• About
  • Disclaimer
  • Helpful Info on Writing Theses/Research
  • Resources

a1000shadesofhurt

a1000shadesofhurt

Tag Archives: cbt

Body dysmorphic disorder: charity video reveals the image anxieties that can push people to the edge

11 Monday May 2015

Posted by a1000shadesofhurt in Body Image

≈ Leave a comment

Tags

anxiety, appearance, BDD, body dysmorphic disorder, cbt, Depression, diagnosis, distress, isolation, medication, misdiagnosis, physical appearance, professionals, suicide

Body dysmorphic disorder: charity video reveals the image anxieties that can push people to the edge

It is a treatable condition suffered by at least 2% of the population, both male and female, that devastates the lives of those who have it and can lead to prolonged depression and even suicide. Now a fledgling charity, the Body Dysmorphic Disorder Foundation, hopes to raise awareness of the obsessive anxiety condition that leaves people convinced there is something flawed or “ugly” about their looks.

The foundation’s first conference, on 30 May in London, is aimed at health professionals, body dysmorphic disorder (BDD) sufferers and their carers, and is being promoted by a two-minute film, You Are Not Alone, directed by Steve Caplin, which tackles one of the greatest issues surrounding BDD: the idea that the person with it is isolated and cannot fit in.

“One of the biggest problems is that this is an under-researched disorder which is not fully understood by either professionals or laymen,” says clinical psychologist Dr Annemarie O’Connor, director of themindworks, a London-based psychology practice, who will be running a workshop at the conference. “This is not simply a case of feeling low or having to change your clothes a couple of times before you go out. It’s an obsessive anxiety disorder which can lead to huge levels of distress.”

That distress in turn can lead to prolonged bouts of depression and often suicide. “There’s such a high level of hopelessness and a real conviction among sufferers that they are ugly to look at or flawed,” explains O’Connor.

“Many sufferers turn to cosmetic intervention, but when that doesn’t change how they feel or how they see themselves. They become utterly convinced that a better way doesn’t exist, and this makes suicide a real feature of the disorder.”

Robert Pattinson, who was catapulted to fame after getting the role of vampire Edward Cullen in the Twilight films, told Australia’s Sunday Style magazine that he suffers from anxiety and BDD issues, which can become crippling before a red-carpet event.

“I get a ton of anxiety, right up until the second I get out of the car to the event, when suddenly it completely dissipates,” said Pattinson. “But up until that moment I’m a nutcase. Body dysmorphia, overall tremendous anxiety. I suppose it’s because of these tremendous insecurities that I never found a way to become egotistical. I don’t have a six-pack and I hate going to the gym. I’ve been like that my whole life. I never want to take my shirt off.”

Scarlett Bagwell’s 19-year-old daughter, Alannah, first began exhibiting signs of BDD at the age of 14. “I noticed that she had lost a lot of weight fast and at first I thought it was anorexia, but then other things began to happen – she would refuse to come out with us, didn’t want to leave her room … I still thought it might be teenage angst, but then one day she dropped out of school, despite having always loved it.

“There was so much turmoil in her head – she couldn’t get on the bus, I’d drive her to school but she wouldn’t go in. She really wanted to, but she couldn’t physically get out of the car. She’s a beautiful girl, but she was convinced there was so much wrong with her – she’d insist that her nose was too big and deformed, that she had tiny, piggy eyes and funny hair.”

As Alannah’s condition worsened, including bouts of self-harm and suicide attempts, so her family struggled to get a diagnosis. “I had to fight the system to get the proper treatment for her,” says her mother. “Just getting a diagnosis was so hard and meanwhile Alannah went from being very independent to being a baby again. At times I even had to force her to wash and I would wash her hair for her. Everything was a struggle. I felt I was failing my daughter.”

The hard-won key to her recovery was a combination of cognitive behavioural therapy (CBT) specifically tailored for BDD sufferers and anti-depression medication.

Alannah is now sitting her A/S exams at a local college and intends to go to university. Her mother hopes that the establishment of a regular conference will lead to further understanding, help and support for those with BDD. “I think that because everybody has slight issues with their appearance – they don’t like their hair, or they think a particular dress makes them look bad – they can’t understand the struggle that actual body dysmorphics go through,” she says. “It stops you functioning. People with body dysmorphia are very isolated; they often can’t bring themselves to go out, no matter how much they want to, they don’t want to be seen.

“We were lucky that Alannah has had help and the support of her family, but I wonder how many people struggle without that support because they are diagnosed later, undiagnosed or misdiagnosed,” she said.

Don’t worry, be happy: overcoming worry may be key to mental health

07 Wednesday Jan 2015

Posted by a1000shadesofhurt in Uncategorized

≈ Leave a comment

Tags

anxiety, beliefs, benefits, cbt, distraction, excessive worry, mental health issues, problem solving, worry

Don’t worry, be happy: overcoming worry may be key to mental health

Are you weary of “new year, new you” positive thinking exercises? Tired of trying to feel Tiggerish in the cold, dark, midwinter mornings? Why not try this quick experiment to redress the balance. All you have to do is imagine that something great has happened in your life: maybe you’ve run into an old friend; perhaps you’ve been promoted at work; or you’re about to head off on holiday. Now ask yourself what could go wrong. In what awful ways could it all fall apart? What disastrous chain of events might unfold? Don’t think solutions, think problems. Open the worry floodgates and allow yourself to be swept away.

