Tag Archives: Psychiatry

Who Is Normal, Anyway? Part IV

15 Nov

Crazy people are considered mad by the rest of the society only because their intelligence isn’t understood

– Weihui Zhou

IV – Psychiatry and the DSM

For someone working to help people deal with these conditions, it is helpful to look at specific symptoms, to classify, and to find common causes, and hence common solutions for these symptoms, if they are problematic for the person.

Systematising in this way is what we do well, and gives us our understanding of the world we have, so I don’t have a problem with it. In fact I fully support it.

However, with the failed biological model, this means that symptoms are given arbitrary disorder names and drugs applied to ‘fix’ them. The mainstream approach is predicated on an often unproven assumption of biological cause which leads to harmful decisions.

It also often means people give up responsibility for their conditions, and even for their actions. While this avoids blame it unfortunately goes further and avoids responsibility, resulting in people giving up and just living with their ‘condition’.

Tom Stafford sayswe know that self-efficacy is one of the best predictors of recovery, so denying people’s role in their own decisions just undermines one of their most important tools for recovery“.

The approach I’m advocating here is that you can take responsibility, and that you can change. It means empowering the individual to change for the better if they want to.

So much has been written on the problems with the DSM and approach of many psychiatrists that I don’t need to detail it here.

One purported disorder is pee-shyness, then there’s “caffeine intoxication disorder” and another is “intermittent explosive disorder“.

As you can see, “having some psychiatric symptoms is part of the human condition and does not by itself indicate the presence of mental disorder. The boundary between the worried well and the psychiatrically ill is fuzzy; arbitrary, and subjective—there is no biological test.

Tom Stafford saysThe fact that the most senior psychiatric researchers in the US are now openly and persistently highlighting that the DSM is not fit for the purpose of advancing science and psychiatric treatment is a damning condemnation of the manual.

Neuroskeptic says that “many people are now being prescribed antidepressants for emotional and personal issues which wouldn’t have been considered medical illnesses until quite recently“. He adds that they don’t work very well either.

We really do have a lot to learn about the brain. It was only 60 years ago that Freeman and Watts went around sticking a rod up people’s eye sockets and wriggling it about to mess up their frontal cortex. The frontal lobotomy certainly made them tractable, but left them in a terrible state, usually mentally and physically retarded and sometimes dead. These guys had sod-all idea of what they were doing. Some may say, ‘ah but today we have such a clear understanding of these issues, science has come so far‘. But some of these drugs are like a blunderbuss to the brain. I think that in another 60 years time many of these drugs will be considered an abhorrent way of treating people.

It’s not a question of whether or not these behaviours exist. It a question of whether the psychiatric approach and classifications are helpful. The disease model is fundamentally flawed. And many psychiatrists recognise this.

Final part – What Does Work in the next post

Part III – Stigma in the previous post.

Who Is Normal, Anyway? Part II

18 Oct

It is sometimes an appropriate response to reality to go insane

 Philip K. Dick

II – The Drugs

One of my most popular posts discusses this area, but it’s worth clarifying some points.

My motive is simple – to get the best possible care for people suffering from sometimes debilitating problems.

The question is what does the evidence say is the best solution?

Drugs may ameliorate some of the symptoms of these conditions, but they do not address the causes.

Much like a pain killer is most welcome when suffering with appendicitis, so some drugs can be beneficial to deal with the worst of the symptoms for some of these conditions. However, to stretch the appendicitis analogy, if you only took the drugs to dull the pain, then the appendix may rupture and the results of that ain’t pretty. Besides pain – while unpleasant – is key to diagnosing the cause of the problem.

Similarly with mental problems, drugs can often mask issues. For example I’ve seen a number of people I know suffering from such issues be subdued with a cocktail of anti-psychotics and anti-depressants. Yes, it reduced their worst symptoms, but it also removed all their emotions, all their motivations and drives. One said to me “I feel like an automaton“, another “I’m just a zombie“. Max movingly saysI don’t know how else to explain them except mental handcuffs“. I’ve heard similar comments from other people. I very much appreciate that this approach took away the worst of their distress and behaviour, but it did not get to the root of their issues and help them deal with the causes of their distress. In fact in some cases I’ve seen, the ‘abnormal’ behaviour was a way of the person working through their underlying emotional problems, and this approach stopped their progress in its tracks.

