Sex Addicts and Cheerleaders on a Hot Stove Lid

(Today’s post talks about sexual addiction, whether it’s a genuine mental health issue and whether ‘addiction’ is the right word. To keep this readable, I’ve used ‘addicts’ to mean people who report trouble controlling their sexual behavior.)

Like sex? Vaughn R. Steele, Cameron Staley and others in the Southwest U.S. ran MRIs on people who really like sex (1). They tested two groups – people who reported trouble limiting the time they spent on porn, and those who reported powerful libidos, but denied it caused them any trouble.

Bartus LeventeliquorresizedSteele, et al watched how the brainwaves changed as the subjects looked at various pictures – neutral, pleasant, unpleasant and pornographic images. For their study, the researchers focused on the P300 – a section of the brain wave that swells when we evaluate something. Mention alcohol, and it will grab an alcoholic’s attention – you can tell by the way their P300 increases in amplitude. When the porn addicts viewed sexy images, their P300 didn’t – at least not more than for those who reported only strong sexual desire. Moreover, there didn’t seem to be any pattern of greater or lesser P300 amplitude in those who reported greater or lesser degrees of compulsive sexual behavior.

This means sex addiction isn’t a legitimate problem, right? Maybe.  The debate has gone on long enough to be discussed on Cartoon Network (NSFW).  The most common points of view can be condensed like so:

If it Walks Like a Duck and Quacks Like a Duck…:

Thesis: Of course it’s an addiction. Around the world, thousands of people report they used sex to cope with anxiety, continued to do so despite negative consequences, but could stick to healthy limits with addiction-model treatment and twelve-step groups.

Pros: Describes the sex addicts’ experience with a clear, compassionate metaphor

Cons:  This study, which found very non-duck-like brainwaves.

No Addictive Substance? No Addiction:

Thesis: Addiction isn’t a pattern of behavior, it’s a state of the brain. If you aren’t introducing an addictive substance to the body, then you don’t have an addiction.

Pros: Adheres to a formal biological definition of addiction

Cons: The brain produces showers of neurotransmitters like dopamine and norepinephrine during sexual arousal – and they’re substances.

There Ain’t No Such Animal #1:

Photo @ 2005 by Paddy Briggs

Photo @ 2005 by Paddy Briggs

Thesis: There’s no addiction,  just selfish, greedy people trying to excuse their irresponsibility.

Pros: Speaks to our values of self-reliance and self-control. Based on careful, clinical assessment of gossip-column items, it seems to fit celebrities well.

Cons: Doesn’t actually explain the recovering addicts who couldn’t take responsibility on their own, but did with the help of addiction-model treatment.

There Ain’t No Such Animal #2:

Thesis: There’s no addiction and really, no problem – just a bunch of self-appointed bluenoses who insist anyone who takes pleasure in what’s pleasurable must have a disease.

Pros: Reminds us not to pathologize behavior of which we disapprove.

Cons: Doesn’t actually explain the recovering addicts who report they got zero pleasure from their behavior, but couldn’t stop without support.

Steele and his fellow researchers argue their findings mean these problems might be treatable by lowering sexual desire. They’re willing to believe those who say their sexual behavior stretches out of their control, but they don’t believe it’s an addiction.

Does it have to be?

Is everything that takes athleticism a sport?

Is everything that takes athleticism a sport?

There’s those who  insist cheerleading is a sport, because it requires intense stamina, training and physical effort. That’s also true of the trapeze and ballet, and neither will be in the Olympics any time soon.  There’s a fifth common viewpoint on sex addiction; one that matches sex addicts’ subjective reports, isn’t contradicted by these findings, and elides some of the debate on phraseology:

“Behavioral Addictions” are Actually Compulsions:

Thesis: Gambling, eating, shopping and sexual behavior become compulsive when they are the main tool for coping with stress and unhappiness.  If  a behavior that pushes the pleasure button in the brain is someone’s only way to get by, that behavior will be repeated again and again, long after rewards stop coming and self-esteem crumbles.

Pros: Addicts reports they consistently engage in sexual behavior to maintain emotional and physiological stability, despite negative consequences. That’s (about) as good a definition of a compulsion as you could ask for.

