Psychiatry is fast approaching a death spiral which we as a society may not be able to recover from. In many residencies, psychotherapy is not even being taught. Many psychotherapists of all professions – psychiatric, psychologists, and social workers – have been intimidated by specious neuro-biochemical theories, while others have simply given up. And now, there aren’t many remaining good therapists in practice anymore.
The chemical imbalance theory of somatic psychiatry has almost completely replaced a genuine understanding of human struggle. The underlying theory of somatic psychiatry is that the source of human struggle is considered to be the brain itself, rather than the person. Treatments that follow from this simplistic, mechanistic, and reductionist notion have been intended to act directly on the brain, which in my experience leads to problematic and misleading outcomes.
The real source of human suffering is not the brain. Suffering is the experience of a person, a human being, in the context of damage to his or her play of consciousness. This damage is the consequence of deprivation and abuse in our emotional environments during the formation of our personalities. This takes place in relation to the unique constellation of our temperaments.
My life’s work has taught me that the art, the science, the discipline, and the wisdom of psychotherapy attends to this damage. Tragically, over the course of one generation, psychotherapy has become almost extinct and has been replaced by drugs. There are no miracles and no shortcuts, such as what drugs — and their bedfellows, ECT and lobotomies — always promise. We have repeated the same mistakes over and over again, and we are doing so today.
Even the APA, when pushed, acknowledges that the chemical imbalance theory is not really true. Never mind that this simplistic and false theory lacks any credible validation. They now add in that there are also vague, environmental factors — whatever those are — but this is all a ruse. ‘Chemical imbalance’ has been accepted by psychiatry and the general public as completely true. People believe that psychiatric conditions – so-called ‘biological depression’, anxiety, psychoses, and even the fictitious ADHD – are ‘illnesses’ that should be treated with pharmaceuticals such as antidepressants, benzodiazepines, anti-psychotics, and amphetamines. (See – “No It’s not the Neurotransmitters. Depression is not a biological disease caused by an imbalance of serotonin.”)
In addition, it is common that therapists are confused by contemporary neuroscience. I find the explosion of neuroscience a wonderful thing. To discover how the brain works is illuminating and fascinating. Any theory of mind has to be consonant with the way the brain actually works. However, a superficial understanding of neuroscience often mistakenly seems to support the neurotransmitter-based theories of the mind. What many neuroscientists don’t understand is that an understanding of the brain also has to be consonant with the way human nature actually operates.
Human nature operates through our consciousness. The more we understand the workings of the mind, the more we come to understand that consciousness is organized in the brain as a play; as stories, with characters, feeling relationships between them, scenarios, plots, landscapes and set designs. We evolve our characters over the course of twenty or so years of child raising. The biology of the brain creates and informs our character as a whole. Parts of the brain — such as neurotransmitters and the various brain modules — do not operate independently. They operate as a whole to simply create the play of consciousness itself. (See – “The Secrets of Consciousness, the limbic-cortex is organized as a drama in the brain.”)
Psychiatric problems reflect how the traumas of deprivation and abuse, in concert with our temperament, create our character. Psychotherapy is the best way to heal from the pain and “symptoms” of being human. In the context of a safe therapeutic relationship, we can mourn the problematic pains of our lives, and write a new play that is more consonant with loving and authenticity.
Human beings have complex inner lives, and psychiatric problems flow from the great mysteries of life. The idea that human struggle reflects a problem with neurotransmitters is absurd and insulting on the face of it. We do not suffer from mysterious brain diseases. To truly be a psychiatrist in the spirit of what was always intended, requires a lifetime of dedication to plumb the reaches of human mystery.
I very frequently get comments from other psychiatrists who say, ”I give antidepressants and do therapy. It helps the therapy”; “Why limit yourself to just therapy as if one size doesn’t fit all conditions. Use everything in your arsenal and give drugs when they are needed.” Many psychiatrists believe that walking some middle road is an open-minded and superior position. Anything different from this is deemed to be dangerous and narrow minded.
This, of course, begs the most important issue – do antidepressants, benzodiazepines, amphetamines help, or do they cause harm? If one studies the real efficacy, they are not useful. I’m making a stronger case than that they are just not useful in the long term. Even regarding short term crises, i.e. depressed, suicidal, or anxious, etc. the use of drugs is misguided. It is, in fact, not hard to reach a patient, which results in the short term crisis passing. The very introduction of a drug removes it from the human sphere and falsely confirms that a crisis is a biochemical disorder and needs a biochemical fix. This is not true. Once people falsely believe a drug fixes what ails them, they depend on that drug. The real issue, whatever it may be — anger, masochism, etc. — needs to be addressed in a real way to truly get to the bottom of it. I believe these uses of drugs interfere with therapy, and do not permit real mourning and healing. Real therapy is useful under all circumstances.
When our current prevailing fad passes — and it will — what are we going to be left with? Our psychiatric community will be composed of empty prescription pads with nowhere to go. We have lost our center. And don’t worry; contemporary psychiatry isn’t planning on folding its tents anytime soon. My fear is that it is already too late. The hope for the future depends on young professionals who think for themselves; people who are drawn to quest for the real item. But who is going to teach them? Will we have to start all over again?
I hope that those of us who remain true, will rise up and put a stop to the present travesty. We need a clear paradigm by which science contributes to a fully lived human life, rather than diminishing it. We need to understand the real implications of psychiatric drugs. We need respect for our patients’ autonomy as they face their issues in therapy. We need to re-establish the proper place of psychotherapy, and passing its wisdom on to the next generation has to be our goal. I hope self-respecting therapists will make their voices heard and not be intimidated by the profound pressures of the APA and big Pharma.
“Psychiatry is fast approaching a death spiral”
and good riddens. If someone has a “brain problem” there are plenty real doctors around. For other problems – they are not medical and should not be medicalized.
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Robert
I like many of your ideas and your spirit of rebellion.
However, I would respectfully suggest that you completely abandon your mission to salvage psychiatry. I believe a much nobler mission would be to actually help push psychiatry into the dust bin of history.
You don’t need to save it in order to do your therapeutic work to help people. Today psychiatry clearly stands as an obstacle to the work of ALL caregivers, and especially to all those people dealing with extreme psychological distress who are forced to come in contact with it.
You said : “When our current prevailing fad passes — and it will — what are we going to be left with?”
I say : Biological Psychiatry is more than just a fad. It is a highly organized institutional system of oppression that is very valuable to the ruling classes at this stage in history to maintain power and control of the masses. We can and must do without it.
You said : “My fear is that it is already too late. The hope for the future depends on young professionals who think for themselves; people who are drawn to quest for the real item. But who is going to teach them? Will we have to start all over again?”
I say : Yes it is too late, and you should be CELEBRATING that fact while hasting the demise of psychiatry from the inside, and conducting this struggle in tandem with those survivors and activists organizing on the outside.
As for the young professionals, I say this may be one situation where we CANNOT rely on the YOUNG psychiatrists to lead the rebellion from within. Young psychiatrist have all been trained (brain washed) in the highly controlled and organized propaganda schools of Biological Psychiatry.
Fifty percent of all psychiatrists in this country are over the age of 55; trained as psychiatrists before the brain/disease drug/based medical model was consolidated in the profession. Many were also positively influenced by the movement of the 1960’s. They are the most alienated section in the profession working today and are more open to the ideas of critical psychiatry.
You said : “I hope that those of us who remain true, will rise up and put a stop to the present travesty.”
I say: Dissident psychiatrists have plenty of important work to do in the next several decades.
1) Create havoc within the psychiatric profession by targeting the leadership, practice, and ideology of Biological Psychiatry at their every meeting and professional gathering.
2) Promote the stories of psychiatric survivors and unite with all activists working inside and outside the mental health system to help create the future material conditions for its complete dismantlement.
3) Learn the science and practice of safe withdrawal from psychiatric drugs and organize a cadre of like-minded psychiatrists to join forces (as equals) with survivors and other citizen scientists helping the millions of victims of the psychiatric drug epidemic.
4) Help build this human rights struggle as part of a much larger movement to dismantle the profit based economic and political system that sustains and benefits from the crimes of Biological Psychiatry, and stands as an historical impediment to the progress of human civilization.
Given that the future of humanity may be at stake, our careers and professional status matters very little in the grand scheme of things.
Richard
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I agree with Richard, thank you for stating your concerns so eloquently. Especially, that “Biological Psychiatry is more than just a fad. It is a highly organized institutional system of oppression that is very valuable to the ruling classes at this stage in history to maintain power and control of the masses.” This really does seem to be the primary function of psychiatry, and even psychology, today. And it is being used for egregiously inappropriate and unethical purposes that do not benefit the majority within society, such as covering up easily recognized iatrogenesis for incompetent and paranoid doctors, and medical evidence of child abuse for the religions.
“Tragically, over the course of one generation, psychotherapy has become almost extinct and has been replaced by drugs.” This is true, and it is tragic. Sometimes a person just needs someone to talk to, and help in overcoming her denial that her three year old child was sexually molested. It took almost six years, after being misdiagnosed then poisoned based upon lies from child molesters, documented in a psychologist’s medical records, for me to finally be weaned from drugs that made me ungodly sick. And it took my oral surgeon’s quote, “Concerns of child abuse are not cured with antipsychotics,” to embarrass a psychiatrist into finally weaning me off a drug class to which I had a family history, and now personal history, of a bad reaction and medically confessed “Foul up.” Over thirteen medical doctors could not comprehend the basic common sense that one oral surgeon easily stated, nor could they comprehend that the neuroleptics make some people ungodly ill.
