Psychotropic Medication, Addiction, Withdrawal, Discontinuation, Relapse

By Dr David Laing Dawson

I can offer some thoughts on this from many years of observation.

Addiction is addiction. Defined as the development of tolerance (requiring more and more of the drug for the same effect) and physiological withdrawal symptoms upon stopping the drug.

Benzodiazepine drugs are addictive. The “pam” drugs. They are safest prescribed for short periods or for intermittent use. But most of us struggle with this because they offer instant relief and there are few alternatives. (this deserves a longer discussion at another time)

SSRI and NSRI antidepressant medications are not (by definition) addictive. We do not develop tolerance and require higher and higher doses. But when they are stopped abruptly patients often suffer “discontinuation” symptoms. Perhaps this is a euphemism for withdrawal symptoms but usually they are not severe, and some people come off SSRI medication without any such symptoms at all.

Usually these symptoms are unlike a true relapse and are short lived. They are described many ways by people using such words and phrases as “not like myself, foggy headed, pinging, buzzing or electric shocks in my head”.

Some of the SSRI and NSRI medications have worse discontinuation symptoms than others. Perhaps Paxil and Effexor XR are the worst offenders. But again, some patients go on and off these medications without any ill effects. Strategies to ameliorate withdrawal effects include very very slow weaning and switching to an SSRI with a longer half-life.

And it is usually not difficult to distinguish these withdrawal symptoms from a relapse of the original illness being treated with these drugs. The withdrawal symptoms are almost immediate, depending on the half-life of the medication; they are odd feelings rather than the slow return of the depression or anxiety disorder they were treating.

A true relapse of the illness may occur months or even years after discontinuation. And usually the discontinuation symptoms last a few days to a couple of weeks. When these illnesses relapse (depression, anxiety, OCD) the symptoms are usually identical to those of the first episode. This fact is one of the reasons it is reasonable to call Depression, Anxiety, and OCD illnesses.

Anxiety disorders and depressions can be chronic persistent disorders or relapsing and remitting disorders. They can be seasonal or more closely associated with events and transitions in life.

Usually these medications work. And the more severe the illness the more dramatically effective they can be.

Do these drugs actually cause a later vulnerability to depression? I think the short answer is “no”. Impossible to prove of course but I have not seen it. But I have seen much relief from suffering and dramatic improvement in function.

With all that, the SSRI’s are undoubtedly over prescribed for less serious mood problems, unhappiness, and disappointment.

Of course if non-pharmacological means of alleviating mood problems do so for you on their own, then by all means use these instead: exercise, meditation, yoga, SADS lamp, counseling and therapies of any kind, better diet and sleep, better balance in life……

But I must admit that in 40 plus years of prescribing life-balance, exercise, meditation and yoga, my patient compliance rate is running roughly 5 percent. It is very hard to initiate any of these activities if you are house bound with anxiety or morbidly depressed.

Reflections on Donald Trump and Reality TV

By Dr David Laing Dawson

I apologize for writing again about Donald Trump, but what is happening in that country south of our border may be very important for all of us. Many pundits have been sharing their views, but when you are living at the time of a tipping point in human affairs it is very hard to see what is coming.

I previously commented on Trump’s off-the-cuff speech pattern being akin to that of a teenager with ADD. (my apologies to all bright articulate teenagers). Well, there are two possibilities: that is his natural speech pattern and it reflects his pattern of thought or… or he is faking it. Which means he is masterfully engaging his audience in this manner because he understands the brain of those raised on Talk Radio and Duck Dynasty. I don’t mean to make light of this. It is a much worse alternative to thinking he simply suffers from some ADD, both for what it says about him, and what it says about our Reality TV and Celebrity Culture.

I remember the moment Television changed democracy. Nixon vs Kennedy. Nixon did not look good on camera. At the time people speculated that FDR would not have been elected had every household owned a television. As we know either Nixon looked better on color television or his consultants taught him how to look better next time around.

Over fifty years have passed since the Nixon Kennedy debate, and since that time the makers of film, television, and other commercial interests have become much more sophisticated in the manipulation of the human mind/brain. Which boils down to tapping into our arousal systems, our reward systems, our primitive fears, anxieties, frustrations, anger, our primitive responses, our seeking of certainty and security. The digital revolution has given them amazing tools to do this. The very tools that can make information and wisdom available to all can be used to make us play video games for days on end, binge watch a cable series, and tune in for another episode of “Reality Television”. We get hooked, we say. Well, yes, that is the point. A bit of fun, then mystery, then anxiety, threat, struggle, fear (albeit vicariously) then resolution and reward, repeat. Our brains love this stuff.

(McLuhan’s famous dictum “the medium is the message” sounds rather quaint now.)

Donald Trump knows this. Or he is a phenomenon created by this “Reality” TV culture.

Perhaps he is a one-off, an accidental politician, a throw-back, the subject of many future dissertations subtitled, “How and why did this happen?”

