I remember trying magic mushrooms and LSD and finding they stimulated my imagination and gave me relief from my depression, and I do miss some of the beautiful hallucinations during psychosis. One time, my GP switched me from Prozac to Zoloft, and for a few months I had a burst of creativity, but it didn’t last permanently. There was even one person I was talking to who said that their keto diet had quieted their voices. I like my food and don’t do quirky diets, so I can’t comment on that, but I am wondering if anything that gives a radical shift in brain chemistry can give relief to entrenched conditions. This would support a common sense approach of trying different chemistry in a range of ways to treat mental illness, including diet and friendship circles without encouraging hype about any one particular wonder drug, which is bound to lead to disappointment.
Thanks for the interesting discussion. I was thinking about psychedelic therapy. When I first tripped on LSD, back in 1988, it was so meaningful, a feeling of connection to everyone and everything, relaxing, calming, beautiful. I chased that with frequent use of LSD & 'shrooms for the next 2 years, trying to recapture but never recapturing. None of my psychedelic use was in a clinical setting, but I wonder, if a person has a breakthrough like mine in clinical use if they'll then head out from that, on their own, trying to recapture, trying and trying, putting them at risk for depression, mania, psychosis as happened to me. The argument that there would be clinical oversight may not matter if the patient sort of goes rogue, pursuing on the sly. There's no way to monitor that, to screen for that prior to clinical use of psychedelics, to know if a patient keeps trying to repeat a good experience with readilty available spores, etc., so available in these times. That's my 2 cents.
I’ve heard this before too. Happens sometimes with profound meditation experiences as well where someone has a blissful experience and then chases after it in vain for years and almost losing their minds in the process. There’s definitely a problem with clinging to experiences, so perhaps addressing that should be considered in clinical use.
Got to agree. I tried all sorts of things to self treat depression as a teenager (I didn’t call it depression at the time, I hadn’t come across the word), including the fascinating world of magic mushrooms and LSD as I approached college age, and I loved how these things creatively stimulated my brain and I think they have a role in treatment. But ultimately, there are deeper issues that need to be addressed in a person who is crippled by despair.
I don’t think this came up in the discussion about attention and concentration deficits but I’m wondering if even what we would consider minor brain injuries (sports-related concussions for example) are a larger contributor than commonly recognized?
Well it was horrendous at the time but it was informative and now I look back at it, it gave everyone I love now an opportunity to see firsthand what I went through the first time it happened, 20 years before. I had no insight for more than six months, which was terrifying for all of us. But I regained insight by starting to take Prozac (I don’t know how that worked). I’m now fully recovered, but my life does read like a pitch black comedy sometimes 🙄
A normally functioning brain that creates a reasonably accurate/useful model of the world (in HD even!) has got to be one of the aspects of life most taken for granted by people.
I appreciated the discussion about the overlap between CPTSD and BPD. For a more compelling book length discussion about this exact topic, “The Trouble With Trauma” by Michael S. Scheeringa, MD really helped illuminate the argument for me.
I was the one that left the question on Peter Gøtzsche, thank you so much for addressing it! Though, I’ve read much of the work on your substacks, I don’t think that an indirect refutation is as valuable as directly addressing his claims one by one.
In EBM, one study may say one thing, then another study might say the exact opposite. The only way to know the truth is through focused and critical appraisal of the quality of the specific studies/evidence given and discussion of the confounding or other factors that could explain results. I have not seen anyone do this with Gøtzsche, and I’ve searched widely for it. As an MS1 very passionate about psychiatry, but wary of its blindspots and nuances, I’d deeply appreciate a detailed response to his points (steelmaning not strawmanning)
No doubt it’s complex. I’m a neuropsychologist and the do about three child and adult ADHD comprehensive assessments per week. I try to keep up with the research. I’d recommend checking out Russell Barkley as he is probably the most prominent ADHD researcher in the world today. The latest New York Times article is interesting but has a number of flaws. Dr. Barkley has three or four videos now going over some of these. Not necessarily the same things we’re talking about but worth looking into. He also goes over the research on the relationship between trauma and ADHD.I don’t know much about psychedelics but I’m interested to learn more. I’ll take a look thanks.
Thanks for the reply. I will check out Russell Barkley. You clearly have more clinical training and experience in ADHD than I do. Maybe we can get more clear about where the disagreement, if any, lies. What seems clear from my engagement with the science and research is that it's a safe bet that the symptoms associated with ADHD will not usually be reducible to genetics/temperament on the one side or environmental influences on the other. But that as in so many mental health conditions, the patient's lived experience is a function of both, again, in varying degrees. Does that claim seem problematic?
Thanks Gary. I agree that mental health conditions have complicated etiological origins. ADHD is the second most genetic of all mental disorders (70-80% heritability estimate) I believe (behind Bipolar Disorder). In the case of ADHD, environment can play a role through brain injuries, parental smoking, fetal alcohol exposure, low birth weight, and other things. Parental style, SES, trauma, do not seem to cause ADHD according to the research. My concern with some of this (I'm not saying you're saying this specifically) is a lot of people these days think that ADHD is caused by trauma in childhood which the evidence does not support. Barkley goes over the research here: https://youtu.be/-8bp39NpU-o?si=SetBuLegGg5kjahU . And here he goes over what the research shows are the genetic and environmental causes of ADHD: https://youtu.be/IDsOnSzbEFM?si=jb0WxobWES7cSrCo. The idea that childhood trauma causes ADHD has been propagated by Gabor Mate in his books and media appearances. Although I think Mate has a lot to offer in other ways, he is not an expert in ADHD and does not seem know the research. Here are a number of videos where Dr. Barkley's reviewing some of Mate's claims (https://youtube.com/playlist?list=PLKF2Eq0eYbbo_a2YMQ-mePJbv6FxW73vq&si=beez_R2wSQ2SRM3k). Based on my experiencing and review of the science, although trauma and other anxiety problems may cause ADHD-like symptoms, they do not ADHD per se. To me, this is important because the treatments would be quite different. The vast majority of individuals with ADHD have underactive frontal lobes and therefore the first line treatments are stimulant medication. However, individuals with anxiety issues usually have the opposite pattern, an overactive brain and the use of stimulants can cause significant problems for them. The psychotherapeutic treatments would also be different as the main issue with anxiety disorders is obviously anxiety whereas the main issue with ADHD is a lack of executive functioning. I can talk for hours about this but I better stop here. Hopefully these videos I've linked are helpful. I really appreciate these Q&A's that you guys do. I find them very informative and I'm very appreciative of your views as a psychotherapist. All the best :)
Hi Rosie! Thank you. I don't have a private practice. These days I work with an intensive outpatient program in the Cleveland, OH, area. If you'd like to know more, send me an email! awaisaftab at gmail
I am a clear counterexample of almost everything that was said in the cPTSD/BPD segment. I have cPTSD which was diagnosed by a psychiatrist who doesn't think I have BPD. She has no reason to since I don’t fit the criteria. I can have cPTSD without having BPD because they’re not the same thing, even if there is overlap.
