorder, or manic-depressive illness, which is deﬁned by the often-rapid succession of depression and mania or euphoria, the different mood states typically last weeks or longer.
To those who are close to them, borderline patients appear to have random and unpredictable emotions. On closer investigation, those emotions often seem to involve heightened emotional reactions to other people. Borderline patients may become distraught at ordinary criticism, which they experience as a blow to self-esteem; may react with rage to a disappointment or minor slight; or may feel terror at a separation that they experience as virtual abandonment. Their emotional, or affective, instability may contribute to their turbulent, often unstable relationships and the inconstancy in their experience of themselves that leads to a confused sense of identity.
Less is known about the brain biology of this instability than about the basis of impulsive aggression, but the borderline person’s overreaction to frustration and disappointment seem to be part of a heightened reaction to almost everything. A particular chemical system of the brain, the norepinephrine system, appears to be involved in regulating our level of arousal and vigilance in reaction to the environment. Neurons that release norepinephrine arise from a structure deep in the brain stem called the locus coeruleus, which acts as the brain’s alarm center, and spread out widely throughout out the brain. Substances that stimulate norepinephrine activity increase alertness and attention to the environment.
To ﬁgure out whether the norepinephrine system is involved in the emotional ups and downs, scientists administered amphetamine, a stimulant that causes extra norepinephrine to be released from the neurons, to people with differing degrees of emotional instability. They found that those least emotionally stable were most sensitive to amphetamine-induced shifts in emotion.
A second chemical system in the brain, the acetylcholine system, also appears to play a role in emotional reactivity. When substances that enhance acetylcholine are given to patients with depressive illness, they become more depressed; when these agents are given to patients in the euphoric phase of bipolar illness, they become depressed, as well. Patients with borderline personality disorder who receive physostigmine, a substance that activates the acetylcholine system, swing to depression; those borderlines with a history of extreme affective instability show the strongest reaction. Procaine, the local anesthetic dentists use to diminish pain, also stimulates the acetylcholine system. When borderline patients receive procaine intravenously, they show marked and variable emotional reactions, especially swings to depression and other unpleasant feelings.
The brain has receptors that might almost have been tailored to ﬁt minor tranquilizers such as diazepam (Valium) or lorazepam (Ativan), like a lock ﬁts its key. Since the brain could not have evolved a receptor in anticipation of a drug product, this intriguing discovery suggests that the brain has its own natural Valium-like substance. We have not yet found the natural Valium, but researchers have identiﬁed a natural brain substance called gamma-aminobutyric acid, or GABA, which enhances operation of these receptors almost like oil lubricating the lock. GABA receptors are found extensively in those parts of the brain most involved in processing emotion, particularly the amygdala— an almond-shaped structure located deep behind the temples on each side of the head. Because GABA may play a role in tranquilizing or damping down sudden surges of emotion, it seems possible that impairments in the GABA system may be involved in affective instability. One conﬁrmation is that three medicines that act as mood stabilizers in borderline patients—lithium, depakote, and carbamezepine—all enhance GABA activity.
We can use brain scanning to observe the activity of brain structures that may be involved in emotional instability. When volunteers get shots of procaine, the substance that evokes intense emotional reactions in borderline patients, their brain activity increases in certain regions of the amygdala, suggesting that those regions may play a role in emotional instability.
BRAIN, PERSONALITY, AND BEHAVIOR
We have seen considerable evidence that improperly regulated brain systems may give rise to impulsive aggression and affective instability in borderline personality disorder. But because these traits are crucial in setting the tone and quality of human relationships, they inevitably become entwined with a person’s psychology and social functioning.
In this way, a predisposition created by the brain becomes an important inﬂuence in the developing personality and contributes to the characteristics of borderline personality disorder.
Infants who are very emotionally sensitive may respond more intensely to the comings and goings of their mother or caretakers and show much greater distress at separating. This may lead to a more insecure attachment between infant and mother. If the infant is more impulsive and aggressive— that is, likely to express emotions forcefully— he may have crying spells and, later, temper tantrums when frustrated or left alone, which can wear down even the most supportive parents and overwhelm those who are depressed or who themselves have trouble with emotional reactivity and impulsiveness. Parents may become frustrated at their inability to soothe such a child and decide not to respond to its distress; at other times they may try everything to indulge the child to appease its upset and rage. These inconsistent (and, to the infant, unpredictable) responses may make it likely that the child will learn to deal with unpredictability by means of emotional storms or tantrums.
Only by looking at the behaviors of someone with borderline personality disorder in that person’s social milieu do we fully understand their meaning.