Cons: Compulsions usually involve the belief the behavior will keep one safe. Sex addicts report they often break the limits they planned to hold when triggered. This makes it seem more like an impulse-control problem than a compulsion – and also matches addicts’ descriptions of their relapses.*

Mark Twain“We should be careful to get out of an experience all the wisdom that is in it — not like the cat that sits on a hot stove lid. She will never sit down on a hot lid again — and that is well; but also she will never sit down on a cold  one anymore.” –  Mark Twain

Our knowledge of the brain has grown so fast, our vocabulary hasn’t kept up. When you start with, “Can this fairly be described as addiction?” the conversation turns to an ethical debate of, “Does this word mean addicts avoid  responsibility or accept  it?” before it becomes a semiotic dispute of, “What do you mean when you say ‘real’?” As Rory C. Reid, PhD, assistant professor of psychiatry at UCLA and colleague of one of the researchers points out, the larger question isn’t, “Is this an addiction?” but “What is an addiction?”

Neurology may add so much to our knowledge that terms like ‘addiction’ and ‘compulsion’ will blow apart from within. In science, this is a good thing.  Read Psychiatric Times‘ article (2) on distinguishing impulsivity from compulsivity, and you’ll notice the authors refer to “sexual compulsion” and “compulsive shopping”, while explaining these are considered impulsivity problems.  When newer, precisely-defined, empirically-validated constructs are ready, tangled tongues won’t complicate our understanding. Until then, let’s be careful that, “This doesn’t fit the clinical definition,” isn’t mistaken for, “There ain’t no such animal.”

* Thanks to Karen E. Engbretsen PsyD, LLC who pointed out the important components of impulsivity in sex addiction.

Citations:

(1) Steele, Vaughn R. ; Staley, Cameron ; Fong, Timothy & Prause, Nicole (2013). Sexual desire, not hypersexuality, is related to neurophysiological responses elicited by sexual images. Socioaffective Neuroscience and Psychology 2013, 3: 20770 – http://dx.doi.org/10.3402/snp.v3i0.20770

(2) Berlin, H., Hollander, E. (2008, July 1). Understanding the Differences Between Impulsivity and Compulsivity. Psychiatric Times

@ 2013 Jonathan Miller All Rights Reserved

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October is AD/HD Awareness Month

To celebrate 2013’s Attention-Deficit/Hyperactivity Disorder Awareness Month, AD/HD-related groups including ADDitude Magazine, the Attention Deficit Disorder Association (ADDA), and CHADD have scheduled free webinars and created a useful page of resources here.

While you’re perusing those, enjoy this distraction from the golden age of MTV:

“Tell me about your childhood.”

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RIP William Glasser / Minimalist Therapy

… one woman had been attending the clinic for three years and had spent most of that time blaming her nervousness and depression on her now-dead grandfather. Glasser told her that he would see her only if she would never again mention her grandfather. She was shocked and responded, “If I don’t talk about my grandfather, what will I talk about?”

– Frew, J., & Spiegler, M. D. (2012). Contemporary Psychotherapies For a Diverse World., pg. 298, London: Routledge.

William Glasser MD, the founder of  “Reality Therapy”, died August 23, 2013 of respiratory failure. He was eighty-eight years old.

William Glasser, around 1953.

William Glasser, around 1953.

Raised in Cleveland, OH, and initially educated as a chemical engineer, Glasser trained in conventional psychoanalysis. At his first residency, he quickly lost faith in Freud. Attributing clients’ behavior to external factors irked him. He could see their insights weren’t leading to change. He noticed his effective sessions were those focused on action in the present. He decided we weren’t motivated by conflicts or drives, but by needs: survival, freedom, power, belonging and fun. In his view, everything we do is a choice we make to obtain those essentials. Mental illness is nothing but coping through negative choices – including unhappiness. Change comes when we turn away from daydreams and unrealistic hopes, commit to a plan of making better choices and follow through.

Such anti-analytical thinking sat poorly with management. Glasser’s residency ended with the conspicuous lack of a job offer. He moved on to the Ventura School for Delinquent Girls in Ojai, CA, where the most insightful analysis had failed young offenders. His new theories, applied as part of a warm, validating relationship,  helped them change.

Glasser was working in the late 1950’s and early 1960’s, a time when great minds were thinking minimally. Artists like Frank Stella and Agnes Martin painted with the simplest of lines, shapes and colors. Composers like Phillip Glass and Steven Reich overlapped tape loops of speech to make music without musicians or instruments. The inspiration was writers like Samuel Beckett, architects such as Ludwig Mies van Der Rohe and designers like the De Stijl school.  The challenge was to create an emotional response with as little stimulus as possible. By stripping away Freudian conflicts, Pavlovian associations and Skinnerian reinforcers, Glasser created a minimalist therapy.

