Tag Archives: Psychiatry and the Business of Madness

The Course of a Psychotic Illness – In Response to Psychiatry and the Business of Madness

By David Laing Dawson MD

In the late 1960’s and early 70’s when a young man or woman in a psychotic state was brought to the hospital by family, by ambulance, by friends or police, we would admit him and keep him safe. He would have a physical examination, some blood tests, and be fed, if he was willing to eat. If she was delusional, hallucinating, talking in an incomprehensible manner, we would optimistically hope that the cause of this was the ingestion of illegal substances, perhaps LSD, Mescaline, mushrooms.  We would wait a few days before concluding otherwise. In fact, we sometimes waited one or two weeks, even three weeks, before concluding that this was a psychotic illness not induced by drugs. Drug induced psychosis actually clears quickly; it doesn’t take weeks, but we might indulge in wishful thinking along with the boy or girl’s family.

The history, the symptoms, the family history might clearly point to one of the psychotic illnesses studied and delineated over the previous hundred years (schizophrenia or manic-depressive illness), or not clearly one or the other, perhaps both. Nonetheless we now had effective treatment, drugs that actually work. These would be prescribed. And over the next few weeks to perhaps 8 weeks, our young man or young woman almost always got substantially better. The few that did not progress that quickly had been quietly ill for years before the admission. Average length of stay in the hospital grew shorter and shorter, at that time somewhere between 20 and 60 days.

But the other bit of folk wisdom with the backing of experience was that it usually took at least three admissions to hospital before such a patient achieved long-term stability. And this happened for four main reasons: we prematurely stopped the medication, severe side effects forced us to stop the medication, the patient stopped taking his medication, or the patient, stable within a quiet, supportive environment, entered a new, complex, chaotic and demanding environment that provoked relapse (a relationship, university, a job, travel, even a poorly considered therapeutic program.)

And throughout this process, the family, the patient, and the caregivers all struggled to find a way of understanding, talking about the illness, and finding a balance between cold truth and hope.

It often took three or four admissions before the patient and his family could come to terms with having a mental illness that required medication for a long time. This was not aided by our own optimism, our hope that a six or twelve month course of these very new medications would be sufficient to keep psychosis at bay for years to come.

What actually happened, inevitably, after stopping the medication, was a three or four or even six month period of wellness sans drugs, giving unfortunate support to the conviction of not needing them, followed by relapse of illness, of psychosis.

So these admissions and recoveries and relapses and re-admissions often spanned 5 to 10 years before stabilization was achieved. And, for those who eventually stayed on their medications, another 5 to 10 years of recovering the lost skills, the lost time, of learning what to avoid, of finding a way to live a full life with a chronic illness. Not least of those adaptations is finding a way of thinking about, accepting, as part of one’s past and present, several periods of psychosis, of misreading the world, of damaging relationships and sense of self, of being delusional.

I have been living in and around the same city now for 45 years. And from that period in the 1970’s I have known a few people who gradually made complete recoveries while consistently taking their medication, adjusted over time. And while they have recovered and lead full lives they know they are vulnerable; they know what to avoid; they know they must stick to some routines. I know others who take their medication and have achieved stability if by no means full recovery. And I know of others who have not, who have never been willing to take this medication over a long period of time. Some have died. A few others I see around town occasionally, one in a torn raincoat, walking down the center of the street gesticulating madly and talking to the clouds, another, a woman, standing outside a variety store haranguing exiting customers about incomprehensible injustices, and another plodding along the sidewalk, his head bent in unusual fashion, talking to himself.

But never, in those 45 years, have I seen someone who suffered from this kind of severe psychotic illness, recover fully without consistently taking his or her medication. You’d think by now, if it were possible, I would have seen it.

See Psychiatry and the Business of Madness in Mad in America