As you’re likely to discover when you attempt this depressing little exercise, with a sufficiently negative outlook even the happiest moments in life can become a source of anxiety and stress. When we worry, we become preoccupied with an aspect of our lives, desperately trying to anticipate what might go wrong and what might happen if it does. Although we might believe worry is constructive, actually all it usually does is lower our mood. And when we start worrying it can be difficult to stop.

So worry can be an immensely powerful psychological mechanism, but might it also be a defining factor in the development of mental illness? Can studying it deepen our understanding of what mental illness is, how it comes about, and how it differs from psychological health?

As you’ll know if you read about the hoo-ha following publication of the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the number of officially recognised psychiatric disorders has mushroomed in recent years, and now stands at around three hundred. That giant total has attracted a lot of criticism – and with some justification – but in fact many of these conditions are pretty similar. It is better to think instead of three main groupings of disorders: internalising (most commonly, depression and anxiety); externalising (addiction, for instance, or anti-social behaviour problems); and psychosis (with its characteristic symptoms often bracketed under the label of schizophrenia). However, even these three broad groupings share many of their causes, which has led some researchers to speculate that underlying and unifying all mental illness may be a single cause: the so-called “p factor of psychopathology”.

At the social level, we know that poverty, isolation, and negative life events all elevate the risk of mental health problems. But when it comes to the psychological p factor, there is increasing evidence that it may be excessive worry. When worry gets out of hand, it now appears, a very wide range of mental health problems can follow in its wake.

This kind of “transdiagnostic” approach represents a major shift in the way we think about worry. Traditionally, problematic worrying has been demarcated as a specific condition: generalised anxiety disorder. And in that box it has remained. (The exception to this rule is depression, for which persistent worry about the past is a recognised symptom. But it’s not called worry: it’s called “rumination”. “Worry” is defined as anxious thinking about the future.)

Yet real life seems to show a lamentable lack of respect for systems of psychiatric classification. Rather than being a separate disorder, excessive worry has been shown to play a significant role in the development and persistence of paranoid thinking, post-traumatic stress disorder, alcohol and drug dependence and insomnia. It has also been linked to the incidence of eating disorders.

The idea that many psychological problems have excessive worry in common seems plausible. As most of us know from bitter experience, worry brings the most unlikely – and unpleasant – ideas to mind, keeps them there no matter how hard we try to shake them off, and convinces us that the events we dread really may happen.

If persistent worry is potentially so damaging to our mental health, what can be done to combat it? Interestingly, we tend to worry less as we grow older. People aged 65-85, for example, report fewer worries than those aged 16-29. But besides simply waiting for the years to pass, the evidence is strongest for an adapted form of cognitive behavioural therapy. This relatively brief, one-to-one treatment is based on a detailed model showing how problematic worry is caused, maintained and overcome. Patients are helped to notice when they’re worrying, to interrupt this habitual thinking style, and then try alternative ways of reacting to life’s problems.

So far this kind of CBT has mostly been used with people suffering from generalised anxiety disorder. A recent meta-analysis of 15 studies, for example, showed that CBT was far more effective than other therapies (or than a non-treatment control) at helping people recover from generalised anxiety disorder and stay well.

But it is now beginning to be piloted for other conditions – the Oxford Cognitive Approaches to Psychosis Group, for example, is testing its efficacy in severe paranoia.

How does CBT tackle worry? For one thing, it helps people to re-evaluate their beliefs about its benefits. Like many of us, individuals who are prone to excessive worry tend to assume that it helps them. They may believe, for instance, that worrying helps them to anticipate and solve problems; that it provides the motivation necessary to tackle those problems; or that it prepares them for the worst if a solution can’t be found. They may even feel that by worrying about an event they can prevent it occurring – despite realising that it’s pure superstition. Learning to challenge these kinds of beliefs can be a huge step forward.

CBT also teaches us to confine our worrying to a regular set period of 15 minutes or so each day. When worrying thoughts arise at other times, the trick is to save them for later and let them go. “Expressive writing” can be effective too: you describe your worries in as much detail as you can, focusing on what it feels like, and resisting the temptation to analyse what’s causing your thoughts. And don’t underestimate the power of distraction: work out when you’re most likely to worry and plan a pleasurable, absorbing activity you can do instead.

Many of CBT’s techniques for tackling worry are not rocket science: with the right guidance we can all put them into practice. By doing so we’re not merely sparing ourselves hours of futile fretting. If excessive worry is truly the p factor it seems to be, we’ll also be addressing one of the key determinants of our mental health.

Dispelling the nightmares of post-traumatic stress disorder

07 Wednesday Jan 2015

Posted by a1000shadesofhurt in PTSD

≈ Leave a comment

Tags

avoidance, behaviour, cbt, distress, Ehlers and Clark, flashback, hyperarousal, interpretations, low mood, Memory, negative thoughts, nightmares, post traumatic stress disorder, psychological effects, psychotherapy, PTSD, reliving, reminders, symptoms, threat, trauma, trauma memories, traumatic event, treatment, triggers

Dispelling the nightmares of post-traumatic stress disorder

On Wednesday morning we woke to the news that a passenger ferry had sunk off the coast of South Korea, with at least four people confirmed dead and 280 unaccounted for. Meanwhile, though the search has continued for the missing Malaysia Airlines plane, relatives’ hopes of a safe landing have long since been extinguished.

