From: Pharmacological treatment of mental disorders in primary health care
© World Health Organization 2009

Basic principles of prescribing

1.16 In general, polypharmacy should be avoided. The term polypharmacy defines the concurrent use of two or more medicines belonging to the same pharmacological class (for example two or more antipsychotics or two or more antidepressants).

Please read Ron Unger’s latest post Anatomy of a Delusion, based on his reading of Robert Whitaker’s Anatomy of an Epidemic. He writes:

What I am struck by is the similarity between the dynamics around the delusions of those who get psychiatric labels, and the delusions of the mental health system itself.

His post then lists some really good delusions of the mental health system which are also uncannily similar to the delusions of mental health clients. This is Ron Unger writing at his usual best. Here’s number 4 on his list of delusions invested in by the client, which is darn similar to the delusion of the mental health system vis a vis medication, when you think about it.

Even starting to question the delusion is scary & upsets psychological equilibrium, as even considering that one might have been so wrong about something creates a sense of “losing one’s grip on reality.” This loss of equilibrium when one starts to question the delusion is taken as evidence that it should not be questioned.

Whitaker in his book, writes about the young woman/old hag optical illusion. This is the drawing that most of us are familar with that shows a young woman, if you look at the drawing one way, and an old hag if you focus on it another way. Whitaker is writing about it more in terms of a perceptual illusion in which the public prefers to believe that psychiatric drugs produce outcomes like the beautiful young woman, but he writes that a closer look will reveal what the public doesn’t see – long term use of psychiatric drugs reveals the old hag, an different picture.

The young woman/old hag drawing is also useful in explaining how illusions/delusions can quickly turn to disillusion when it comes to psychiatric medication. Seeing the beautiful young woman is the illusion that I invested in the first couple of years of Chris’s “illness.” Gradually, disillusionment set in and and I finally was able to see the old hag. Both are there, if you look for them, but once you have seen the hidden perception, it is hard to regain the original image. Now, trying to recapture the beautiful young woman image is almost impossible for me. I know she’s supposed to be there, but I don’t see her.

It’s Mother’s Day in France. Since I missed getting this out earlier, here are some selections from the New Yorker Book of Mom Cartoons.

Little girl dining out with her parents. “You order for me, Mommy. You know what I like.”

Little boy walking with his father: “Dad, if Mom ever gets another boyfriend, I hope he’s just like you.”

Mother and female friend sitting on couch with little boy spray painting “I need love” on the wall behind them. “Oh, he’s just trying to get my attention.”

Father and son about to cross in the middle of a busy street: “Tell your Mom we crossed at the corner.”

Gift card categories to choose from for Mother’s Day: Earth; Career; Loving, Biological; Surrogate; Unwed; Unfit

Hollywood producer type welcoming his ancient mother into his office: “Mom, baby!”

Woman at cocktail party: “I don’t have to choose between baby and a career. I’m a surrogate mother.”

Here is a comment that I posted today to Family Dysfunction and Mental Health: Dr. Allen, like so many psychiatrists, sees schizophrenia as a special case, a “true brain disease,” that is generally unresponsive to anything but medications.

Dr. Allen: When I began writing this blog, I expected to be attacked by those folks who think that child abuse and dysfunctional family interactions are a figment of the imagination of a bunch of whining liars, and that the problem with modern psychiatry is that we are just not prescribing near enough drugs. I was waiting with baited breath to hear the phrase, “Parent Bashing.”

My response:
Hang on, hang on, here. To quote you “This blog covers mental health, drugs and psychotherapy with an emphasis on the role of family dysfunction in behavioral problems.” A lot of what you call negative comments come from people who take issue with your opinion that schizophrenia and bipolar are “true” brain diseases. The commenters I have seen who take issue with your opinion of bipolar and SZ are people who actually believe (including me) that these conditions arise from Family Dysfunction. Many people diagnosed as bipolar and schizophrenic believe that it is family dysfunction that made them what they are and you are telling them that they are wrong? Oh, no, you have a true brain disease, you say. Take this pill and go away.

How many ways do you want to have this, Dr. Allen? To replay one of your answers to an earlier comment of mine, you wrote “I certainly do not want the mothers of psychotic patients to blame themselves for their child’s illness, as such guilt generally is toxic to everyone in the family.” Hello? Your blog is about linking Family Dysfunction to Mental Health. I am linking Family Dysfunction to Schizophrenia. Your professional view of schizophrenia is a bit schizophrenic, IMO. It is weird, quite frankly, that you see schizophrenia and bipolar as a brain disease and not a mental health problem.

