{"id":41309,"date":"2013-11-04T08:00:40","date_gmt":"2013-11-04T13:00:40","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=41309"},"modified":"2013-11-04T06:48:58","modified_gmt":"2013-11-04T11:48:58","slug":"point-made-and-taken","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/11\/04\/point-made-and-taken\/","title":{"rendered":"point made and taken&#8230;"},"content":{"rendered":"<div align=\"justify\"><a target=\"_blank\" href=\"http:\/\/en.wikipedia.org\/wiki\/Emil_Kraepelin\">Emil Kraepelin<\/a>&#8216;s term, Dementia Praecox, literally means a markedly abnormal mental state that came on in young adulthood, usually progressing to an early death. He thought it was a deteriorating brain disease. <a target=\"_blank\" href=\"http:\/\/en.wikipedia.org\/wiki\/Eugen_Bleuler\">Eugen Bleuler<\/a> later wrote about the cases in greater detail &#8211; noting that many cases recovered and left the hospital. He described &quot;the four As&quot;: Ambivalence, Autism, Affect, and Associations &#8211; respectively an inability to resolve conflicting ideas, a private logic, inappropriate or flattened emotional reactions, and a disjointed train of thought. Later, &quot;the 5th A&quot; was added &#8211; Anhedonia &#8211; referring to a seeming poverty of positive emotional experience [negative symptoms].&nbsp; <a href=\"http:\/\/en.wikipedia.org\/wiki\/Kurt_Schneider#First-rank_symptoms_in_schizophrenia\" target=\"_blank\">Kurt Schneider<\/a> listed first rank symptoms of Schizophrenia including:<\/div>\n<blockquote>\n<div align=\"justify\">&bull; Auditory hallucinations<\/div>\n<ul>\n<div align=\"justify\">1. Voices heard arguing or giving instructions [2nd person]<\/div>\n<div align=\"justify\">2. Voices heard commenting on one&#8217;s actions [running commentary, usually describing the patient in the 3rd person]<\/div>\n<\/ul>\n<div align=\"justify\">&bull;  Somatic\/thought passivity experiences [delusions of control \/ of being controlled]<\/div>\n<div align=\"justify\">&bull;  Thought echo [thoughts being heard aloud]<\/div>\n<div align=\"justify\">&bull;  Thought withdrawal<\/div>\n<div align=\"justify\">&bull;  Thought insertion [thoughts are ascribed to other people who are intruding into the patient&#8217;s mind]<\/div>\n<div align=\"justify\">&bull;  Thought broadcasting [also called thought diffusion]<\/div>\n<div align=\"justify\">&bull; Delusional perception [linking a normal sensory perception to a  bizarre conclusion, e.g. seeing an aeroplane means the patient is the  president]<\/div>\n<\/blockquote>\n<div align=\"justify\">There have been many others &#8211; <a target=\"_blank\" href=\"http:\/\/en.wikipedia.org\/wiki\/On_the_Origin_of_the_%22Influencing_Machine%22_in_Schizophrenia\">Viktor Tausk<\/a> who described delusions involving an Influencing Machine; <a target=\"_blank\" href=\"http:\/\/www.jstor.org\/discover\/10.2307\/2770703?uid=3739616&#038;uid=2&#038;uid=4&#038;uid=3739256&#038;sid=21102862601587\">John Cameron<\/a>&#8216;s ideas about the Pseudocommunity in paranoid delusions; or <a href=\"http:\/\/www.medscape.com\/viewarticle\/752207_5\" target=\"_blank\">H.C. R&uuml;mke<\/a>&#8216;s concept of the Praecox Feeling. And so it has gone for the last century as countless people have tried to nail down an answer to the questions raised in <a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/11\/03\/a-guest-post-from-sandy-steingard\/\">a guest post from Sandy Steingard&hellip;<\/a>. And there are a lot of questions. What is<em> Schizophrenia<\/em>? Is there even an entity <em>Schizophrenia<\/em>? Where&#8217;s the line between a delusion and an odd belief? Are psychiatrists helping people with psychosis? And with every question, there&#8217;s the explicit or implicit &quot;<em>how do you know that?<\/em>&quot; To complicate matters, there&#8217;s the question of &quot;help seeking&quot; patients, patients who present to physicians looking for help. Many of the patients under discussion don&#8217;t seek help. They&#8217;re brought relucantly by family, friends, or policemen. And many are very vocal about not wanting to be there. From a description of Tausk&#8217;s 1919, The Influencing Machine:<\/div>\n<blockquote>\n<div align=\"justify\"> The delusion often involves their being influenced by a &#8216;diabolical  machine&#8217;, just outside the technical understanding of the victim, that  influences them from afar. It was typically believed to be operated by a  group of people who were persecuting the individual, whom Tausk  suggested were &quot;to the best of my knowledge, almost exclusively of the  male sex&quot; <strong><font color=\"#660033\">and the persecutors, &quot;predominantly physicians by whom the  patient has been treated&quot;<\/font><\/strong>.