1 Boring Old Man

If I hear one more pompous maroon blathering on about The Dopamine Theory of Everything… how it explains methamphetamine addiction, interpersonal attraction, the relationship between solar flares and fluctuations in the rate of atomic decay of Cesium 137….

I find the entire subject very… triggering, as my younger colleagues would say. Liberman’s proved that hallucinations really ARE part of everyday experience– hell, I’m having one right now. I’m flashing back to the lowest moments of my clinical training… I can see the power point slides with graphics of the little neurons with the receptors shooting out little multticolored paratroopers across the synaptic gap…

This kind of nebulous theorizing hasn’t emptied any mental hospitals that I am aware of. Crackpot ideas were never this dull 30 years ago. Bring back the orgone chamber! I’m going down to the garage to build one right now…

The British Psychological Society frames the discussion of psychosis and schizophrenia to suit themselves rather than to acknowledge the full impact of patients’ symptoms (which the BPS prefers to label as “experiences”). The BPS dumbs down psychosis and schizophrenia to an ‘alternative adaptation’ condition, attributed without compelling evidence to childhood trauma and abuse. Hallucinations become the experience of hearing voices; delusions become the experience of unusual beliefs; paranoid thinking becomes the experience of anxiety – never mind that the great majority of patients with clinical anxiety disorders are not at all paranoid in the way that psychotic patients are. They also make much of the fact that milder forms of these “experiences” are common in the general population – as are milder forms of many clearly medical symptoms. In short, they fail to acknowledge the state transition that demarcates mild or prodromal symptoms from outright psychotic illness.

This approach is what I call domesticating psychosis. The BPS document fails adequately to convey the range of symptoms and associated behaviors in psychosis/schizophrenia. Even when these are mentioned, they are not addressed in a way that matches their clinical salience. Thus, decompensating psychotic crises are discussed unhelpfully in the framework of poor sleep habits. Acute inpatient psychiatric units are discussed in a patronizing way and are faulted as being unhelpful for some patients – never mind their rescue function. Catatonia as a common feature is not acknowledged. Psychotic terror and panic are not acknowledged. Formal thought disorder with truly crazy speech is not acknowledged. The 10% lifetime incidence of suicide among schizophrenic patients is not acknowledged. Core negative symptoms are brushed away as demoralization or as neuroleptic drug side effects. All of the recommendations made in the BPS document for improvement of psychological and social services are admirable but none are really new – they all fall within the traditional biopsychosocial model of psychiatry. We can all agree that psychiatry has not implemented that model consistently, in large measure because of underfunding, but that does not invalidate the model.

Their intellectual bias is further evidenced by their halfhearted endorsement of the need for antipsychotic drugs. They go out of their way to emphasize that, even though these are sometimes helpful, “… there is no evidence that (the drugs correct) an underlying biological abnormality.” Well, bless my heart, we can say the same of most drugs used in medicine: steroids for autoimmune diseases; bronchodilators for respiratory diseases; anticonvulsant drugs for seizure disorders … So, what is their point here, exactly, beyond gratuitous negative innuendo? It seems to me that the BPS document is a manifesto in the professional turf wars, heavily slanted towards gaining funds from the U.K regulators, rather than driven by an understanding of the classic psychotic disorders.

All that said, I join Dr. Mickey in his views about Jeffrey Lieberman. His over-the-top Medscape piece is a disservice to psychiatry.

http://www.behindthelabel.co.uk/does-language-matter/#comment-15909

Following links from the above candidate to the executive committee of ISPS, and voting for her, I think we, surviviors, sufferers, family members and others, having experienced the many pitfalls and abysses of what’s called madness, and the equally mad pitfalls and abysses of “scientific” medical psy-treatments, can say that time has come for a paradigmatic shift in thinking. The foundations of the still maledominated profession of psychiatry is scientifically untenable. Human compassion, care and kindness – basic needs met – is essential. I do not expect any help from those who profit from the reigning madness, the likes of Lieberman, thousands of anonymous doctors, CEOs of Big Pharma, politicians and others on the take. But things are changing. The waterfront is receding. Dr Mickey and doctors like him deserve thanks for diligently exposing selfserving fraudsters, without use of scientific-sounding language and stigmatizing labels.. Language matters.