“Human nature operates through our consciousness. The more we understand the workings of the mind, the more we come to understand that consciousness is organized in the brain as a play; as stories, with characters, feeling relationships between them, scenarios, plots, landscapes and set designs. We evolve our characters over the course of twenty or so years of child raising. The biology of the brain creates and informs our character as a whole. Parts of the brain — such as neurotransmitters and the various brain modules — do not operate independently. They operate as a whole to simply create the play of consciousness itself.” I agree, but find it odd that the psychiatric industry in it’s majority believes the concerns / consciousness of their patients are “irrelevant.”
“The idea that human struggle reflects a problem with neurotransmitters is absurd and insulting on the face of it.” It’s also an insane belief system, one I find it amazing that an entire industry supposedly fell for, are the majority psychiatric practitioners truly that stupid? Or do the majority of psychiatric practitioners know that their primary function is social control for the unethical and greedy in formally respectable professions?
“The very introduction of a drug removes it from the human sphere and falsely confirms that a crisis is a biochemical disorder and needs a biochemical fix. This is not true …. The real issue, whatever it may be — anger, masochism, etc. — needs to be addressed in a real way to truly get to the bottom of it. I believe these uses of drugs interfere with therapy, and do not permit real mourning and healing.” Well stated.
“I hope that those of us who remain true, will rise up and put a stop to the present travesty. We need a clear paradigm by which science contributes to a fully lived human life, rather than diminishing it. We need to understand the real implications of psychiatric drugs. We need respect for our patients’ autonomy as they face their issues in therapy. We need to re-establish the proper place of psychotherapy, and passing its wisdom on to the next generation has to be our goal. I hope self-respecting therapists will make their voices heard and not be intimidated by the profound pressures of the APA and big Pharma.” I agree, and hope my brilliant child, who has chosen psychology as a major, despite my concerns of such, is not being brainwashed with misinformation from the APA and big Pharma.
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I agree with you. This argument about having faith in the young psychiatrists coming into the profession or the many people who are trying tom do a good job and who care for their patients who need their help is a constant argument I hear in France in particular. It is held by well meaning individuals who still have a blind faith in the healing power of psychiatry.
Well meaning is key. It’s a form of paternalism which permeates psychiatry.
They agree there is a lot of bad practice and that things need to change but they instinctively reject the implications of this much needed change, i.e. the demise of psychiatry and the choice of a different paradigm of care.
They, the well meaning psychiatrists trying to do a good job, end up portraying themselves as pseudo victims of unjust attacks by eccentrics and others who just don’t know what they are saying, people like me, like the many other activists who would clearly put people in danger by pushing the self-determiantion agenda….
In France a collective of such psychiatrists ws formed in 2009 which completely drives the so called reform agenda, in other words they exist to preserve psychiatry as a “science” and as a corporation. They have a lot of influence in the media and all dissenting voices are promptly shot down into silence. They are supported by many so called user organisations and by family organisations, both often funded by pharma.
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Exactly.
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“You don’t need to save it in order to do your therapeutic work to help people. Today psychiatry clearly stands as an obstacle to the work of ALL caregivers, and especially to all those people dealing with extreme psychological distress who are forced to come in contact with it.” ….
Thanks…. Psychiatry right now is the basis for all Mental Health treatment in this country. It is the foundation for behavioral treatments offered by the insurance companies. It is those insurance companies who decide who gets help, and how much help they get. Those insurance companies love medication management. Putting people on drugs, is very profitable to them. If you consider therapy costing $100 and hour for 2 years at about $10,000. Versus medication management at four time a year $250 a visit 2 years is only $2000. The rest is profit. When people realize that they have been strung out on drugs, very much like a drug dealer stings and addict out, there will be a catastrophic problem for the insurance companies.
But what else can they do?
The delivery system functions as if mental health issues are medical in nature. When in fact they are not.
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You’re getting more radical in your old age Richard. (I can say that since I’m slightly younger.) 🙂
I would respectfully suggest that you completely abandon your mission to salvage psychiatry. I believe a much nobler mission would be to actually help push psychiatry into the dust bin of history.
While I agree that “saving psychiatry” per se is not a useful endeavor, I see Mr. Berazin’s actual concern more as being the decline of “legitimate” psychotherapy, which deals with people’s real problems, inner contradictions, etc. independently of biology.
While you continue to differentiate “biological psychiatry” from alleged “other” psychiatry, all psychiatry by definition, and by virtue of the mandatory medical degree, purports to be a medical (hence biological) specialty. It was the (sometimes unwitting) acceptance of medical metaphors by non-medical practitioners which provided the logical/ideological preconditions for the subsequent “biologization” of problems in living.
Many of those who initially used terms such as “mental illness” recognized that they were using a metaphor, much as we sometimes do when we talk about being “emotionally scarred,” etc.; we understand that there are no actual scars. Such loose metaphorical associations led not only to the entire “mental illness” lexicon but to terms such as “psychotherapy,” practitioners of which rarely examined closely the implications of the “therapy” portion of the term. But they knew they weren’t treating actual diseases any more than were preachers who addressed “spiritual sickness” or those who discussed the problems of a “sick” economy.
Psychiatry then jumped in to take advantage of this metaphorical language by treating it concretely. Soon “mental illness” left its semantic proximity to such expressions as “raining cats & dogs” and became, in the language of psychiatry, an actual disease to be treated by actual doctors (the equivalent of calling the SPCA for the cats and dogs).
Although the “psychotherapy” whose decline Dr. Berezin understandably bemoans has nothing to do with this convoluted twisting of language, I think it can be seen in retrospect that, by allowing the “therapy” metaphor to creep into it’s sphere, the world of “psychotherapy” allowed an opening for psychiatry to infiltrate with it’s ideological (as well as literal) poison.
At this point I don’t know if there is a way for legitimate “psychotherapy” to save itself, but if it happens it will require a name change and a straight-up assertion that it has nothing to do with medicine or what is commonly understood as “therapy.” Maybe a good start would be to change psycho”therapy” back to psychoanalysis, and for Dr. Berazin and others who practice it to recognize and emphasize to others that what they are doing has no relation to or dependence on a medical degree.
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Also I must be more tired than I realized; normally few things bug me more grammatically than misplaced apostrophes (i.e. “it’s”).
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Thank you Dr. Berezin for stating these things and for being supportive and believing in alternatives to the present system as we know it.
I have no hope that psychiatry can be reformed.
I have no hope in the young psychiatrists at all. One of the worst psychiatrists at the state hospital where I work was a young, woman resident. We have an educational arrangement to cycle med students and resident psychiatrists through our hospital from the university medical center which is in the same city. This particular psychiatrist wanted to shock every last one of the “patients” with ect that the psychiatrist on the unit where she was assigned gave her to work with. Her answer for everything was to give people ect, whether they wanted it or not. She wouldn’t listen to her “patients” and often was heard cursing them with profanity in the offices of the unit. She is not so very different from most of the residents who come through my hospital.
I refuse to have anything to do with them since they’re so arrogant and full of themselves because they are “doctors.” Their ignorance in how to deal with people in a respectful and dignified manner is profoundly shocking.
The problem as I see it is that these students and residents are fairly typical of the arrogant and highly ignorant people who are going through the medical system to become so-called “doctors.” it’s not just the ones who choose to become psychiatrists who are so bad mannered and lacking in bedside manner. I lived for five years in the neighborhood where many of these med students and residents lived and they marched down the street without saying a word to anyone and if you said good morning to them they ignored you and kept right on walking down the street. They are full of themselves.
Frankly, I fear that it’s not just psychiatry that needs to be dismantled. I feel that the entire medical system needs to be taken apart and restructured because right now, the so-called “patient” is just a commodity to make money for the medical system and the drug and insurance companies. We are not consumers, we are commodities to be milked for every dime that can be gotten out of us.
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Exactly.
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As long as ‘mental health practices’ are profit-driven, and the clinical relationships are power-based, I would not trust this paradigm to offer long-term effective healing support; in fact, I’d expect it to do more harm than good. Considering the overwhelming testimonial evidence offered on this site and elsewhere, I would say I’m not alone in this.
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Amen.
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Can you explain what a power-based clinical relationship is? Thank you. When you say profit-driven, does that include the selling of books written by mental health professionals?
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A psychiatrists can physically force you to take drugs and imprison you in a hospital. You have no power to get out and not take the drugs. Does not get any more power-based than that.
Of course there are more subtle ways too.
Selling books is not a big source of revenue. I believe Alex had kickbacks from pharma in mind.
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Can you explain what a power-based clinical relationship is? Thank you. When you say profit-driven, does that include the selling of books written by mental health professionals?
I was asking Alex, so I’m hoping to hear from him. Thanks for your opinion. Would you confirm your claims with specific, documented examples if you get a chance? Thanks.
“As long as ‘mental health practices’ are profit-driven” Which practices are profit driven? Considering the average indebtedness in 2012 for a medical school graduate ranged between $170,000 and $190,000, practicing medicine better generate some serious income.
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How about those like Rebecca Riley, a toddler, who died thanks to Biederman’s bogus single handed invention of the child ADHD and bipolar epidemics to push the latest drug cocktails of his real clients, Big Pharma. Biederman has already gone down in infamy for creating the bipolar fad fraud epidemic for children and toddlers no less, probably in many if not most cases the iatrogenic effects of the ADHD stigma and kiddie cocaine epidemic he created just about single handedly just as he did with child bipolar.
