Saturday, March 28, 2015

How To Ruin Your Life Without Being Dangerous

Changes in Personality and Decision-Making

The above table is really all that you need to know. You don't need to know anything about psychiatric diagnoses. You don't need to know anything about medications. That is typically how the problem is approached these days. What could have gone wrong? What kind of mental illness could account for what happened to this person? Let's get a panel of experts together, put them all on TV and have them speculate about what type of mental illness the person might have. I have never observed this to be a useful exercise. How could it be? There are just too many conflicts of interest and too much entertainment bias for anything of value to occur. The diagram is meant to illustrate the basic transitions associated with many mental illnesses and how the problems occur. It appears to be very simple and it is even more simple than depicted.

The top two zones - both Dangerousness and Altered State of Consciousness can be combined because Dangerousness has no medical or psychiatric meaning.  It is a legal and/or managed care definition.  From the legal side of things it determines grounds for civil commitment, guardianships and conservatorships. More importantly it determines when courts can dismiss these cases and not spend money on the people brought to their attention.  In the case of managed care companies, they view dangerousness as the only reason that somebody needs to be in a psychiatric hospital.  The diagram illustrates why they are wrong.  Rather than considering this process to be tabular a Venn diagram might be a better way to view things.  I constructed this one looking at some relative contributions of these conscious states.  Keep in mind that the dangerous conscious state here is an artificial legal and insurance company construct and that all of the demarcations here are permeable to indicate that transitions between states commonly occur.  A porous line might be better but I am limited by my software.  The diagram also illustrates that in these transition zones the difference between an altered and even dangerous state may be practically indistinguishable from the baseline state.

The simple 3 row table also describes what families have observed happening since ancient times.  It has only recently been modified to include the role of physicians, medications, insurance companies and local governments.   What do I mean about family observations?  Within the timeline of any family, the generations observe their members starting out as a vigorous young people and going through the expected developmental stages of adulthood.  The trajectory is predictable with some notable exceptions.  Some family members will get sick and die unexpectedly.  Some may get sick or injured and become disabled.  That is as true today as it was a hundred years ago.  It is also the case that the disabilities can be mental problems as well as physical health problems.  They can be something that you are born with or something that you acquire along the way.  Most families have stories about members who experienced some kind of transitional event and they were never the same afterwards.  That transitional event could have been a serious illness, an accident,  an episode of psychological trauma, exposure to combat,  excessive exposure to street drugs or alcohol, changes in interpersonal relationships, or losses of significant people in their life.  There is a consensus in the family.  They all see the person as changed.  That change is sometimes positive, but typically the person seems less well and less capable of handling life's everyday stressors.  The diagram attempts to illustrate what families observe in terms of personality characteristics and decision-making.

In the diagram, the diagnosis is really not the most important consideration.  All diagnoses and all problems for that matter are mediated by a conscious state.  All human beings have a unique conscious state that starts in the morning when we wake up and our feet hit the floor.  We have a stream of ideas and thoughts that occur in familiar ways every day and our behavior patterns and personalities are fairly predictable to our friends and family.   There are very limited discussions of conscious state in any discussion about psychiatric diagnosis or the ways that diagnosis impacts on a person's ability to function.  A further complicating factor is that most of the considerations about problems functioning suggest that there is a linear relationship between the mental illness and the inability to function.  For example, in the case of schizophrenia the diagnostic criteria may be met, but at some point a determination of the person's insight and judgment is made.  Problematic behavior is often taken as proof of a lack of insight.  Anosognosia or a form of neglect has been cited as one of the reasons for impaired insight in schizophrenia.  The actual sequence of events looks something like this:

Baseline -> Symptoms of schizophrenia ->  Diagnosis of schizophrenia ->  Problematic behavior

The real sequence of what happens is far from that linear.  Problems are often noted over a number of years.  Drug use and other behavior problems are often theories that families have before there are more clear cut symptoms allowing the diagnosis.  The concepts of pre-clinical, sub-clinical, and latent syndromes are described by some researchers.  But the main point I am trying to make here is that the pathway is not linear and there are associated changes in the person's conscious state.  There is rarely a sequential pathway to a significant mental illness.  There are starts and stops and often misdiagnosis along the way.  People can pass back and forth between an altered state of consciousness and their baseline mental status for a long time before any psychiatric diagnosis is declared.  

Psychotic depression is often a difficult illness to diagnose and treat.  Consider another common scenario.  An elderly woman walks into her kitchen and discovers her husband pointing a shotgun at himself.   She convinces him to put the gun down and go to see their doctor.  She is completely shocked about the suicidal behavior and did not see it coming.  They have been married for 40 years.   Her husband had no prior history of suicidal behavior or depression.  As they talk with his primary care physician, she corroborates that he seemed to have been sleeping well, but seemed less spontaneous and "happy".  She was shocked to find out that he had lost about 15 pounds.  He is sent to a local hospital where he talks with a psychiatrist and at one point says: "I just could not go on living anymore."  Further questioning leads to a discussion of an event that occurred when he was in high school (over 65 years ago) that he was guilty and embarrassed about.  His worries about the event continued to build until he got to the point that he saw suicide as his only means of relief.  He was too embarrassed to discuss it with his wife.  He had the original suicidal thought over 6 months ago and he observed it "come and go" over time.   This is a good illustration of how delusional guilt can be associated with transitions between baseline and then within the altered states model to one that is potentially dangerous.  It also illustrates how the individual life experience of the person is relevant. 