The problem is, these treatments tend to be predicated on the assumption of a biological cause.

Psychiatrist Dr Joanna Moncrieff says “psychiatric drugs…”work” by producing drug-induced states which suppress or mask emotional problems, which may suppress the symptoms of psychiatric disorders, along with other intellectual and emotional functionsThat sounds good. If your brain is not functioning properly“, however what if these reactions to environmental and psychological triggers are in fact adapted functions of the mind, evolved methods of coping with negative situations?

Professor Peter Kinderman saysPsychiatric diagnoses are not only scientifically invalid, they are harmful too. The language of illness implies that the roots of such emotional distress lie in “chemical imbalances“. This leads us to be blind to the social and psychological causes of distress. More importantly, we tend to prescribe medical solutions – anti-depressants and anti-psychotic medication – despite significant side-effects and poor evidence of their effectiveness. This is wrong.”

Allen Frances says that “Medication should be a last resort used only for the clearest, most impairing, and most persistent disorders. Instead the meds are often prescribed carelessly-almost like candy“.

It should be added that most of these conditions cannot be considered in the same way as physical diseases – the pathologies just aren’t there. They are arbitrary assignations that enable us to understand and treat certain common behaviours and feelings. (And that’s not to deride or belittle them in anyway.)

It is clear also, that positive effects of mind-altering drugs can be brought about through the power of the mind, say through meditation.

People say ‘But, but, look at all these people that call it an illness, that treat it with drugs’ – Appeal To The Crowd.

But this doctor with a white coat prescribed these drugs’ – Appeal To Authority.

But they have been treated this way for decades’ – Appeal To Tradition.

People talk about chemical imbalances: correlation? Yes. Causation? Not necessarily. In fact, such markers should be thought of as the result of difficult life circumstances. This is how the brain responds to external events. Hunger is a chemical imbalance. You don’t take drugs to make the feeling go away, you look to the cause of the hunger. You eat food.

While there is evidence of genetic markers that mean people are more prone to, say, depression than others, it’s still their environment that triggers those reactions. Epigenetics is still in its infancy, but it’s clear that environment can activate and deactivate genes.

The gene blame game makes popular headlines but is not scientifically accurate. It’s a little more subtle than that.

The biological / genetic model is appealing. Its reductionist and simplistic approach makes it easy to understand and to treat. However that doesn’t mean it’s always correct.

So beware the seductive but pernicious idea that medication heals people in all of these situations. The evidence shows it doesn’t. It only manages symptoms. Or worse, is used to make people manageable.

Part III – Stigma in the next post

Part I in the previous post.

Who Is Normal, Anyway?

3 Oct

The Mad Hatter: Have I gone mad?

Alice: I’m afraid so. You’re entirely bonkers. But I’ll tell you a secret: all the best people are.

– Alice In Wonderland

People who have had nasty stuff happen to them are likely to act a bit differently, particularly when placed under stress.

Some people who don’t act normally are called mentally ill, and given labels to say they have this or that disorder.

While there is utility in such arbitrary labels, it is clear that there are also counterproductive results.

It’s a matter of subjective judgement whether certain behaviours are considered abnormal. And that’s often as much down to the way society works as the individual.

For example not so long ago homosexuality was a mental illness, with it’s own symptoms and then it wasn’t. Just like that. Now it’s considered as normal and healthy. Even nostalgia was defined as an illness until recently. Again, whether delusions are considered problematic can be a grey area: “Delusions, in the medical sense, are not simply a case of being mistaken, as the everyday use of the term suggests. They are profound and intensely held beliefs that seem barely swayed by evidence to the contrary – even to the point of believing in the bizarre.” Religion is a great example of this, but we don’t pathologise such behaviour. The thing is, everyone holds some delusional beliefs – it’s part of the human condition.