Follow the money?

As a technically trained non-physician, I have read “Understanding Psychosis and Schizophrenia”, and many responses to the piece by professionals in psychiatry and psychology. I must in all candor suggest that neither the advocates for talking therapies nor those for psychoactive medication seem to have the least understanding of what they are talking about! It’s still the same old guild argument from the 1970s, rehashed. It’s not really about helping people in crisis. It’s about continuing to make a living from discredited theories.

Psychologists persistently gloss over the cognitive disorganization and severity of effects experienced by people who go through some variety of psychotic break. You surely cannot propose to treat people who literally don’t understand what you’re talking about!

Meantime psychiatrists persistently ignore conclusive evidence that the brain chemical model for major emotional or cognitive crisis is unsupported by science or observation. They also persist in treating severely non-functional people with medications known to be ineffective in their primary actions, and dangerously damaging in secondary effects.

It seems to me that the only proportionate and fair response to the current crisis in professional psychiatry may be to burn the whole damaged edifice to the ground and start over from scratch.

Sincerely,

“Who does Jeffrey Lieberman think he is?”

I watched his Medscape video, and this was my thought exactly. Frankly, he seemed really unhinged. He didn’t make any actual arguments to advance his view and just looked like somebody who was angry that his authority wasn’t being respected. In the long run that can only serve to undermine respect for him and psychiatry.

He also routinely calls people who advocate public health measures against obesity and cardiac illness and who question the possibly overly optimistic pronouncements about the value of personalized medicine and genetic testing as scientific “know-nothings.”

That said, I want to commend Dr. Carroll for providing a reasoned and fact-based critique of the British Psychological Society’s report.

In short, they fail to acknowledge the state transition that demarcates mild or prodromal symptoms from outright psychotic illness. This approach is what I call domesticating psychosis.

If it is “domesticating psychosis,” that may, in part, be a response to a kind of other-izing which minimizes the humanity of these patients. Sometimes, I think it stems from a need to preserve self-esteem. Some people want to make everything about the patients different so that they can feel more secure in their own sanity.

Can you flesh out your concern about the state change? Maybe clarify for a non-expert what you mean by a state change in this context? The snow here in New England is sublimating straight to gas right now, so the nature of states is on my mind a bit.

I don’t in, any way, want to suggest that psychosis is a cozy thing, but I’m also nervous about the opposite process–making it more wild than it is and cutting it off from the continuum of psychological experience. I’m not a physician, but I don’t know whether decisions about when to treat chronic conditions in other areas, like diabetes, are always made when there has been a clear state change.

http://onlinelibrary.wiley.com/doi/10.1111/acps.12355/full

By John Read

Yes, I completely agree with Dr. Lawhern’s second paragraph. It also seems to me that psychologists, at least in the BPS, have created their own mythology of the brain chemical model for psychosis. It’s a convenient talking point for the BPS in their interdisciplinary turf wars but it never was the whole story. As a stand-alone model it never was compatible with the biopsychosocial model of psychiatry. You won’t see it in the writings of the pioneers like Arvid Carlsson, who identified the dopamine blocking property of antipsychotic drugs or Philip Seeman who discovered the dopamine D2 receptor. Some of the second and third tier KOL hacks may have pushed the idea but the BPS should know better than to take them seriously. The great contribution of Arvid Carlsson, Philip Seeman, and a few others was to establish that dopamine hyperactivity in the brain is a proximate cause of florid psychotic symptoms. With that understanding, there is still room and need for work on distal causes like developmental insults, intercurrent stresses, and genetic predispositions. The dopamine theory of psychosis doesn’t exclude psychological and social factors – it never did.

To EastCoaster’s query about a state transition, maybe the simplest answer is to remind us all that the clinical crises aren’t called psychotic breaks for nothing. That’s the appropriate term that Dr. Lawhern used, too.

BC: I watched someone dear to me get very sick, and it’s not really clear to me that there was an obvious break. There were experiences–like being afraid that she’d been in a car accident when there was no evidence that her experience was real–which seemed to flow seamlessly into more overt psychosis. Of course, there was probably a period when she’d already had a break but didn’t share it for fear of seeming crazy.