Reality Therapy (RT) was simple enough to help others through a paperback book. With small adjustments, it translated well to other cultures. (In China, therapists don’t ask, “Is this behavior  bringing you closer to your goal?” but, “Do your actions bring shame or honor to your parents?”) Unlike Skinner’s operant conditioning, it addressed the fact that people have innate needs. RT, which Glasser later refined into Choice Theory,  can be viewed as an ancestor to ‘activation therapies’,  like ACT and Dialectical Behavioral Therapy. Since the therapist’s job is to help the client generate better choices, it’s like an empty apartment – one that can be furnished with any therapeutic intervention that helps the client choose more wisely.

William Ira Glasser, in 2009, photo copyright 2013 by Brother Bulldog

William Ira Glasser, in 2009, photo copyright 2013 by Brother Bulldog

At times, Glasser’s reductionism went too far. To claim that all mental illness consists of poor choices is to ignore the reality of delusions and hallucinations. Telling someone with Post-Traumatic Stress Disorder to focus on the present and move forward does nothing for their nightmares and flashbacks. In 1998, Glasser wrote, “We choose everything we do, including the misery we feel.”  By then, neurology had already demonstrated that our rational mind’s personal agency is something less than 100%.

Since Glasser’s principles could be surprisingly subtle, they were also easy to misuse. When an adult tells a child with AD/HD, “You can choose to raise your hand before speaking, or you can choose to stay after school,” they’ve twisted ‘personal responsibility’ into a passive-aggressive head game – one that lets them escape the responsibility to properly assess the child’s needs.  Glasser stressed, “No blaming, no punishment,” in dealing with clients;  it’s ironic to see his  “success identity” concept corrupted into, “I chose to be successful. Others chose to be losers. Therefore, they don’t deserve any help or sympathy.”

Glasser’s reductionism was a route to an effective therapy – not the definition of everything involved. He knew no one consciously decides, “I feel like feeling depressed today.” By reframing emotions as actions, he helped agitation seem more controllable. He understood no one leaps into changes in behavior. By repeatedly returning to, “What’s your plan?” he focused the Ventura School students on small steps towards new habits. The girls there had been told their upbringing meant they were not responsible for their criminal acts. In a compassionate, understanding way, he told them that they were. Neurology, environment and abuse all played a role in his clients’ problems.  Glasser succeeded in helping them change, because he ignored everything except what a reform-school kid could control.

Minimalist art sometimes created a minimal impression. Glasser’s therapy provided clients with a more-than-minimal level of control.

@ 2013 Jonathan Miller All Rights Reserved

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Depression: Overdiagnosed by the Overwhelmed

(Full disclosure: Dr. Mojtabai kindly furnished a copy of his article for review. I don’t think this freebie altered my judgement but then, no one ever does.)

A new study shows that 3/5ths of those diagnosed with depression don’t have Major Depressive Disorder. Damning proof America’s mental health system is riddled with quacks, right? Actually, no. But it suggests a worrisome disconnect between those with mild depressive symptoms and those trained to treat them.

Ramin Mojtabai, MD, PHD, MPH

Ramin Mojtabai, MD, PHD, MPH

Ramin Mojtabai of the Johns Hopkins Bloomberg School of Public Health studied 5,639 adults who reported, “a doctor or other medical professional,” diagnosed them with  depression in 2009 or 2010. He found only 38.4% had met criteria for a major depressive episode in the past twelve months. Nearly three-quarters of those who did not meet criteria had been prescribed medication.

Who’s making these diagnoses? Probably primary care doctors – the people we’re most likely to talk to if we gain weight, lose energy or have trouble sleeping. In 2011, Mojtabai found 7% of all doctor visits involved a prescription for antidepressants.[i]  For his current study, he started with data collected through the United States National Survey of Drug Use and Health. While this study didn’t ask participants what type of medical professional diagnosed them, he found only 34.6% of those who hadn’t met criteria for a major depressive episode received outpatient mental health services. It’s not much of a leap to surmise primary-care doctors are responsible – especially considering  Mitchell and Vaze’s 2009 study, which found such doctors misdiagnosed depression more often than they identified it correctly.[ii]

Is it a problem if family doctors reach for a quick fix when they encounter mild-to-subclinical depression? Per the studies Mojtabai cites, there’s little evidence antidepressants help such cases. Effective treatments include a referral to counseling, advice on boosting one’s mood with diet and exercise, or watchful waiting. Instead of these, three-quarters of those with only mild depressive symptoms got a prescription.

Three possible solutions come to mind. None would be quick, easy or cheap.