It seems clear that psychiatry makes some of these judgements based on what is acceptable to society as much as what is unhealthy for the individual. It’s not exactly rigorous science. While there are biological markers for a few states of mind, for the majority there are not, so we resort to classifying behaviour. How do we define what behaviours are the results of “mental illness” and what are normal? One suggestion is defining the behaviour of the majority as the norm, and classifying everyone outside of that average as disordered. The faults with that approach are immediately clear. Another suggestion is whether that behaviour causes self harm. If so smokers, or those with a bad diet, are defined as mentally ill.

So we then look to the perceptions and feelings of the person. Phenomenology, is the best tool for this, but is again subjective and imprecise. We can also look at whether these behaviours affect a person’s ability to lead a normal life, which requires normality within their culture to be defined.

Of course there are many difficult conditions that one would have difficulty arguing against being classified as problematic in any society. I’m acutely aware that severe depression can be debilitating, that psychosis can mean a person is unable to care for themselves. I’ve seen it first hand. Mind says that 1 in 10 adults are experiencing depression at any one time. Over 10% of mothers experience post-natal depression. Around 1% of people experience bipolar symptoms at some point.

However, while these methods will have clearer conclusions at the extremes of behaviour, there are massive grey areas in between.

The conclusion then, is that this is not a simple, easily solvable area. An acceptance that we don’t have black and white definitions is necessary, much as that is not satisfying. And as a result we don’t have panaceas either.

Part II – The Drugs in the next post

The Drugs Don’t Work

15 Jul

Instead of asking what is wrong with you, we need to ask what has happened to you.

– Dr Lucy Johnstone

Recently the British Psychological Society called bullshit on those claiming the efficacy of the arbitrary psychiatric diagnoses in the DSM†, and the drug based treatments in which they usually result.

They have released a report whose abstract reads:

The DCP believes there is need to move away from psychiatric diagnoses such as schizophrenia, Attention Deficit Hyperactivity Disorder, personality disorder and conduct disorder, which have significant conceptual and empirical limitations, and develop alternative approaches which recognise the centrality of the complex range of life experiences in the emergence of mental distress, and the personal impact of social and relational circumstances including trauma.

The best overview of the report comes from this short interview with Johnstone on Radio 4, which is well worth the listen. I’ve added an abridged version of the interview text below.

Of course the BPS are not the only ones to hold this view. The National Institute of Mental Health issued an inflammatory press release criticizing current psychiatry for being “brainless and invalid“. Plenty of others have been publicly pushing this, and much stronger views, for many decades. For example, in the sixties, notable luminaries such as RD Laing and Michael Foucault, not to mention many “survivors” groups.

The Interview
John Humphries: “Schizophrenia is a terrible disease. It destroys many lives, the people who suffer and those who have to live with them, and yet there is no scientific evidence that a diagnosis of it is vital or useful. That is the view of the British Psychological Society itself. The same goes for bipolar disease.

I’m joined by Dr Lucy Johnstone who’s a Consultant clinical psychologist, and she’s on the working party that drew up that statement.

Dr Lucy Johnstone: “This isn’t an argument between psychologists and psychiatrists. Many psychologists, many psychiatrists and many health professionals are united in saying that the evidence for the current way of understanding mental distress, just doesn’t exist“.

The DCP [Division of Clinical Psychology, part of the BPS] has issued this consensus statement: there is actually no evidence for the current view – and we agree with many senior psychiatrists in saying that – we do have an overwhelming amount of evidence that even severe psychiatric breakdown is actually the end result of a complex mix of social and psychological circumstances. People who have suffered things like bereavement, loss, discrimination, poverty, trauma, abuse, domestic violence, in other words things that have happened to you.

John: “So where does that leave us in terms of treating it? Because there is no question that it is a disease. Schizophrenia is a horrible thing?

Lucy: “Well actually that’s exactly what we are questioning. We are questioning the disease model, along with many psychiatrists. Of course the distress is very real.

John: “Doesn’t that make it a disease? If you are desperately distressed, to the point sometimes of killing yourself, or harming somebody else perhaps, doesn’t that make it a disease?