It was upsetting to hear a psychiatrist say that people who claim to have the diagnosis of cPTSD don't have trauma histories that are "even remotely convincing" and that if we did, we would be "truly, truly nonfunctioning in a profound way". You went on to say about your patients, "there’s no identifiable trauma; it's just you can’t deal". How does one get a cPTSD diagnosis without an identifiable trauma?
Most of us understand that perhaps the most harmful thing you can do to a trauma survivor is to not believe or to minimize their story. My experiences were often disbelieved, minimized, or unnoticed by caretakers, so the last thing I need are mental health providers who reinforce that soul-destroying pattern. Also, despite severe developmental trauma, I'm highly functional with no obvious signs of a "real brain disorder", as are countless people with cPTSD. (Stephanie Foo, who wrote the wildly popular memoir about cPTSD, What My Bones Know, comes to mind immediately.) We're out walking the street, sipping lattes and going to work just like everyone else. Crazy!
It never occurred to me that a trauma history or a cPTSD diagnosis would be an excuse for anything. It's very hard for me to imagine what one might be trying to get excused. Do you think I want this? Of course not. I don’t know who’s coming to your office, but they’re not like me.
It's hard to watch three male doctors discuss two disorders that affect mainly women in such a dismissive way. What I heard is that, regardless of which diagnosis you decide to slap on, we are fragile, untrustworthy, and emotionally volatile patients. I listened to this section of the video twice to be sure I heard right, which was really hard to do. I know you don’t want to contribute to stigma. I know you know that trauma is real. cPTSD is also real. If you want to help us, you have to believe us.
Very interesting post, thanks for writing. I tried to comment but it's for paid subs only. There's much you wrote that I agree with. Without going through everything point by point, I'd say 3 things briefly:
1) I don't hold to a particularly "tight" conception of BPD and I am very much opposed to throwing around the diagnosis, especially as a way to label "difficult" patients. I have many weak points as a psychiatrist, but I do pride myself on being careful with diagnoses. Too many psychiatrists toss this and that diagnosis around (not just BPD) and that can have a very bad impact on patients' lives. I'd estimate that I diagnose BPD less than most psychiatrists, and I'm generally quite willing to say that a young patient is basically going through a hard time in one way or another that isn't amenable to easy diagnostic labelling. So I don't want anyone to get the impression that I'm dismissing those or other patients.
2) Just because I haven't seen a convincing case of cPTSD in my work doesn't mean I think it's in intrinsically invalid idea. The point of my comment was genuinely to say I haven't seen it in my hospital work, and hence my somewhat more skeptical attitude, not to state confidently that it doesn't exist. The particular patients I was referring to are ones who, for various reasons, tend incorporate trauma into their own explanations of why they are suffering. Sometimes it make sense, but very often it doesn't. That doesn't mean bad things have never happened to them, of course, but rather that assigning it a major causative role in one's development can sometimes be a stretch, and can potentially be counterproductive depending on the case.
3) In terms of the "fragile" comment, I didn't mean to sound as dismissive as it may have come across. We can all be fragile at times, in our own ways, some of us more so and more often than others. We all have ways to deal with it, sometimes productive, sometimes not. And most importantly, if someone is struggling, I'd never say "they're fragile, send them on their way". I'd try to help them understand the source of their suffering, if possible, and find ways to overcome it, deal with it, reframe it if possible, and harness their own strength. Put another way, part of what I was getting at is that many of these people are not as fragile as they sometimes make themselves out to be, and I try to show them that if I can.
Thanks a lot for reading my response and taking it seriously. I'm glad you don't hold the BPD diagnosis to tightly.
I'm glad you aren't dismissing cPTSD out of hand, either. I'm sure you know that Judith Herman proposed cPTSD as a less punitive alternative to BPD and/or DID in cases of profound developmental trauma—to that end I think it's a very useful category. cPTSD's greatest utility is it hermeneutical utility, to my mind.
I agree with you that in this day and age "trauma" as a (very ill-defined) concept is asked to do way too much heavy lifting in both patients' narratives about their suffering, AND in outpatient psychotherapy, especially in particular modalities/schools of thought. I think this definitely limits what's possible in treatment sometimes, and, as you say, can even be counterproductive.
I think I mostly understand with what you were saying in your Q&A, and I agree with a lot of it, IF I'm understanding it generously. I'm sure you can glean from what I wrote that my main frustration with your comments was what I perceived to be a very flippant attitude toward patients' suffering. I'm sure you also gleaned that I am especially sensitive to doctors' flippancy toward patients' suffering, for reasons having to do with my constitution, and to do with my psychiatric history. I'm not the type to ask people to walk on eggshells, but I do think it's worth considering how language like "fragile" will land on [former] patients. People who wind up in inpatient psychiatry are obviously at some of the most fragile moments in their lives. I think that talking about these patients in terms of their inability to cope with their everyday lives is, uh, not where it's at.