Or he is a sign of the times, a man of these times, a man who understands the way entertainment can tap into the human brain and destroy the boundary between truth and fiction, the manner repetition creates reality, the manner in which simple phrases can instill anxiety, the manner in which bluster can convince, and our brains’ desire to repeat that anxiety, fear, struggle, resolution, reward cycle as often and as quickly as possible.

Like the despots who managed to corrupt nascent democracies in the past Trump stirs up primitive anxiety, fear and anger and then offers us fentanyl, the quick fix. And he does this with a mastery of the new media and an accidental or calculated understanding of the brains of the fans of Reality TV.

Well, for the sake of my grandchildren I hope this is a one-off, and less to do with the impact of absorbing reality TV, entertainment, and video games with faster and faster editing taking us through that anxiety/arousal/reward cycle over and over again for many hours each day – I hope it has less to do with that and more to do with the residual racism and sexism in the American culture. The latter can be improved over time. I don’t know what we do with the former.

Some Personal Thoughts on the Locked Doors of Psychiatric Wards.

By Dr David Laing Dawson

In the late 1960’s through the 1970’s I was one of many who worked to unlock the doors of psychiatric wards. We were, after all, highly influenced by the idealism of those years. And to a large degree we succeeded. At least here and there. At least until this century when they began to be locked again.

Suicide was never the main concern. An actively suicidal inpatient had already come to the hospital (which meant he or she wanted help) or had been brought to the hospital (which meant he or she had let their “intentions” be known to someone, and thus, at least partially, welcomed intervention). Besides, we still had seclusion rooms and one on one staffing to watch over such a person while we waited for the treatment to take effect. And usually it did. In fact, the highest suicide rate of any demographic is during that first year post discharge from a psychiatric ward. And usually (with some autopsy evidence to back up this observation) after they stop taking their medication.

An elopement followed by an act of violence was the real concern with unlocked doors. In theory and practice, we need but recognize that potential for violence in timely fashion and quickly institute treatment for the underlying illness, usually a psychotic illness, usually very treatable.

Still, that was the fear. And that fear encompassed our fear of failing, or making a mistake, of the consequences to a victim and the patient, of the community reaction, and of any legal repercussions. Not to mention the frustration of the police who had just apprehended and brought this man to hospital last week and now were looking for him again.

And there is another day-to-day reality. On a ward of 20 or 30 patients there might be only three or four of concern. One might be demented, confused, and likely to wander, perhaps over to the pediatric ward. Another might be actively psychotic and still talking of revenge. And another might be planning a break to acquire drugs. Another, a teen or youth, might simply want to go partying with his friends and be bridling at any restrictions.

So each day the ward staff would have to decide to keep the door locked or not, or place a nurse or security person on the door through the day and lock it at night. Or put each of these three or four at-risk patients on one-to-one staffing. And each of these solutions, save the permanently locked door, is expensive. And sometimes that number of worrisome patients might exceed 50% of the total with insufficient staff to assign one-on-one.

Statistically an elopement from a psychiatric facility, locked or not, followed by an act of violence is very rare, but always news worthy. Far more often the act of violence is committed by someone who should be in a psychiatric facility receiving treatment but is not. (Vince Li)

Elopements from psychiatric facilities, whether locked or not, are usually followed by inconvenience, folly, worry, drama and comedy. The whole human condition. Here are just a few of my experiences:

One evening the ward calls me at home to say William has eloped, and then he has phoned the hospital from a pub to say he is suicidal. I drive 30 miles in a rainstorm, find him in the pub, buy him and his newfound friends a drink, and drive him back to the hospital.

She has been divorced 20 years, but is now a little manic. She elopes. I am called by an irate ex-husband who tells me he arrived home to find her naked in his bed with a bottle of champagne. I cannot help but chuckle at the image; he tells me it is not a laughing matter.

The young man has been gone a few days. We worry about him. He has some unhealthy attitudes about the police. He is also manic. The police bring him back to the hospital. They found him making a loud and rambling speech from the roof of the police station.

She elopes. She is gone a few days, and not returned to her home. We receive a call from a psychiatric facility 400 miles away. Traveling on a Grey Hound Bus she had threatened suicide and been dropped off at their hospital. At our expense they would send her back.

He eloped from the open door facility, having refused treatment for his bipolar illness. He went straight to the Vancouver Aquarium, jumped in and swam with the Orcas, which attracted much attention, and then gave a press conference for some Vancouver reporters.

On the other hand, another woman suffered from depression but appeared much better now. Her husband said he wanted to take her home for the weekend. This seemed to be a reasonable step in her recovery. But on that weekend-leave from the hospital he took her to visit Niagara Falls. She jumped to her death.

Doors locked or unlocked or partially locked or locked at the discretion of the staff. It has, I suppose, very strong symbolic meaning.

