Tag Archives: psychosis

Anti-Psychiatry

By Marvin Ross

I really don’t get it – anti-psychiatry that is. I can understand that if someone has had a bad experience with a psychiatrist, they might be wary and hostile. After all, not all doctors are good and I have no doubt that most of us have run into a bad one over the course of our lives. I certainly have seen my share of rude, arrogant and stupid doctors from family practitioners to cardiologists but I do not condemn them all. I do not devote my energy to attacking emergency medicine because of a bad ER doc I’ve encountered.

A lot of the anti-psychiatrists I’ve encountered fall into this category. They’ve had a bad experience and generalize to all. But a lot of the others aren’t in this group. They are people who have decided that their time should be devoted to attacking psychiatry as their contribution to freedom of the individual or to the good of mankind. And, for the most part, they know very little of neuroscience, medicine or mental illness. If they truly want to make a difference, they should devote their time to advocating for better care and treatment for the seriously mentally ill or to help with the growing problem of refugees, world peace, homelessness, child poverty, and the list goes on.

For the most part, they are mistaken in their views of psychiatry as Mark Roseman pointed out so brilliantly in his review Deconstructing Psychiatry. I highly recommend that people read that. His analysis is far more detailed than mine but I would like to comment on a few of the common myths that he covers in more detail.

The one complaint that is common among the anti-psychiatry mob is that psychiatrists are controlling people who give an instant diagnosis and then force their patients to take toxic drugs.

People do not go to see psychiatrists by calling one up or walking into their offices. They need to be referred by a general practitioner or via a hospital like an emergency room. And they would only be referred to a psychiatrist if they had psychiatric problems that were beyond the expertise of the general practitioner. That referral would only be made after the general practitioner had ruled out non-psychiatric causes of the symptoms and behaviour.

Like all doctors, the psychiatrist will take a detailed history from the patient, consider possible diagnoses and recommend appropriate treatment. The treatment recommended is based on the professional guidelines outlining evidence based strategies. These are the practice guidelines used by the American Psychiatric Association. Similar guidelines are used in different countries. The cornerstones of any medical practice are to do no harm and to relieve suffering.

I often hear comments and criticisms that a psychiatrist put someone on toxic drugs that they were then forced to take for eternity. A comment to my blog on the anti-psychiatry scholarship at the University of Toronto stated “based on the results of a positive diagnosis (from a 15 minute questionnaire score) a patient (including young children) may receive powerful psychoactive drugs for years, the long term effects of which are not yet known.”

As I said above, the diagnosis is not based on a 15 minute questionnaire but on an extensive evaluation. And, regardless of the medical area, drugs are always (or should be) prescribed in the lowest dose for a short period of time and the patient brought back in for evaluation of efficacy and side effects. The goal is to find the lowest dose that is effective with minimal side effects. This is a process called drug titration.

If the drug is not effective or if it causes too many unwanted side effects, it will be changed. No one is forced to take a drug that does them little good in any discipline of medicine. Surely, the patient does have choice to continue with that doctor or not and to take the advice that is offered. People who see psychiatrists are not held captive.

When it comes to children, they are not seen in isolation as the anti-psych criticism I quoted above implied. They are seen with their families who, understandably, do not want their kids on powerful drugs. There are long discussions with the psychiatrist where all less invasive means are explored. When pharmaceuticals are prescribed, the parents are at complete liberty to stop them if they do not work or if they cause troublesome side effects. The children are not held captive by the psychiatrist and force fed pills against the wishes of the parents.

When a child does continue to take the medication it is because it is having a benefit and there are no troublesome side effects. I remember a mother who resisted Ritalin for her hyperactive child for years telling me how well it worked once she decided to give it a try. “I wish I had tried it much earlier”, she told me. “It would have saved so much grief.”

The anti-psychiatry bunch also assert that mental illnesses do not exist and cite the lack of any one definitive test to prove bipolar disorder, schizophrenia or other afflictions. Quite true but the same can be said for many other maladies. How about Parkinson’s as but one example. Doctors cannot measure the amount of dopamine in the brain (which is depleted in Parkinson’s) to definitively say that the person has the condition. They determine the presence of this condition based upon observing the person and his or her movements.

Alzheimer’s is another. Like with schizophrenia, it is diagnosed by eliminating all possible other reasons for the observed dementia and when none can be found, the diagnosis of Alzheimer’s is made. On autopsy, there will be found specific markers but no one ever gets an autopsy to prove that the doctor was correct. And rarely is anyone with schizophrenia autopsied on death but this is a lengthy list of the abnormalities that demonstrate that it is a disorder of the brain.

The anti-psychiatry group should be looked upon with the same disdain that sensible people look upon the anti-vax faction.

Results of Family Survey – Onset of Schizophrenia

By Dr. David Laing Dawson and Dr. Giampiero Bartolucci

Background

Our ability to see, hear, read, and correctly interpret pre-textual and contextual* information is a brain function independent of I.Q. This ability in the normal population continues to improve (from birth) long past the age that other skills fall off.