Anyway, thanks for the Q&A. Even the part that pissed me off helped me clarify some of my thoughts about the BPD nosology, haha!
Totally valid critiques. I appreciate the feedback. Sometimes I can sound more dismissive than I am, that's how I come across sometimes unfortunately, still a work in progress... I try very hard never to dismiss my patient's problems though (it's not good treatment, and it also would make me cynical I think). One reason I care so much about this whole issue is that these diagnoses can cause very real and very serious iatrogenic harm, eg. if overdiagnosed, and especially if it leads to inappropriate/unneeded treatment. So when diagnoses receive attention or are in vogue, talking about them can a double edged sword. You don't want to dismiss people's real suffering, but neither do we want to blindly endorse every narrative either, and history has shown us that we're liable to both errors.
Also, FWIW, I personally like conceptualizing the BPD issue in terms of "what psychological defenses are available and unavailable to this person, now and in general?" We all use "borderline-level" defenses, e.g. splitting, sometimes, especially in crisis. But what characterizes someone traditionally labelled "borderline" is a pervasive reliance on certain defenses and an inability to regularly use more adaptive ones. It keeps the emphasis functional rather than whether someone is on the border of this or that. Nancy Mcwilliams has great stuff on this if you aren't already familiar with her work.
edit: and I've met quite a few patients who truly met BPD criteria in their teens-20's, but after working on themselves seriously for a few years, they really did get better and the diagnosis was no longer appropriate. So it's not necessarily a lifelong thing.
Thanks for this.. I enjoyed reading your essay and the comments here. I’m glad you pointed out the more nuanced responses by Borjesson and Aftab.. I didn’t find you snarky, but I have deep wells of snark so I may not be a good judge.. I do believe that words matter, and it terrifies me that I might ask for help that I really need and land in the office of someone who minimizes my distress or doubts my story, even if that’s not what they say to my face. **Especially** if that’s not what they say to my face... Over diagnosis is clearly a problem, but in my mind it’s not the patient’s responsibility (although clearly it’s our problem). Like you said, people still need to be helped even if the doctor’s colleagues got the diagnosis wrong. I’m also not at all anti-psychiatry and have been helped tremendously by psychiatrists and still am. I see my psychiatrist twice a week (really good insurance). We don’t always agree, but I do trust her. This is all ambiguous terrain, and I’m glad to see that doctors and patients are wading through it together. So thank you, Dr. Greenwald (if you’re still reading my comments). I really do appreciate you putting these conversations out there.
I see patients who are hospitalized, not in the clinic. A significant percentage are not highly functional and don’t go to work sipping lattes like everyone else, nor are they yoga instructors, small business owners, or authors. I’ve also treated people who have suffered trauma that most people think are reserved for scary movies. So I don’t come at this from a perspective of total ignorance. That said, it’s obvious that trauma is a grossly overused excuse these days for just about everything, and most people recognize this. It’s a fad, and psychiatry has lots of them. We’re always searching for ways to say that something outside of us caused us to be the way we are and made our life circumstances difficult. “Trauma” has expanded as a category much like ADHD or autism has, one result being that many people latch onto the diagnosis as a way to understand themselves. My point was not to say that people who end up diagnosed with cPTSD (for whatever reason) haven’t had hard lives. The point is that we should question the utility of diagnoses when they create theoretical or practical problems, or otherwise don’t seem to fit in with the broader picture. I think cPTSD has many such problems, while other people disagree, which is fine.
Thanks for your response. I definitely don't think you're ignorant and apologize if my comment came off that way. You and I have different sets of experiences, and some of what I heard troubled me. I agree completely that the word "trauma" is overused and that's harmful to me as well. I also understand that many people with extensive trauma are not highly functional. Certainly in our culture, occupation is one dimension of that, but functionality was only one part of the point I was trying to make. The more important one is about the need to be respected and believed. Of course inpatients become outpatients (I have) and vice versa, so people are indeed leaving your hospital and stopping at Starbucks for a latte and no one bats an eye... I don't know the problems this diagnosis creates for psychiatrists, but I believe you when you say it does. Despite all of this, you spoke very broadly about people diagnosed with cPTSD in a way that was not flattering or compassionate, in my opinion. As a patient listening in, what I hear is you talking about are human beings (me), not theory or psychiatry's diagnostic problems in general. Clearly the need for this very exchange demonstrates those very problems as we both have experienced the cPTSD diagnosis very differently.
We’ve all seen “truly, truly non functioning, in a profound way” before. They’re the people with severe schizophrenia who have nowhere to go outside the psychiatric ward because they have no support network. And yet no one is prepared to make the connection. There is too much cognitive dissonance; in other words, the pioneers of psychiatry were sure that they were going to find a brain disorder that could be tested for and treated. They are still dedicated to this, the point of the profession is based on it. They want to treat psychological disorders with chemistry. The problem is: what do we mean by chemistry? There are two kinds. The pill kind and the human kind. I think psychiatry is a vocation that I wish some of its members would be less flippant about. But these discussions are a good thing. Stick around and make sure your voice stays heard ❤️🩹
Thank you! I plan to stick around even though so far my attempts to speak up as a person with lived experience haven’t been at all satisfying. If what I say actually challenges someone, then the very thing that (I believe) gives me credibility to speak up is the thing that makes my words easy to discredit. Calls for patient voices feel performative. I’m not sure that’s what’s happening here, but it’s a concerning dynamic. Anyway, I’m enjoying your substack! Thanks for chiming in!
There’s definitely still a lot of patronising comments and lip service from some people but we have to start somewhere, right? When the field of psychotherapy was being formed, a few of the early pioneers were women, but they were dismissed as too emotionally volatile for the calm work of therapy. Now no one would make such a dismissal- women have proved their naysayers wrong about that. Now the problem is a self selecting group of mostly male consultants (sorry guys, but you know it’s true even if you are very good at your jobs) - as female doctors struggle to juggle children and work. This is only going to change if couples share childcare more fairly. I’d also like to see more diversity and people who have recovered from mental illness going into this work. Sometimes I get disheartened myself, I have had my own battle and the toll it has taken on me, and many people who should know better have kept their distance from me because they still mistakenly think I might be mad and become some kind of threat to them, although I had one major episode that lasted 6 months 25 years ago, and I have never been diagnosed with any major disorder. I had a second episode caused by a head injury, but the trigger was physical in that case. I do my blog while others who are too ill to advocate for themselves have few people who are prepared to do it for them.