Dr. Carroll: I have a few comments regarding some of your observations. First, do you deny that there exists compelling evidence supporting the contribution of trauma to schizophrenia? There is a substantial and credible literature here that has been almost entirely ignored by biological psychiatry. Second, how do you reconcile your complaint that the BPS fails to “acknowledge the state transition that demarcates mild or prodromal symptoms from outright psychotic illness” with consistent evidence that psychotic/schizophrenic symptoms have a dimensional as opposed to a taxonic distribution in the general population? Third, you dismiss the BPS observation that drugs for schizophrenia do not correct an underlying abnormality without acknowledging that this is how they have been advertised – quite explicitly and vigorously – by psychiatry and drug companies to the public and patients for decades. The BPS statement in this regard corrects a common and consequential misconception promulgated by psychiatry; labeling this as “gratuitous negative innuendo” sounds, in all honesty, like something Jeffrey Lieberman would say. Lastly, you criticize the BPS for advocating a model that is not compatible with the “biopsychosocial model of psychiatry.” Although your point that one-sided models are necessarily incomplete and inaccurate is well-taken, it would carry more weight if psychiatry had not all but abandoned the biopsychosocial model since DSM-III (as Dr. Nardo has so thoroughly documented) – nowhere more so than in its approach to schizophrenia. I don’t highlight these observations to out you on the spot, but rather to discourage a too-quick dismissal of the BPS statement on arguably questionable grounds.

To Brett Deacon’s points: Thanks for bringing these up. Concerning the contribution of trauma to schizophrenia, we need to be careful. The major review of this topic by Read and colleagues was actually quite unclear on the diagnoses of the subjects. Their focus was on individual symptoms rather than on operational diagnoses of schizophrenia. Their main positive finding concerned hearing voices, but it is clear from their Table 3 that the results were weak for delusions, and they were outright negative for thought disorder and for negative symptoms. This means those subjects mostly would not qualify for an operational (DSM) diagnosis of schizophrenia. As we all learned in training, one hallucination does not a schizophrenia make. I am persuaded by their data that physical and sexual abuse in childhood are often followed by hallucinatory experiences in adulthood, but other diagnoses like prolonged PTSD or dissociative identity disorder may be more appropriate. Anyway, it’s clear that more work on this issue is needed and I do disagree with your assertion about the strength of the evidence linking childhood physical or sexual abuse with schizophrenia proper.

To your second point, does it really matter whether psychotic/schizophrenic symptoms have a dimensional as opposed to a taxonic distribution in the general population? As Robert Spitzer (REF) reminded us in the lead-up to DSM-III, we are not concerned with symptoms as atomistic behaviors but with clinical diagnoses. The state of psychotic decompensation goes far beyond dimensional psychoticism in the community, just as the state of diabetic ketoacidosis goes far beyond a dimensional measure of blood glucose in the community. Both states are allostatic collapses, infinitely more complex than a simple dimensional measure.

Next, I do think the chemical imbalance myth is an unhelpful preoccupation of groups like the BPS. The importance of the dopamine discovery is that it gave us a point of leverage for treatment. Of course it is not the whole story and it never was. Do you have examples of psychiatry saying that it is the whole story? [Please don’t respond with drug company materials.]

I think we can agree about the historical failure consistently to implement the biopsychosocial model in the care of patients with schizophrenia. I alluded to that earlier. Let’s hope the leaders of all the mental health disciplines can get it back on the rails.

Brett, My reading of the literature linking child adversity and other life events to schizophrenia, even the studies favored by the authors of Understanding Psychosis is that while there is some association, it is nowhere near what the authors require for the strong connection they claim. In making this assessment, I’m paying attention to one of the studies actually done by one of these authors.

To EastCoaster’s query about a state transition, maybe the simplest answer is to remind us all that the clinical crises aren’t called psychotic breaks for nothing. That’s the appropriate term that Dr. Lawhern used, too.

Dr. Carroll, I guess that I wasn’t clear in what I was looking for, and maybe it was too much to ask for in the comment section of a blog. I was hoping for something a bit less simple–like what you would tell a medical student on a psychiatry clerkship or a 1st year resident (not an expert, but someone interested in learning in an in-depth way). Alternatively, how would you explain it to a philosopher of science?