Human tragedies like these are the stuff of daily news, but we rarely hear about the long-term psychological effects on survivors and the bereaved, who may experience the symptoms of post-traumatic stress disorder for years after their experience.

Although most people have heard of PTSD, few will have a clear idea of what it entails. The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) defines a traumatic event as one in which a person “experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others”. PTSD is marked by four types of responses to the trauma. First, patients repeatedly relive the event, either in the form of nightmares or flashbacks. Second, they seek to avoid any reminder of the traumatic event. Third, they feel constantly on edge. Fourth, they are plagued with negative thoughts and low mood.

According to one estimate, almost 8% of people will develop PTSD during their lifetime. Clearly trauma (and PTSD) can strike anyone, but the risks of developing the condition are not equally distributed. Rates are higher in socially disadvantaged areas, for instance. Women may be twice as likely to develop PTSD as men. This is partly because women are at greater risk of the kinds of trauma that commonly produce PTSD (rape, for example). Nevertheless – and for unknown reasons – when exposed to the same type of trauma, women are more susceptible to PTSD than men.

What causes it? In one sense, the answer is obvious: a specific trauma. Yet this is only part of the story, because not everyone who is raped or badly beaten up develops PTSD. Of the contemporary psychological attempts to answer that question, the most influential is the one formulated by the clinical psychologists Anke Ehlers and David Clark at the University of Oxford.

They argue that PTSD develops when the person believes they are still seriously threatened by the trauma they have experienced. Why should someone assume they are still endangered by an event that happened months or even years previously? Ehlers and Clark identify two factors.

First is a negative interpretation of the trauma and the normal feelings that follow, for example believing that “nowhere is safe”, “I attract disaster”, or “I can’t cope with stress”. These interpretations can make the person feel in danger physically (the world seems unsafe), or psychologically (their self-confidence and sense of well-being feel irreparably damaged).

Second are problems with the memory of the trauma. Partly because of the way the person experiences the event, the memory somehow fails to acquire a properly developed context and meaning. As a result, it constantly intrudes. Ehlers and Clark liken the traumatic memory to “a cupboard in which many things have been thrown in quickly and in a disorganised fashion, so it is impossible to fully close the door and things fall out at unpredictable times”.

These factors change the way people behave. They may avoid situations that might spark a memory of the trauma, and will sometimes try to deaden their feelings with drink or drugs. Yet these strategies tend to entrench and exacerbate the problem.

PTSD can be treated with antidepressants or various kinds of psychotherapy, including prolonged exposure therapy and eye movement desensitisation and reprocessing. However, a recent meta-analysis of 112 studies conducted over the past 30 years found that cognitive behavioural therapy (CBT) was the single most successful type of treatment.

CBT typically comprises three main strands. First, it evaluates the individual’s excessively negative thoughts about the trauma and its aftermath – for example by helping them understand that they are not to blame or that their feelings are normal and natural. Second, the treatment works on the person’s memory of the trauma: the individual might be asked to write a detailed account of the event; relive it in their imagination; revisit the site of the trauma; or be shown how to cope with the kind of objects or situations that trigger the traumatic memory.

The final strand involves tackling the kind of behaviours that tend to fuel PTSD, for example by demonstrating that attempting to suppress a thought is futile (if you doubt it, try right now not to think of a white bear) or that avoiding a situation only strengthens one’s fear.

A course of CBT for PTSD normally involves meeting with a therapist once or twice a week over several months. Given how debilitating the problem can be, that can seem like a very long time to wait to get one’s life back on track. However, pioneering research published in last month’s issue of The American Journal of Psychiatry suggests that there may be an alternative. Instead of months, it may be possible to tackle the symptoms of PTSD in just seven days.

Anke Ehlers at the University of Oxford and her colleagues randomly assigned 121 patients with PTSD (about 60% female, 40% male) either to a seven-day course of intensive CBT; weekly sessions of CBT for three months; a type of psychotherapy known as emotion-focused supportive counselling; or to a 14-week waiting list. Participants in the first three groups all received the same amount of therapy (18 hours).

The results were striking. The intensive CBT proved almost as successful as the standard three-month course, with respective recovery rates from PTSD of 73% and 77%, and the intensive version produced its effects more quickly. For the supportive counselling group, recovery was 43% (another finding that undermines the idea that all types of psychotherapy are equally effective). Among the waiting list group, just 7% had recovered. Both courses of CBT also led to large reductions in levels of anxiety and depression.

Most importantly, the benefits lasted: 40 weeks after entering the study, about two-thirds of the CBT patients were still free from the symptoms of PTSD. The therapy isn’t easy – it confronts highly distressing events and feelings, after all – but it works.

Follow @ProfDFreeman and @JasonFreeman100 on Twitter

If psychosis is a rational response to abuse, let’s talk about it

03 Wednesday Dec 2014

Posted by a1000shadesofhurt in Uncategorized

≈ Leave a comment

Tags

abuse, cbt, culture, diagnosis, hearing voices, medication, paranoia, psychological support, psychosis, schizophrenia, trauma

If psychosis is a rational response to abuse, let’s talk about it

There is something of a sea change in the way we understand experiences that have traditionally been labelled as psychotic. In our culture at least, experiences such as hearing voices or seeing visions have long been viewed by the medical establishment as unequivocal symptoms of mental illness. Treatment has tended to focus on the suppression of such “symptoms” using antipsychotic medication.