It looks like we'll have to disagree. I'm sorry, but I just don't see the logic in medicalizing problems based on the idea that "we do have good reasons to think that some combination of mechanism is malfunctioning (schizophrenia is a good example) but not always." It seems to me that we would need more than "some combination" to conclude the problem is a form of dysfunction or to formulate treatment intended to correct or ameliorate that dysfunction, without doing a lot of collateral damage, both physiologically and socially. This sounds like a discussion that deserves a separate and more comprehensive space. Thanks for the exchange!
Just to clarify, the logic behind medicalization primarily is the practical benefit, IMO, not hypotheses about dysfunctions. That is, whether a medical treatment helps a person achieve relief from distress and disability or not.
If you are speaking of palliative only treatment, then I agree. Any form of distress can be soothed with chemicals, regardless of its official designation as a mental disorder. The question is whether we are up front with clients about this. I have no problem with my clients who want a chemical (or ECT, surgical) solution, but it would be disingenuous and contrary to the principle of informed consent to state or even imply to the person that they have a dysfunction to be corrected, "just like heart disease and diabetes," as the APA says, when there is no evidence of such. It would be just as disingenuous to tell a patient they have diabetes without some firm evidentiary support. I recognize that not all psych clinicians take this medicalized stance, but those who don't are a tiny minority.
1. Can Gary please elaborate on/provide sources about non-biological causes of ADHD and a connection to reporting of ACEs? I thought a high heritability coefficient (~0.8, off the top of my head, and executive function, specifically, being entirely genetic) was uncontroversial. Also, I haven’t successfully tracked down the studies, myself, but I’ve read that longitudinal studies found that ACEs aren’t associated with poor mental health outcomes, but rather that poor mental health is associated with increased retrospective reporting of ACEs.
2. Can Gary please explain what he means about using IFS, but considering it contraindicated in patients who are at risk of identifying with parts? My understanding was that IFS therapists claim that the multi-agent model of mind is literal, not figurative. (Source: Robert Schwartz’s forward to Robert Falconer’s “The Others Within Us,” the book Scott Alexander reviewed, as mentioned by Awais)
Regarding IFS, perhaps I wasn't being sufficiently clear. The issue is not the risk of patients identifying with their parts. (With certain caveats, that's part of the point!) I meant only that with patients on the more psychotic end of the spectrum, there's a danger that IFS work will exacerbate their symptoms inasmuch the identifying of parts can further encourage splitting. Hope that helps.
Good questions. ADHD is not my area of expertise, and no doubt there is a high heritability coefficient, but to my knowledge it is relatively uncontroversial--in many neurodevelopment disorders--to acknowledge that environmental factors may also be relevant. Even if one is skeptical of Gabor Maté's strong thesis in his book Scattered Minds: the origins and healing of ADD, you can find many citations to the research on this point.
Here's a study on the correlation with ACE scores, though as we acknowledged in the conversation, it's not so easy to tease out which comes first, the adverse experiences or the ADHD-behaviors that contribute to them.
100% with you about starting somewhere. I was pushed out of Tulane’s MSW program earlier this year for speaking up about a class where extremely stigmatizing misinformation about bipolar disorder was being taught to future clinicians. I also have bipolar, which I (naively) disclosed as the basis for speaking up. I was literally told I was in no position to speak on the matter by the DEI dean of the school of social work. Based on this experience and others I’ve heard, I would argue that the mental health field isn’t so keen on letting us in either. I know advocacy of some sort Is my work, but I have to find my footing again — and sort out my very mixed feelings about disclosure. At some point, I’ll restart my Substack and tell that story in detail. It was grueling. Anyway, thanks for your responses! 💚
Unfortunately it’s my understanding there’s no cause evidence that childhood trauma causes ADHD. It may cause ADHD like symptoms. The correlation studies are confounded by the genetics. It might be worth consulting Dr. Russell Barkley’s work and YouTube channel where he discusses this. A lot of this is propagated by Gabor Mate which as far as I understand has been debunked.
I don’t think you’ll find much support for your view. Most experts are in agreement that the causes are complex and not well understood. They also agree the factors are both genetic and environmental, the ratio varying according to specific cases. In my most recent note, on ADHD, psychedelics and other questionables, I provide links you may find useful.
I don't know that there's evidence to support this view. Psychedelics are not drugs of abuse. And there's lots of evidence--admittedly far from conclusive, thanks to 60+ years of war on drugs--that psychedelic therapy can help treat alcoholism, smoking, and other addictions. Not to mention the work being done on ibogaine as a treatment for intractable opiate abuse.
Go out and do some street level work with those suffering with substance use problems. There are layers of illness that won’t be fixed quickly. Ibogaine data is slim and there are few if any long term studies of success
I remember trying magic mushrooms and LSD and finding they stimulated my imagination and gave me relief from my depression, and I do miss some of the beautiful hallucinations during psychosis. One time, my GP switched me from Prozac to Zoloft, and for a few months I had a burst of creativity, but it didn’t last permanently. There was even one person I was talking to who said that their keto diet had quieted their voices. I like my food and don’t do quirky diets, so I can’t comment on that, but I am wondering if anything that gives a radical shift in brain chemistry can give relief to entrenched conditions. This would support a common sense approach of trying different chemistry in a range of ways to treat mental illness, including diet and friendship circles without encouraging hype about any one particular wonder drug, which is bound to lead to disappointment.
Thank you for the response. I continue to encourage a de-medicalization of these issues, including the language used in discussing them.