"I need more training in what, now?" (photo: Adam Ciesielski © 2013)

“I need more training in what, now?” (photo: Adam Ciesielski © 2013)

1. Better training in diagnosis

If misdiagnosis is the problem, more training is the answer, right? Bear in mind, for every public health problem, the initial thought is, “Let’s get the primary care doctors on the case.”  Family doctors are expected to follow up on everything from lead exposure to trampoline safety.  Depression has to compete with every other disease in need of greater public awareness.

2. Counter-programming

Primary care doctors are barraged by pharmaceutical companies which promise quick and easy solutions, based on often-dubious research. Olfson and Marcus found antidepressant use doubled from 1996 to 2005. In the same period, the number of patients who received therapy as well as antidepressants dropped by a third.[iii]  (Essay question: Should we allow unscrupulous Big Pharma to exploit human suffering by placing profit ahead of facts and the public’s health, or should jackbooted government thugs trample free speech by placing unaccountable technocrats in charge?)

Organizations such as the American Counseling Association and the American Psychology Association should return fire with their own brochures. On the front cover: fit, attractive people of all ages and cultures beaming over the success of their non-pharmaceutical treatment. Inside: large-print bullet-points on how to differentiate the different intensities of depression, and the relative efficacy of medication, lifestyle improvements and counseling. Last page: a handy list of local therapists for referrals.

3.  A nationwide program

In his article, Mojtabai mentions the United Kingdom’s National Health Services’ “Improving Access to Psychological Therapies“. This program trained thousands in cognitive-behavioral therapies and provided general practitioners with free on-line training about depression. As a result, patients move easily from a more-accurate diagnosis to a simpler referral for help.

In the U.S., surveys show we dislike government programs and government spending, but we do like the benefits that spending on government programs brings. Per NHS data, their big-government program moved 45,000 workers off public benefits by getting them back to work. It also benefited the UK’s economy by an estimated £272,000,000 by preventing the need for more expensive treatments.  The program has been criticized for restricting the range of therapies available and providing lightly-trained staff. Even with these limitations, it has delivered a respectable (if non-astonishing) recovery rate of 42.5%.

For the next go-round:

Mojtabai’s study is enticingly exasperating; the kind that raises more questions than it answers. Tough questions for a follow-up:

1. Exactly who provides these misdiagnoses? Which specialty is most on-target, and which is most likely to misdiagnose? Master’s-level counselors, social workers and psychologists should all be assessed for accuracy.

2. Out of the patients who received outpatient mental health treatment, what percentage received counseling and which only received more meds from a psychiatrist?

3. How hard is it for a primary medical doctor in other countries to refer a client to therapy? How much resistance do clients offer, and what would help doctors address their concerns?

The 3/5ths of participants that grabbed the headlines may not have met criteria for Major Depressive Disorder, but it’s a safe bet they weren’t happy and fulfilled, either. More information for better diagnoses and more-appropriate treatments, please.

Citation:

Mojtabai R. Clinician-identified depression in community settings: concordance with structured-interview diagnoses. Psychother Psychosom. 2013;82(3):161-9. doi: 10.1159/000345968. Epub 2013 Mar 27.

© 2013 by Jonathan Miller. All Rights Reserved


[i] Mojtabai R, Olfson, M. Proportion Of Antidepressants Prescribed Without A Psychiatric Diagnosis Is Growing.  Health Aff August 2011 vol. 30 no. 8 1434-1442. doi: 10.1377/hlthaff.2010.1024

[ii] Mitchell A, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009; 374: 609–19

[iii] Olfson M, Marcus SC. National Patterns in Antidepressant Medication Treatment. Arch Gen Psychiatry. 2009;66(8):848-856. doi:10.1001/archgenpsychiatry.2009.81.

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BAD THERAPY? A DISGRUNTLED EX-PSYCHOTHERAPY CLIENT SPEAKS HER PIECE

Valuable perspective from the client’s side. Can’t agree with everything that’s written here, but I count description of six significant ethics violation. Wish Disequilibrium1 knew how many ethical, competent therapists already follow her seven suggestions.

Disequilibrium1's Blog

In blogs and book reviews, I see reference by therapy professionals to the “disgruntled ex-client.”  I assume this label is pejorative and the classification perhaps is to warn therapists to create a strong filter when one hovers nearby.

So here’s my warning label: I’m a disgruntled ex-client.  My therapy mostly was harmful.   Before I’m tuned out, I hope some therapists may consider listening as I speak my piece, so they might find fewer like me at large.

I entered therapy hoping to broaden my social life and to confirm my suspicion that my typical family—wasn’t.  I never was in crisis.  My past persona was far too obliging and obeisant to authority, but not unlike a significant population percentage.  Pre-therapy I had friends, a job, occasional dates and was reasonably cheerful.  My total tally in treatment (I hate that word) was just under three years with different clinicians in different formats.