But a psychiatric facility is a world of illness, despair, insanity, confusion, risk, drama, worry, folly, comedy and tragedy. A world of decisions being made about people’s complex lives with limited tools to do so, sometimes with limited information, often with limited staffing. A world in which we now have effective treatments but a myriad set of rules restricting their use. A world in which the staff are asked to keep everybody safe, but with the least possible restrictive methods. A world in which questions of civil liberties, freedom from illness, the right to refuse treatment, the right to be insane if not harmful, the right to unrestricted movement, the right to die – it is a world where all those profound issues are debated every day, and not merely as theory.

I am no longer as concerned about a locked or unlocked door as I once was. As long as everybody is doing their best to care, to protect, to keep safe, to reduce harm, to comfort, and to treat mental illness. And as long as we have hospitals and staff to do this.

Addendum to Belief Systems, Mad in America and Anti-psychiatry

By Dr David Laing Dawson and Marvin Ross

Reading the comments to this blog and others of ours, there is a lot of a-historic and naive thinking. Recently, someone posted my Huffington Post blog on Open Dialogue in Finland to the Spotlight on Mental Health group set up by the Boston Globe to foster discussion of their series on the sad state of mental illness treatment and care in Massachusetts. One person criticized it claiming that I had no right to comment because I have never been to Finland, and the Finnish psychiatrist I quoted had no right to be critical because he had never been to Lapland. This is part of what that person said:

That paper by Marvin Ross is written around totally wrong information:

1) Marvin Ross has never been to Lapland to check what he wrote; thus he does not know what he speaks about…

2) The psychiatrist whom he telephoned in Helsinki, i.e. some 800 km from Lapland, had never been either…How she knew any of that I do not know.

One person commented on this blog that 10 times as many people diagnosed with schizophrenia die in the first year post diagnosis than 100 years ago and that olanzapine has killed 200,000 people worldwide.

Taking data from a number of public sources, Dr. Dawson put these statistics together:

Some American Statistics

1880

Total population: 50,000,000

A total of 91,959 “insane persons” were identified, of which 41,083 were living at home, 40,942 were in “hospitals and asylums for the insane,” 9,302 were in almshouses, and only 397 were in jails. The total number of prisoners in all jails and prisons was 58,609, so that severely mentally ill inmates constituted only 0.7 percent of the population of jails and prisons.

Average Life expectancy for entire population: low 40’s for whites

Low 30’s for blacks

2016

2016 total population: 324,000,000

Average life expectancy: men 76, women 81 (lower than Canada and most of Europe, lower still for minority groups. Much of this improvement from 1880 by preventing childhood diseases.)

U. S. Prison population : 2,200,000 (2014)

Or 716 per 100,000 American citizens are in prison. (a seven fold increase from 1880)

Mentally ill in prison estimated/measured to be 30% to over 50%

So 700,000 to over one million mentally ill are incarcerated in US prisons.

Incarceration in jail reduces life expectancy by roughly a factor of 10 years for every 5 years incarcerated. (all inmates)

Estimates/measurements of homeless in the USA:  1.5 to 2 million.

Estimates of homeless mentally ill range from 30% to over 50%.

So 500,000 to one million mentally ill are either homeless or living in shelters.

The homeless mentally ill are not receiving consistent psychiatric treatment. The incarcerated mentally ill may be receiving some limited treatment.

Adding this up:

One to two million mentally ill people are either homeless or  incarcerated in prison in the USA.

A high proportion of people with severe mental illness live in poverty.

Severe mental illness without treatment confers higher risks and co-morbidities for several serious diseases, such as cardio vascular disease. People with severe mental illness have a much higher risk of cigarette smoking and poor diet.

Untreated depression, bipolar disorder, and schizophrenia confer a much higher risk of suicide.

Homelessness and incarceration in and of itself reduces life expectancy by a considerable number of years. Neither of these groups is consistently receiving psychiatric treatment.

Psychiatric drugs do have side effects. (as do all pharmaceuticals) In a good outpatient or inpatient facility these can be monitored and treatment adjusted in partnership with patients.

But the real causes of contemporary poor life expectancy of the seriously mentally ill can be found in:

  • The illness itself untreated
  • Reduction and closing of hospitals.
  • Incarceration in jails and prisons
  • Poor or no housing. Homelessness
  • Poverty
  • Poor diet. Illicit drug use. Smoking.
  • Stigma leading to isolation and victimization
  • Poor, inadequate, or limited health care
  • Absence of good consistent psychiatric treatment.

And the overall cost of not providing good early consistent psychiatric treatment in both inpatient and outpatient facilities is calculated in the following article:

http://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/

Belief Systems, Mad in America and Anti-Psychiatry

By Marvin Ross

I keep reading comments from people wondering how anyone could possibly support Donald J Trump. Fact checking his statements demonstrates how wrong he is on much of what he says. And then there are the numerous comparisons of statements that he makes that contradict each other.