Thanks for the interesting discussion. I was thinking about psychedelic therapy. When I first tripped on LSD, back in 1988, it was so meaningful, a feeling of connection to everyone and everything, relaxing, calming, beautiful. I chased that with frequent use of LSD & 'shrooms for the next 2 years, trying to recapture but never recapturing. None of my psychedelic use was in a clinical setting, but I wonder, if a person has a breakthrough like mine in clinical use if they'll then head out from that, on their own, trying to recapture, trying and trying, putting them at risk for depression, mania, psychosis as happened to me. The argument that there would be clinical oversight may not matter if the patient sort of goes rogue, pursuing on the sly. There's no way to monitor that, to screen for that prior to clinical use of psychedelics, to know if a patient keeps trying to repeat a good experience with readilty available spores, etc., so available in these times. That's my 2 cents.
I’ve heard this before too. Happens sometimes with profound meditation experiences as well where someone has a blissful experience and then chases after it in vain for years and almost losing their minds in the process. There’s definitely a problem with clinging to experiences, so perhaps addressing that should be considered in clinical use.
Got to agree. I tried all sorts of things to self treat depression as a teenager (I didn’t call it depression at the time, I hadn’t come across the word), including the fascinating world of magic mushrooms and LSD as I approached college age, and I loved how these things creatively stimulated my brain and I think they have a role in treatment. But ultimately, there are deeper issues that need to be addressed in a person who is crippled by despair.
I don’t think this came up in the discussion about attention and concentration deficits but I’m wondering if even what we would consider minor brain injuries (sports-related concussions for example) are a larger contributor than commonly recognized?
My second major episode of psychosis was caused by hitting my head on a concrete water slide
Oof! I hope your recovery went well.
Well it was horrendous at the time but it was informative and now I look back at it, it gave everyone I love now an opportunity to see firsthand what I went through the first time it happened, 20 years before. I had no insight for more than six months, which was terrifying for all of us. But I regained insight by starting to take Prozac (I don’t know how that worked). I’m now fully recovered, but my life does read like a pitch black comedy sometimes 🙄
A normally functioning brain that creates a reasonably accurate/useful model of the world (in HD even!) has got to be one of the aspects of life most taken for granted by people.
Glad to hear that you’re fully recovered!
I appreciated the discussion about the overlap between CPTSD and BPD. For a more compelling book length discussion about this exact topic, “The Trouble With Trauma” by Michael S. Scheeringa, MD really helped illuminate the argument for me.
I was the one that left the question on Peter Gøtzsche, thank you so much for addressing it! Though, I’ve read much of the work on your substacks, I don’t think that an indirect refutation is as valuable as directly addressing his claims one by one.
In EBM, one study may say one thing, then another study might say the exact opposite. The only way to know the truth is through focused and critical appraisal of the quality of the specific studies/evidence given and discussion of the confounding or other factors that could explain results. I have not seen anyone do this with Gøtzsche, and I’ve searched widely for it. As an MS1 very passionate about psychiatry, but wary of its blindspots and nuances, I’d deeply appreciate a detailed response to his points (steelmaning not strawmanning)
Are there any particular issues that Gøtzsche brings up and that seem persuasive to you or resonate with you that you'd like to see addressed?
During the discussion about psychedelics I’m sure I saw Dr Greenwald turn into a squirrel monkey briefly. Must check those mushrooms I ate……😉
No doubt it’s complex. I’m a neuropsychologist and the do about three child and adult ADHD comprehensive assessments per week. I try to keep up with the research. I’d recommend checking out Russell Barkley as he is probably the most prominent ADHD researcher in the world today. The latest New York Times article is interesting but has a number of flaws. Dr. Barkley has three or four videos now going over some of these. Not necessarily the same things we’re talking about but worth looking into. He also goes over the research on the relationship between trauma and ADHD.I don’t know much about psychedelics but I’m interested to learn more. I’ll take a look thanks.
Thanks for the reply. I will check out Russell Barkley. You clearly have more clinical training and experience in ADHD than I do. Maybe we can get more clear about where the disagreement, if any, lies. What seems clear from my engagement with the science and research is that it's a safe bet that the symptoms associated with ADHD will not usually be reducible to genetics/temperament on the one side or environmental influences on the other. But that as in so many mental health conditions, the patient's lived experience is a function of both, again, in varying degrees. Does that claim seem problematic?
Thanks Gary. I agree that mental health conditions have complicated etiological origins. ADHD is the second most genetic of all mental disorders (70-80% heritability estimate) I believe (behind Bipolar Disorder). In the case of ADHD, environment can play a role through brain injuries, parental smoking, fetal alcohol exposure, low birth weight, and other things. Parental style, SES, trauma, do not seem to cause ADHD according to the research. My concern with some of this (I'm not saying you're saying this specifically) is a lot of people these days think that ADHD is caused by trauma in childhood which the evidence does not support. Barkley goes over the research here: https://youtu.be/-8bp39NpU-o?si=SetBuLegGg5kjahU . And here he goes over what the research shows are the genetic and environmental causes of ADHD: https://youtu.be/IDsOnSzbEFM?si=jb0WxobWES7cSrCo. The idea that childhood trauma causes ADHD has been propagated by Gabor Mate in his books and media appearances. Although I think Mate has a lot to offer in other ways, he is not an expert in ADHD and does not seem know the research. Here are a number of videos where Dr. Barkley's reviewing some of Mate's claims (https://youtube.com/playlist?list=PLKF2Eq0eYbbo_a2YMQ-mePJbv6FxW73vq&si=beez_R2wSQ2SRM3k). Based on my experiencing and review of the science, although trauma and other anxiety problems may cause ADHD-like symptoms, they do not ADHD per se. To me, this is important because the treatments would be quite different. The vast majority of individuals with ADHD have underactive frontal lobes and therefore the first line treatments are stimulant medication. However, individuals with anxiety issues usually have the opposite pattern, an overactive brain and the use of stimulants can cause significant problems for them. The psychotherapeutic treatments would also be different as the main issue with anxiety disorders is obviously anxiety whereas the main issue with ADHD is a lack of executive functioning. I can talk for hours about this but I better stop here. Hopefully these videos I've linked are helpful. I really appreciate these Q&A's that you guys do. I find them very informative and I'm very appreciative of your views as a psychotherapist. All the best :)
This is fascinating. I encourage you to put all this in Substack as a post of your own if you have enough time available.
