Note: This post isn’t like most of my others. I’m not in the habit of simply saying what I think without documentation, or in areas this far outside of my area of expertise. But I’ve got a really strong feeling here. Take it for what it’s worth – just a strongly felt, definitively stated, but nonetheless speculative feeling… Maybe it’s a polemic too – my polemic… I titled and ended the last post <to be continued>… not just because I was going to have more to say on the topic, but because it’s the only thing I’m absolutely sure of – that this debate will keep on and on just like it has since the dawn of 1boringoldman time [in psychiatry] and for that matter, before…
A controversial argument, especially one refuting or attacking a specific opinion or doctrine.
A person engaged in or inclined to controversy, argument, or refutation.
A polemic is a contentious argument that is intended to affirm a specific understanding via attacks on a contrary position. Polemics are mostly seen in arguments about very controversial topics. The art or practice of such argumentation is called polemics… The word is derived from Greek polemikos, meaning "warlike, hostile", from polemos, meaning "war".
The BPS report is a polemic
["a contentious argument that is intended to affirm a specific understanding via attacks on a contrary position
"]. It’s built on the failures and weaknesses of the current system, a system assumed to be created by psychiatry and psychiatrists, and proposing to reverse that approach as a way to solve its problems. I’m not going to go line by line through the British Psychological Society’s [BPS]
, Understanding Psychosis and Schizophrenia
. It has already been well discussed by others who have done an excellent job of parsing it. I’d recommend reading:
I obviously agree with them about the paternalism of many psychiatrists [which side of the street?…
]. And in reading through the official psychiatric positions [which I recommend doing]..
and from the NIMH RAISE Project
[now adopted by SAMHSA
… it’s obvious that the main thrust of the recommendations is an attempt to keep patients on maintenance medications to prevent relapse as a primary goal. But we should note that Dr. Jeffrey Lieberman who was vice chair of the committee that produced the APA guidelines was at the same time the Principle Investigator of a major NIMH study [CATIE
], that definitively showed that the patients didn’t agree, and didn’t stay on the medications:
Every compliance study I know of shows the same thing – differing only in the rate of discontinuation [and leave it at that…
]. So while the contention of the British Psychological Society
and Robert Whitaker’s Mad in America
group that the official channels of psychiatry recommend ongoing maintenance medication as a first-line treatment is correct, it just doesn’t happen. Here’s a long term VA
study of 2138 patients:
Medication compliance is already in the hands of the patients in the vast majority of cases. So the medication approach recommended by the BPS report is likely to make little to no change as it’s already in place. I would add to that my own anecdotal report on a small sample. I had more cases than most in psychotherapy and was pleased with the outcome. They were like the cases quoted here, "good prognosis" cases. I started with the belief that medication was only needed for acute episodes, but with experience, I changed my tune because relapses were so disruptive, discouraging, and expensive. I went from constant worry about relapse to less worry about relapse but constant worry about harms. As with any toxic medication, there’s only worry. The decision to use maintenance medication with holidays was, by definition, collaborative. The decision to stop medication down the road was always in the patient’s hands and they usually knew when to give it a shot. Again, I’m talking about a small number of patients with everything excepting this affliction in their favor – on the right end of the spectrum.
on the medical model and diagnosis
In storm duties… I talked about the bio·psycho·social model suggested by George Engel that, in my opinion, was never really implemented. It’s my "medical model" of choice. I would agree with the BPS that diagnosis can be stigmatizing and either used or experienced as an indictment. It can and has been used to imply an etiology when, in fact, none is known. And people can be misdiagnosed. Even worse, the categorical criteria can be intrinsically flawed [as they definitely are in the DSM-III+ with depression]. Those are all bad things to avoid or even preach against on any available pulpit. But the BPS report suggests that for those reasons, we should abandon categorization altogether, any model that underlies that categorization with it, and goes on to argue that the category doesn’t really exist, but simply represents phenomena along a spectrum with normal mental life.
I have no great love for the DSM-III+, but in this case, I think they did a decent job. First, the diagnosis was initially the gloomy Dementia Praecox popularized by Emil Kraepelin in 1893. In 1911, Eugen Bleuler re-evaluated the syndrome and coined the term Schizophrenia. He described a broad spectrum of people, presentations, and outcomes including complete recovery following a psychotic episode. With Bleuler, diagnosis was not destiny. In the 1980 DSM-III, they separated out Brief Reactive Psychosis and added duration and functional impairment to make sure that the diagnosis didn’t rest on symptoms alone, though they didn’t name a pathognomonic symptom [a symptom that is unique to a syndrome that nails the diagnosis]. I happen to think there is one – the complex described as negative symptoms [though they are inadequately described in the DSMs]. I’ve not seen a case where I was able to explore the history in depth and the negative symptoms weren’t present in some form or another long before the outbreak of frank psychosis [I’m including kids I grew up with and kids of my friends who later developed the classic disorder].
While that may seem an idiosyncratic idea, I’m mentioning it because it has implications. Antipsychotic medications do nothing for negative symptoms, and may make them even more pronounced, particularly in high doses. That could explain the reason so many discontinue medication – it doesn’t help them where they hurt. And it’s in the area of negative symptoms where those who recover are able to improve, either on their own or with help. But here’s what the APA guidelines
Treatment of negative symptoms begins with assessing the patient for syndromes that can cause the appearance of secondary negative symptoms. The treatment of such secondary negative symptoms consists of treating their cause, e.g., antipsychotics for primary positive symptoms, antidepressants for depression, anxiolytics for anxiety disorders, or antiparkinsonian agents or antipsychotic dose reduction for extrapyramidal side effects. If negative symptoms persist, they are presumed to be primary negative symptoms of the deficit state. There are no treatments with proven efficacy for primary negative symptoms.