Lucy: “Well there’s no evidence that it does. We are told a great deal of stuff about genes or biochemical imbalances, and as one of America’s most senior psychiatrists said only a couple of weeks ago, we have been telling patients for several decades that we are waiting for biomarkers, in other words evidence for a disease process. We are still waiting. So these are very serious problems, but there is an increasing amount of evidence that there is a way of understanding them, for example very often as the end result, not always, of extremely severe trauma.

John: “But you can’t turn back the clock, you can’t remove that trauma or make it never happen, so how do you deal with this, whatever you call it, disorder?

Lucy: “We would probably not want to use the term disorder. It does bring into question all the traditional vocabulary. We are actually calling for a change of language among other things.

John: “How does this understanding change the way you treat it?

Lucy: “It changes it in a very helpful and ultimately very productive way: in essence, instead of asking what is wrong with you, we need to ask what has happened to you? People break down for reasons, those reasons aren’t always immediately obvious, it can take quite a while to put the pieces together, but once we know those reasons we can offer them the right help to recover.

John: “Which would probably be counseling rather than drugs would it?

Lucy: “Well drugs might well play a part but i think we have to be clear about the role of medication. If we’re talking about the end result of complex social and relationship problems, by definition medication can’t solve those. It can certainly help keep people going, it can certainly help with some of the more overwhelming themes of distress. But essentially, what psychologists would say, we use a jargon word, which is formulation, which is a way of putting together the psychological evidence about the impact of very difficult life experiences, understanding how those affected the person in front of you, the personal meaning of those events, and on that basis you draw up an individual plan which will actually have a very good chance of helping that person recover.

John: “Well that’s encouraging. Dr Lucy Johnstone, thank you very much indeed.

Conclusion
As a close friend of mine with first hand experience of such issues said: “I sincerely hope that this discussion will eventually go on to reduce a lot of unnecessary suffering“.

† The DSM is the  Diagnostic and Statistical Manual of Mental Disorders, containing definitions of certain states of mind from depression to “Disruptive Mood Dysregulation disorder”, with has implications on how people are diagnosed and hence treated. I’ve referred to this previously.

How Well Does Freud’s Work Stand the Test of Time?

18 Jun

I recently went to a lecture by psychiatrist Allen Frances MD in which he argued that Sigmund Freud was half right and half wrong. And just because half of his ideas aren’t right it doesn’t mean that we should throw out the rest, as is popular these days.

Interestingly, Frances asserts that Freud didn’t come up with many original ideas, rather he was excellent at bringing together the latest ideas into an overarching and coherent model linking the brain and the mind. In particular he took Darwin’s work and popularised it. The excessive sexualisation within Freud’s work comes from the idea that natural and sexual selection “leads to the evolution of instincts, emotions and intellect“. What this means is that psychological behaviour is informed by sexual selection, i.e. we try to be more attractive. And therefore in Freud’s mind, the key link between the brain and the mind is the libido. He used the analogy of the brain as a hydraulic power plant, and the libido as the power source. As such, issues with the mind are due to build up, discharge or transfer of this energy.

From Darwin he took the ideas of “instinct interacting with the environment” and “everything has or once had a purpose“, ideas still alive and well today. He also took “introspection and dream analysis“: dreams “explain not only symptoms, but myth, art, literature and psychopathology of everyday life“. He saw the unconscious as having a major role in influencing behaviour. Dreams therefore are a great research tool as a window into the unconscious. However the jury is still out on what dreams & sleep are really about, though there is a clear link between them and memory and psychological stability.

Freud also took from Darwin the idea of comparing animal and human behaviours. He challenged human exceptionalism, that being the idea that we humans are somehow above all the other animals. I’ve written about this before, and it’s clear that we can learn much about ourselves by studying other animals, such as the bonobo ape. This was quite revolutionary thinking at the time – Frances called this “the most amazing discovery in the history of psychology“.

Also controversial at the time was his materialist view of human nature. No Cartesian dualism for him.

While he is most famous as the father of psychoanalysis he “began his professional career as a neurologist and made several notable contributions to the fields of neurology, neuropathology, and anesthesia“. He had the “ability to observe and describe a variety of disease processes“. He predicted epigenetics and pushed forward our understanding of neurons with his experiments. He did a lot to help further understanding how brain nerve cells worked and communicated.