Research (often funded by drugs companies) has been largely concerned with the brain as a physical organ, rather than with the person within whose head it is housed, or indeed with their life experience. And, because of the presumption that psychotic symptoms are the preserve of mentally ill people, estimates of the numbers affected have been based on the numbers who have received a particular diagnosis.

But a report published last week by the British Psychological Society’s division of clinical psychology, challenges many of these assumptions.Understanding Psychosis and Schizophrenia presents a compelling case for trying to understand psychotic experiences as opposed to merely categorising them. It argues that such experiences can be understood from a psychological perspective, in the same way as other thoughts and feelings, rather than being placed on the other side of an artificial sick/healthy divide.

And, indeed, they appear to be much more common than is frequently supposed. According to the report, up to 10% of the population has heard a voice speaking when nobody was there and almost one in three holds beliefs that might be considered paranoid. Two in three people who had heard voices or seen visions did not seek help because they were untroubled by them. And, of course, there is huge diversity in the way such experiences are understood and valued in different cultures.

For those who find their experiences unwelcome and disturbing (and they can be extremely disturbing; I don’t think anyone questions that) the range of help on offer is decidedly limited. Despite the National Institute for Health and Care Excellence recommending that everyone with a diagnosis of schizophrenia is offered cognitive behaviour therapy(CBT), only one in 10 has access to it. Treatment by medication alone, forcibly if needed, is the norm.

It is widely accepted that early life experience, trauma, abuse and deprivation greatly increase the risk of developing psychosis. Indeed,research suggests that experiencing multiple childhood traumas gives approximately the same risk of developing psychosis as smoking does for developing lung cancer.

Many people object to the psychotic label because they consider their experiences a natural reaction to the abuse they have suffered, and even a vital survival tool. What they want above all is space and time to talk about their experiences and to make sense of them. It is shocking how few are given this opportunity.

Of course, psychological approaches to helping those with psychosis will not suit everyone. There are those for whom a diagnosis can come as a welcome relief. Many people find medication helpful, as treatment on its own or alongside talking therapies.

In fact, one of the most persuasive messages of the report is that people should be allowed to understand their experience in their own way, without professionals insisting on a particular interpretation.

It is a highly collaborative approach and fitting that at least a quarter of those who contributed to the report have lived experience of psychosis. Their opinions and experiences are as varied as you would expect with any group of individuals but together they comprise an enormously powerful and vivid testimony to the full range of human experience and to the many and varied ways in which we can help each other to make sense of it.

Scandal of mental illness: only 25% of people in need get help

18 Monday Jun 2012

Posted by a1000shadesofhurt in Uncategorized

≈ Leave a comment

Tags

anxiety, cbt, Children, Depression, mental health issues, physical health, stress, Therapy

Scandal of mental illness: only 25% of people in need get help

The “scandalous” scale of the NHS‘s neglect of mental illness has been described in a report which suggests only a quarter of those who need treatment are getting it.

The report claims that millions of pounds are being wasted by not addressing the real cause of many people’s health problems. Nearly half of all the ill-health suffered by people of working age has a psychological root and is profoundly disabling, says the report from a team of economists, psychologists, doctors and NHS managers, published by the London School of Economics.

Talking therapies such as cognitive behaviour therapy relieves anxiety and depression in 40% of those treated, says the Mental Heath Policy Group led by Lord Layard. But despite government funding to train more therapists, availability is patchy with some NHS commissioners not spending the money as intended, and services for children being cut in some areas. “It is a real scandal that we have 6 million people with depression or crippling anxiety conditions and 700,000 children with problem behaviours, anxiety or depression,” says the report. “Yet three quarters of each group get no treatment.”

Layard added: “Mental health is so central to the health of individuals and of society that it needs its own cabinet minister … The under-treatment of people suffering from mental illnesses is the most glaring case of health inequality in the NHS … Despite the existence of cost-effective treatments it receives only 13% of NHS expenditure. If local NHS commissioners want to improve their budgets, they should all be expanding their provision of psychological therapy.”

A third of families have a member suffering a mental illness, the authors found. The report says mental health problems account for nearly half of absenteeism at work and a similar proportion of people on incapacity benefits.

In 2008, Layard and others won the argument that treating anxiety and depression saved the NHS money. A programme called Improving Access to Psychological Therapy (IAPT) was set up to train thousands more therapists.

Official figures, however, show that too few people are getting treatment across the country. There were 6.1 million with treatable anxiety or depression in England but only 131,000, or 2.1%, entered talking therapy in the last quarter of 2011.

There are stark differences between primary care trusts. Walsall did best, with 6.4% of depressed and anxious people in talking therapy, followed by Swindon with 5.8% and Northumberland with 5.5%.

But Hillingdon, west London had only 0.1% in treatment – 17 out of 29,000. Barnet and Enfield, both in north London, had 0.3% and 0.4% respectively.