This ability allows us to hypothesize the intention and motivation of other people, that is, to be aware of (up to a point of course) the workings of the others mind. That includes the perception of others as having minds, feelings, intentions, motivations, roles, responsibilities, needs.

This allows us to experience empathy, to grasp from this information both what is likely to happen next and what is expected of us in any given situation.
It allows us to formulate an internal social map of which we are a part. It allows us to develop a rational appraisal of cause and effect in our social world. It allows adaptability. New contextual information can be used to modify our internal map.

This ability begins to develop before language. From the moment the infant smiles at mother and mother smiles back.

The brain is an analyzing and organizing machine. It will organize information to formulate cause and effect and predictability. If the information is contradictory or missing it will seek further information. Anxiety/arousal will spur this seeking. Anxiety will continue until the brain is satisfied with its cause/effect organizational answers.

One part of this ability allows us to perceive objects according to their function in the human world. We perceive a chair turned upside down as still a chair because we know the object’s function. A three year-old child with normal pre-textual/contextual ability will approach a toy car and push it along the floor. An autistic child may pick up the car and spin it’s wheels with his fingers. This action may be fascinating to him. For the other child, the human function of a car and car-toy is more important. This child with good pre-textual/contextual information processing skills may race the car, turn corners with the car, stuff a small model in the car, and crash it into another toy.

It is this contextual information processing ability that allows affiliation: Being one of a pair or group and then operating within that group in ways acceptable to that group.

As textual language develops it can complement non-textual skills. But non-textual skills are required to modify and modulate language in social context. The child without, or less adept at pre-textual communication skills, may develop impressive textual skills that lack contextual nuances. His words and sentences are heard as overly formal, and often devoid of cadence, and/or contain unusual cadence and prosody.

As textual skills develop without pre-textual skills and as these are used to understand and interpret the social world around us, and formulate an internal map of cause and effect and expectations, that map will become inflexible, black and white, as stark as the usual text message.

In our average social world, for example, the word “yes” can be spoken in many ways, and guided by many facial and body language cues, to mean anything from a clear affirmative to a hesitant “Maybe” and even, really, “No.” But in text, “yes” is “yes”.

It is possible to reduce the need for pre-textual, contextual information processing skills by social isolation. And, uniquely today, we can retreat to a virtual social world where meaning and organization can be found in text alone. The player of a computer game, even one with multiple players, enters that world as an expressionless alias, an avatar, and engages through text and basic actions. Strategizing may be involved but the actions range simply from aggressive to evasive. If an affiliation is developed it is developed through text and mission.

While isolation protects one from the anxiety of being part of an incomprehensible (unpredictable) social world, it leaves the brain with little to work with as it develops its maps of cause and effect, social organization, expectations of behaviour, and ways of understanding ourselves within this social world.

But for our human brains, this is an imperative. It must do this.

We have long hypothesized that some non-affective psychotic illnesses (setting aside those psychotic illnesses that can be clearly traced to seriously abnormal mood states – e.g.. feelings of exaltation, elation, power, invulnerability, extreme energy leading to a conclusion (an assessment of affiliation) that one must be a prophet, a messenger of God, or God himself) – that non-affective psychotic illnesses are the result of the brain developing a system of cause and effect, an internal map, from whole cloth as it were, because it is experiencing an inability or decay in the ability to process contextual information. The intervening state is anxiety, followed by compensatory behaviours. When these compensatory mechanisms fail, psychosis develops. **

These are the psychotic illnesses that often receive the diagnosis of schizophrenia.

The Survey

Our survey used the internet to reach the family members of people who have developed psychotic illness and received the diagnosis of schizophrenia. 240 completed the survey though it required reading a long introduction and the choices were complicated.

The questions were designed to separate different pathways to psychotic illness, with five choices. Participants could choose one pathway or more than one if a combination was a better fit.

Choice one (1) implied a deficit in pre-textual/contextual information processing from infancy or childhood, with devolution to psychotic illness later.
36 chose this category alone, and 58 alone and in combination with others.

Choice two (2) implied a normal development of pre-textual/contextual information processing through childhood followed by a deterioration of this skill in adolescence.
43 chose this category alone, and 80 alone and in combination with others.

Choice three (3) implied a normal development of pre-textual/contextual information processing through childhood followed by over-interpretation of bits of information, finding meaning and linkages where none exist, or unable to filter out random and coincidental information.
16 chose this category alone, and 33 alone and in combination with others.

Choice four (4) implied a primary problem with emotional regulation: The emotional over reaction to interpersonal events followed by mistaken interpretations of them.
14 chose this category alone, and 56 alone and in combination with others.

Choice five (5) tried to separate those clinical situations in which hallucinations, hearing voices, might have been the first symptom of a developing psychotic illness.
22 chose this category alone, and 58 alone and in combination with others. Though in the comment section many stated that the confession to hearing voices came late in the illness and they then surmised it was an early symptom.