Prior to Freud people were really writing about how the mind works from a first person perspective, and what Freud introduced was a slightly more empirical approach. He did this by looking at other people, even his own children. However, “he didn’t have much respect for experimental psychology, and certainly not for statistics“. So his approach was more rationalist than empirical: he would build up a convincing sounding theory but then not bother to do experiments to verify them.

This was one of his big blind spots: he was unable to keep followers that disagreed with him so couldn’t benefit from criticism. In fact he maintained that his detractors were neurotic! Frances claimed that what he saw in his patients were in fact his own modes of thinking he was protecting onto others. He wasn’t aware that someone could see things differently if they had a different set of experiences.

Sadly, Frances says, this still goes on today, with various groups and institutes having their own grand theories, and so closing their ears to new theories and research.

Francis added other defenses of Freud’s contributions, the big one being psychoanalytical practice – he can be considered the father of all modern talk therapies. He came up with the idea that psychosis is just carrying dreams in to waking state so the subconscious is not repressed. This clearly fits with the data today and means the condition is much easier to understand. He made the amusing observation that economists are just coming up with the idea that humans are not rational actors – if they’d have read Freud they might have come up with this earlier. I disagree with this – just because we don’t always understand our motivations, it doesn’t necessarily imply a lack of rationality.

One thing Frances didn’t mention was Freud’s negative view of the unconscious. He considered it to contain thoughts and urges  that are unacceptable to society: dark and immoral desires. Hence Freudian slips, and so on. It was, in his mind (pun intended), something to be controlled and kept at bay. Some have said that this held back research into the mind for decades.

However we now see the unconscious as something valuable, full of black box functions that allow us to do things without thinking. For example, I’m not thinking about the keys I’m pressing, the letters, morphemes or structure of this sentence. I’m simply considering the meaning I’m trying to convey and the rest is taken care of for me by my unconscious mind.

He summed up saying that we still understand so little about the brain and how it links to the mind, and consciousness. Brain imaging (fMRI) doesn’t say as much as we think – it’s way oversold. Plenty of people have commented on this saying that neuroscience is in its infancy. However we now have a much better model of the mind, that being the computational one: it’s about information processing rather than energies, and symptoms are a result of either hardware of software malfunction.

Addendum – Psychiatry In Crisis

Allen Frances is a sound chap. He is a psychiatrist who “was the Chair of the Task Force that prepared the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), often called the bible of the American psychiatric profession. However, he has been a vocal critic of the new DSM V, condemning what he calls its diagnostic hyperinflation. His new book, Saving Normal, explores why psychiatry has always been subject to so many fads, while deploring the medicalisation of everyday human experience and the excessive use of psychiatric medicine“. Given that overview I was sold.

During questions he opened up on the idiocy of much of modern psychiatry. He is a psychiatrist and he says that big pharmaceuticals have taken over the profession, and pedaled the nonsense that biological changes can be made with drugs and so fix people’s problems due to their “chemical imbalances“. He says this has harmed people. The brain is a very sophisticated computer so yes we need to understand it’s biology, but we also need to understand its workings.

He says that DSM III was useful to give more standard accepted criteria by which to admit people to hospital, but the unintended consequence is that people now just get 10 minutes with a psychiatrist ticking off items on a DSM checklist and prescribing drugs. 80% of these mind-altering drugs are prescribed by GPs or psychiatrists in such short consultations. Now “the DSM is rushed to publication to make money, by a small American association with 35000 members“. He reiterates his point, saying it’s so dangerous because these new silly diagnoses mean more harmful drugs are given to people. He quoted one psychiatrist who says that she recognises herself in almost every condition in the DSM. Some people like labels: it helps them feel understood and part of a group. But people can feel permanently stigmatised, and too often is used to explain away behaviours or abdicate responsibility.

Everything we do in life has a psychological impact. The great thing is this means that psychotherapy changes brain functions. The theme he kept coming back to was that in psychological therapy, it’s the relationship that makes the difference.

He quoted Hippocrates who said “it’s more important to know the patient that has the disease than the disease that the patient has“.

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