Thanks Sarah. I wish I had time but unfortunately don't.
Hi Awais,
An aside from your ever fascinating thinking and sharing...are you taking clinical referrals and how can we refer to you??
Many thanks
Rosie
Hi Rosie! Thank you. I don't have a private practice. These days I work with an intensive outpatient program in the Cleveland, OH, area. If you'd like to know more, send me an email! awaisaftab at gmail
I am a clear counterexample of almost everything that was said in the cPTSD/BPD segment. I have cPTSD which was diagnosed by a psychiatrist who doesn't think I have BPD. She has no reason to since I don’t fit the criteria. I can have cPTSD without having BPD because they’re not the same thing, even if there is overlap.
It was upsetting to hear a psychiatrist say that people who claim to have the diagnosis of cPTSD don't have trauma histories that are "even remotely convincing" and that if we did, we would be "truly, truly nonfunctioning in a profound way". You went on to say about your patients, "there’s no identifiable trauma; it's just you can’t deal". How does one get a cPTSD diagnosis without an identifiable trauma?
Most of us understand that perhaps the most harmful thing you can do to a trauma survivor is to not believe or to minimize their story. My experiences were often disbelieved, minimized, or unnoticed by caretakers, so the last thing I need are mental health providers who reinforce that soul-destroying pattern. Also, despite severe developmental trauma, I'm highly functional with no obvious signs of a "real brain disorder", as are countless people with cPTSD. (Stephanie Foo, who wrote the wildly popular memoir about cPTSD, What My Bones Know, comes to mind immediately.) We're out walking the street, sipping lattes and going to work just like everyone else. Crazy!
It never occurred to me that a trauma history or a cPTSD diagnosis would be an excuse for anything. It's very hard for me to imagine what one might be trying to get excused. Do you think I want this? Of course not. I don’t know who’s coming to your office, but they’re not like me.
It's hard to watch three male doctors discuss two disorders that affect mainly women in such a dismissive way. What I heard is that, regardless of which diagnosis you decide to slap on, we are fragile, untrustworthy, and emotionally volatile patients. I listened to this section of the video twice to be sure I heard right, which was really hard to do. I know you don’t want to contribute to stigma. I know you know that trauma is real. cPTSD is also real. If you want to help us, you have to believe us.
this section of the discussion was so noteworthy that i wrote a whole essay about it lol. it might be of interest to you. https://sshawrichner.substack.com/p/in-which-i-reflect-on-some-socratic
Very interesting post, thanks for writing. I tried to comment but it's for paid subs only. There's much you wrote that I agree with. Without going through everything point by point, I'd say 3 things briefly:
1) I don't hold to a particularly "tight" conception of BPD and I am very much opposed to throwing around the diagnosis, especially as a way to label "difficult" patients. I have many weak points as a psychiatrist, but I do pride myself on being careful with diagnoses. Too many psychiatrists toss this and that diagnosis around (not just BPD) and that can have a very bad impact on patients' lives. I'd estimate that I diagnose BPD less than most psychiatrists, and I'm generally quite willing to say that a young patient is basically going through a hard time in one way or another that isn't amenable to easy diagnostic labelling. So I don't want anyone to get the impression that I'm dismissing those or other patients.
2) Just because I haven't seen a convincing case of cPTSD in my work doesn't mean I think it's in intrinsically invalid idea. The point of my comment was genuinely to say I haven't seen it in my hospital work, and hence my somewhat more skeptical attitude, not to state confidently that it doesn't exist. The particular patients I was referring to are ones who, for various reasons, tend incorporate trauma into their own explanations of why they are suffering. Sometimes it make sense, but very often it doesn't. That doesn't mean bad things have never happened to them, of course, but rather that assigning it a major causative role in one's development can sometimes be a stretch, and can potentially be counterproductive depending on the case.
3) In terms of the "fragile" comment, I didn't mean to sound as dismissive as it may have come across. We can all be fragile at times, in our own ways, some of us more so and more often than others. We all have ways to deal with it, sometimes productive, sometimes not. And most importantly, if someone is struggling, I'd never say "they're fragile, send them on their way". I'd try to help them understand the source of their suffering, if possible, and find ways to overcome it, deal with it, reframe it if possible, and harness their own strength. Put another way, part of what I was getting at is that many of these people are not as fragile as they sometimes make themselves out to be, and I try to show them that if I can.
Thanks a lot for reading my response and taking it seriously. I'm glad you don't hold the BPD diagnosis to tightly.
I'm glad you aren't dismissing cPTSD out of hand, either. I'm sure you know that Judith Herman proposed cPTSD as a less punitive alternative to BPD and/or DID in cases of profound developmental trauma—to that end I think it's a very useful category. cPTSD's greatest utility is it hermeneutical utility, to my mind.
I agree with you that in this day and age "trauma" as a (very ill-defined) concept is asked to do way too much heavy lifting in both patients' narratives about their suffering, AND in outpatient psychotherapy, especially in particular modalities/schools of thought. I think this definitely limits what's possible in treatment sometimes, and, as you say, can even be counterproductive.
I think I mostly understand with what you were saying in your Q&A, and I agree with a lot of it, IF I'm understanding it generously. I'm sure you can glean from what I wrote that my main frustration with your comments was what I perceived to be a very flippant attitude toward patients' suffering. I'm sure you also gleaned that I am especially sensitive to doctors' flippancy toward patients' suffering, for reasons having to do with my constitution, and to do with my psychiatric history. I'm not the type to ask people to walk on eggshells, but I do think it's worth considering how language like "fragile" will land on [former] patients. People who wind up in inpatient psychiatry are obviously at some of the most fragile moments in their lives. I think that talking about these patients in terms of their inability to cope with their everyday lives is, uh, not where it's at.
