3. from n equals one

Posted on Tuesday 23 August 2011

In the case I was talking about, there wasn’t any question about diagnosis. She met the criteria of the day as they changed when the manual was revised. When she was psychotic, she had it all – voices, disjointed thought, paranoia, odd affect, magical thinking, automatisms, thought broadcasting, etc. In between, she had some version of what are called "negative symptoms" most of the time. I can’t imagine treating her without medications, acutely or chronically. I tried that experiment and the results were definitive – decompensation. I think she’d say the same thing. The voice of restraint with neuroleptics was mine, not hers. She would’ve gladly up-ed the doses along the way, and there were times when I used anti-anxiety medication to keep her from using a neuroleptic like an "as needed for anxiety" drug.

Now back to the initial point – the Prodromal Risk Syndrome. I’m sure it exists, though I wouldn’t have  picked that term, at least in this case. She’d had some version of her illness from the start – and still does. So I guess I’d want the name to reflect that chronicity but I can’t think of an alternative. I don’t know what causes Schizophrenia or how the antipsychotics work. But I don’t think they work by reversing the basic problem – because the basic problem persists both during psychotic episodes and in the spaces in between. To me, however, the antipsychotics are more than just "symptomatic," because they seem to uniquely take the wind out of the sails of whatever drives active psychosis, though they’re certainly no cure. They are "anti-psychotic" but not "anti-schizophrenic" drugs. In this case, there was nothing to suggest that they were a "chemical straight jacket" or made her a "zombie." They did neither. And she was not a patient whose symptoms "melted" quickly, but rather diminished gradually over days or weeks. She always remembered her psychotic experiences, and wanted to talk about them after the fact. My impression was that she got more mileage out of looking back at the precipitating events and warning signs than at the content of her psychosis, but we talked about both – a lot.

So would preemptive treatment with antipsychotics have helped her? I doubt it. She had taken them and they didn’t help, but beyond that, neither she nor her family would’ve made the changes necessary without a cataclysmic wake-up call. At the time of her suicidal contemplations, I think she was on a neuroleptic [the same one we used later]. In her case, I don’t think the psychotic episodes hurt her long term, but that’s just an impression. Do I think psychotherapy is the treatment for Schizophrenia? Of course not. That "lecture" was about supportive psychotherapy, and that’s what it was. This patient had a supportive family, financial resources, a lot of personal internal resources, and a stick-to-it-ness that allowed her to learn how to live with the illness, not get over it. In her case, there was no attempt to uncover forces in her mind or defense mechanisms. If I had to characterize what we did, it was three things. First, we managed her medication use between the poles of "help" and "hurt." Second, she needed a person-anchor that was focused on helping her fit her life to the person she was with the illness she had – interrupting her high achievment family ideals. And finally a "learning" therapy that I’ve described above – learning to be schizophrenic. She was an atypical patient in some ways, but also instructive in general.

I’m of a mixed mind about the inclusion of the Prodromal Risk Syndrome. because I think it’s just part of the course of Schizophrenia itself [that opinion is from a lot bigger n than one]. But I don’t question that it exists, so that speaks to inclusion. I’m suspicious that including it will be followed by clinical trials that show statistical significance that will get drugs through the FDA and we’ll see a lot of people unnecessarily medicated with potentially dangerous drugs. Many such patients do not have schizophrenic breaks with reality, known since Bleuler and recently reaffirmed [Early Intervention for Schizophrenia: The Risk-Benefit Ratio of Antipsychotic Treatment in the Prodromal Phase]. I can envision creative Direct-to-Consumer medication ads in that future with their mumbled warnings in the background ["blah, blah, diabetes, blah, blah, irreversible neurological symptoms, blah, blah"]. I’d prefer to say "ask your doctor if the time-honored medical principle of ‘watchful waiting’ and informed supportive therapy is right for you" and maybe add "until the place of medication treatment is studied long term without the obvious bias of drug manufacturers."

And as for n=1 science – I’d like to see the n=30 science take the fact that it’s also 30 n=1s more into account. Similarities and differences both matter. Schizophrenia was a big determinant in the course of this woman’s life, but there were a lot of other important factors. Medication was an important part of her treatment, but there were also a lot of other important things. Psychiatry is not much different from any other medical specialty that deals with chronic disease. In medicine, it’s called "following the patient" or "management". We just use different names.

When I read the articles about antipsychotic medication trials, or articles like this one where the issue is "premedication," I often think of this patient. They seem to to leave out something essential. In previous times, many schizophrenic people lived out their lives in a sanatorium or a state hospital under varying conditions. Some few were in environments adapted to fit the illness, many others ended up in "snake pits" that warehoused them away from from the rest of the world. When the antipsychotic medications came along, it became possible to take a lot of the power out of psychotic illness [albeit sometimes at a cost to the patients]. The hospitals emptied, but for many schizophrenic patients, the medication did little to alter the underlying problems of chronic schizophrenic living – what my old teacher called emotional ataxia and living literally. Modern medical psychiatry seems solely focused on medication research. But the practice of medicine is much more than that. It’s using what’s understood about the course and nature of diseases that don’t go away to help people have better lives under circumstances of chronicity. That’s medical too. My real reaction to this editorial is that it’s too focused on the question, to medicate or not medicate, as if the only question is stamping out or preventing psychotic episodes. That is, of course, a legitimate question, but it obscures the other equally important medical question, how to help people live schizophrenic lives…
    August 23, 2011 | 11:04 AM

    I am very intrigued by these last two posts. It appears to me that you are approaching treating schizophrenia in a way not dissimilar to how, as a rheumatologist, you would treat a patient with an autoimmune disease. That is, knowing you will not “cure” the problem and that you do not know the cause, you focus on dealing with symptoms and making necessary life adjustments. This is very helpful to me as I think about a couple of people I am working with supportively.

    I am glad you are continuing this blog.

Sorry, the comment form is closed at this time.