Manic and hypomanic patients often have transitions in their mood state.  Families members will call and say that the person needs to be in the hospital because they are keeping the whole family up all night and there have been some dangerous confrontations as a result of the sleep deprivation.  The patient can present very calmly and declare that the only problem is their family.  They may not acknowledge that they are spending money excessively, driving recklessly and starting to drink a lot.  Since they do not believe that there are any problems they will refuse crisis care, sleep hygiene advice or medication changes.  They are incapable of recognizing a change in their conscious state that puts their marriage, finances, and health at risk.  With many people this can be a self limited change, but in others it can lead to mania and psychosis or severe depression.  At the critical point where the altered conscious state could be treated, they are unable to process that information and make a decision in their best interest.  They may come back later and tell the psychiatrist who was trying to make an acute assessment that they were really out of it at the time but during the acute episode they were not able to see this reality.

Altered conscious states also occur in outpatient settings.  It is not uncommon to talk with professionals who need a specific medication that is prohibited by their licensing or regulatory body.  These are typically professions that regulators decide can inflict a significant amount of damage if they are compromised in some way by prescription or illicit drugs.  In the case of a person concerned about losing that profession, not reporting the medication or not taking it can happen.  That can occur as both a direct attempt to mislead regulators or as a result of impaired decision making from a substance use or mental disorder.

From what I have seen about the way that mental illness and substance use can alter conscious states, figuring out how to recover baseline conscious state is far from clear.  The first issue is that there is no real focus on the problem.  Psychiatric hospitalizations depend on a handful of yes-no questions about suicide and in some cases homicide.  I was recently told that a psychiatric hospital said that their admission criteria was: "You have to be suicidal and we have to be able to discharge you in less than a week."  That statement is so far from the reality of how mental disorders need to be treated it is stunning.  That statement shows a lack of regard for quality assessment and treatment.   There is no apparent interest in restoring a person to their baseline or even finding out what that baseline was.  On the other hand, I have had active discussions with psychiatrists who were interested and actively talked about these things to their patients each day.  If you are such a psychiatrist, patients will often say that in retrospect their very interested and compulsive psychiatrist missed the fact that they had significant suicidal thinking or that their were probably psychotic in a previous interview.  

The life ruining events discussed in this post and the possible mechanism illustrate that our lives are a complicated web of social interaction.  We make decisions based on that web every day and all day long.  Going into a hospital and being discharged based on whether or not the suicide question is endorsed or whether or not you are aggressive is a very low standard of social behavior and ability to function.  It takes a lot more than that to stay married, stay on the job and perform it safely, stay in the role of spouse and parent, and stay in a stable living situation.  Those are the real goals of assessment and treatment when it comes to recovery rather than ruin. The necessary decision making is linked to a conscious state that may be in a state of flux during an acute episode mental illness.

It is important to recover and recover completely.  Being familiar with baseline conscious state rather than a list of symptoms as being a good measure for this seems like a reasonable approach.  

George Dawson, MD, DFAPA


  1. Slightly but not really off topic, since this is about altered states, in that same edition of Atlantic that the other commenter linked to there is a pretty good lay article about AA vs the Finnish Naltrexone approach. Would be interested in your take. I've had some success treating with Naltrexone:

  2. I would not consider the commentary about AA or inpatient rehabilitation in this article to be accurate. All of the people I see with alcohol use problems and nearly all of the people I see with opioid use disorders get at least two conversations about naltrexone. The common misconceptions are that it is like Antabuse and that it is an "anti-craving" medication. Recognizing that it has an effect in the decision-making to pick up a drink is a difficult concept for most people to grasp. When I tell them the following vignette it is easier:

    "Some people will take naltrexone for 4 months and notice that they have had an episode of drinking once or twice a month. They conclude that it is not effective and stop it. At that point resume drinking every day. Remember that the indication here is that it reduces the number of days drinking per month."

    I agree with offering everyone who does not have obvious contraindication naltrexone or acamprosate. I think the naltrexone is the drug of choice based on once a day dosing and the abundance of evidence. I would of course also recommend 12-step recovery and be able to discuss the options for agnostics and atheists. It is not quite as black and white as the author here believes.

  3. That being said, there is a treatment center in Malibu advertising 100 percent success with TV ads. They need to knock that off or be stopped by the FDA/FTC.

    I have not used acamprosate.alone or in combination with naltrexone.

  4. At the other end of the spectrum there is also a "biologically based" recovery treatment in the Twin Cities that is all outpatient and operates on the theory that the only thing that you need to recover is vitamins and lots of them. Intravenous Vitamin C I believe is the vitamin of the day. They also claim very high recovery rates and play off the fact that they are superior and that they treat the biochemistry behind the disease. They also have a paper on their web site that claims "Eighty-five percent of the subjects reported themselves as “abstinent and stable” at 12 and 42 months post-treatment."

    It is a new era of orthomolecular therapy.

  5. I suppose it's like dieting...depending on how one defines noncompliance, one can always claim 100% success...everyone who falls off the wagon didn't comply with the that definition "Just Say No" is 100% effective too

    About those eighty five percent...they are making the same mistake that the pain management optimists made about need to ask collaterals how they are doing...

    1. Agree and random drug and alcohol screens as well..