You must be aware that many think Biederman is very guilty of great crimes against humanity and its children especially since he sold them out for personal self aggrandizement and millions of drug company money to the point that reporters were shocked when he was on the stand in the courtroom and compared himself with God, typical of psychiatry. Even many drug pushing psychiatrists felt Biederman had gone too far with the child bipolar epidemic while many feel the same about the child ADHD epidemic. Isn’t it odd that with real medicine nobody has to argue whether or not real illnesses or diseases exist within their own profession? With no evidence other than being voted in by consensus and no tests to prove anyone has these voted in junk science DSM stigmas, psychiatrists can argue all day over their fictitious disorders they mostly inflict with their invalidation, disempowering lies about those suffering traumatic life events as being “mentally ill” due to their supposed bad genes or chemical imbalances rather than their toxic environments.
And Dr. Thomas Insel, Head of the NIMH, has been forced to admit that all DSM junk science stigmas are totally invalid because they lack any science or medical evidence behind them while their so called treatments leave much to be desired too.
If you don’t think poisoning children’s brains based on bogus, life destroying, voted in DSM stigmas to make billions from the biopsychiatry/Big Pharma cartel to line the pockets of corrupt politicians and others using children as fodder for greed, power and sadism, I guess there is not much else we can say here to convince you that these are horrific assaults against our nation’s children and society in general thanks to our increasingly fascist government using psychiatry to rob people of all their civil, democratic and human rights in the guise of “mental health.”
To put children on lethal neuroleptic drugs for misbehavior is so evil and criminal, it boggles my mind. And this is not medicine in any sense of the word or even antipsychotics. They are merely major, major tranquillizers intended to disable one’s brain, feelings, creativity, sex life, health and life in general to make them poisoned, obese zombies with miserable destroyed lives often with tardive dyskinesia and other horrific effects that cause early death by 25 years on average and that’s only in adults. Think what will happen to those children poisoned with psychiatric drugs and their life spans thanks to the likes of Joseph Biederman.
I can’t believe anyone could advocate perpetrating such crimes against children in the guise of mental health to maintain such a sordid “career.”
And though some abusive, criminal parent thought having their child a drugged zombie was an improvement while doing nothing to check out the toxic effects of these poison drugs says far more about the parent(s) than anything positive about the horrible neuroleptic drug poisons.
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‘Karen Hen Ninger writes- Did you know that Archie Bunker was anti-psychiatry? Heard this on a rerun tonight…
“Anyone that goes to a psychiatrist should have his head examined!” Archie Bunker’
(Then they may find out something fishy- fraudulent- has been going on)_
I’m with Archie- jim k-
The exposure, reporting of, and hopeful activism resulting from the exposure/reporting of:
Consent,coercion,disclosure,involuntary treatment, culpable negligence,misrepresentation,conflict of interest, fraud, ghostwriting, health risks, harmful outcomes &alternatives issues related to: professional ethics, conduct and standards issues in psychiatry&mental health.
The hopeful result is to improve the outcomes of people with mental ‘illness’, and the ‘mental health’ of individuals, their families and communities.-
https://www.facebook.com/jpkeis
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Robert
I too would question why, given your stated beliefs regarding the origins of human struggle and the usefulness of medications, you see the need for people such as yourself to remain inside the tent of medical-practitioner-psychiatry.
It seems the only benefit that tent provides are that of medication prescription rights and (currently legal) coercion into “care”, neither of which show the “respect for our patients’ autonomy” to which you refer.
While I appreciate that staying in the tent may give you, in your later years of practice, an opportunity to help educate doctors and reform some practices in the short term, perhaps the kindest thing you could do for patients would be NOT to try and reform the profession.
Arguing instead for the shutting down of psychiatry as a medical specialisation would seem to be more in line with your stated beliefs that human struggles relate not to biological disturbances or medical conditions but to “deprivation and abuse in our emotional environments during the formation of our personalities.”
Perhaps your wish to save psychiatry relates to insurance benefits/support for its practitioners and patients? Or to the prestige, respect and power associated with being a “real” doctor (which creates a fundamental imbalance in the therapeutic relationship)?
You express significant certainty in your beliefs regarding the origins of your patients’ struggles, as you have done in some of your other posts, and yet these are no more universally proven scientific/medical “truths” which would pass tests required for evidence-based medicine than are the drug-based approaches.
Perhaps (and just perhaps) if practiced with compassion, respect for the individual and to the highest ethical standards, your approaches could be of benefit. On the other hand, the legal protections and powers enjoyed by the medical profession are antithetical in their nature to transparency, questioning and challenge that might ensure patients are protected from damaging and/or unethical behaviour and/or treatments, be these drug or psychotherapy. They are also antithetical to the meeting of people as equals which is ultimately the healing experience you seek to provide.
Leave the tent…fight instead for the the winding back of psychiatric and/or medical power in a realm in which it can only inflict further damage.
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Yep.
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There’s a lot of systemic corruption and gullible people out there unfortunately, but i’m hopeful that i’ll see some serious dents in psychiatry in my lifetime.
Hurts to say it, but even on this site i’ve seen some strange stuff, even the co-owner looking to get into some potential race/gender baiting etc.
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Dr Berezin, I suppose that the state of your profession’s current contribution to its legacies for tomorrow is at its worst when it comes to stewardship over the vast information resources it accesses through direct encounters with people looking for help and guidance. It is exceedingly rare that cases once botched are ever straightened out even a little. Not only is everyone different, but the information shared in the aggregate is gobbledygook and pretend in the achievement of objectivity.
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My son is a “botched” case.
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Mwilcox- Me too, or I’d not be so glib. I respect the motivation of Dr. B., to look for worth in his trade cartels’s fix-it plans for Joe Average. Meanwhile, the glaring fact that the paperwork on me is treated as gospel and me like a noncompetent nonentity is hardly touched on by “critival psychiatrists”. These sacred files get the evil eye at best. The joke starts with having to recite the terms of your diagnosis to get habeas corpus to apply for you. Next you have to pretend the diagnosis was of something really detected, when in fact there was no such procedure or intention to follow one. Then you have to spend the rest of your life parsing meanings and safely packaging the concept of mis-perceptions when “caregivers” have invariably been happier to help the labels work than to ask for details of experiences and identify coping skills you know to trust. This whole industry isn’t just “corrupt” or “too impersonal” or “lacking precision in its approaches”. It’s thoroughly dehumanized, and unfortunately just the way Thomas Szasz says–by collectivistic-minded self-styled liberals.
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Sorry about the spelling error. Not a hidden meaning…just should be “critical”.
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True.
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It’s got to be difficult to come to the realization that one’s profession is, and always has been, a complete fraud, and that one’s life work is therefore based on lies. Better now than never. In other words, Dr., you are now in the perfect position to exert your influence bravely, like those who have already paved the way, such as Thomas Szasz, and now Peter Breggin and Robert Whitaker. If a Nazi soldier discovered what was really happening to the Jews during World War II, he would not be doing justice by trying to salvage whatever was good in the Gestapo. The real heroes helped rescue the Jews and the others who were suffering, and resisted the terrors of totalitarianism. Now, the real heroes expose the lies of the psycopharmaceutical industrial complex and shine a light on the atrocities that psychiatry continues to perpetrate under the guise of “treatment” and “medicine.”
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Several Nazi big shots were hung for their crimes. Goering cheated and snuck some cyanide because he was refused a proper military execution by a firing squad. Anyway, we had their names and lots of records and eyewitness testimony as evidence to use against them.
Do you know any of the names of those psychiatrists and/or pharmaceutical executives who have committed these atrocities? Credible evidence for their role in committing the atrocities and reliable documentation which describes the exact nature of the atrocities?
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“Do you know any of the names of those psychiatrists and/or pharmaceutical executives who have committed these atrocities?”
You mean people who committed criminal offenses which led to harm of hundreds, potentially thousands of people? I don’t know, let’s start with this guy:
http://www.naturalnews.com/023408_Dr_Biederman_psychiatric_drugs.html
You can also look for people involved in numerous cases involving drug companies marketing drugs in an illegal way and getting away with a slap on the wrist while many people died or suffered harm. Look at Zyprexa papers:
http://psychrights.org/Articles/NYTimesZyprexa12-17-06html.htm
I’m not even mentioning obvious cases as people involved in MKUltra program or the despicable individuals involved in post-9/11 torture. Or those who imprison and torture “mentally ill” daily across the world. Do I have to go on?
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“shine a light on the atrocities”
Which atrocities, precisely- and committed by whom, other than Biederman, exactly?
Biederman withheld financial information. What atrocity did he perpetrate on hundreds of people?
“criminal offenses which led to harm of hundreds” Do we know who these hundreds are? Do we have their names and verified proof of the causes and nature of the harmful atrocities they suffered? If not, how do we know they were the victims of criminal offenses? Without specific answers to these kinds of questions, I am afraid it is all just bluster, nothing more.
“Now, the real heroes expose the lies of the psycopharmaceutical industrial complex and shine a light on the atrocities that psychiatry continues to perpetrate under the guise of “treatment” and “medicine.”
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As far as the junk science, invented, voted in ADHD life destroying stigma to push the vile kiddie cocaine drugs to a make a literal killing by biopsychiatry when it sold out to Big Pharma in the 1980’s, I will trust Dr. Fred Baughman, lifelong Child Neurologist, and author of ADHD Fraud any day of the week when he speaks of such psychiatric fraud as the worst medical crimes ever perpetrated against humanity. We can thank Dr. Joseph Biederman for such crimes against children when he personally sold out the nation’s children to the drug companies he was truly serving when he almost single handedly created both the ADHD and bipolar epidemics in children just like DSM III and IV perpetrators created the adult bipolar epidemic in adults and now the DSM V perpetrators are pushing for adult ADHD. This Dr. Mengele like psychiatric monstrosity never ends. And ADHD drugs are now being promoted for the brand new DSM bogus stigma of “binge eating disorder” with an article about it posted in the news section of MIA with many upset because these toxic drugs put people at risk for heart attacks and other lethal effects with children far from immune as many children have died from these dangerous drugs.