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Revolution: NIMH turns away from the DSM

dr-insel-2011

Thomas R. Insel, MD, director of the NIMH

Two weeks ago, National Institute of Mental Health director Thomas R. Insel, MD announced a revolution. The world’s largest mental-health research organization will no longer fund studies based solely on Diagnostic & Statistical Manual (DSM) diagnoses.  If, “NIMH will be re-orienting its research away from DSM categories,” sounds less subversive than, “Give me liberty or give me death,” pay attention.  The whole system of diagnosis may be upended.

The Golden Rule: Those with the gold make the rules.

When insurers began to require a DSM diagnosis,  the American Psychiatric Association (APA) cornered the market in mental health nosology. No other U.S. group has had the money, staff and interest to create a competing system.  Ambitious alternatives such as the Psychodynamic Diagnostic Manual settled for expanding on the existing design. The APA, which has earned an estimated 100 million dollars from the DSM, flaunts their monopoly in  DSM-5’s $133 cover price. By comparison, Thomas Pynchon’s “Against the Day”  is 112 pages longer,  1/10th the cost and exponentially better-written.

Forbes’s Matthew Herper believes DSM’s diagnostic weaknesses have led to failed drug trials, and so is one reason for Big Pharma’s shift from developing new psychiatric medications.  The NIMH’s 2013 budget totals nearly 1.5 billion dollars. Insel’s ready to spend some of that towards more valid diagnoses.

Reliability vs. Validity.

The last time the DSM was reformed, rather than revised, Robert Spitzer was chair and reliability was weak. Psychiatrists could only agree on a diagnosis  20% to 40% of the time.  Spitzer’s goal was for different assessors to reach the same diagnosis from the same facts as consistently as possible. He chaired contentious meetings of obstinate psychiatrists, and condensed the best opinions down to abstraction-free criteria of what a clinician could see and a client could report.  Reliability improved – some.

One offers valid insights into the human condition. The other is required by insurance companies.

One offers valid insights into the human condition.
The other is required by insurance companies.

Validity improved less. As the book defines Antisocial Personality Disorder, only three of seven criteria must be met for a diagnosis. It’s hard to argue this diagnosis describes an actual mental health disorder when it could fit two bad actors with nothing in common.   As Maria Konnikova points out, Spitzer’s subjective-observation-and report-only approach meant the APA bet everything on the least empirical source of data available.   While other fields of medicine have developed biological, physiological and genetic studies of physical diseases, the APA hasn’t kept up. Noted DSM critic Gary Greenberg tells a disheartening tale of how the DSM-5 committee rejected a proposed reinstatement of melancholia, in part because there was biochemical evidence it should be defined separately from depression.

RDoC: a system to break free of systems.

Also subversive and clever; an Omaha, NE punk band have named themselves "DSM-5".

Also subversive and clever; an Omaha, NE punk band have named themselves “DSM-5”.

To NIMH and many others,  the validity issue makes controversies over DSM-5’s changes as superficial and irrelevant as complaints about Bernie Madoff’s office décor.  In 2011, Insel announced the Research Domain Criteria (RDoC) project. This new approach defines disorders on multiple levels of data. Constructs such as negative affect, positive affect, cognitive processing and social-process systems would be tracked across dimensions of behavior, self-report, cells, genes and physiology.  Clients’ symptoms would be placed along a range from normal to abnormal, instead of being forced into discrete categories. If new influences on emotions and behavior are discovered, new layers of information can be incorporated into the model. Research projects involving DSM diagnoses will still be accepted, but researchers will be expected to think in broader terms than subjective assessment of symptom clusters.

Insel denies that RDoC is meant to replace the DSM-5. The NIMH is already developing “walk-across” list to align DSM and RDoC diagnoses. Given that RDoC 1.0 is probably years from public release, even critics as sharp-tongued as Allen Frances concur that the DSM is the best system of diagnosis clinicians have now.  None of that changes the existential threat to the APA’s subjective-observation-only model. If RDoC rebuilds diagnosis’ operating system and obtains  more-valid results, will insurers’ money stay with the DSM?

@ 2013 Jonathan Miller All Rights Reserved

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Hippocrates on Social Anxiety Disorder

Hippocrates of Kos (c. 460 BCE – c. 370 BCE)

Hippocrates of Kos (c. 460 BCE – c. 370 BCE)

I’m catching on that many Anxiety Disorder NOS diagnoses may be Social Phobia. To quote the Father of Medicine:

“(this man) … through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him.”

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