Not so surprising, sadly enough, when we look at the people who believe what Robert Whitaker and the anti-psychiatry movement believe.

Put simply, Whitaker and the Mad in America anti-psychiatry folks are adamant that anti-psychotic medication for schizophrenia makes people sick and shortens their lives. Research fails to support these contentions but they persist and the data is ignored. The two latest studies provide overwhelming evidence that anti-psychotics help – but more on that in a moment.

The late Dr William M. Glazer of Yale writing in Psychiatric Times four years ago had this to say of Whitaker:

Should we accept the analysis of a journalist who (1) to my knowledge, has not treated a patient or implemented a study and (2) reaches conclusions that run counter to well-established practice guidelines? Whitaker’s ideological viewpoint, which is implied throughout the book, is that our guidelines are inaccurate and driven by industry and our own need for income—that we are dishonest brokers. Beauty is in the eye of the beholder.

Criticisms of Whitaker have been done by many eminent psychiatrists but my favourite is by blogger Natasha Tracy in Healthyplace.com. Natasha explained why she refused to even read his book with these words:

Sure, he cites studies, he just contraindicates what the study actually proves. And nothing ticks me off more than this because people believe him just because there is a linked study – no one ever bothers to check that the study says whatever Whitaker says it does.

Except, of course, the people who do – the doctors. You know, the people who went to medical school for over a decade. You know, the people actually qualified to understand what all the fancy numbers mean. You know, those people.

And I, for one, rely a lot on what doctors make of medical data and they are the ones most able to refute Whitaker’s claims.

As for the contention by Whitaker and his minions that anti-psychotics make people sick, let’s look at two recent studies.

In 2013, the highly respected British Medical Journal, The Lancet, published a German meta-analysis on the efficacy and side effect profile of all anti-psychotics. The results are summarized simply in a blog by Dr Gerhard Gründer with a link to the original study.

The meta-analysis combined 212 studies with a total of 43,049 patients. All of the anti-psychotics produced improvements that were statistically better than placebo. The best agent was clozapine.

The most recent study was conducted in the Province of Quebec and published in July and was based on real world evaluations of all people prescribed with anti-psychotics for schizophrenia between January 1998 and December 2005. The cohort consisted of 18 869 patients. Outcome measures consisted of mental health event (suicide, hospitalization or emergency visit for mental disorders) and physical health event (death other than suicide, hospitalization or emergency visit for physical disorders).

The researchers pointed out that data from randomized control trials are often limited in terms of generalizability thus real world studies like this one are much more realistic. What they found was that taking anti-psychotics reduced the risk of having either a mental or a physical problem compared to those who discontinued taking them. The only anti-psychotic that performed poorly was quetiapine (seroquel) while clozapine had the best results.

The other criticism from the anti-psychiatry bunch is that taking anti-psychotics results in premature death for people with schizophrenia. Studies have shown that people with schizophrenia do die years earlier than others but the reasons are not well understood.  One hypothesis that I mention in my book Schizophrenia Medicine’s Mystery Society’s Shame is discrimination by health care practitioners. Studies show that people with schizophrenia often do not get adequate basic medical care and treatment.

Researchers in Sweden conducted a real world analysis of 21,492 patients with schizophrenia. Subjects were followed up from 2006 through 2010. Data on drug use and outcomes was obtained from national registers.

What was found was that Antipsychotics and antidepressants were associated with a significant reduction in mortality compared with no use. The opposite of what the anti-psychiatry crowd claim. However, there was a clear dose-response curve for benzodiazepine exposure and mortality. More benzos, greater mortality. Note that benzodiazepine drugs are not anti-psychotic medications. They provide short term relief from anxiety, but they are addictive when used over a long period. Which means with long term use people develop tolerance and then crave more. And if they stop them they experience serious withdrawal symptoms. They are never prescribed alone to treat psychosis.

Psychotropic medications prescribed properly to those who need it, are beneficial despite what you may hear from some journalists and a vocal minority.

 

The Unfiltered Mind of Donald Trump – A Tentative Psychiatric Evaluation

By Dr David Laing Dawson

It has become a pastime for some of us, to try to understand the phenomenon of Donald Trump, and a pastime for others to try to stop him from gaining the Presidency.

There are moments, it seems, in which he simply lacks a filter. What comes to his mind is spoken. Spoken without consideration of context, of purpose, of audience, of historical and present taboos, manners, etiquette.

Everybody occasionally makes that slip. Every politician, in a lifetime of public service, makes that slip at least once, and then has to explain, and apologize, and sometimes resign.

Clinically there are people who not only never make that slip, but punish themselves for bad thoughts, or who must undo the thought through a ritual. And others who cannot enter the simplest social conversation without first rehearsing their words. This is the problem of OCD. It is a treatable condition. Would that Donald Trump had a little of this problem.