<\/div>\n<\/blockquote>\n<div align=\"justify\">I came to psychiatry from Internal Medicine looking to learn about the tangles I&#8217;d encountered in my medical patients, and just to confirm what everyone thinks about psychiatrists, I was looking at my own tangles at that point as well. In addition, my only sibling had been rescued from a very dark place by a successful analysis. Such things are big influences. And then I was on the super-acute service at Grady Hospital in Atlanta spending my days with psychotic people in an era when the old State Hospitals were deinstitutionalizing &#8211; a euphemism for closing down &#8211; and we were flooded with patients. My previous experience with psychotic people wouldn&#8217;t make a handful and I might as well have been lowered into a jungle in Viet Nam without basic training. At least that&#8217;s how it felt.        <\/div>\n<p align=\"justify\">But there&#8217;s something about psychosis that&#8217;s intrinsically fascinating, at least to me. I read all those books and many others, and once I got my head above water, I mused some about the questions Sandra raised. I say &quot;some&quot; because the cases that made it to Grady weren&#8217;t subtle &#8211; they were psychotic with a capital &quot;P&quot;. But later, in the clinics and mental health centers where I followed people who came of their own accord not under extreme duress, I struggled with those same questions. I must add that it was a very different time &#8211; actually a better time in my view. It was a time when psychiatrists, psychologists, social workers, nurses, etc. were judged [to borrow a metaphor] not by the color of their degree, but by the quality of their skill in helping our patients. And the model was bio<font color=\"#200020\">psycho<\/font><strong><font color=\"#200020\">social<\/font><\/strong>. The divisions of labor and the strictly biomedical role of the psychiatrist wasn&#8217;t so much a part of things. About that time, I took on a patient I&#8217;ve described here [<a href=\"http:\/\/1boringoldman.com\/index.php\/2011\/08\/22\/1-from-n-equals-one\/\">1. <em>from n equals one<\/em>&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2011\/08\/22\/2-from-n-equals-one\/\">2. <em>from n equals one<\/em>&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2011\/08\/23\/3-from-n-equals-one\/\">3. <em>from n equals one<\/em>&hellip;<\/a>]. I&#8217;ve seen psychotic patients throughout my career, but this is the patient I followed from right after residency until I retired, and a lot of what I think is based on that case. I make no apology for that. Not many people have that kind of opportunity.<\/p>\n<div align=\"justify\">I mention the case in response to the debate in Sandy&#8217;s post and the comments about differentiating a psychotic thought from something else. In those posts, I describe as much as I intend to about the case [by the way, she did once spontaneously tell me if talking about her would help anyone, it was fine except for identifying information and certain experiences]. In response to Sandy, Dr. Carroll talked about &quot;<em>insight<\/em>&quot; and added later &quot;<em>no one sign is a touchstone for diagnosis or prognosis or response to treatment<\/em>.&quot; I agree with both of those things, but something my patient said along the way always stayed with me. A colleague of mine had written a paper that noted that patients who looked back on their psychotic experiences with interest and tried to figure out what was going on had a better prognosis than people who pushed the experience off the table and didn&#8217;t want to talk about it. My patient was definitely in that former group, and we went over and over what lead up to her periodic psychotic episodes:<\/div>\n<blockquote>\n<div align=\"justify\">She became adept at identifying things that &quot;triggered&quot; her discomfort. She had numerous flirtations with psychosis. So for a time, we met  erratically &ndash; when she felt &quot;it&quot; happening. <strong><font color=\"#660033\">Her way of describing the  danger signal was &quot;special meanings.&quot; She meant that when she felt like  something happening was a communication meant uniquely for her.<\/font><\/strong> Those  things always went back to either emotional ambiguity or confusing  abstract meanings &ndash; always.