Layard said commissioners were wrong “if they think ‘why don’t we cut a bit of that [talking therapies]’ when they are spending money on infinitely lower priority conditions. Depression is 50% more disabling than conditions like angina, arthritis, asthma or diabetes.” Even including those on medication, treatment only reaches a quarter of those in need.

Commissioners needed to understand that treating people with mental illness saves money, the report says. Layard pointed to a survey at two London hospitals which found that half the patients sent for an appointment with a consultant had physically inexplicable symptoms, such as chest and head pains for which there was no organic explanation. “These are people with somatic symptoms as a result of mental stress,” he said.

In the long term he said he would like to see psychologists and therapists working alongside physical medicine doctors in the acute sector, to help determine the real cause of people’s apparently inexplicable symptoms.

Dr Andrew McCulloch, chief executive of the Mental Health Foundation, said the report showed mental health remained a poor relation to physical health for the NHS. “The government has rightly committed to a parity of esteem between physical health and mental health in the health and social care bill, and surely they must now deliver on what they have promised.”

Dr Clare Gerada, the chair of the Royal College of GPs, applauded the efforts of Layard and his colleagues to increase the availability of talking therapies.

“We live in a stressful society and the number of patients with mental health problems presenting to GPs is on an upward spiral,” she said. “GPs face tremendous challenges in caring for patients with mental health problems in primary care and we welcome any development which will help us improve their care.”

The care services minister, Paul Burstow, said: “Mental ill-health costs £105bn per year and I have always been clear that it should be treated as seriously as physical health problems … the coalition government is investing £400m to make sure talking therapies are available to people of all ages who need them. This investment is already delivering remarkable results.”

More:

NHS is’failing’ mental health patients

The Mass Production of Mental Illness and What To Do About It

01 Wednesday Feb 2012

Posted by a1000shadesofhurt in Psychiatry

≈ 1 Comment

Tags

'Anti-Psychiatry', 'AntiPsychiatry', cbt, chlorpromazine, diagnosis, drugs, DSM, ECT, Kraepelin, Laing, medication, Medicine, mental health issues, misdiagnosis, psychiatry, Rogers, Rosenhan, schizophrenia, Skinner, Szaza, treatment

The Mass Production of Mental Illness and What To Do About It

DOCTORING THE MIND: IS OUR CURRENT TREATMENT OF MENTAL ILLNESS REALLY ANY GOOD?
By Richard P. Bentall
NYU Press, 364 pages. $29.95

“Conventional psychiatry, which reached its zenith with the neo-Kraepelinian movement, has not only failed to deliver tangible benefits for patients (antipsychotics…were an accidental discovery) but has also failed to deliver a credible explanation of psychosis. It is not that there is a lack of biological evidence; rather, the evidence has been misinterpreted and shoehorned into a biomedical framework that fits it poorly. A radical new approach to understanding severe mental illness, which brings together the evidence on the social, psychological and biological causes of psychosis, is urgently required.”

In the 1960s, a movement called “antipsychiatry” (prompted in Britain by R. D. Laing and in the U.S. by Thomas Szazs) questioned the basic assumptions about mental illness and its treatment. Not only psychiatry, but methods popular earlier in the twentieth century, such as the prefrontal leucotomy, electroconvulsive therapy (ECT), and insulin coma therapy, lay thoroughly discredited. The anti-psychiatrists encouraged treating the patient as a whole person, putting his “madness” in the social and environmental context. Unfortunately, with the passage of the counterculture the medical establishment returned with a vengeance to explaining mental illness strictly as a manifestation of physical disorders of the brain and treating it with particular medications.

Dr. Richard P. Bentall, professor and practitioner of clinical psychology in Britain, who earlier wrote Madness Explained: Psychosis and Human Nature (2003), exposes the highly dubious nature of reigning presumptions about the causes and treatment of mental illness. He favors the “recovery-oriented, autonomy-promoting” model, particularly cognitive behavioral therapy, over the “paternalistic-medical” model, which favors reductionist diagnosis, genetic causation, and reliance on drugs to correct so-called “chemical imbalances.” Bentall explores why the biomedical approach has become dominant, instead of a social approach to madness, which was gaining traction in the 1960s. There is little evidence to show that psychiatric drugs are effective in the long run; by making spurious connections between damaged brains and drugs alleged to overcome such disfigurement, the medical profession ignores better treatment options.

In his important book The Rise and Fall of Modern Medicine (1999), James Le Fanu identifies twelve definitive moments in the history of medicine, one of which is the discovery of the drug chlorpromazine in the early 1950s. Over the long run, however, the medical profession has been manifestly unable to improve recovery outcomes for patients suffering from mental illness. A striking finding is that patients in developing countries, with much less health care expenditure per capita, recover better from schizophrenia than patients in developed countries. The accidental discovery of chlorpromazine by a French doctor must be viewed in the context of the state of psychiatric treatment, a shambles before the excitement caused by the new drugs. As Le Fanu concludes, “Why should a compound that blocks histamine in the tissues of the body also interfere with an entirely different chemical–dopamine–in the brain in a way that alleviates the symptoms of schizophrenia? What is schizophrenia? What is its cause? The map of mental illness, like that of Africa before the arrival of the Victorian explorers, remains a blank.” Medical discoveries have sharply fallen off since their post-World War II peak; both “The New Genetics” and “The Social Theory” (attributing disease to lifestyle choices) have failed to halt the rise of illness, particularly psychiatric illness.