At the opposite end, clinically, are people who blurt out whatever is on their minds. Some of these have ADD. The words are said, the deed is done, before the brain can say, “Wait a minute, this might not be a good idea.”

The autistic spectrum produces a problem reading social context, but usually with an accompanying anxiety that is protective. Still, some on the spectrum have rudely pointed out my double chin, asked about my age. Others can obsess and rant about a subject of no interest to the listener.

Manics, under a pressure of speech, may step close and make an inappropriate personal remark, a comment on age, breath, body odor, or sexual parts. Though usually their thoughts are elsewhere, pondering grander questions.

People with psychotic illness, struggling to create a usable mental map of the world, can sometimes spout racist theories and generalizations that make their caregivers blanch.

Well, The Donald is not manic, nor psychotic, nor autistic. He could have some ADD (attention deficit disorder). He is bored easily, easily distracted, not known to concentrate for long on any problem, uninterested in detail, and, in a sense, quite creative. He also speaks as a teenager with ADD. Seldom can he start a sentence and bring it to logical closure without an insert or two, these inserts often derailing the original intention of the sentence.

In one of his recent gaffes, he hinted that a gun owner might limit the Presidency of Hilary Clinton. It was almost possible to read his thoughts, and watch his brain struggle to forge his original thought into something appropriate for this audience.

He is speaking. He tells us if Hilary is elected she will pick Supreme Court Judges opposed to the second amendment. “No way of stopping her folks.” And then he has the thought, “unless a gun owner shoots her”. This thought must come out. He struggles for a split second and manages to obscure it just a little, “Although the Second Amendment people, maybe there is.”

So, he has ADD.

That alone might not disqualify him from being President. Others can handle the details, keep him on schedule and on time, debrief him briefly, channel his energy and his charisma, write his speeches for him, teach him to say no comment and smile enigmatically. That is if he is smart enough and generous enough to let himself be guided.

But in the last few days he announced that Barack Hussein Obama was the founder of ISIS. He blurts this out, likes the reaction he gets, and runs with it. He does manage an explanation that Obama pulling troops out of Iraq so quickly left a vacuum that ISIS filled, then having strained his brain with someone else’s more complex explanation, he jumps back to the word “founder”.

Finally he relents, and tweets, “They don’t get sarcasm?”

So, we have another clue to the puzzle. He is only semi-literate. Calling Obama the founder of ISIS is not sarcasm. Sarcasm is saying, “That Obama, he sure made short work of ISIS.” It might have required a knowing smile and an “Eh? Eh?” at the end. That would be sarcasm. I wonder if he understands irony and double entendre and tongue-in-cheek.

So with his juvenile sentence structure, his limited vocabulary, and his failure to understand sarcasm, I have to conclude he is just not very smart.

So now we have ADD, semi-literacy, and room temperature IQ.

Even then, if he were a generous soul, a selfless soul, a man of great principle with an altruistic nature, he might be okay. Forrest Gump for president.

But there is more to this man as we know. He is insufferably narcissistic. His hair, his painted tan, his constant boasting, his angry reaction to any perceived slight.

And he is more than a little sociopathic. His empathy for others is very limited. His ability to anticipate the consequences of his words and actions is limited. He does not appear to suffer any doubts, any anxiety, nor any regrets. The fault always resides with others.

So there it is. A candidate for President who is:

  • Attention Deficit Disordered
  • Semi-literate
  • Not especially smart
  • Narcissistic
  • More than a little Sociopathic.

I do not want this man to have control over anything that might affect my life, my family, my city, my Province, my country, or my world.

Note: Writing the above, because I am a psychiatrist and Donald Trump is not my patient and has not given me permission – writing the above could be considered unethical. However, between a small ethical violation and the safety of the planet, the choice is simple.

Psychiatry, Eugenics and Mad in America Scare Tactics – Part II

By Dr David Laing Dawson

I am not shocked that we passed through a phase in our evolving civilization when we seriously considered Eugenics. Until we understood a little about genes and inherited traits, every serious abnormality must have been considered an accident or an act of God, perhaps a punishment for some immoral thought or deed. Certainly a stigma and something for a family to hide, if it could. And, at the time, the tribe or village would feel no collective responsibility to look after the impaired child, the disabled adult. This infant and child would be a burden on the family alone until she died, usually very young.

But coinciding with a time our tribes, our villages, our city-states, and then our countries developed a social conscience, a new social contract, and accepted the collective burden to care for these disabled members, we began to learn of their genetic origins. It would be entirely logical to then consider the possibility of prevention.

When medicine discovers a good thing, it always takes it too far, and then pulls back. When men and institutions have power we always, or some of us at least, abuse it, until we put in some safeguards. And there is always at least one psychopathic charismatic leader lurking nearby willing to bend both science and pseudo science to his own purposes.