Those who did not choose a category and commented described unusual situations and/or late onset psychosis. (Onset age 40 for example, or many years of drug abuse)

Interpretation and conclusions:

A. Family members are eager to find answers and willing to spend time helping this pursuit.
B. The internet provides a very efficient way of collecting this kind of data and could be used for much wider studies.
C. The largest group of individuals diagnosed with schizophrenia followed a pattern of apparent social success in childhood, followed by developing social failure in adolescence, isolation and retreat, compensatory and seeking behaviours, and then delusions and disorganization.
D. The second largest group appears to have had pre-textual and contextual information processing problems throughout childhood, leading to various degrees of social failure. In adolescence this increases and devolves into psychotic illness.

Less common pathways to psychosis and the diagnosis of schizophrenia may not involve a failure to develop, or a loss of, contextual information processing skills, but rather begin with (3.) an affect regulation disturbance.
(4.) an uninhibited or excessive interpretive mechanism (search for meaning)
(5.) abnormal auditory, visual or tactile experiences.

Though usually 3 to 5 were observed in combinations with 1 or 2.

The diagnosis of schizophrenia is applied to psychotic illnesses that may have different causation and pathways. Our historical attempts to delineate these have relied, not on distinct pathways, but differences in the later psychotic state or outcome.

The results of this survey reinforce the need to consider the diagnosis of schizophrenia as encompassing several different illnesses. Each may have a different set of genetic and epigenetic etiological factors. If we can further delineate these pathways it will help us with early detection, screening tools, focused treatment, perhaps prevention.

Two pathways stood out:
Failure to develop pre-textual and contextual information processing skills in childhood, devolving into psychosis later.
A slippage or decay in this ability in adolescence. (Adolescence is the time of final development of the brain through a process of increasing and reinforcing neural pathways that allow adult function while pruning networks no longer needed.)
­­——————–
*Several words are commonly used to categorize the information being exchanged in human communication beyond, or other than, actual text (words): non-verbal, contextual information, pre-textual communication, pragmatics. The words used reflect the field of enquiry: e.g. ‘pre-textual’ in primate studies refers to forms of communication that precede the development of language (words). The linguists are fond of the word ‘pragmatics’.
We have chosen to use the words ‘pre-textual’ and ‘contextual’. Pre-textual to emphasize how this non-verbal communication precedes text and is primal. Contextual to refer to everything beyond actual text from cadence of text, choice of specific words, to facial expression, eye and pupil movements, to surroundings, situation, role, and history.

** Schizophrenia in Focus, Human Sciences Press, New York, 1983
David Dawson, Heather Munroe Blum, Giampiero Bartolucci

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

About That Ladder of Scientific Progress – Reminscences of a Psychiatrist

By Dr David Laing Dawson

stone of madnessIn 1971, before my own son was born, a seventeen year old boy left his family home in Ontario, and traveled to the southern United States with his guitar and little else. This young man, Derek, dressed in a robe and sought out an audience for his message of peace and love. He was hospitalized there, his parents contacted, and they drove down to bring him home. Back in Ontario they brought him to the new Community Psychiatry Program at the Medical Center. This was the Thursday before the Easter Holiday weekend. The young man, fully alert and full of energy, was convinced that he had been appointed by God to deliver these messages. But he didn’t want my medication, and he did not want to be admitted to hospital. His parents agreed to take him home and bring him back for a second visit the following week.

This family went to church on Easter Sunday, and to everybody’s dismay, the young man jumped to his feet, interrupted the Priest, and began a loud, rambling sermon of his own. An ambulance was called and he was taken to hospital. His response to medication was good, and when well, he proved to be a bright, engaging, sensitive, smart young man, capable of succeeding in College and life. But he did not like taking the medication. He preferred, quite understandably, the sensation of invulnerability, of energy, of warmth and possibility, of certainty, that accompanies a state of hypomania and delusions of grandeur. He remained my patient for five years, and I struggled with him to find a pharmacology that would keep him sane without taking away his enthusiasm. He often stopped the pills, became ill, and then reluctantly agreed to try again.

After five years I moved to head a different clinic in another part of town, and then out of town, and then five years later, back to town. I had lost track of Derek, and now my own son was that age, seventeen, and I was driving him to something. I think it was October and the leaves were changing on Aberdeen, a wide road of old and stately houses, some of which had been converted to group homes. We slowed at a busy corner, and on that corner a bearded man with unruly hair and disheveled clothing stood, paced, gesticulated and shouted at imagined specters or people in the street, in the clouds, and in the trees. It was unmistakably Derek, now in his mid 30’s.

“Shit.” I said.

“What’s wrong?” asked my son.

“That man,” I explained. “He was my patient years ago, when he was your age.”

He looked at the psychotic man raving at invisible targets. “Dad,” he said, “It’s not your fault.”

Ahh, yes. I remember that moment because of the heart-warming display of empathy and understanding coming from my teenage son.

But really, we did fail Derek, didn’t we?