Anyway, thanks for the Q&A. Even the part that pissed me off helped me clarify some of my thoughts about the BPD nosology, haha!
Totally valid critiques. I appreciate the feedback. Sometimes I can sound more dismissive than I am, that's how I come across sometimes unfortunately, still a work in progress... I try very hard never to dismiss my patient's problems though (it's not good treatment, and it also would make me cynical I think). One reason I care so much about this whole issue is that these diagnoses can cause very real and very serious iatrogenic harm, eg. if overdiagnosed, and especially if it leads to inappropriate/unneeded treatment. So when diagnoses receive attention or are in vogue, talking about them can a double edged sword. You don't want to dismiss people's real suffering, but neither do we want to blindly endorse every narrative either, and history has shown us that we're liable to both errors.
Also, FWIW, I personally like conceptualizing the BPD issue in terms of "what psychological defenses are available and unavailable to this person, now and in general?" We all use "borderline-level" defenses, e.g. splitting, sometimes, especially in crisis. But what characterizes someone traditionally labelled "borderline" is a pervasive reliance on certain defenses and an inability to regularly use more adaptive ones. It keeps the emphasis functional rather than whether someone is on the border of this or that. Nancy Mcwilliams has great stuff on this if you aren't already familiar with her work.
edit: and I've met quite a few patients who truly met BPD criteria in their teens-20's, but after working on themselves seriously for a few years, they really did get better and the diagnosis was no longer appropriate. So it's not necessarily a lifelong thing.
also, FWIW, as a somewhat strident person who puts her foot in her mouth more frequently than she would like, I feel you!!!!
Thanks for this.. I enjoyed reading your essay and the comments here. I’m glad you pointed out the more nuanced responses by Borjesson and Aftab.. I didn’t find you snarky, but I have deep wells of snark so I may not be a good judge.. I do believe that words matter, and it terrifies me that I might ask for help that I really need and land in the office of someone who minimizes my distress or doubts my story, even if that’s not what they say to my face. **Especially** if that’s not what they say to my face... Over diagnosis is clearly a problem, but in my mind it’s not the patient’s responsibility (although clearly it’s our problem). Like you said, people still need to be helped even if the doctor’s colleagues got the diagnosis wrong. I’m also not at all anti-psychiatry and have been helped tremendously by psychiatrists and still am. I see my psychiatrist twice a week (really good insurance). We don’t always agree, but I do trust her. This is all ambiguous terrain, and I’m glad to see that doctors and patients are wading through it together. So thank you, Dr. Greenwald (if you’re still reading my comments). I really do appreciate you putting these conversations out there.
I see patients who are hospitalized, not in the clinic. A significant percentage are not highly functional and don’t go to work sipping lattes like everyone else, nor are they yoga instructors, small business owners, or authors. I’ve also treated people who have suffered trauma that most people think are reserved for scary movies. So I don’t come at this from a perspective of total ignorance. That said, it’s obvious that trauma is a grossly overused excuse these days for just about everything, and most people recognize this. It’s a fad, and psychiatry has lots of them. We’re always searching for ways to say that something outside of us caused us to be the way we are and made our life circumstances difficult. “Trauma” has expanded as a category much like ADHD or autism has, one result being that many people latch onto the diagnosis as a way to understand themselves. My point was not to say that people who end up diagnosed with cPTSD (for whatever reason) haven’t had hard lives. The point is that we should question the utility of diagnoses when they create theoretical or practical problems, or otherwise don’t seem to fit in with the broader picture. I think cPTSD has many such problems, while other people disagree, which is fine.
Thanks for your response. I definitely don't think you're ignorant and apologize if my comment came off that way. You and I have different sets of experiences, and some of what I heard troubled me. I agree completely that the word "trauma" is overused and that's harmful to me as well. I also understand that many people with extensive trauma are not highly functional. Certainly in our culture, occupation is one dimension of that, but functionality was only one part of the point I was trying to make. The more important one is about the need to be respected and believed. Of course inpatients become outpatients (I have) and vice versa, so people are indeed leaving your hospital and stopping at Starbucks for a latte and no one bats an eye... I don't know the problems this diagnosis creates for psychiatrists, but I believe you when you say it does. Despite all of this, you spoke very broadly about people diagnosed with cPTSD in a way that was not flattering or compassionate, in my opinion. As a patient listening in, what I hear is you talking about are human beings (me), not theory or psychiatry's diagnostic problems in general. Clearly the need for this very exchange demonstrates those very problems as we both have experienced the cPTSD diagnosis very differently.
We’ve all seen “truly, truly non functioning, in a profound way” before. They’re the people with severe schizophrenia who have nowhere to go outside the psychiatric ward because they have no support network. And yet no one is prepared to make the connection. There is too much cognitive dissonance; in other words, the pioneers of psychiatry were sure that they were going to find a brain disorder that could be tested for and treated. They are still dedicated to this, the point of the profession is based on it. They want to treat psychological disorders with chemistry. The problem is: what do we mean by chemistry? There are two kinds. The pill kind and the human kind. I think psychiatry is a vocation that I wish some of its members would be less flippant about. But these discussions are a good thing. Stick around and make sure your voice stays heard ❤️🩹
Thank you! I plan to stick around even though so far my attempts to speak up as a person with lived experience haven’t been at all satisfying. If what I say actually challenges someone, then the very thing that (I believe) gives me credibility to speak up is the thing that makes my words easy to discredit. Calls for patient voices feel performative. I’m not sure that’s what’s happening here, but it’s a concerning dynamic. Anyway, I’m enjoying your substack! Thanks for chiming in!