But we have, here in the western world, passed through those phases (and hope to not repeat them). Now every year we find genetics is more complicated, that there are more factors involved. And every year we pinpoint at least one more detectable genetic arrangement (combinations, additions, deletions, modifiers, absences) that cause specific and serious abnormalities.

But here is where we are now medically and socially in the Western World: We can test the parents’ genetic makeup, we can test the amniotic fluid, if indicated we can test the fetal cells, we can offer parents a choice to abort or not; we can tell them of projected difficulties, available treatment or lack thereof, likely outcome, and possible future improvements in treatment and cure. We have also socially evolved sufficiently (and are rich enough) for the state to assume some, or, if necessary, all of the burden of care.

That is where we are, notwithstanding the difficulties of providing this care, and the antiabortion crowd: Some genetic certainties, some intrauterine tests, some blood tests for carriers, some absolute and some statistical predictions, and parental choice.

Now we come to genetics and mental illness. We have no certainties; we have some statistics; we have no intrauterine tests, no blood tests, and we have parental choice.

For science to not continue to pursue a genetic line of inquiry for serious mental illness would be a travesty.

Nature/Nurture. I think I entered psychiatry at the height of this academic debate. On one hand the psychoanalysts dominated US psychiatry, while biological psychiatry (Kraepelian psychiatry) dominated British psychiatry. (R.D. Laing was an outlier). Meanwhile psychology figured if you could train a dog to salivate at a bell you could train any kid to do anything. At the same time many poets, essayists, and not a few Marxist sociologists were telling us that the insane were not insane. It was the world around them that was insane. From Biological Determinism to parental cause to the Tabula Rasa and back to Social Determinism.

Other psychiatrists worked hard to find a way of including all possible factors: the bio/psycho/social model. (Which I would like to see redefined as the bio/socio/psychological model, for it is clear to me that our behaviors are driven first by our biology, secondly by our social nature, by social imperatives, and thirdly by our actual psychology, our cognitive processes. (Just watch Donald Trump)

How much of our nature is determined genetically, or epigenetically in the womb, and how much by our experiences as infants and children and teens and adults? When it comes to human behavior it is clearly all of the above, to different degrees and proportions.

The studies show that the risk of developing schizophrenia is 50% if your identical twin has schizophrenia, whether raised together or apart. This was often touted to show that 50% of the causative factors for schizophrenia must be environmental. But we now know that identical twins are not really genetically identical. And the interplay of genes, genome, brain development and environment is time sensitive. (Despite her fluent English my wife still stumbles on some English sounds. They were just not the sounds her brain was hearing at age 3.)

On the other hand identical twins reared apart are later found to have developed surprisingly similar traits, speech patterns, skills, and interests. And on every visit with my daughter in Australia she complains about the knees I bequeathed her.

As I mentioned before, genetics gets more complicated the more we are able to study it. Some DNA sequences seem to predict a mental illness in adolescence or adulthood but not the exact one.

Of course that finding may reflect not so much on environmental influences as on the vagaries of our definitions, our current diagnostic system.

An old colleague once remarked that our criteria for the diagnosis of schizophrenia are at the stage of the diagnosis of Dropsy in about 1880. I think he exaggerated. They are closer today to a diagnosis of Pneumonia in 1940. (Note that we can now distinguish a pneumonia that is bacterial caused, from viral, or autoimmune, or inhalational, and which bacteria, but our antibiotics help only one form of pneumonia, and each of these forms of pneumonia may have one of numerous underlying problems (biological and social) causing the vulnerability to developing pneumonia.)

For mental illness the development of drugs (1960’s on) that actually work much of the time threw a monkey wrench into this ongoing debate and inquiry. It tipped the balance to biological thinking for many of us. But it is a logical fallacy to assume a treatment that works reveals the original cause. The treatment is disrupting the chain of pathogenesis at some point but not necessarily at the origin of the chain.

We will continue to argue nature/nurture, and science will continue to investigate. And doctors will continue to treat with the best tools they have available.

If Dr. Berezin is correct (which he is not) and serious mental illnesses like schizophrenia, manic depressive illness, autism, and debilitating depression, OCD, and anxiety are all caused by “trauma”, much hope is lost and we will not find good treatments and cures for centuries. For today, despite what Donald Trump and Fox News tell us, in our childhoods in Europe and North America we experience far less trauma, strife, deprivation and loss than every generation before us. Yet mental illness persists in surprisingly persistent numbers.

Dr. Berezin is taking a leaf from the Donald J Trump book. He is trying to frighten you with images of violence, abuse, regression, lawlessness for his own purposes. He is waving Eugenics and Hitler at you in much the same way Donald conjures images of rapists, criminals, illegals, and terrorists streaming across the American border.