As the child matures, he may draw on these interpersonal strategies in order to regain emotional equilibrium. For example, when an upsurge of depression follows a blow to self-esteem, the borderline person may try to bolster her self-esteem by devaluing someone else. When feeling alone and abandoned, she may behave recklessly to stimulate the worry and involvement of others. To onlookers, these behaviors may appear manipulative because their purpose is to bring another person to attend to the borderline’s needs. But because of their heightened sensitivity to the availability of others, people with borderline personality disorder often feel that they are not in charge of their own emotions—their emotions depend on the behavior of those around them. Attempting to control their own feelings, they ﬁnd themselves trying to control the behavior of people they depend upon and care about. Repeated again and again, these patterns of behavior become ingrained. The borderline person experiences these styles of relating as the only way to survive emotional ups and downs and the feeling that others cannot be trusted to support her.
People with borderline personality disorder translate their anger or disappointment into impulsive action that they have difﬁculty reﬂecting upon or delaying. Their sense of abandonment by the ending of a relationship may make them feel desperate and enraged. To make themselves feel better, they act in ultimately counterproductive ways, using drugs or alcohol to soothe upset feelings, plunging promiscuously into sexual activity, turning their anger at themselves in self-destructive acts like cutting their arms or wrists, or indulging in impulsive gambling or binge eating. These measures may temporarily alleviate their distress, but they will bring destructive long-term consequences. The same behaviors often lead mental health professionals to “rescue” them by intervening with hospitalization, giving borderline people the attention they crave.
THE TIGHTROPE ACT OF TREATMENT
Only by looking at the behaviors of someone with borderline personality disorder in that person’s social milieu do we fully understand their meaning. For although temperamental vulnerabilities of impulsiveness and affective instability may drive these behaviors, the interpersonal environment can buffer or provoke them. Some of the most effective treatment approaches address the interpersonal and the temperamental domains in tandem.
Early in treatment, the person with borderline personality disorder must be helped to recognize his tendency to become disillusioned with people, drawing others into intense involvements only to push them away when they disappoint even slightly. This recognition is a crucial ﬁrst step, because the pattern inevitably will develop in the relationship with the therapist, threatening to end it before it starts. Unless the person with borderline personality disorder can examine this pattern, he will be unable to sustain a treatment relationship and will not be open to efforts, through either medication or learning new strategies to diminish his temperamental vulnerabilities.
Once a treatment alliance is established, the individual can begin to take responsibility for his behavior. Medications may then help reduce impulsiveness and emotional instability. Behavioral therapies may also help, teaching skills that reduce vulnerabilities. Unfortunately, the maladaptive interpersonal patterns that the borderline develops to cope with temperamental vulnerabilities become ingrained and typically do not lessen when impulsiveness or emotional overreactivity begin to diminish. He must learn what his characteristic maladaptive patterns are, when they are likely to be brought into play, what purpose they serve, and how to substitute more adaptive coping strategies.
This is the domain of psychotherapy. Some people learn how to identify and modify their behavior patterns in cognitive-behavioral therapy, which uses a step-by-step analysis of the triggers of their maladaptive behaviors and provides training in new coping skills. Others learn how their behavior patterns emerge, what purposes they serve, and how to defuse them by searching for and exploring how they show up in their ongoing relationship with their psychotherapist (called a transference-based psychotherapy). Researchers are seeking to learn what forms of therapy best serve which individuals with borderline personality disorder and are developing new medicating strategies to address the underlying vulnerabilities.
For example, Melanie was ﬁnally able to ﬁnd a therapist who treated her with a form of cognitive-behavioral therapy and introduced her to skills training as part of a special approach called Dialectical Behavioral Therapy. Melanie was started on a selective serotonin re-uptake inhibitor (like Prozac) and a mood stabilizer by a psychopharmacologist. While her life is still somewhat unsettled, Melanie has not overdosed again and has started a relationship with someone who seems to respect her.
Some of the most effective therapies may be interpersonal, while medications may raise the threshold beyond which aggressive behavior or upsetting emotions erupt, making psychotherapy more effective. To ignore differences in the biology of the brain that make the person with borderline personality disorder susceptible to emotional and interpersonal turmoil is to repeat the lack of validation that they experienced growing up. To absolve people with borderline personality disorder from responsibility for managing these vulnerabilities, however, is to license them to indulge their maladaptive predispositions because “they can’t help it.”
We can look at the notion of vulnerabilities in the biology of the brain as being similar to the vulnerabilities predisposing a person to hypertension or diabetes. Diabetic or hypertensive patients are responsible for managing these vulnerabilities, just as people with borderline personality disorder can take responsibility for their behavior while acknowledging the struggles they will face in managing their turbulent emotions and precipitate actions. The power of the mind can be brought to bear on managing the brain.
- Types of borderline personality disorder (psychscoop.wordpress.com)
- Schema Therapy for Borderline Personality Disorder (authorjaenwirefly.wordpress.com)
- Are you Borderline or do you have BPD? (authorjaenwirefly.wordpress.com)
- Borderline Personality Disorder: New Reasons for Hope (A Johns Hopkins Press Health Book) (untreatableonline.com)
- Types of borderline personality disorder (hawkruh1.wordpress.com)