I can’t help but notice that you are getting most comments from people with a bipolar or schizophrenia background. Something about your blog twigs with them, but not with other people, judging from the lack of comments. But you are dismissing them as being negative and insisting that THEY’VE got it wrong. You are getting almost no comments from anybody else, I’ve noticed. Where are the personality disorder people that you treat? Can’t they come up with a comment or two? What about fellow psychiatrists. Where are they in the comments? I would appreciate it if you would look at the people who actually are caring enough to respond to you and think about perhaps opening your mind just a smidgen to the possibility that mental health and family dysfunction includes schizophrenia and bipolar.

When I read a book about schizophrenia, I am always looking to see what things that I can emulate in order to help my son get through his own particular version of schizophrenia. This kind of guidance is virtually non-existent unless you read about it from people who have been there themselves.

It is easy to dismiss Elyn Saks as an over-achieving drama queen. Many people think that hers must be a mild case of schizophrenia since she is such a high achiever. I am amazed that she racked up all the credentials that she has while clearly psychotic much of the time. However, by doing this she has also demonstrated the elasticity of this diagnosis, and she has anecdotally pointed out some valuable insights for the rest of us. Her story will be disappointing for people who see getting off medications as a pathway to recovery because she finally admitted to herself, after years of refusing to take them, that she needed the medication to function. It just goes to show that there is no one size fits all solution.

When I read these first person narratives, I always ask what information is available now that wasn’t available then or what did the person not do that might have helped? None of this guarantees, of course, that the outcome would have been any different. Elyn Saks did not explore vitamin therapy. Vitamins in large doses such as vitamin B3 (niacin) act like drugs and there are no negative side effects. Energy medicine, which has also helped my son, was not widely known back then, and so there is no mention is this book of therapies that could correct an energy imbalance

I have learned enough through my own investigations to see that certain factors were in her favor outside of just being female. One is that her family let her do her thing. It is sometimes said that the family has to be involved but not over-involved. This is what is called Expressed Emotion (EE). Patients with families exhibiting low EE are found to have better outcomes when it comes to schizophrenia. When I first was trying to find out some useful information about what to do for my son, I was intrigued to read that many doctors feel that people do best whose families don’t seem to notice that their relative is ill. Elyn Sak’s parents win top prize in that category, though it probably wasn’t a deliberate strategy on their part. Once I caught on to this simple but elegant idea, I began practicing it with my son. It seems to work because it thrusts a certain responsibility on the person while they remain clueless about how really worried you are. They are less anxious this way. You will eventually be less anxious, too, by practicing low EE.

People who get labelled schizophrenic are often overly attached to their family. They are usually the dutiful, thoughtful, “good as gold”, achieving child. This almost guarantees that their passage into adulthood will be troublesome in really weird ways. Becoming an adult and leaving the framework of the family frightens them. Rather than get angry and rebel (a time-honored method of achieving independence), many go psychotic. Highly sensitive to begin with, they simply freak when it becomes apparent that soon they will soon be venturing further into the world or that the world is putting more demands on them. They are, of course, way too “considerate” of their parents. German theologian and counsellor Bert Hellinger says that individuals with schizophrenia are particularly sensitive to (though consciously unaware of) family trauma often originating four generations in the past. They “self-sacrifice” for a parent as a way of atoning for past family trauma. In this case, Elyn Saks is no exception. Early on, she told a therapist that she no longer wanted to see her (Karen) because her parents were upset that the therapist hadn’t figured this out and come up with a plan, and that it cost them too much money to continue to see her. “It never occurred to me back then (and if it occurred to Karen, she didn’t say so) that I was taking better care of my parents than I was of myself.”

The drug rehab program that she was forced into in high school by her parents left her no time to think for herself beyond the confines of what she was told to do and how to act. This may have worked to her advantage, not because she was abusing drugs (she wasn’t) but because it gave her a framework of hard work and structure to her day that she was able to use throughout her psychosis. She always reached out for someone to hang onto, like clinging to a doorframe in a high wind, using that person as a frame of reference for her day. In her Oxford years she allowed time for herself to be clearly psycho within a framework of rigorous Kleinian psychotherapy, and then sobered up somehow during the rest of the day and went back and racked up more academic credentials. It was astonishing to me that the analysis that she underwent on a daily basis for three years in England didn’t seem to lift her psychosis. She literally clung to the analyst right up until the day she left to go back to the United States, weeping and being her usual psychotic self. She had unknowingly done what psychiatrist Thomas Szasz advises. She found herself a contractual psychiatrist unconnected to an institution. She paid out of pocket for the privilege and she got what she wanted, rather than having the State force its one size fits all approach on her.