And the real experts have exposed that any supposed differences in the brains of so called ADHD and normal kids are due to the toxic drugs given to those stuck with a junk science ADHD stigma due to abusive families, bullies and other social stressors and certainly not any faulty brains. Diet may be a factor especially today, but the current model is always blame the victims for any lethal effects inflicted by the current robber barons of our time, the real “patients” of psychiatry today as was the case with the robber barons of the 1930’s who along with psychiatry created the eugenics theories that led to the Nazi Holocaust after psychiatrists practiced by gassing to death those they stigmatized as “mentally ill.” Today, they just drug and shock children and adults to early death by about 25 years after torturing and profiting from them during their greatly shortened lives thanks to the biopsychiatry/Big Pharma cartel.
And Dr. Thomas Insel, Head of the NIMH, has admitted recently that all DSM junk science stigmas that would include ADHD, bipolar and other recent voted in fad frauds of psychiatry are totally INVALID and lacking any science, medical or other evidence whatsoever.
Thus, I think that despite blakeacake’s attempts to “educate” MIA members about all the great science behind the bogus invented ADHD stigma created to push amphetamines on innocent children that have been proven to cause much harm and little help or positive results after about three years and often ending up with an even worse bipolar assault due to the lethal effects of the kiddie cocaine pretense of help, MIA members and many others are all too well informed about the total junk science behind ADHD, bipolar and any other life destroying degradation rituals perpetrated by psychiatry/Big Pharma to force their brain disabling treatments on a literally brain washed public. But, the cat is out of the bag and more and more people are catching on thanks to all the corruption exposed in both psychiatry and Big Pharma not to mention all the destroyed, disabled lives exposed by Robert Whitaker in his many articles and books like Mad in America and Anatomy of an Epidemic.
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Re: Biederman, he should be chilling in the slammer, IMO.
http://www.alternet.org/story/88333/exposed%3A_harvard_shrink_gets_rich_labeling_kids_bipolar
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So what do you say, Dr.? Join the fight for truth and liberty.
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Dr Berezin, how would incorporate psychotherapy for the working and lower middle classes?
For many there isn’t the time off from work or the money to spend on therapy even if it is only a co-pay. Most people struggling just want (and need) to be functional and many times I’ve seen where a short-term fix is chosen over what is best for the long-term in matters both psychological and medical.
I’m not sure how it is in medicine or academia but the business world is merciless. For those that fall behind, it reminds me of a boxer with an eye swollen shut; just put out a call for a doctor to slice the bruise, stitch the cut and wipe the blood out of his eye so he can get back into the fight. Why? So he can go out and get his head beat in even more? But fight is what he is taught to do, isn’t it. It is what we are all taught to do.
So until the world changes, I won’t hold my breath that either the eradication of psychiatry or the return of psychotherapy will solve the issues of people that need to support themselves and their families while not in prime working condition.
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That is a great observation I have to agree with. Everything is broken and psychiatry is only one more machine to keep the broken system rolling.
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Hey Anon, Great Stuff. You’ve got some powerful perspective there my friend. Punch, get punched, fall down, get up and start again. How/why am I going to make psychotherapy fit into my schedule and budget?
Thank you
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Are you saying that the unique constellation of our temperament, our genetic make up, cannot be flawed?
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Paul Markovitz believes 80 mgs of Prozac to treat BPD is the best dosage based on the literature. Have you found psychotherapy to be helpful when you work with a patient with BPD? What if he is engaged in suicidal behavior? Are you familiar with the work of Dr. Markovitz?
I suppose treating brain cancer with chemicals is a recognized tool within the field of medicine to attack the cancer. Something like a “critical mass” of cancer cells within the brain likely interferes with the individuals mood and cognitive functioning, is safe to say. Why do we rely upon chemicals to fight these cancerous cells, which if successful, could restore one’s mood and thinking abilities, if the health of neurons doesn’t depend upon and cannot be restored through the use of drugs?
Brain tissue is just that. It is composed of living cells. Living cells break down. Living cells die and become diseased, infected, old and worn. How is it possible, given the marvels of modern science, that they would exist outside the realm of all we know about biology and chemistry and electricity? Without a sufficent supply of sodium ions, dendritic activity falters.
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1. Who is Paul Markovitz? And why should I know him?
2. BPD is not an illness. It’s a label for somebody who at times shows or is thought to show certain behaviours (out of a checklist) which may or may not be related to that person’s personality, life experiences and/or current life circumstances. It’s one of the most bs diagnosis out of the DSM and they are all pretty much useless.
3. “80 mgs of Prozac to treat BPD is the best dosage based on the literature”
There are no approved drug therapies for BPD (even assuming this is a “disorder”). Psychiatry has a habit of throwing each and every type of their 5 or so classes of drugs at the poor “patient” and looking if something sticks. I’ve seen people recommending long-term use of benzos for BPD and other atrocities. It does not cure or even treat anything, at best it’s introducing iatrogenic sedation and emotional numbness. Not to forget that SSRIs have actually been linked to increased risk of suicide and Prozac is an SSRI. All those “recommendations” are out of a random number generator – I can find swaths of studies on Pubmed showing each a different drug at a different dose doing opposite things in different studies. Nothing coherent ever came out of it.
4. I’m not sure what you’re getting at with the brain cancer. Yes, brain cancer can affect mood and any other mental function. Yes it can be treated with drugs and/or surgery. This has no bearing for the psych drug treatment. Cancer is a pretty well defined disease with known etiology – a mass of cells coming from mutated precursor which escaped genetically programmed apoptosis and brakes on unlimited proliferation. The drugs which are directed at cancer are meant to kill the cancer cells as specifically as possible (which is super hard so the cancer drugs are very toxic) so attacking the root cause of the symptoms – growing cell mass. These drugs are only taken for a short time – their toxicity cannot be tolerated very long and if the don’t work within a certain time window they are unlikely to work at all (cancer is treatment-resistant). One assesses recovery not by symptom disappearance but by the reduction of the tumour mass and markers (e.g. via imaging and blood tests). Again that has no resemblance to the subjective checklists of psychiatry.
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“even the fictitious ADHD – are ‘illnesses’ that should be treated with pharmaceuticals such as antidepressants, benzodiazepines, anti-psychotics, and amphetamines.” Dr. Berezin
Dr., then what is ADHD? If it is a fictitious illness, then how should it be classified? Or, are you saying that what is described as symptomatic of ADHD is really nothing at all? Nothing more than typical behavior from normal young boys with lots of energy? Do you believe that everyone has sufficient capacity “to attend to” and that any depiction of attentional deficits is bogus?
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Again, Dr. Fred Baughman, Neurologist and author of ADHD FRAUD, has shone the light on this vile topic and exposed that not only is ADHD a total fraud, but also, every one of psychiatry’s voted in by consensus junk science DSM stigmas created in the 1980’s when psychiatry sold out to Big Pharma as Dr. Peter Breggin, Psychiatrist, describes in books like Toxic Psychiatry, Your Drug May Be Your Problem, 2nd ed., Talking Back to Ritalin, Reclaiming Our Children as well as Bob Whitaker’s books Mad in America and Anatomy of an Epidemic. Of course, there are now countless books and articles available exposing the junk science of the invented ADHD bogus stigma to push kiddie cocaine just like the child bipolar fad fraud was created to push more lethal neuroleptics on children.
And if you are not aware that studies have shown that ADHD drugs provide no real benefit and only make things much worse for those really suffering from life problems, abusive environments, bullying, poverty and other social stressors for the most part then it would seem that you have your own reasons for wanting to promote this ever increasing assault on our nation’s children and society in general.
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Donna, I recommend that you locate Baughman’s most recent, published, peer-reviewed research and present it here.
Yannis Paloyelis,corresponding author1 Fruhling Rijsdijk,1 Alexis C. Wood,1,2 Philip Asherson,1 and Jonna Kuntsi1
Abstract
Previous studies have documented the primarily genetic aetiology for the stronger phenotypic covariance between reading disability and ADHD inattention symptoms, compared to hyperactivity-impulsivity symptoms. In this study, we examined to what extent this covariation could be attributed to “generalist genes” shared with general cognitive ability or to “specialist” genes which may specifically underlie processes linking inattention symptoms and reading difficulties. We used multivariate structural equation modeling on IQ, parent and teacher ADHD ratings and parent ratings on reading difficulties from a general population sample of 1312 twins aged 7.9–10.9 years. The covariance between reading difficulties and ADHD inattention symptoms was largely driven by genetic (45%) and child-specific environment (21%) factors not shared with IQ and hyperactivity-impulsivity; only 11% of the covariance was due to genetic effects common with IQ. Aetiological influences shared among all phenotypes explained 47% of the variance in reading difficulties. The current study, using a general population sample, extends previous findings by showing, first, that the shared genetic variability between reading difficulties and ADHD inattention symptoms is largely independent from genes contributing to general cognitive ability and, second, that child-specific environment factors, independent from IQ, also contribute to the covariation between reading difficulties and inattention symptoms.