At times, some people may appear inexpressive, withdrawn, listless, apathetic or unmotivated. They may find it difficult even to find the energy to prepare food or generally to look after themselves. Traditionally these difficulties have been thought of as ‘negative symptoms’: part of an illness. However, they can often be a result of feeling overwhelmed by experiences and trying to cope, or arise from feelings of helplessness and depression. They can also be unwanted effects of the drugs that people are often prescribed
So negative symptoms are either an untreatable indictment ["primary negative symptoms of the deficit state"] or not even there at all – just an illusion or artifact of other processes. Among the many "normalizing" assertions in the report, this one stands out to me as frivolous and potentially counter-productive or even harmful – as harmful as the gloomy APA interpretation. Whether one thinks as I do that the negative symptoms are the primary problem, or have some other way of understanding them, simply whisking them away is an abandoning intervention.
Speaking of the dawn of 1boringoldman time, on the first day I was a psychiatry resident, I was assigned several patients who were already on the acute ward where we worked. The first one I met was a twenty something year old mother of three who had been brought to the hospital after drowning one of her sons to death in the lake in Atlanta’s central park. She had been stopped by bystanders during her attempt to drown the second one, directed to do so by the voice of God. By the time I met her, she had been declared NGRI [not guilty by reason of insanity] and was awaiting definitive placement. She’d been there for a while, and was an obvious favorite of the nurses – a long-stay patient on a short-stay unit. One of the nurses took me aside and asked that I have my sessions with her at times other than between 3PM and 5PM when she watched the after-school children’s programs. The nurse called it "being with her kids" – something she had done with her children daily when they got home from school. The other patients intuitively complied and left the day room to her or sometimes even watched with her.
By the time I met Gloria, she was not psychotic. She would answer questions about what happened with her kids, but didn’t really engage the topic. Her family visited often, and they didn’t talk about her son’s death either. Like the nurses, there was always a tear nearly visible as their looks conveyed both the tragedy and their love. The thing that most struck me about her was her flattened affect and her literalness. She was on a low dose of a first generation neuroleptic which might’ve explained some of the emotional flattening, but I doubted that. It seemed like part of being her. We were taught in those days to assess abstracting ability by asking the meaning of proverbs. She had no idea what they meant. I’m not even sure she got the point of my asking. And her general literalness was pervasive in all conversaton – striking even to my then untrained ear. I awkwardly asked her mother about those things. I think I was wondering if the medication was responsible. But her mother knew exactly what I was asking and said something like, "Oh no, she’s always been like that! I only wish I’d known where it was headed!" And cried painful tears.
I didn’t know it then, but Gloria was the nidus for what I now think about this affliction. As dramatic and disruptive as the psychosis of Schizophrenia can be, I no longer think of it as primary, though it can certainly be an overwhelming and sometimes insurmountable problem. I see the baseline state as the primary affliction – what people call "negative symptoms" or Eugen Bleuler called "Anhedonia." It’s what I was trying to get at in birdman…. To Gloria’s literalness [living in a world without abstract meanings] and her difficulty experiencing or accessing an emotional compass, I would now add a confusion in reading and understanding the subtle but ubiquitous metacommunications in interpersonal experience. Those things contribute to the oft-expressed sense of non-being, of identity diffusion, of confusion, of deadness, or the many other ways people try to explain something that others rarely ever even think about because for them, it is intuitively present and operating automatically. I tried to talk about this in 1. from n equals one…, 2. from n equals one…, 3. from n equals one…, etc. with another example. I know that if a person showed up seeking psychotherapy with just those complaints without psychosis in the story, I’d still be likely to give it my best shot. Those things alone are heavy burdens to carry into a life, particularly a life among people.
I’m not trying to mount an antecdote war here, just trying to give an example. Effective psychotherapy requires a shared view of what the problem is, and is informed by the nature of the problem. Patients can learn how to identify, live with, compensate for, or even change what happens in these states of confusion if that’s the focus of the work. I’ve never seen a patient who came for a therapy who was hurt or demeaned by talking about negative symptoms [again the never word]. They already know about them – every day. And I worry that any approach that doesn’t take them on as a central focus will flounder much in the same way as relying only on medications does. In fact, some of the examples in their own report address these very problems and I was glad to see that. End of sermon.
on rights and laws
It’s not my area of expertise, but it sounds like Thomas Szasz redux to me. Their suggestions are likely to lead to the same thing that we already have in the US – Jails and Prisons filled with mental patients. Psychiatrists are no longer central the commitment process here and there’s no place to commit to, even if they were. It’s a judicial process and the only facilities available to Judges are Jails and Prisons. Maybe it’s different in the UK, but be careful what you ask for.
Their traumatic theory is as speculative as some of the biological theories. I personally doubt its primacy, but how about some proof before NICE buys into the radical change in mental health policy suggested. Chasing trauma has had a powerful pull throughout history [and brought down some of the best of us], but only really worked in patients with clear PTSD as specifically defined. Having spent a career treating a lot of traumatic illness, I don’t personally think that Schizophrenia is primarily a post-traumatic syndrome – certainly not without some solid consistent evidence.
Note: All of that said, I’m the biggest supporter of an informed and focused psychotherapeutic approach to this
illness affliction with the careful use of medications as you’ll ever find [in patients who will come]. But I’m afraid my read on this BPS Report is "back to the drawing board." It’s a polemic. Define what you have in mind in terms other than just not-what-those-psychiatrists-have-thought and set up a pilot project to prove it works. Be sure to take all comers…