There’s definitely still a lot of patronising comments and lip service from some people but we have to start somewhere, right? When the field of psychotherapy was being formed, a few of the early pioneers were women, but they were dismissed as too emotionally volatile for the calm work of therapy. Now no one would make such a dismissal- women have proved their naysayers wrong about that. Now the problem is a self selecting group of mostly male consultants (sorry guys, but you know it’s true even if you are very good at your jobs) - as female doctors struggle to juggle children and work. This is only going to change if couples share childcare more fairly. I’d also like to see more diversity and people who have recovered from mental illness going into this work. Sometimes I get disheartened myself, I have had my own battle and the toll it has taken on me, and many people who should know better have kept their distance from me because they still mistakenly think I might be mad and become some kind of threat to them, although I had one major episode that lasted 6 months 25 years ago, and I have never been diagnosed with any major disorder. I had a second episode caused by a head injury, but the trigger was physical in that case. I do my blog while others who are too ill to advocate for themselves have few people who are prepared to do it for them.
It looks like we'll have to disagree. I'm sorry, but I just don't see the logic in medicalizing problems based on the idea that "we do have good reasons to think that some combination of mechanism is malfunctioning (schizophrenia is a good example) but not always." It seems to me that we would need more than "some combination" to conclude the problem is a form of dysfunction or to formulate treatment intended to correct or ameliorate that dysfunction, without doing a lot of collateral damage, both physiologically and socially. This sounds like a discussion that deserves a separate and more comprehensive space. Thanks for the exchange!
Just to clarify, the logic behind medicalization primarily is the practical benefit, IMO, not hypotheses about dysfunctions. That is, whether a medical treatment helps a person achieve relief from distress and disability or not.
If you are speaking of palliative only treatment, then I agree. Any form of distress can be soothed with chemicals, regardless of its official designation as a mental disorder. The question is whether we are up front with clients about this. I have no problem with my clients who want a chemical (or ECT, surgical) solution, but it would be disingenuous and contrary to the principle of informed consent to state or even imply to the person that they have a dysfunction to be corrected, "just like heart disease and diabetes," as the APA says, when there is no evidence of such. It would be just as disingenuous to tell a patient they have diabetes without some firm evidentiary support. I recognize that not all psych clinicians take this medicalized stance, but those who don't are a tiny minority.
Thanks for doing this.
1. Can Gary please elaborate on/provide sources about non-biological causes of ADHD and a connection to reporting of ACEs? I thought a high heritability coefficient (~0.8, off the top of my head, and executive function, specifically, being entirely genetic) was uncontroversial. Also, I haven’t successfully tracked down the studies, myself, but I’ve read that longitudinal studies found that ACEs aren’t associated with poor mental health outcomes, but rather that poor mental health is associated with increased retrospective reporting of ACEs.
2. Can Gary please explain what he means about using IFS, but considering it contraindicated in patients who are at risk of identifying with parts? My understanding was that IFS therapists claim that the multi-agent model of mind is literal, not figurative. (Source: Robert Schwartz’s forward to Robert Falconer’s “The Others Within Us,” the book Scott Alexander reviewed, as mentioned by Awais)
Regarding IFS, perhaps I wasn't being sufficiently clear. The issue is not the risk of patients identifying with their parts. (With certain caveats, that's part of the point!) I meant only that with patients on the more psychotic end of the spectrum, there's a danger that IFS work will exacerbate their symptoms inasmuch the identifying of parts can further encourage splitting. Hope that helps.
Good questions. ADHD is not my area of expertise, and no doubt there is a high heritability coefficient, but to my knowledge it is relatively uncontroversial--in many neurodevelopment disorders--to acknowledge that environmental factors may also be relevant. Even if one is skeptical of Gabor Maté's strong thesis in his book Scattered Minds: the origins and healing of ADD, you can find many citations to the research on this point.
Here's a study on the correlation with ACE scores, though as we acknowledged in the conversation, it's not so easy to tease out which comes first, the adverse experiences or the ADHD-behaviors that contribute to them.
https://www.sciencedirect.com/science/article/abs/pii/S1876285916304168#:
This deep dive conversation of Andrew Huberman with psychiatrist and ADHD expert John Kruse is the best overview I've come across recently.
https://www.sciencedirect.com/science/article/abs/pii/S1876285916304168#:
100% with you about starting somewhere. I was pushed out of Tulane’s MSW program earlier this year for speaking up about a class where extremely stigmatizing misinformation about bipolar disorder was being taught to future clinicians. I also have bipolar, which I (naively) disclosed as the basis for speaking up. I was literally told I was in no position to speak on the matter by the DEI dean of the school of social work. Based on this experience and others I’ve heard, I would argue that the mental health field isn’t so keen on letting us in either. I know advocacy of some sort Is my work, but I have to find my footing again — and sort out my very mixed feelings about disclosure. At some point, I’ll restart my Substack and tell that story in detail. It was grueling. Anyway, thanks for your responses! 💚
https://open.substack.com/pub/tightropesandteacups?utm_source=share&utm_medium=android&r=5jm3em
Unfortunately it’s my understanding there’s no cause evidence that childhood trauma causes ADHD. It may cause ADHD like symptoms. The correlation studies are confounded by the genetics. It might be worth consulting Dr. Russell Barkley’s work and YouTube channel where he discusses this. A lot of this is propagated by Gabor Mate which as far as I understand has been debunked.
I don’t think you’ll find much support for your view. Most experts are in agreement that the causes are complex and not well understood. They also agree the factors are both genetic and environmental, the ratio varying according to specific cases. In my most recent note, on ADHD, psychedelics and other questionables, I provide links you may find useful.
People w addiction issues are the worst populations to offer psychedelic treatments
I don't know that there's evidence to support this view. Psychedelics are not drugs of abuse. And there's lots of evidence--admittedly far from conclusive, thanks to 60+ years of war on drugs--that psychedelic therapy can help treat alcoholism, smoking, and other addictions. Not to mention the work being done on ibogaine as a treatment for intractable opiate abuse.
Go out and do some street level work with those suffering with substance use problems. There are layers of illness that won’t be fixed quickly. Ibogaine data is slim and there are few if any long term studies of success