As I said, if that’s too much for a blog comment section, I understand.

What a fine discussion this has turned out to be. Thanks to all!…

Bernard: I appreciate your thoughtful response. I agree with Mickey – this has been a fine discussion. I am far from an expert in schizophrenia and appreciate your thoughts (and those of Dr. Coyne) on the status of the science linking trauma and psychosis. Regarding the second point, I again appreciate your perspective. Clinical experience has shown me that individuals diagnosed with schizophrenia can indeed embody the allostatic collapse you described, but that many others exhibit levels of symptoms and functional impairment that differ quantitatively, not qualitatively, from people without the diagnosis. In the absence of a valid biological test, I am skeptical of claims that “real schizophrenia” (or ADHD, or depression, or whatever) exists and can be cleanly distinguished from “not real schizophrenia.” I respectfully differ in the relevance of the chemical imbalance myth briefly debunked in the BPS statement. From my perspective, the chemical imbalance story has been psychiatry’s de facto causal explanation for most varieties of psychopathology in recent decades. I don’t have examples of psychiatry saying that is the “whole story.” But I do have many, many examples of patients who were told by psychiatrists that their problems are the product of a chemical imbalance, and that psychotropic medications correct this imbalance. It’s not just psychiatrists who engaged in this practice, but it was embraced in psychiatry like nowhere else. I worked at Mayo Clinic for two years as a postdoctoral fellow and witnessed staff psychiatrists promote the chemical imbalance story to their patients as fact in routine clinical practice. Hell, APA president Steven Sharfstein went on the Today Show and told Matt Lauer the chemical imbalance story was true. Patients genuinely believe they have a chemical imbalance. The general public genuinely believes mental disorders are caused by a chemical imbalance. This is not the product of a few ignorant practitioners, it is the result of a well-documented effort to promote the chemical imbalance story by psychiatry, the pharmaceutical industry, and the patient advocacy movement (among others; I discuss this matter a bit here in case it’s of interest: http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/biomedical_model_commentary.pdf). That the chemical imbalance story may not have been the “whole story” misses the point that this explanation was heavily promoted despite its obvious lack of scientific credibility. As I said earlier, I think the BPS statement’s note that “antipsychotics” do not correct a chemical imbalance is useful because it addresses a common and consequential misconception promulgated by psychiatry.

Brett,

Thanks for your comments. I speak neither for “psychiatry” nor Dr. Carroll, but myself. It’s kind of hard to be in this kind of discussion, I think, having been in many. There’s the science involved and there’s what people did with it. I first heard the “chemical imbalance” phrase from a patient who had been told it by a psychiatrist. But the next time was on one of those “talking head” Zoloft commercials. I share your outrage, and did back then all those years ago. Mercifully, I haven’t heard it in a long time, but I’ve heard its derivatives – and I continue to cringe when patients continue to believe some version of it.

As a psychiatrist, I feel ashamed. On the other hand, I feel equally bad for my Biological Psychiatrist colleagues who have worked in the mainstream of legitimate and critical science to understand the biological aspects of mental illness and the mechanisms of action of our drugs. They’ve been disenfranchised by all of this too. Speaking, again for myself, I’ve never seen proof that the antipsychotic drugs act on the basic mechanisms of any disease, but they certainly do have an effect on psychosis, though beyond their biochemistry, I don’t personally know how. That they have a lot of other effects goes without saying.

The clinical issue now is about maintenance medication, and I, for one, am neither an expert on that topic nor know the answer that’s coming down the road. The drugs are a relapse preventive, but at what cost? So I’m not engaging that topic because I don’t know the answer, and I hope it will ultimately be a scientific answer rather than from a debate about the sins of our fathers [and there are plenty of sins around to get in the way].

I have some problems with the BPS report too, and I hope they’re not derivatives of some disciplinary war or related to my own professional identity. The reason that they aren’t in a full blog post yet is that I’m still thinking about that.

But I appreciate both you and Dr. Carroll engaging in this discussion in the way you have in the comment section here. It makes it worth the time I spend blogging. And I’d just like to say that the actual blog above was about Dr. Lieberman’s self-righteous and unprofessional response to Dr. Luhrman and the BPS report. We’ve had far too much of his kind of blather already.