Keywords: ADHD, Reading disability, Inattention, Comorbidity, Twins, IQ
Introduction
The co-occurrence between attention deficit-hyperactivity disorder (ADHD), which is characterized by developmentally inappropriate levels of inattentive and/or hyperactive-impulsive behaviours (American Psychiatric Association (APA) 2000), and reading disability, whether defined as diagnostic categories or quantitative traits, is well documented (August and Garfinkel 1990; Dykman and Ackerman 1991; Trzesniewski et al. 2006; Willcutt and Pennington 2000a,b). It reflects a strong phenotypic association between reading disability and ADHD inattention symptoms, which has been largely attributed to shared genes (Martin et al. 2006; Willcutt and Pennington 2000a; Willcutt et al. 2000, 2007b). The present study, using a genetically informative design, extends this research by investigating to what extent the common genetic variability between reading difficulties and ADHD inattention symptoms is also shared with general cognitive ability, as measured by IQ.
Previous twin studies have shown that both reading ability/disability (Alarcon and DeFries 1997; Byrne et al. 2008; Gayan and Olson 2003; Harlaar et al. 2005a; Tiu et al. 2003; Wadsworth et al. 2000) and ADHD symptoms (Kuntsi et al. 2004; Wood et al. 2009) share genetic variability with IQ. Therefore, it is possible that any shared genetic variability between inattention symptoms and reading disability could reflect a common genetic association shared with general intelligence. This idea was supported by evidence that genetic and environmental influences shared with IQ accounted for the covariance between reading performance and a cognitive attention measure (Zumberge et al. 2007). However, it is not possible to generalize directly from cognitive attention processes to behavioural inattention problems (Marzocchi et al. 2009; Warner-Rogers et al. 2000). Similar manifestations of inattention problems may reflect diverse cognitive deficits, and the relationship between overt behavioural inattention and deficits in cognitive attention is neither simple nor direct (Marzocchi et al. 2009; Warner-Rogers et al. 2000).
Indeed, behavioural and genetic evidence at the overt symptom level suggests that shared aetiological influences between inattention symptoms and reading disability are likely to be independent of IQ. A recent study reported similar estimates of common genetic influences between a brief measure of hyperactive/inattentive behaviours and a composite measure of academic achievement (including reading) before and after adjusting the latter for IQ (Saudino and Plomin 2007). Other studies have shown that early inattention symptoms predicted later reading achievement even after controlling for prior reading ability and IQ (Rabiner and Coie 2000; Rabiner and Malone 2004).
There is a need to understand better the aetiology of the covariance between ADHD inattention symptoms and reading disability because, to be effective at improving reading performance in the context of inattention problems, intervention programs need to address the specific deficits giving rise to the covariance between these disorders (Rabiner and Malone 2004). If the covariance could be attributed to shared aetiological influences that are independent of IQ, this would indicate the presence of specific neurocognitive deficits contributing to these disorders that were independent of possible “generalist” mechanisms spanning cognitive processes and learning abilities/disabilities across domains (Haworth et al. 2009).
Bivariate studies allow the parsing of the covariance between two phenotypes into distinct genetic and environmental components. The genetic and environmental correlations provide estimates of the degree to which the covariance between two phenotypes reflects shared genes or environmental factors, respectively. The inclusion of additional variables of interest in the multivariate case makes possible the estimation of the extent to which the genetic (or environmental) overlap is further shared with the additional variables (such as IQ). Multivariate designs offer improved power by decreasing the rate of false positive type I error rate (by decreasing the number of tests) and by taking into account the covariance among traits for each individual (Hottenga and Boomsma 2008).
Existing studies have employed bivariate designs, examining the aetiology between reading deficits and a single ADHD subtype, or ADHD symptom dimension, at a time, excluding IQ (Martin et al. 2006; Willcutt et al. 2000, 2007b). In the present study we replicate and extend previous research by using a general population sample and employing a multivariate design, including measures of IQ and both ADHD inattention and hyperactivity-impulsivity symptoms. The use of an unselected, general population sample avoids possible selection biases associated with clinic-referred or selected community samples and allows the generalization of findings to the general population. Inattention, hyperactivity-impulsivity and reading disability are all considered to be the tails of normally distributed traits, reflecting the normal distribution of genetic risk in the population (Chen et al. 2008; Harlaar et al. 2005b; Levy et al. 1997; Shaywitz et al. 1992). Studying general population samples is useful in understanding the extremes, as quantitative genetic and epidemiological evidence supports the validity of making inferences from population data to clinical cases in ADHD (Chen et al. 2008).
Specifically, our study aimed to: (1) Confirm the substantially larger phenotypic and genetic correlations between reading difficulties and ADHD inattention symptoms, compared to hyperactivity-impulsivity symptoms. (2) Investigate, for the first time, to what extent the common genetic variability between ADHD inattention symptoms and reading difficulties is also shared with IQ and hyperactivity-impulsivity symptoms. (3) Assess how much of the variance in reading difficulties could be attributed to aetiological influences shared with the ADHD symptom domains and IQ, thus providing an estimate of their relative importance in understanding the aetiology of reading difficulties. (4) Finally, examine the possibility of gender differences in the aetiology for the covariation between reading difficulties and inattention symptoms.
Method
Sample and Procedure
Participants are members of the Study of Activity and Impulsivity Levels in children (SAIL), a general population sample of twins aged 7.9–10.9 years. They were recruited from the Twins’ Early Development Study (TEDS; Trouton et al. 2002), a birth cohort study which had invited parents of all twins born in England and Wales during 1994–1996 to enrol. Despite attrition, the TEDS families continue to be reasonably representative of the UK population with respect to parental occupation, education and ethnicity (Oliver and Plomin 2006). Zygosity has been determined using a standard zygosity questionnaire which has shown 95% accuracy (Price et al. 2000).
TEDS families were invited to take part if they fulfilled the following SAIL project inclusion criteria: twins’ birthdates between September 1, 1995 and December 31, 1996; lived within a feasible travelling distance from the research centre; White European ethnic origin (to reduce population heterogeneity for molecular genetic studies); recent participation in TEDS, as indicated by return of questionnaires at either 4- or 7-year data collection point; no extreme pregnancy, perinatal difficulties, specific medical syndromes, chromosomal anomalies or epilepsy; not participating in other current TEDS substudies; and not on stimulant or other neuropsychiatric medications.
Of the 1,230 suitable families contacted, 672 families (55%) agreed to participate. Overall, the sample is as representative of the general population as is feasible for a study of this kind, and previous analyses on TEDS indicated that attrition was not due to ADHD symptoms. For example, Saudino et al. (2005) found that twins who participated at age 7 assessments were not significantly different in parent ratings of hyperactivity from lost twins at age 2 (t=1.77; p=0.08). However slight bias towards higher parental occupational classification, compared to the original TEDS sample, should be noted (39% of mothers and 52% of fathers in managerial or professional jobs, compared to 28% and 40%, respectively). Thirty-two children were subsequently excluded due to: IQ<70, epilepsy, autism, obsessive-compulsive or other neurodevelopmental disorder, illness during testing or placement on stimulant medication for ADHD. The final sample consisted of 1312 individuals: 255 monozygotic (MZ) twin pairs, 183 same-sex dizygotic (DZ) and 206 opposite-sex DZ twin pairs, as well as 24 singletons coming from pairs with one of the twins excluded. Data for the 24 singleton twins were also used in the structural equation modelling (see Neale et al. 2003). Participants were invited to our research centre for cognitive assessment (see Kuntsi et al. 2006), where ratings on the Conners’ scale and the reading difficulties questionnaire were collected from parents. Teachers’ ratings on the Conners’ scale were obtained through post.
The mean age of the sample was 8.83 (SD=0.67), and half of the sample were girls (N=663, 50.5%). Children’s IQs ranged from 70 to 158 (M=109.34, SD=14.72). Parents of all participants gave informed consent following procedures approved by the Institute of Psychiatry Ethical Committee.
Measures
Wechsler Intelligence Scales for Children, Third Edition (WISC-III; Wechsler 1991) The vocabulary, similarities, picture completion and block design subtests from the WISC-III were used to obtain an estimate of the child’s IQ (prorated following procedures described by Sattler (1992)).
Ratings of Inattention and Hyperactivity-Impulsivity Parents and teachers were asked to complete the Long Versions of the Conners’ Parent and Teacher Rating Scales (Conners et al. 1998a,b). Teacher ratings were collected from the main class teacher for each child. Previous analyses on the TEDS sample indicated that the majority of twins had been rated by the same teacher (Saudino et al. 2005). In a study looking at scholastic achievement and hyperactivity/inattention in the TEDS parent sample, the aetiology of the covariance was similar for ratings provided by the same or different teachers or parents (Saudino and Plomin 2007). From both scales, we used the 9-item inattention and 9-item hyperactivity-impulsivity DSM-IV symptoms sub-scales. Inter-rater agreement for parent and teacher ratings was .46 (p<.001) for inattention and .40 (p<.001) for hyperactivity-impulsivity, which are comparable to those obtained in previous studies (Saudino et al. 2005; Thapar et al. 2000). We created DSM-IV composite inattention and hyperactivity-impulsivity scores by summing up standardized parent and teacher ratings on the corresponding subscales. Teacher ratings were missing for 151 individuals and parent ratings for two individuals. Those with missing teacher ratings on the Conners’ scale did not significantly differ from the rest of the sample on the reading difficulties questionnaire (F(1, 667)=0.61, p=.43), in IQ (F(1, 667)=3.55, p=.06) or parent hyperactivity-impulsivity ratings (F(1, 666)=3.49, p=.06), but were slightly older (M=9.12, SD=0.71; F(1, 667)=17.88, p65 as indicated in the manual) (Conners 1997). These estimates match or exceed the estimated ADHD prevalence rate in the population (Ford et al. 2003; Polanczyk et al. 2007).