Emil Kraepelin (1856-1926) is the key figure in the classification of psychiatric disorders, making a distinction between dementia praecox (senility of the young, later relabeled schizophrenia) and manic depression. The growth of mental asylums, particularly in the U.S., didn’t abate until the middle of the twentieth century. Also in parallel, extreme remedies including electroconvulsive therapy, prefrontal leucotomy, and insulin coma therapy became popular. Walter Freeman, the American evangelist for prefrontal leucotomy, used “a hammer to tap an ice-pick-like instrument placed above the eyeball and against the orbital bone behind,” after which “he would move…[the instrument] from side to side in order to produce the desired lesion.” Rosemary Kennedy, sister of President John F. Kennedy, was a famous victim of Freeman: “a woman who had perhaps suffered from mild intellectual impairment, but who could read and write…was left incontinent and able to utter only a few words.” In insulin coma therapy, patients’ “brains were starved of glucose,” and they would slip into a coma. Brain-cell death, and the desired catatonic state, resulted.

Contesting behavior modification programs, articulated by pioneers B. F. Skinner (author ofWalden Two) and Carl Rogers, varied in their approaches to control versus autonomy, but the impact of innovation remained limited in the asylums and clinics. David Rosenhan published a famous paper in Science in 1972, called “On being sane in insane places,” throwing doubt on the supposed empirical nature of psychiatric diagnoses. With seven other “pseudo-patients,” Rosenhan showed up at psychiatric clinics pretending to have symptoms of schizophrenia. Staff at the hospitals were unable to change their diagnostic presuppositions to match the pseudo-patients’ perfectly normal behavior once admitted: “A pseudo-patient waiting outside a cafeteria half an hour before it opened (there was nothing else to do) was described by one psychiatrist as having an ‘oral acquisitive syndrome.’ When observed making notes, another was said to exhibit ‘obsessive writing behavior.'” Interestingly, the patients picked up that the pseudo-patients were journalists or professors.

Meanwhile, unable to rise to the challenge posed by Thomas Szazs’s groundbreaking The Myth of Mental Illness (1960), psychiatrists doubled down on the idea that there is something “wrong with the brains of mentally ill patients.” Thus came about the “chemical-imbalance explanation for mental illness, an idea that was to prove more potent in the minds of ordinary people than anything dreamed up by the antipsychiatrists.” In other words, even as Freudian assumptions about the unconscious, the role of sexuality, and repressed fantasies were being discredited, the science of biological psychiatry emerged to put forth the idea that “too much dopamine at the [brain synapses]…causes schizophrenia,” and that “an imbalance in the neurotransmitter serotonin” causes depression. Note that these two ideas are at the basis of every psychiatric drug peddled since the 1960s, and if they can be thrown into doubt, so can the efficacy of all the drugs currently on the market. Certainly, the drug companies’ interests (as Marcia Angell, above all, has pointed out in her work) are well-served, but can we say the same for patients? Even the president of the American Psychiatric Association lamented in 2005: “As a profession, we have allowed the biopsychosocial model [of mental illness] to become the bio-bio-bio model.”

The new biological researchers styled themselves neo-Kraepelinians, and the American Psychiatric Association’s landmark Diagnostic and Statistical Manual-III (DSM), issued in 1980 and since then further revised, is a monument to Kraepelin in sharply distinguishing between the normal and the sick, in separating discrete categories of mental illnesses, and in focusing on the biological approach to mental illness. If each of these dubious propositions can be shown to be weak or even false, then the entire edifice of current psychiatric practice also collapses. Neuroscience, not any sort of talking therapy, was to be the panacea; “manipulating neurotransmitters, not…understanding and interpreting the patients’ thoughts and feelings,” was what young psychiatrists should learn. Has the DSM led to more accurate diagnoses than was the case before? Lauren Slater, in Opening Skinner’s Box: Great Psychological Experiments of the Twentieth Century (2004), describes replicating Rosenhan’s experiment by presenting herself as a patient at psychiatric emergency rooms.

Now to the dismantling of each of the three key propositions upon which present psychiatric practice rests. First, are psychiatric diagnoses meaningful? The concepts of both dementia praecox (schizophrenia) and manic depression, first proposed by Kraepelin, have undergone repeated transformations over the last century, with allied growth in various neuroses (anxiety disorders), subdivided into many classes. The DSM sought to achieve consistency in psychiatric diagnoses, but precision remains spurious. A significant obstacle to precision, according to Bentall, is comorbidity; often patients suffering one psychiatric illness seem to suffer from others as well, which keep shifting in intensity over time. As Bentall concludes damningly, “If the same drugs work for everyone, the diagnosis given to the patient has virtually no implications at all.”

Second, as to the boundary between the “sick” and the “normal,” many people have psychotic symptoms without requiring treatment. Schizophrenia is best perceived on a continuum, rather than as the dark side of a clear dividing line between normality and a lifetime of helplessness. In recent years, psychiatrists have desperately sought to preserve the structure of diagnostic precision by resorting to increasing “fractionation,” for example of the “bipolar spectrum into bipolar 3 disorder, bipolar 4 disorder, and so on.” Schizophrenia and bipolar disorder, instead of being thought of as ‘real conditions,” might be better seen as ‘scientific delusions.”