My own point in this is that “psychiatry” is not a person. I would prefer hearing “a common and consequential misconception promulgated by many psychiatrists in responsible positions as well as pharmaceutical ads,” but I honestly wonder if I could say it that way myself, if I had another professional identity.

Brett: good to hear back. Let’s maybe set aside the dimensionality issue because that reframes the discussion to the long term management of patients with schizophrenia. I appreciate that you see my point about a state change in psychotic decompensation.

I will push back on your views about diagnoses. The BPS also seems to want to ditch them. The demand for a biological test misses the point. To use a real example that I have discussed before, by all means plan to tell the magistrate at your next commitment hearing that you were serious when you commandeered an airliner at the departure gate, prevented the scheduled passengers from boarding it, declared yourself the owner of the airline, announced that you were going to fly your entire extended family to London to meet with Margaret Thatcher, became obstreperous with the security personnel, and that the psychiatrist who said you suffer from mania must be wrong because he hasn’t shown the court a laboratory diagnostic test for mania. There are more extensive discussions of my views on this here and here.

Your review article, to which you linked, speaks approvingly of the biopsychosocial model, which means we are on the same page there. But you continue to harp on the myth of the chemical imbalance theory, as though that were some kind of ex cathedra pronouncement by official psychiatry. That’s bosh.

We should understand that the chemical imbalance idea began as a simple clinical intervention for communicating to patients, with clear therapeutic intent, the nature of their condition and the consequent need for continuing with treatment. If you want to call that simplistic, I wouldn’t disagree, but for many patients it is an explanation pitched at a level that they can grasp. As we know, we have to meet the patient on her own level.

This simple explanation then was memed and demonized by groups like the BPS and celebrity cranks like the actor Tom Cruise, not to mention the Church of Scientology. By now, their indignation over the chemical imbalance meme is a real yawner and a silly straw man argument, as James Coyne also has observed. He has a cogent post up today on the BPS report.

You mentioned Steven Sharfstein’s appearance on the Today Show. The transcript of his remarks shows that he was quite reasoned in his views. As a matter of fact, the most revealing point in the show came when Katie Couric hoisted Dr. Joseph Glenmullen on his own petard for using antidepressant drugs even though he said he doesn’t believe in the chemical imbalance theory – [Couric: Well, obviously, are they helping with brain chemistry?] Glenmullen’s reply was incoherent.

Dear all, I have posted my take on Understanding Psychosis leveling diagnostic distinctions with cherry-picked poor examples. It is a polemic piece, but I think I document my points better than the document I comment on . Come see and weigh in if you’d like at

http://blogs.plos.org/mindthebrain/2015/02/26/understanding-psychosis-and-schizophrenia-and-mental-health-service-users/

Mickey and Bernard, I hear what you are saying about the complexities involved in addressing the origin, dissemination, and popularity of the chemical imbalance story. You make a good point about my attributing promotion of this story to “psychiatry,” but this issue is complicated given that we’re talking about a practice that was/is undeniably the status quo in the profession but has long been recognized as an oversimplification and/or simply false by those in the know. My experience seems to differ from yours in that from where I’m sitting, the chemical imbalance story remains the status quo in clinical practice, continues to be accepted as fact by the vast majority of the population, and is promoted to this day by high-profile sources (I’ll spare you the links but they are easy to find). Each year, a sizeable percentage of my undergraduate abnormal psychology students think I am a nutjob conspiracy theorist for claiming that the chemical imbalance story is not established scientific fact. My research lab recently attempted a study of causal explanations of OCD among sufferers in support groups, but we cancelled our study right out of the gate when a psychiatrist who led a support group called and complained to my university that his group members were “up in arms” about language in our study materials that questioned the chemical imbalance story they had been fed by their providers (more details here: http://www.madinamerica.com/2013/09/united-states-biomedical-model-five-anecdotes/).

I think it’s a bit more complicated that claiming this story is about the past, is a straw man, or is a source of controversy drudged up by Scientologists. The reality is that this story was presented as fact (not just a simplified metaphor) by many psychiatrists (among others) and was taken as fact as a result by patients and the public. Its exposure as obvious pseudoscience creates a genuine problem for psychiatrists willing to confront their profession’s enthusiastic adoption of pseudoscience, and for patients who grapple with the realization that they were told they had a literal brain abnormality/defect/disease that turns out not to exist. I firmly believe that we need to understand the lessons of the past lest we repeat them. There are important lessons to be learned here and I fear that we have too quickly gone from all-chemical-imbalance-all-the-time to nothing-to-see-here-let’s-move-on.