Reading Difficulties Questionnaire (RDQ; Martin et al. 2006; Rommelse et al. 2009; Willcutt et al. 2010b) This 6-item parent rating scale is part of an instrument screening for learning disorders. On a scale which ranges from 1 (“Never/not at all”) to 5 (“Always/a great deal”), parents are asked to report to what extent their child has difficulties with spelling, learning letter names or phonics (sounding words out), and to what extent their child reads slowly, below expectancy level or has required extra help at school. In the validation study, using four independent referred and general population samples (N=4158), all items loaded on a single factor and the scale showed excellent internal consistency (mean Cronbach’s α=.90) and high inter-rater (r=.83) and 1-year test-retest (r=.81) reliabilities (Willcutt et al. 2010b). In that study RDQ showed high correlations with a range of objective reading and spelling measures (overall r=.64; CI:.60 to .68) but low correlations with measures of other learning difficulties (r=.07–.024), attesting to its good criterion and discriminant validity (Willcutt et al. 2010b). In our sample (using data collected as part of the TEDS project, Trouton et al. 2002), the RDQ showed similarly high correlations with a measure of word reading efficiency (r=−.63, p<.001, N=301, unpublished observations; Test of word reading efficiency, Torgesen et al. 1999) and teacher ratings for reading attainment (r=−.58, p<.001, N=975; unpublished observations). Moreover, RDQ scores have shown high heritability (h2=53% to 83%) and high genetic correlations (−.71 to−.89) with a composite measure of reading performance (Astrom et al. 2009; Martin et al. 2006). Parent and teacher ratings of inattention and hyperactivity-impulsivity showed remarkably similar correlations with RDQ scores (inattention: parents:.41 (CI95:.37 to .46), teachers:.47 (CI95:.45 to .51); hyperactivity-impulsivity: parents:.22 (CI95:.17 to .23), teachers:.17 (CI95:.11 to .18)).
Analyses
Overview of the Twin Method In univariate analyses, correlations between members of a twin pair for each trait are used to apportion phenotypic variance to additive genetic (A), dominant genetic (D) or shared environment (C), and child-specific environment (E) components (which also subsumes measurement error) (Neale and Cardon 1992; Plomin et al. 2001). Based on the assumptions that (a) MZ twins are genetically identical and therefore share 100% of genetic variation, whereas DZ twins share, on average, 50% of their segregating alleles contributing to A and 25% contributing to D, and (b) both MZ and DZ pairs share 100% of their C but are discordant for E, the phenotypic variance for a trait is partitioned into constituent A, D or C and E influences. Greater phenotypic similarity between MZ twins compared to DZ twins suggests genetic influences on trait variance. If the phenotypic similarity of MZ twins is more than twice that of DZ twins, this suggests the presence of D, otherwise only A is suggested. DZ twin correlations greater than half the MZ twin correlations suggest the presence of C. The extent to which MZ twins are not 100% concordant for a trait reflects E (Rijsdijk and Sham 2002).Structural equation modelling provides a tool for the formal estimation of variance components (A, C/D and E parameters) and for testing alternative models describing possible component contributions to trait variance or covariance. When only twin pairs reared together are used, the available information allows the estimation of only a C or D component at a time. In multivariate genetic analyses, as well as partitioning the phenotypic variance of single traits, it is also the covariance between traits that is decomposed into A, C/D and E influences following exactly the same logic as above and using the ratio of MZ:DZ differences in cross-twin cross-trait correlations, (e.g. inattention symptoms in twin 1 with reading difficulties in twin 2) (Rijsdijk and Sham 2002).As multivariate models have increased power over univariate models (Schmitz et al. 1998), we do not present parameter estimates from univariate models. Univariate modelling was used to inform the choice of parameters for the multivariate models (e.g. the choice of C or D parameters) and to test for sex effects.
Structural Equation Modelling Structural equation modelling was performed using Mx (Neale et al. 2003). Models were fitted to age- and sex-regressed standardized residual scores, which were logarithmically transformed to minimize skewness. All estimates are provided with 95% confidence intervals (the inclusion of zero indicates non-significance). The relative goodness of fit of the competing hierarchical (or nested) models was assessed using a likelihood ratio test. This was computed as the difference in the −2LL statistics of two models, which is distributed as a χ2 with degrees of freedom (df) equal to the difference in the parameters estimated with each model. A significant χ² suggests a significant deterioration in fit for the more constrained model; if the χ² is not significant, the model with the fewer parameters is preferred for being more parsimonious. In the case of multivariate genetic analyses with large samples, the χ2 difference from the saturated model is likely to be significant. In such cases, as well as when comparing models that are not nested, Akaike’s information criteria (AIC) can be used to assess the relative fit of models. The lowest AIC value indicates the best fitting model, given the data and the set of candidate models (Wagenmakers and Farrell 2004).
Saturated Phenotypic Model This model fully describes the data using the maximum number of free parameters and provides a baseline comparison for subsequent genetic models. We constrained this model in accordance with the assumptions of the genetic method (that is, means and variances within traits and phenotypic correlations across traits were equated across twins in a pair and zygosity groups) to obtain phenotypic correlations representative of the whole sample while taking into account the non-independence of the data (i.e. data of related subjects).
Sex Effects Qualitative sex differences are found where the nature of the A, C/D and E influences differs, i.e. different genes or different environmental influences underlie the variance in the trait for males and females. The data indicate quantitative sex differences if the magnitude of A, C/D and E influences underlying a trait are significantly different for males and females. Scalar sex differences are found where only unstandardized A, D/C and E estimates differ (but standardized estimates are the same), due to variance differences in the trait distribution between males and females. There were neither qualitative nor quantitative sex differences underlying the variance in traits, although scalar differences were observed for reading difficulties, and inattention and hyperactivity-impulsivity symptoms. Therefore, in the multivariate modelling male phenotypic variances for these traits were pre- and post-multiplied by a scaling factor. As there are no significant qualitative or quantitative differences in variance components between the sexes, MZ and DZ correlations are not presented for each sex. However, given the scalar differences between the sexes, means and standard deviations are broken down into sex- and zygosity-specific groups (Table 1).
Table 1
Table 1
Cross-Twin Correlations (with 95% Confidence Intervals in Brackets) and Means (and Standard Deviations) for and Across IQ, Inattention, Hyperactivity-Impulsivity and Reading Difficulties Ratings
Parameter Selection for the Multivariate Models In the univariate analyses, an ACE model provided the best fit for IQ, while ADE models (with scalar sex differences) fitted best for the remaining three phenotypes (as we would predict from the MZ:DZ ratios of cross-twin correlations for these traits, Table 1). In this study we were interested to assess the contribution of broad-sense shared genetic influences to the covariation between reading difficulties and inattention (that is, not distinguishing between A and D effects), and the extent to which they are independent from genetic effects also shared with IQ. Therefore, in the multivariate models we parsed the variance contributing to the covariation among the four phenotypes into A and E components, with A reflecting broad-sense genetic effects. Due to the lack of qualitative or quantitative sex differences in the univariate analyses beyond scalar differences, the computational intensity of modelling sex effects and additional power issues (Neale et al. 2006), only scalar differences between males and females were allowed in the multivariate models.
Multivariate Genetic analyses A Cholesky triangular decomposition, which postulates a series of hierarchical genetic (A1–A4) and child-specific environment (E1–E4) factors, was used (Fig. 1). The order of the traits in the Cholesky model was decided a priori, with a view to estimating the aetiological influences that contribute to the covariance between reading difficulties and inattention symptoms independent of the other traits. A different ordering of the traits would produce the same fit of the model, but address different questions. The Cholesky model can be converted to the mathematically equivalent correlated factors solution (Fig. 2; Loehlin 1996), in which the order of traits is of no importance. This mathematical solution allows the estimation of the extent to which the same genes or environments contribute to the covariation between traits (i.e. the genetic and environmental correlations), irrespective of the extent to which they are shared with other traits in the model. For instance, in the Cholesky model, the proportion of the covariance between reading difficulties and inattention symptoms due to common genes (or environmental factors) which are not shared with hyperactivity-impulsivity symptoms and/or IQ can be estimated as the product of the paths linking these phenotypes with latent factor A3 and dividing by their covariance. In the same model, the proportion of the variance in reading difficulties which is not due to genetic (or environmental) effects shared with any of the other traits measured in this study is estimated by dividing the square of the path linking RDQ with latent genetic factor A4 by the variance in RDQ scores.Two additional multivariate models were employed to address the question of whether the covariance between the four traits in our study could be attributed to genetic and child-specific environment effects that are common to all, either directly (common factor, independent-pathway model, Fig. 3a), or through a common latent factor (common-factor, common-pathway model, Fig. 3b).
Fig. 1
Fig. 1
Multivariate Cholesky triangular decomposition with unstandardized parameter estimates. The best-fitting ACE(IQ)-AE model is presented (for twin one only)
Fig. 2
Fig. 2
Correlated factors solution of the best fitting ACE(IQ)-AE multivariate Cholesky decomposition model presented in Fig. 1 (for twin one only). Path estimates presented as square roots are the unstandardized parameter estimates (the basis of the …
Fig. 3
Fig. 3
Illustration of the multivariate independent pathways (a) and common pathway (b) ACE(IQ)-AE models which were compared to the multivariate Cholesky model presented in Fig. 1
Results
•Aim 1: Are the phenotypic and genetic correlations between reading difficulties and ADHD inattention symptoms larger compared to hyperactivity-impulsivity symptoms?