The third fundamental error of psychiatry follows from the “neo-Kraepelinian… assumption that psychiatric disorders are genetically determined diseases that are little influenced by the trials of life.” The most that can be argued is that “genes play some role at some point in increasing the risk of mental illness, but nothing else.” Bentall explains that “the only findings that have proved to be even marginally replicable concern genes that confer only a very small risk of psychosis and which are absent in the majority of patients” and that “if there were any genes with more direct and marked effects, they would have certainly been discovered by now.” It is important to consider that “not a single…[patient] has ever benefited from genetic research into mental illness.”

Yet current psychiatric practice prefers unchanging genetic influence over environmental factors–particular stresses and traumas in life–in aggravating mental illness. As Bentall argues, “Insecure attachment and victimization appear to contribute to paranoia, sudden trauma appears to cause hallucinations, and parental communication deviance has been implicated in thought disorder.” Yet the psychiatrist’s job these days is focused on getting the patient to agree to a discrete diagnosis, followed by quick agreement to take the prescribed medication. At the research level, psychiatric geneticists are busy trying to identify specific genes involved in schizophrenia, bipolar disorder, and other conditions–a fool’s errand, if ever there was one, since the venture is premised on ignoring environmental influences.

The neo-Kraepelinians, i.e., the majority of the psychiatric profession today, have been obsessed with reliance on CT scans, and more recently MRI’s, to locate the exact sites of brain disease. Yet even if dopamine neurones are involved in paranoia, it stands to reason that “the nervous system of an animal living the life of repeated victimization will become highly attuned to the detection of further threatening events.” So it is reasonable to think that “the dopamine system becomes sensitized as a consequence of adverse experiences that predate the onset of illness,” rather than being the cause.

The excessive profits of drug companies–“in 2002, the combined profits for the ten [largest] drug companies…[exceeded]…the profits of all the other 490 companies put together”–can be explained by our unreasonable expectations about what medical science can deliver. In The Role of Medicine: Dream, Mirage or Nemesis (1979), Thomas McKeown argues that most of the “health gains achieved during the nineteenth and early twentieth centuries were the consequence, not of advances in medical science, but of improvements in nutrition and sanitation.” This concept leads to the recent global movement embracing evidence based medicine, which, Bentall argues, has so far not affected the psychiatric profession. Big Pharma continues to exploit loopholes in the concept of the randomized controlled trial (RCT), to adduce greater effectiveness for drugs than warranted.

In the late 1980s, SSRI’s (serotonin re-uptake inhibitors), represented by Prozac, became immensely popular. The drug industry made extravagant claims for their effectiveness. Yet “subsequent metaanalyses have reported that nearly all of the therapeutic response to both the old and new antidepressants can be attributed to the placebo effect.” Drug company data, submitted to the FDA in support of licensing applications, is kept secret, but when occasionally it comes to light severe problems of duration, size, and sample become manifest. For example, data from “47 trials of the six most popular new antidepressants…[shows] that the most rigorous of the studies had examined the patients for a mere eight weeks without any attempt to find out what happened to them afterwards, and that drop-out rates were so high that only 4 out of the 47 were able to report what happened to more than 70 percent of the patients.” In short, psychotic drug trial data cannot be trusted.

Rather than adhere to the Hippocratic Oath of “first do no harm,” psychiatrists are recently pushing for the earliest possible intervention–lifetime prescription of psychotic drugs–based on the manifestation of pre-symptoms, rather than actual illness, and for the inclusion of the widest possible population in such prescreening. Contrary to this drive, studies have shown that “first-episode…patients benefit less from…treatment than patients who have been ill for some time.” Big Pharma and psychiatrists also claim that so-called second-generation drugs have fewer side effects, but many studies show that this is clearly not true. Of even more concern is the fact that long-term administration of psychotic drugs may worsen symptoms because of “the proliferation of the number of D2 receptors in the brain”–in other words, “the brain responds to having its dopamine receptors blocked by making more of them.”

If drugs have been oversold, what is to be done then? Cognitive behavior therapy (CBT), which seeks to alter negative thought patterns, is one approach. It may or may not be more effective than other forms of psychotherapy, but at least it shows more respect for the patient than condemning him to a lifetime of medication, and making him feel useless because of irremediable genetic dysfunction in the brain. Many patients can manage the symptoms of schizophrenia without having to be condemned or committed. The aim should be to help patients improve their quality of life, rather than relying on bright-line distinctions between normality and illness. In the “paternalistic-medical” model, patients’ preferences about treatment are ignored because their judgment is not trusted; in the “autonomy-promoting” model Bentall advocates, patients are actively involved in deciding the course of treatment. Bentall offers a neat schematic splitting the two models along the axes of principal advocates, beliefs about mental illness, attitude toward diagnosis, goals of treatment, attitude towards patients’ judgments, attitude towards treatment, attitude towards the therapeutic alliance, attitude towards risk and coercion, and attitude towards medical skills that sharply distinguishes the polarities between the two approaches.

