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Lenny: ...it is in the best interest of the member to support what the professional community has or would suggest. In the specific case of psychosis there are a variety of prescription methodologies which mitigate many of the most severe symptoms and offer considerable relief to the patient.
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Ivan Tyrrell and Richard Bentall discuss patient-centred new approaches to the understanding and treatment of psychotic illness.
PROFESSOR RICHARD BENTALL holds the Chair in experimental clinical psychology at the University of Manchester.
IVAN TYRRELL is a psychotherapist, writer and lecturer who, with JOE GRIFFIN, developed the human givens approach.
Tyrrell: ... You say, in effect, that modern psychiatry has been based on two completely erroneous ideas.
Bentall: Yes. The orthodox approach, which I think is so wrong, is based on two false assumptions: first, that madness can be divided into a small number of diseases, for instance schizophrenia and manic depression; second, that the 'symptoms' of madness cannot be understood in terms of the psychology of the person who suffers from them.
The German psychiatrist Emil Kraepelin is really the man who set psychiatry off in this wrong direction — the Kraepelinian paradigm remains almost unchallenged within the mental health professions, even today. It is the organising principle for psychiatric practice and research. It was Kraepelin's idea that psychoses fell into a small number of discoverable types and that these could be independently identified by studying symptoms. Although his ideas were fiercely debated at the time, his system of diagnosis — on the basis of specific symptoms — was embraced by most clinicians.
Tyrrell: Interestingly, hints that the truth might lie elsewhere weren't followed up. For instance, you write about the Swiss psychiatrist, Eugen Bleuler, who took the same basic approach as Kraepelin but refined some of his ideas, and introduced the concept of schizophrenia. In 1867 he took over the psychiatric clinic on an island in the Rhine. When a typhoid epidemic broke out in the village, he recruited some of his patients as nurses. He noted that they performed extremely well, prompting him to suggest that, in a general crisis, mental illness, far from dominating the life of the patients, could retreat into the background.
This is actually a far-reaching insight which we are still struggling to get orthodox psychiatrists and psychodynamic psychotherapists to see today — directing people's attention outwards, off their own problems, helps break the cycle of their illness.
Working as nurses gave people a sense of meaning and purpose, self respect, a degree of control, a chance to help others — all things which are crucial to mental health. But, alas, Bleuler didn't make these connections, and what became emphasised in psychiatry was symptom classification.
Bentall: And the system doesn't work. For a categorial system of diagnosis to work, patients must all fit the criteria for a particular diagnosis and not be able to fit the criteria for more than one disease, unless they are very unlucky indeed. That means more and more sub-categories are required, to try to accommodate everybody.
Tyrrell: Could you explain that a bit more?
Bentall: current Diagnostic and Statistical Manual — DSM-IV — there are five subtypes of schizophrenia; two milder forms of psychosis (schizophreniform disorder and brief psychotic disorder); schizo-affective disorder; delusional disorder; shared psychotic disorder; psychotic disorder due to a medical condition; substance-induced psychotic disorder; and, finally,
the catch-all "psychotic disorder not otherwise specified"!
DSM-IV states that patients may not be diagnosed as suffering from schizophrenia if they also meet the criteria for schizoaffective disorder, major depression or mania.
Similarly, the criteria for bipolar disorder specify that the patient's symptoms shouldn't be better accounted for by schizoaffective disorder and must not be imposed on schizophrenia, schizophreniform disorder, delusional disorder or other psychotic disorders. But what researchers found when they tested the criteria was that 60 per cent of people who had met the criteria for one disorder had also met the criteria for at least one other at some time. They concluded that suffering from one disorder put people at greater risk of suffering from another.
Strangely, they didn't discuss the possibility that their findings might reflect the inadequacies of the neo-Kraepelinian system! The most likely explanation for the strong associations observed between schizophrenia, depression and mania is that these diagnoses do not describe separate disorders.
Tyrrell: Absolutely! One of the central planks of your book is that
the problems involved in categorising and 'explaining' schizophrenia and manic depression and so forth disappear if we look at the circumstances behind, and meaning of, people's psychotic experiences. We need to listen to what they have to say about it themselves, and accept that there isn't such a huge divide between people who have psychotic experiences, such as hearing voices or delusions, and those who don't. ...
Tyrrell: That brings me on to my next point. Neuroleptics.
Bentall: What's striking about the story of the neuroleptics is that, in terms of efficacy in their effect on the so-called positive symptoms of schizophrenia (hallucinations and delusions), there has been no real improvement since the discovery of chlorpromazine, the first neuroleptic to be used on psychotic patients. There is no evidence that the new 'atypical' neuroleptics that are available today, and that have been pushed by drug companies at a huge expense to the British taxpayer, are any more effective than the older drugs.
Neuroleptics do have an effect on positive symptoms, and I believe that's been proven, given the amount of trial evidence available. But they have many negative effects, which are also well understood. The old fashioned, so-called typical, neuroleptics, for example, produce side effects that are really dreadful: the patients have parkinsonian symptoms; they have a terrible inner sense of restlessness and depression; they get muscle dystonias, which are muscle spasms. In some cases they get tardive dyskinesia — pronounced involuntary movements of, for instance, the tongue, the lips and mouth, which can be very debilitating to people.
And these drugs also appear to have an extremely negative effect on people's motivation, so that patients taking them often have what's been described as a neuroleptic-induced deficit syndrome. So, although users may experience fewer positive symptoms, they're also less able to achieve things in their lives.
Now, the new, or atypical, neuroleptics are being touted as much better because they don't produce these side effects, but the truth is that they produce lots of other side effects. For example, if you take a drug like olanzapine, which is probably the most widely used neuroleptic in this country at the moment, massive weight gain is a serious problem. At least 50 per cent of people have sexual dysfunction and there is also a high risk of diabetes, so these drugs have pretty nasty side effects.
Tyrrell: Clearly, any benefits need to be balanced against all those side effects.
Bentall: Ah, but you also have to take into account that maybe a third of patients don't get any benefits at all; they don't get a reduction in positive symptoms, although they are still given the drugs and so still get the horrible side effects.
Tyrrell: So why do they keep on being prescribed the drugs?
Bentall: Psychiatrists tend to think the drugs are the only thing there are, therefore they must be prescribed, even if the patient is not getting any obvious benefit. I think
patients should be asked if they want to take these drugs. The benefits and the side effects should be explained, and, if they do want to take them, they should be given a low-dose typical neuroleptic like chlorpromazine for three months. At the end of that time, a detailed account should be taken of the costs and benefits, and then the patients should decide if they want to continue or to try another drug. If the costs seem to be outweighing the benefits, then it makes sense to try another drug. If that doesn't work after another three months, it makes sense to try an atypical neuroleptic. If that doesn't work, then step four is to give up on the drugs. But that never happens.
You find, in Britain, that
probably under five per cent of psychotic patients are not given neuroleptic drugs and they're usually people who have been labelled as non-compliant: the people who have the guts to say firmly that they don't want to go down that route. And they're treated in a very pejorative way by the psychiatric establishment because of that. If taking a drug were based on an analysis of cost and benefits, you'd probably find just 50 per cent of patients would be on neuroleptic drugs.
Read the full article here: "What Was That You Said?" -- A New Look at Psychosis
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See also:
- Dr. Ricahrd Bentall: Madness Explained: Psychosis & Human Nature
- The Human Givens Institute
- Dr. Bertram Karon: Schizophrenia & Psychotherapy
- Dr. Loren Mosher - Still Crazy After All These Years
- Chemical Warfare: An Interview With Robert Whitaker
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