A medium phenotypic correlation between reading difficulties and inattention symptoms was observed, which was substantially and significantly higher than the correlation with hyperactivity-impulsivity symptoms (p1 SD) below those of their peers had normal reading scores at the post-kindergarten assessment. However, existing evidence suggests that reading difficulties in the context of inattention symptoms may not be caused by inadequate tutoring, given the failure of a behavioural intervention program to improve reading performance only in the comorbid cases (Rabiner and Malone 2004).
The findings from the current study can only apply to reading difficulties and ADHD inattention symptoms as reflected in parent and teacher ratings; they cannot be extrapolated to any specific process in either domain. ADHD inattention ratings represent pervasive inattentiveness across different domains in real life over an extended period of time. Therefore our conclusions cannot be extended to any specific cognitive attention process, as overt behavioural problems cannot be linked in a simple and direct manner to possible underlying deficits in cognitive attention processes, while similar manifestations of inattention problems may reflect diverse cognitive deficits (Marzocchi et al. 2009; Warner-Rogers et al. 2000). Studies using specific cognitive attention measures may lead to different conclusions regarding the extent of shared aetiological influences with IQ, depending on what particular measure in used (Zumberge et al. 2007).
It is important to understand the causal links between inattention problems or deficits in cognitive attention processes and the development of normal reading skills or the act of reading. Reading disability is a multifactorial disorder (Bosse et al. 2007; Vellutino et al. 2004), and for behavioural interventions to be effective they need to address the specific aetiological factors involved in each case (e.g. focusing on self-regulation versus targeting a specific neurocognitive process) (Rabiner and Malone 2004; Stage et al. 2003). Inattention is unlikely to be associated with reading difficulties only at the behavioural level and, in line with existing research, our findings are consistent with the idea that specific neurocognitive processes underlie the covariance between these two traits, which reflects shared genetic and child-specific environment influences that are largely independent from IQ. Indeed, cognitive attentional processes are being recognized as being involved in many stages of the reading process (Bosse et al. 2007; Reynolds and Besner 2006; Shaywitz and Shaywitz 2008; Vidyasagar and Pammer 2010). In the future we need evidence from longitudinal twin studies, measuring objectively a range of specific reading skills as well as of processes likely to contribute to behavioural inattention problems. Such studies will identify with greater specificity the neurocognitive processes that link behavioural inattention with deficits in specific reading skills, and examine causal relationships between these traits though development, as well as examine whether the contribution of IQ differs throughout development.
Acknowledgements
The Study of Activity and Impulsivity Levels in children (SAIL) is funded by a project grant from the Wellcome Trust (GR070345MF). Yannis Paloyelis is supported by a studentship from the Medical Research Council. Thank you to all who make this research possible: the TEDS-SAIL families, who give their time and support so unstintingly; Rebecca Gibbs, Hannah Rogers, Eda Salih, Greer Swinard, Kate Lievesley, Kayley O’Flynn, Suzi Marquis and Rebecca Whittemore; and everyone on the TEDS team.
Declaration of Interest None
Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
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blakeacake,
Has it ever occurred to you that if someone has difficulties with reading due to dyslexia, comprehension, visual perceptual problems, auditory processing, that they are going to have trouble attending to what they are reading without appropriate instruction that addresses their reading weaknesses? This research you mentioned doesn’t seem to address that. I would appreciate if you would address my concern and not just deliberately ignore me as you have chosen to do in the past.
So far, it seems your only agenda here is to spread your agenda without seriously listening to what people on this site are telling you. You talk over us and around us and it is coming across as very insulting even though I am sure that wasn’t your intention. It is getting very hard to take anything you say seriously because of this issue.
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“Has it ever occurred to you that if someone has difficulties with reading due to dyslexia, comprehension, visual perceptual problems, auditory processing, that they are going to have trouble attending to what they are reading…”
Now you are talking. You bring up an excellent point. Proper diagnosis is critical. IEPs need to be based on the best information available. The subtest scores on the Woodcock-Johnson Battery pinpoints each component of the child’s cognitive functioning.
Like
(Test 2: Visual-Auditory Learning
Long-Term Retrieval (Glr )
Associative memory
Paired-associative encoding via directed spotlight attention; storage and retrieval
Test 3: Spatial Relations
Visual-Spatial Thinking (Gv )
Visualization
Spatial relations
Visual feature detection; manipulation of visual images in space; matching
private speech
Test 4: Sound Blending
Auditory Processing (Ga )
Phonetic coding
Short-Term Memory (Gsm )
Working memory
Auditory Processing (Ga )
Speech-sound discrimination Resistance to auditory-stimulus distortion
Hope this helps
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blakeacake,
Why do you recommend that Donna locate Dr. Baughman’s “most recent, published, peer-reviewed research”? Do you mean a medical journal article? Are you so naïve as to believe that a medical journal is some sort of bastion of scientific integrity? Do you believe that a published journal article has more credibility than a published book? If so, why? Donna is obviously too well informed to share your blind faith in the stuff that the medical journals post.
Donna’s not alone:
https://www.psychologytoday.com/blog/dsm5-in-distress/201501/the-crisis-confidence-in-medical-research
I would guess that most people who visit this site are too well informed to share your sychophantic devotion to the Church of (so-called) Evidence Based Medicine. So if you’re looking for converts to proselytize, you’re not going to find them here.
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A dad wrote,
“I hope that the legitimate questions about reporting potential conflicts of interest does not obscure the fact that young children can exhibit Bipolar disorder symptoms and that medications can help. Our youngest son was diagnosed with ADHD and then bipolar after he was hospitalized just prior to his 4th birthday. Medications have helped tremendously (though not completely) to give him a chance at a normal life. If other diseases can develop at a young age, why not psychiatric disorders? Just because it has not been in standard lexicon in the past doesn’t mean that it is not legitimate. Running clinical trials on children is notoriously complicated, so I would take criticism of small studies (referring to Biederman) with a grain of salt. Large studies on every group of children would be welcome, but quite difficult. In the meantime, children like my son are able to lead more stable lives that are less harmful to themselves and others.”
Westinghouse wanted to exploit the potential benefits of modern electricity production. Tesla invented and tested alternating current which he believed to be far superior to Edison’s DC. Westinghouse backed Tesla financially. His revolutionary concept with the support of Westinghouse changed the world.
Although “drug” companies finance the production and testing of their experimental chemical compounds through well known medical professionals, it does not follow that they therefor produce an inferior therapeutic. Remember something important here: they want the same thing. If the product doesn’t work, it won’t be viable, economically. If the product isn’t safe, the company and the doctors may be exposed to law suits and ruined reputations. If doctors receive enough negative feedback from their patients, they will stop prescribing those drugs.
Gary Null, personally, is being sued by consumers of his products even as he is suing his supplier.
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ADHD and bipolar in a 4yr old? Are you kidding me?
“Remember something important here: they want the same thing.”
No they don’t. Pharmaceutical companies, like all corporations are psychopathic machines designed for one thing and one thing only: making more money. They will be totally OK with putting out a product which harms and kills people as long as they can cover it up for a long time and get away with murder when it comes out eventually by paying only a small fine/compensation (fraction of profits). There’s a reason too why they spend so much money on ads promoting drugs or disease-mongering. As N. Chomsky says:
“Those of you who suffered through an economics course know that markets are supposed to be based on informed consumers making rational choices. But industry spends hundreds of millions of dollars a year to undermine markets and to ensure, you know, to get uninformed consumers making irrational choices.”
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Amen B!
I suppose the comment from “a Dad” was supposed to be scientific evidence of that poor kid being destroyed by the bogus bipolar stigma and toxic neuroleptic drugs getting great treatment. The “Dad” like the kid’s “doctors” should be in jail if we had a government and society with any conscience, but sadly psychopaths and their sycophants have hijacked the globe.
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“Pharmaceutical companies, like all corporations are psychopathic machines designed for one thing and one thing only: making more money. They will be totally OK with putting out a product which harms and kills people…”
All corporations are OK with killing people. I disagree. Thank you for offering your opinion.
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Blakeacake, you are aware that stimulants cause a manic reaction right and that a diagnosis can’t be made on the basis of a drug reaction? So I am very suspicious of the bipolar diagnosis that dad’s kid got at 4.
And diagnosing someone at 4 with ADHD and putting them on stimulants? Are you bleeping kidding me? How we know there wasn’t a misdignosis when there are so many other conditions that resemble ADHD?
Why are you taking Dad’s word as scientific proof?
You’re wrong about drug companies and doctors. Many doctors simply refuse to believe that meds have side effects and will coerce patients into taking them come heck or high water. This is true with all med and not just ones that are psych. Drug companies will find ways to lie about their products so they get prescribed.
With all due respect, you seem very naive and trusting of the medical profession. I just hope you don’t have a hard crash like many of us did when we woke up and realized how we were lied to.
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Hi Dr. Berezin,
Would you like to comment on my posts?
Thank you
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Perhaps he doesn’t wish to and that is the reason he hasn’t responded. No author is obligated to respond to every comment.