But lets get real:

Serious mental illness (schizophrenia, manic depressive illness, debilitating anxiety and OCD, true medical, clinical depression) are little helped with non-pharmacological treatments alone. The reason we do not see today, mute and stuporous men and women lying in hospital beds refusing to eat and wasting away is because we have the pharmacological means (and ECT) to treat depression. The reason we do not have four Queen Victorias and six Christs residing in every hospital is because we now have drugs that control Psychotic Illness. The reason we don’t see thin elated starving naked men standing on hills screaming at the moon until they die of exhaustion is because we now  have drugs that control mania. The reason we don’t have as many eccentrics living in squalor collecting their own finger nail clippings and urine is because we now have very effective pharmacology to treat serious OCD.

All of these people also need social help and someone in their corner, but without the actual pharmacological treatment it will get us nowhere.

(Though, I must admit, today, you may be able to see untreated catatonia, untreated stuporous and agitated depression, untreated mania and untreated schizophrenia in some of our correctional facilities).

But lets look at the less serious mental problems as well for a minute. A patient tells me she is afraid of flying, and always avoided it. But her father is dying in another province and she needs to fly there to see him one last time. She is terrified of getting on that plane. She imagines having a panic attack and disrupting the flight.

A fear of flying. A phobia of flying. Those of us who have such a phobia can usually manage by avoiding travel by plane.

But my patient. She needs to make this trip. Now perhaps I should send her to a trauma therapist who might uncover the fact a school friend was lost over Lockerbie and have her grieve about this, and still be afraid of flying; or perhaps to a cognitive behavioural therapist who might try to convince her that her fears are unfounded, pointing out how air travel is safer than car travel; or perhaps a desensitization approach in which the counselor uses relaxation techniques and has her imagine being at the airport, boarding the plane, and perhaps accompanying her to the airport on the day of travel; or perhaps I should find out if the fear is based on sitting so close to 300 strangers for 5 hours, or riding in a 20 ton contraption at the speed of sound two miles in the air; or spending 5 hours locked in a cigar shaped coffin with 300 strangers…..

Or I might simply prescribe for her five dollars worth of Lorazepam and offer a few encouraging words to get her through the trip.

Then lets look at something in between, like ADHD, one of the diagnoses mentioned by Dr. Berezin.

It is not a difficult equation for me. The child can’t sit still in class, he is too easily distracted, lacks focus, can’t concentrate, always being reprimanded by the teacher, socially ostracized because he intrudes, he pokes, he speaks out of turn, he angers too easily.

To become a successful adult he needs to succeed in at least one thing, if not more than one thing, in his childhood. If, with accommodation at school, and some parental strategies, some adaptational strategies, such as being allowed to wear earphones and take an exercise break every 20 minutes, have one-on-one instruction, good diet, better sleep – if these work, then he may not need medication.

If they don’t work it means he will fail socially and academically and maybe at home as well. He will be in trouble all the time. He will become surly, or give up, or become more aggressive, or depressed. In his teens he will self-medicate.

If the difference between a child failing or succeeding socially and academically is a single pill taken with breakfast it would be, to use that word again, a travesty to not prescribe that pill. And that is true whether the ultimate or necessary causative factor is inherited or acquired, or some complex combination of biological vulnerability, epigenetics, infantile and toddler experience, parenting styles, pedagogic methods, diet, and video game addiction.

 

 

Psychiatry, Eugenics and Mad In America Scare Tactics – Part I

By Marvin Ross

Much of what I read on the Robert Whitaker website, Mad in America, stretches logic but this newest blog has to be one of the biggest stretches I’ve seen. Dr Robert Berezin, a US psychiatrist, warns that psychiatry is moving closer and closer to eugenics.

As defined by dictionary.com “eugenics is a word that made everyone at the event uncomfortable. … The very subject evokes dark visions of forced sterilization and the eugenics horrors of the early 20th century. … The study of hereditary improvement of the human race by controlled selective breeding.”

The most famous proponent of eugenics was Adolph Hitler who wanted a pure Aryan race but the subject has been advocated by many in recent history in an attempt to eradicate debilitating diseases. In fact, one could say that the reason for amniocentesis is to do just that. Sampling of the amniotic fluid of pregnant women can predict such things as Down’s Syndrome. And some parents will opt for abortion if Down’s is found but many do not.

Amniocentesis can also predict such genetic conditions as Tay Sachs Disease where the infant usually only lasts to about age 4. But, nowhere in the article by Dr Berezin does he actually show that modern psychiatry is planning to eliminate anyone who suffers from schizophrenia or any other psychiatric disorder.