Bernard, I understand the need to provide patients with an explanation of their problems that is at their own level. This argument can also unfortunately provide an excuse for shoddy practice. It risks patronizing patients as too stupid to understand the biopsychosocial model, which can be clearly summarized in a few minutes by any thoughtful provider. (As an aside, I provide my anxious clients with a rather involved cognitive-behavioral explanation of their problems that purports to explain how their maladaptive beliefs about threat are paradoxically maintained over time by their avoidance behavior, and they have no trouble understanding it.) In my opinion, it is unethical to provide obvious misinformation to patients under any circumstances. Simplifying complex information is one thing, but telling patients they have a literal brain disease, or a literal “imbalance” in their brain’s neurotransmitters in the absence of any direct evidence from test results, is just plain BS. Cardiologists should not tell their patients they suffer from heart disease in the absence of direct evidence. Pulmonologists should not tell their patients they suffer from respiratory disease in the absence of direct evidence. Psychiatrists should not tell their patients they suffer from brain disease in the absence of direct evidence. This is not rocket science. It’s Ethics 101.

Bernard, I have a straightforward response to your clinical anecdote. It is obvious that your fictitious patient has a serious problem characterized by delusional thinking and inappropriate behavior fitting the description of mania. What reasonable person could deny that the patient has a serious problem? What is not obvious, and can only be established via laboratory testing, is whether or not his problem is the product of brain abnormality. The problem with the DSM diagnostic symptom and its role in the biomedical approach is that mental health problems are attributed to biological disease in the absence of evidence of actual disease. People who claim that mental disorders aren’t literal disease entities readily acknowledge the existence of mental health problems. We just believe that a disease cannot simply be confirmed, or even necessarily confidently inferred, from aberrant behavior.

My recollection of the Steven Sharfstein Today Show interview is that after lying about the validity of the chemical imbalance story, he complained that Tom Cruise didn’t strike a properly respectful tone. I admit I probably lost my ability to dispassionately assess the extent to which his views were reasoned after that.

I want to end by noting that I don’t approach these issues from a position of holier-than-thou smugness because my own profession of clinical psychology is rife with pseudoscientific theories and practices. This reality affects my own credibility as a psychologist and it bothers me deeply. Any student who has taken a course from me knows that I devote the majority of my critical analysis to shoddy ideas and practices in my own profession, of which there are countless examples.

It has been my pleasure to have this dialogue with you all. This has been a fun and stimulating exchange.

Brett, this is getting old.

First, the patient I described was not fictitious – he was real, as I stated. I don’t understand why you want to twist that.

Second, you do indeed come across as self-righteous and holier-than-thou when you smirk about Ethics 101.

Third, your position about not inferring disease from aberrant behavior is specious. To repeat the Katie Couric line of thinking, if mania can be treated as well as prevented by a medication like lithium that alters brain chemistry then why would we not attribute it to brain dysfunction? Where else do delusional thinking and grandiose behavior of this degree come from if not from the brain? For convergent validity, throw in the phasic course, the seasonal patterns, the high genetic loading and the well-known causes of secondary mania caused by medical conditions affecting the brain. And you want to call it a no-brainer? – pardon the joke! If we pedantically followed your rigid line of thinking then we would until recent decades have refused to call Parkinson’s disease a brain disease because there were no lab tests and no demonstrated pathology – yet neurologists confidently diagnosed it as a brain disease on clinical grounds alone for 150 years before the recent developments.

And by the way, you are quite wrong when you say that the DSM diagnostic system attributes mental health problems to biological disease in the absence of evidence of actual disease. DSM is explicitly atheoretical (to a fault, as some of us think).

Last, you accused Steven Sharfstein of lying. I think you should walk that back. I gave a link earlier to the transcript – readers can judge for themselves.

By now I feel we are talking past each other so this looks like a good time to stop the discussion. Thanks for engaging.