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“Human nature operates through our consciousness. The more we understand the workings of the mind, the more we come to understand that consciousness is organized in the brain as a play; as stories, with characters, feeling relationships between them, scenarios, plots, landscapes and set designs. We evolve our characters over the course of twenty or so years of child raising. The biology of the brain creates and informs our character as a whole. Parts of the brain — such as neurotransmitters and the various brain modules — do not operate independently. They operate as a whole to simply create the play of consciousness itself.” Dr. Berezin
Neurotransmitters do not operate independently, in your opinion. But, do they operate perfectly? Is it your position, Dr., that neurotransmitters are not a part of human anatomy in some sense? Are there any other “modules” within the human body that behave like neurotransmitters, that is, as part of the whole without imperfection?
These questions are intended for any MDs or PhDs not just the good doctor.
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“The real source of human suffering is not the brain. Suffering is the experience of a person, a human being, in the context of damage to his or her play of consciousness. This damage is the consequence of deprivation and abuse in our emotional environments during the formation of our personalities. This takes place in relation to the unique constellation of our temperaments.” Dr. Berezin
Dr., I think I understand what you mean. However, if the brain itself is sick, the person will likely be sick, too.
If I want to reflect on my childhood, I can cut my hand off and still think all I want to about my youth. Thinking doersn’t depend on my hand. If I remove my brain, well, thinking might not go too well. If my brain is not working properly, my mental state will suffer.
You don’t entirely disagree with that position, either, do you? “I certainly judiciously use, anti-psychotics for schizophrenia and manic depression, both in the context of real psychotherapy” you said.
How can it be that you would use drugs for those conditions but deny their usefulness in treating depression or ADHD?
Thanks Dr.
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“I certainly judiciously use, anti-psychotics for schizophrenia and manic depression, both in the context of real psychotherapy”
They do not treat a condition, they merely suppress the symptoms. And if there’s any benefit it’s basically sedation. Which some folks in extreme states of mind may prefer but I’d be skeptical because the same drugs have also been shown to worsen prognosis long-term.
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“I suppose the comment from “a Dad” was supposed to be scientific evidence of that poor kid being destroyed…”
I don’t think the dad was promoting a scientific fact. I think he was expressing his opinion about the healthcare his son was receiving and his pleasure that the child was doing much better. He seemed to be grateful that his son was getting a real shot to live a full life.
I think his question was a good one and I haven’t seen a scientifically established answer to it either way. The diagnostic criteria has recently expanded to include children as young as 4 for ADHD. I don’t know why children cannot be afflicted with various kinds of illnesses. Apparently, 4 years of age is the cutoff for Bipolar.
“I certainly judiciously use, anti-psychotics for schizophrenia and manic depression, both in the context of real psychotherapy” Dr. Berezin
Dr. Berezin, do you or would you include 4 year olds among the patients you treat for Bipolar or Manic Depression?
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I suggest you discuss your opinion with Dr. Berezin.
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Thank you for sharing.
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If the product doesn’t work, it won’t be viable, economically. It will be replaced. If the product isn’t safe, the company and the doctors may be exposed to law suits and ruined reputations. If doctors receive enough negative feedback from their patients about their meds, they better stop prescribing them or they will be sued out of business or lose their customer base.
Free markets. We have the greatest heath care industry in the world, by far. No other nation compares. Competition weeds out companies that don’t produce a better product at a better price. Notice Toyota is the worlds largest car maker, again.
Hyundai-Kia is bigger than Chrysler and Ford. So is Volkswagen.
If a doctor screws over her patients, they can and do move on. What, we have around 700,000 M.D.s in the U.S.?
If drug companies don’t manufacture drugs that offer relief, or otherwise do what they publish they will do, they will go bye-bye, or lose market share. Plenty of hungry businesses out there vying for more customers.
Lawyers love big pharmaceuticals, too. Love. They have a way of pressuring them to behave. The government dose, too, and they work with private sector lawyers to protect consumers. Look at TAP, for example.
Have the abused by psychiatrists/psychiatric meds ever filed a class action?
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Great and now why the “Free markets” won’t work:
– “If the product isn’t safe, the company and the doctors may be exposed to law suits and ruined reputations.”
Except that you have to first survive or have a family which will fight for the truth should you die. Even when you survive but get totally disabled you also may not have the strength and resources. Patients, especially psych patients are usually poor. Doctors are usually quite well off and pharma companies are well wealthy corporations. We are not dealing with the equal powers here. But even when you put together the strength, patience and resources and find a lawyer who will not look at you diagnostic label ad decide you’re crazy from the get go you still have to prove that the drug caused the damage. For this you need to be able to point to scientific studies. Which are mostly funded and sometimes ghost-written by pharma. MIA is full of reports about corruption in FDA, scientific fraud, doctors being bought to publish studies showing effectiveness of the drug and hiding side effects, problems with reporting side effects… I could go on. And it’s not only on MIA – you can go to Cochrane project or find a TED talk about problems with not publishing negative results etc. If you’re suing individual doctor – forget about it, all he needs to show is that he prescribed according to the standard of practice and currently standard practice involves prescribing poisons so he’s off the hook. If you’re suing the corporation and happen to be a billionaire with unlimited amount of free time and good lawyers – well, you may be able to get somewhere eventually but you still have to deal with lack of scientific studies an/or these studies being full of pharma lies. If you’re super lucky maybe you come upon a whistleblower and find some leaked internal pharma papers showing they knew about the harms but that’s a rare occurrence. The pharmaceutical companies have also lost a lot of lawsuits already, quite remarkably, and somehow it did not influence their bottomlines. You may want to read about how black box warnings were put on SSRIs or on Zyprexa papers. These drugs are still on the market, doctors prescribe them left and right and no one went to jail. And if you develop diabetes type II on Zyprexa or your kid jumps of the 10th floor on an “anti-depressants” good luck finding any type of justice. And even if you do – nobody is going to hear about it above the nice music in the background of pharma ads.
– “We have the greatest heath care industry in the world, by far”
And one that sucks considerably compared to most other developed nations on pretty much every measure. And the only one which does not have a reasonable public option…
– “If a doctor screws over her patients, they can and do move on. What, we have around 700,000 M.D.s in the U.S.? ” Yeah but that won’t help you if you realize your doctor was an idiot/criminal after you already have tardive dyskinesia or diabetes or you’re dead because of some other lovely side effects. And the next person coming to this doctor’s office won’t know your story so they will not know that they’re dealing with a quack.
– “Lawyers love big pharmaceuticals, too. Love. They have a way of pressuring them to behave. The government dose, too, and they work with private sector lawyers to protect consumers. Look at TAP, for example.”
Are you kidding? I really hope so…
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I dont think these people with opposing views are living in my area
Sure do wish I could meet some of them
and develop a support group of our own
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Doctor,
I quite agree with you that the medical model based study and practice of psychiatry, is by my estimation, the residual fall-out of trauma, lack of real clinical cultural attunity plus all of the other variables stemming from physical issues. My idea of “mental illness” or “psychiatry” is that they are indeed representative of our inherent sociallly stratification of people who are vulnerable, marginalized and disenfranchised men, women, youth, children, ancestors and affected tribes… the fire that burns in the belly of these raging psychiatric survivors, consumer’s, consumer/survivor/expatient is akin to a slave’s response to abusive acts of power multigenerationally.
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“My idea of “mental illness” or “psychiatry” is that they are indeed representative of our inherent sociallly stratification of people who are vulnerable, marginalized and disenfranchised men, women, youth, children, ancestors and affected tribes… the fire that burns in the belly of these raging psychiatric survivors, consumer’s, consumer/survivor/expatient is akin to a slave’s response to abusive acts of power multigenerationally.
Excellent, I agree completely. It is human and reasonable to rage at being rendered powerless simply due to social agreements about on whom to project prejudice based on ‘social desirability.’ That is social abuse and bullying, and it is wholly dispiriting, to say the least.
It would be enlightened to create a better world, having learned what it is like to feel marginalized and blatantly discriminated against, which is what greatly undermines mental and physical health and overall quality of life.
John Howard Griffin developed deep empathy for this when he underwent changes so that he could traverse the deep South as a Black man, which he chronicled in his 1960 classic, Black Like Me.
There is no way to experience and understand this very particular feeling of being pushed to the margins and all that this means to the mind, body, and spirit, without putting one’s self in that position and living it first hand. I had a brief dose of it for a few years when I went through the system as a temporarily disabled person, and it was more than enough to wake me up. Shifted my perspective on humanity and especially on our society 180 degrees.
In the process, I completely relinquished the beliefs with which I was raised, in my professional academic middle class suburban family. They were pillars of society, and now I see how it was at the expense of others, a total and complete illusion, like a hologram.
Stigma and prejudice are inherent in the fabric of that society, and it when it is not driving people insane, it is killing them.
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Psychiatry is a reflection of an increasingly sick society. Poor people, working class people, even middle-class people…their/our problems don’t matter. Shut them up, one way or another. This goes double for unwanted people in families of any social class…always has, now that I think about it. I’ve heard shrinks say that so and so wasn’t “good enough for an atypical,” so they get Haldol. Not “good enough” for Xanax, so its Klonopin.
I realize that psychiatry has always been about control, but I get the sense that for a while there psychiatry had…I dunno…a softer touch, maybe? We’ve gone from Not Guilty By Reason of Insanity (and, rarely, Temporary Insanity) to having psychoprisons and a growing prison psychiatry industry. I think this reflects an increasing level of inequality and class warfare in American society. Gone are the days of noblesse oblige when the upper classes would at least throw scraps at people below them in social hierarchy. Now the rich have a genuine contempt for the masses, and everybody hates the poor. This shows up in “Treatment.”
Talk helps…if you can afford it. For most of us..its pills, shock, etc.
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