What he talks about is the fact that genetics is being employed to try to understand these conditions better. He states that:

The accepted (and dangerous) belief is that psychiatry deals with brain diseases – inherited brain diseases. We are back to absolute genetic determinism. Today’s extremely bad science is employed to validate not only the idea that schizophrenia and manic-depression are genetic brain diseases, but that depression, anxiety, phobias, psychopathy, and alcoholism are caused by bad genes

I have no idea why he considers the genetic research to be bad science other than he does not agree with it. So what if he doesn’t. He does state that “The temperamental digestion of trauma into our personalities is the source of psychiatric conditions.” But, as Dr David Laing Dawson has written on this blog:

Childhood deprivation and childhood trauma, severe and real trauma, can lead to a lifetime of struggle, failure, depression, dysthymia, emotional pain, addictions, alcoholism, fear, emotional dysregulation, failed relationships, an increase in suicide risk, and sometimes a purpose, a mission in life to help others. But not a persistent psychotic illness. On the other hand teenagers developing schizophrenia apart from a protective family are vulnerable, vulnerable to predators and bullies. So we often find a small association between schizophrenia and trauma, but not a causative relationship.

Dr Berezin’s concern does not come from anything that anyone has said about aborting fetuses that genetic testing proves will be born with schizophrenia or bipolar disorder or any serious psychiatric condition. And the reason for that is that genetics and the understanding of the causes of these diseases is nowhere near a point that this can be demonstrated with 100% accuracy. Science is a long way from getting to that point if it ever is able to.

Suggesting that these research avenues will lead to abortion, eugenics or something similar is absurd and nothing but scare tactics perpetrated by someone who does not agree with the causation theories being investigated. If these avenues lead nowhere and it is discovered that science has been on the wrong path, then science will self correct. Attempting to generate unfounded fear is counterproductive.

Next Part II by Dr David Laing Dawson

Police Entrapment, Terrorism and Wasted Resources

By Dr David Laing Dawson

Years ago a not-so-bright young man stole a Cadillac convertible. He had always wanted to ride in one, like a country and western star in a small town parade. This was the only way he imagined it could happen. The ensuing police chase, crash, lawyers, court appearances, sentencing was extremely costly. It would have been, I noticed at the time, much, much cheaper to buy him a Cadillac for a birthday present.

Another young woman had a penchant for setting fires. Whether she was in a jail, a hospital, or a boarding home. She was mentally ill, and we were trying to help her, but there was always a risk that her pyromania would cause many deaths as long as she was residing with others. Her care was costing the taxpayers in the neighbourhood of $200,000 per year. While in our institutions someone had to watch her at all times. A decent little house was selling for about $50,000 at the time. I proposed we buy her a detached house and take our services to her.

These two stories came to mind when I read about John Nuttall and Amanda Korody. It has been reported that the RCMP spent about $1,000,000 “entrapping” them.

Two marginalized people. Addicts. Neither bright nor sophisticated. Probably with their fair share of grievances and yearnings. Both destined to be burdens on the taxpayer for years to come. And both in that state of mind, that existential position, of searching for someone or something to blame and a way of elevating their sad lives.

Neither capable, on their own, of condensing those grievances into strategic action. Neither capable, on their own, of buying the ingredients and making a bomb, and successfully delivering it. Probably neither capable on their own of formulating a coherent argument why they should do this.

So, having discovered this despairing pair of hapless would-be terrorists, would it not have been much cheaper to give them a Lotto win of $100,000 and send them on their way. I know there is no sane way of doing that, but perhaps, instead of this elaborate sting operation, the RCMP could have alerted the local social services that this at risk couple needs extra help. Assign a new worker, a counselor to them. Review their needs, (social, educational, medical) and plan with them a better life.

So much less expensive and damaging and wasteful than all that police work, surveillance, subterfuge, and legal work, court costs.

Addiction services, psychiatric treatment, disability benefits, social housing, educational programs. These are all expensive. But so much cheaper than the alternative.

On the Jail Sentence of Toronto Police Constable James Forcillo

By Dr David Laing Dawson

As much as I know the shooting death of Sammy Yatim was entirely unnecessary, and as much as I know by simply looking at pictures of Constable James Forcillo that he is pugnacious by nature and that his fear/aggression response is close to the surface, easily triggered, I still have qualms about his conviction and sentence.

We put the gun in his hand. We assigned him to that job.

And in doing so we made one of two mistakes. Either he and his fellow officers were not sufficiently trained and prepared, or wrongly trained and prepared, or he is not a man we should have put in that position in the first place.

If 99 out of 100 officers could have resolved that event peacefully, without anyone getting hurt, then Constable Forcillo should have been reassigned years ago. To a desk job, community liaison work, anything not requiring a gun.

If only 40 out of 100 officers could have resolved that event peacefully, without anyone getting hurt, then their training and supervision is wrong. Tragically wrong.

I know it can be a combination of both. But those are the two tools we have: Screen and monitor our officers for signs that their primitive fear/aggression response is dangerously close to ignition, and train, train, train them to react differently in those situations.

See previous blogs on police training at https://dawsonross.wordpress.com/2016/04/04/on-improving-police-confrontations-with-the-mentally-ill/ and https://dawsonross.wordpress.com/2016/04/04/on-improving-police-confrontations-with-the-mentally-ill/.