The high school drug rehab program also gave her a lifelong aversion to taking any drugs, whether legal or illegal. If you read Robert Whitaker’s new book, Anatomy of an Epidemic, you will see that her success, messy as it is, may be in large part because she continually refused to take the antipsychotics that were offered her. Whitaker’s book extensively documents that long term use of psychiatric drugs leads to poorer outcomes. Psychiatrist Daniel Carlat says: “We often talk about neuro-transmitters like serotonin and noroepharin. But that really ends up being neurobabble. It sounds impressive to patients and it makes them think we know what we’re doing when we’re prescribing the medications. But we don’t really know how these meds work.” Side effects, said Carlat, can be serious or in some cases, unknown. “We don’t know enough about the side effects to know how many people we’re putting at risk.”

Elyn Sak’s very messy psychotic life almost tempts me to say that an antipsychotic introduced earlier would have helped get her life together, and I am someone who is not at all in favour of relying on drugs to solve personal problems in living. Reading this book I am tempted to think “oh, please, just try an antipsychotic,” but I am only too aware that psychiatric drugs can put you in a never-ending nightmare. They are major tranquillizers that set most people spinning off into long periods of relapse, weight gain, apathy, and unemployment. Should Elyn Saks have chosen the drug route, my guess is that she would not be where she is today, but there is also the possibility that had she received drugs earlier, she may have pulled herself together sooner and spared herself years of agony.

Another affirmation I got from this book is, if someone tells you that a certain therapy worked for them, then don’t wait for the latest “scientific” evidence or psychiatrists to give it their blessing as a therapy in order to try it for yourself. Everybody “knows” apparently, that psychoanalysis “doesn’t work for schizophrenics.” Elyn Saks gives Kleinian psychotherapy (think Freud) major credit in helping her cope. Freud has been routinely trashed by modern psychiatry as unhelpful for schizophrenia. However, as her therapist pointed out to her back in the early 1980s, therapists have built on Freud’s work as the basis of their work with schizophrenia. This influence doesn’t seem to be well recognized today in an age where people think Freud has no relevance. Luckily for Elyn Saks, she didn’t know what everybody else knows.

One can quibble by saying that since she still suffers from psychosis, then what good did psychotherapy do? I understand that she is now in training to be a psychoanalyst so she must believe in it strongly. People say the same things about cognitive behavioural therapy, which is finally getting a rethink after many years of being dismissed for schizophrenia. Most psychiatrists don’t want to get that involved with their psychotic patients. It’s easier and more financially rewarding to medicate them than to do the really hard work of getting to know them. I can’t believe the number of people who won’t try something because “there is no scientific evidence” that it works for schizophrenia. Well, individuals are not statistics, you are the persons most interested in your own recovery and you should do whatever it takes to get there. I have introduced to my son some truly unusual therapies, short of dancing on a toad’s grave, but if I thought that might work, I’d be game. I noticed that most of these non-sanctioned therapies moved him forward in some way. The bottom line here is think for yourself. You are you, but you are simply a statistic to the medical profession as it stands today.

To make a long story short, I think this is a great book with a lot of insight.

Here is a quote straight from the horse’s mouth of psychiatrist Daniel Carlat:

“We often talk about neuro-transmitters like serotonin and noroepharin. But that really ends up being neurobabble. It sounds impressive to patients and it makes them think we know what we’re doing when we’re prescribing the medications. But we don’t really know how these meds work.” Side effects, said Carlat, can be serious or in some cases, unknown. “We don’t know enough about the side effects to know how many people we’re putting at risk.”

It irks me that patients and relatives have been saying this for years, then suddenly young Daniel Carlat “sees the light” and is gathering great respect and a book contract with this wisdom. My eyes used to quickly glaze over with all the psychobabble trash talk that meant absolutely nothing to me and only raised my suspicions. Seemed like a lot of smoke and mirrors. Neurotransmitters? Who cares? Serotonin, neurotonin, dopamine, up, down, down, up, blah blah blah blah blah.

No doubt Daniel Carlat still sees schizophrenia as a “special case”, so I will not go out of my way to praise his latest efforts, but at least these things are starting to be said by people who supposedly count – the medical profession. Actually, as Gianna Kali points out, Carlat is still drinking the kool-aid. He’s still digging into his grab bag of labels and symptom hunting. The only difference now is that he has expanded his world vision to include the possibility that meds don’t solve everything.

“Thinking outside the box might be facilitated by having a somewhat less intact box,” says Dr Ullén about his new findings.

ScienceDaily (May 18, 2010) — New research shows a possible explanation for the link between mental health and creativity. By studying receptors in the brain, researchers at Karolinska Institute have managed to show that the dopamine system in healthy, highly creative people is similar in some respects to that seen in people with schizophrenia.

Rossa’s comment: The “schizophrenic” brain apparently looks normal enough to these researchers.