At stake in this debate is the utilitarian (Benthamite) versus deontological (Kantian) ethic. Both moral philosophies emphasize individual rights, the Kantians in particular arguing that individuals should always be treated as ends in themselves, rather than as means to ends. Present psychiatric practice, heading as it is toward condemning large swaths of the population to a perpetual sentence of mental deviance, doesn’t even match the less rigorous scales of utilitarianism when it comes to individual autonomy. The present model is based on coercion, and coercion is wrong on several counts as an approach to mental illness.

Joanna Moncrieff, in The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment(2008), has pointed out that we should free ourselves of the delusion that there can be specific drugs for discrete mental illnesses. She demonstrates that “a majority of the published trials show that antidepressants are a bit better than placebo, but despite the many possible biases which make positive results more likely, many studies found that antidepressants were no better than placebo and some found that they were worse.” She also shows how “decades of research have failed to produce clear and independent evidence of a dopamine abnormality in people with psychosis or schizophrenia that cannot be attributed to some other cause” and that “there is little evidence to suggest that there is a characteristic abnormality in [the serotonin and noradrenalin]…systems that is associated with depression.” Instead, Moncrieff argues that “the early marketing campaigns for antidepressants had to establish the idea of depression as a common, medically treatable condition”–the more common, the better, from the drug companies’ point of view.

In addition to recognizing the limitations of drugs, more emphasis needs to be placed on the sociological roots of depression (as Bentall points out, the majority of mentally ill patients tend to be unemployed, and employment tends to assist in recovery). Psychiatry, since the early 1950s, has stalled; the revolutionary impetus of the 1960s is gone; the profession needs to reboot, and start treating people again as people, not as “plants.” The motivation behind the new drugs remains the same as it was for the radical remedies of electroconvulsive therapy, prefrontal leucotomy, and insulin coma therapy.

Recent Posts

  • Gargoyles, tarantulas, bloodied children: Research begins into mystery syndrome where people see visions of horror
  • Prosopagnosia
  • How mental distress can cause physical pain

Top Posts & Pages

  • Gargoyles, tarantulas, bloodied children: Research begins into mystery syndrome where people see visions of horror
  • Prosopagnosia
  • How mental distress can cause physical pain

Enter your email address to follow this blog and receive notifications of new posts by email.

Archives

  • February 2022
  • August 2020
  • May 2017
  • February 2017
  • August 2016
  • April 2016
  • November 2015
  • August 2015
  • June 2015
  • May 2015
  • March 2015
  • February 2015
  • January 2015
  • December 2014
  • September 2014
  • August 2014
  • July 2014
  • June 2014
  • May 2014
  • April 2014
  • March 2014
  • February 2014
  • December 2013
  • November 2013
  • October 2013
  • September 2013
  • August 2013
  • July 2013
  • June 2013
  • May 2013
  • April 2013
  • March 2013
  • February 2013
  • January 2013
  • December 2012
  • November 2012
  • October 2012
  • September 2012
  • August 2012
  • July 2012
  • June 2012
  • May 2012
  • April 2012
  • March 2012
  • February 2012
  • January 2012
  • December 2011

Categories

  • Adoption
  • Autism
  • Body Image
  • Brain Injury
  • Bullying
  • Cancer
  • Carers
  • Depression
  • Eating Disorders
  • Gender Identity
  • Hoarding
  • Indigenous Communities/Nomads
  • Military
  • Miscarriage
  • Neuroscience/Neuropsychology/Neurology
  • Older Adults
  • Postnatal Depression
  • prosopagnosia
  • Psychiatry
  • PTSD
  • Refugees and Asylum Seekers
  • Relationships
  • Self-Harm
  • Sexual Harassment, Rape and Sexual Violence
  • Suicide
  • Trafficking
  • Uncategorized
  • Visual Impairment
  • War Crimes
  • Young People

Meta

  • Register
  • Log in
  • Entries feed
  • Comments feed
  • WordPress.com

Blogroll

  • Freedom From Torture Each day, staff and volunteers work with survivors of torture in centres in Birmingham, Glasgow, London, Manchester and Newcastle – and soon a presence in Yorkshire and Humberside – to help them begin to rebuild their lives. Sharing this expertise wit
  • GET Self Help Cognitive Behaviour Therapy Self-Help Resources
  • Glasgow STEPS The STEPS team offer a range of services to people with common mental health problems such as anxiety and depression. We are part of South East Glasgow Community Health and Care Partnership, an NHS service. We offer help to anyone over the age of 16 who n
  • Mind We campaign vigorously to create a society that promotes and protects good mental health for all – a society where people with experience of mental distress are treated fairly, positively and with respect.
  • Research Blogging Do you write about peer-reviewed research in your blog? Use ResearchBlogging.org to make it easy for your readers — and others from around the world — to find your serious posts about academic research. If you don’t have a blog, you can still use our
  • Royal College of Psychiatrists Mental health information provided by the Royal College of Psychiatrists
  • Young Minds YoungMinds is the UK’s leading charity committed to improving the emotional well being and mental health of children and young people. Driven by their experiences we campaign, research and influence policy and practice.

Create a free website or blog at WordPress.com.

  • Follow Following
    • a1000shadesofhurt
    • Join 100 other followers
    • Already have a WordPress.com account? Log in now.
    • a1000shadesofhurt
    • Customize
    • Follow Following
    • Sign up
    • Log in
    • Report this content
    • View site in Reader
    • Manage subscriptions
    • Collapse this bar