<\/div>\n<\/blockquote>\n<div align=\"justify\">I&#8217;d add that &quot;special communication&quot; to the mix. I can spare you the effort of shooting my comment down. There are jillions of perfectly sane people who say &quot;there are no coincidences&quot; or find &quot;special messages&quot; all over the place, but what my patient was describing was qualitatively different. We both thought that. And as long as I&#8217;m talking about it, the temporal course of things has always seemed important. In psychosis, the unusual ideas escalate fairly rapidly and take over the mind. In her case, I once found her locked in the bathroom of my office for safety within 24 hours of one of those &quot;special&quot; communications.<\/div>\n<p align=\"justify\">But back to the homogeneity of Schizophrenia. Although the cases that fit Bleuler&#8217;s classical description of Schizophrenia feel like a unitary syndrome to me, one my patient fit to a tee, I take Dr. Steingard&#8217;s point. It&#8217;s what I &quot;think&quot; or &quot;feel&quot;, not what I &quot;know&quot;, and those cases are only a subset of patients labeled Schizophrenic. I find her observations in her practice intriguing. Is the psychosis we&#8217;ve called Schizophrenia or some sub-set of it biological? I think probably so, but again, it&#8217;s a &quot;think&quot; or a &quot;feel&quot;, not a &quot;know&quot;. So point made and taken. But there&#8217;s one thing I do <u>know<\/u> for sure. Psychosis is <u>not<\/u> an &quot;antipsychotic deficiency.&quot; While I never did think that, I have appreciated Robert Whitaker&#8217;s perspective on the light use of medication for acute symptoms and then backing off. That&#8217;s what I actually did with the case I&#8217;m talking about as best I could. I never could get her totally medication free for long. If I were seeing her now, I would&#8217;ve tried maintenance anxiolytics rather than a low dose neuroleptic. My intuition is that would&#8217;ve worked. I just didn&#8217;t know that then. I&#8217;d much&nbsp; rather that we had worried about dependency than dyskinesia.<\/p>\n<p align=\"justify\">Parenthetically, there&#8217;s something that hasn&#8217;t gotten its fair share of press. Drs. Taylor and Fink have successfully peeled <a target=\"_blank\" href=\"http:\/\/ajp.psychiatryonline.org\/article.aspx?articleID=176314\">Catatonia<\/a> out of the Schizophrenia spectrum in the DSM-5 and described its treatment in detail. While it&#8217;s a rare syndrome and only a piece of the puzzle, theirs is a fine accomplishment. Something else to throw into the parentheses, historian Ned Shorter has a blog post up on the very topic of the non-unity of Schizophrenia in <strong><font color=\"#0066cc\">Psychology Today<\/font><\/strong> &#8211; <a target=\"_blank\" href=\"http:\/\/www.psychologytoday.com\/blog\/how-everyone-became-depressed\/201311\/breaking-schizophrenia\"> Breaking Up &ldquo;Schizophrenia&rdquo;: Following science will soon lead to other ways of describing chronic psychosis<\/a>. And finally about those antipsychotics, even Dr. Clinical Neuroscience, NIMH Director Tom Insel, made a stab at listening to the music recently [<a target=\"_blank\" href=\"http:\/\/www.nimh.nih.gov\/about\/director\/2013\/antipsychotics-taking-the-long-view.shtml\">Director&rsquo;s Blog: Antipsychotics: Taking the Long View<\/a>, <a target=\"_blank\" href=\"http:\/\/www.huffingtonpost.com\/bruce-e-levine\/schizophrenia_b_4093287.html\">NIMH Director Rethinks Standard Psychiatric Treatment for Schizophrenia<\/a>].<\/p>\n<div>And thanks again Sandy. Come again&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Emil Kraepelin&#8216;s term, Dementia Praecox, literally means a markedly abnormal mental state that came on in young adulthood, usually progressing to an early death. He thought it was a deteriorating brain disease. Eugen Bleuler later wrote about the cases in greater detail &#8211; noting that many cases recovered and left the hospital. He described &quot;the [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-41309","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/41309","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=41309"}],"version-history":[{"count":26,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/41309\/revisions"}],"predecessor-version":[{"id":41335,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/41309\/revisions\/41335"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=41309"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=41309"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=41309"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}