Monday, October 3, 2016
Psychosis Idealized
I thought I would provide a counterpoint to the New York Times editorial entitled "Medicating A Prophet" written by Psychiatrist Irene Hurford (1). The opinion piece is available free online and I encourage anyone interested in the topic to read the article rather than accepting my summary here as adequate. I will say from the outset that I am not a stranger to any of the issues that Dr. Hurford discusses either clinically or personally. The bulk of my career was spent treating people with severe mental illnesses and addictions. Once you have worked in that setting, it is clear that many people who are severely ill need involuntary treatment and that is one of the decision points that she addresses.
In her essay, Dr. Hurford describes an early call experience during her residency. She was asked to assess a man in the emergency department (ED) who had been delusional for 30 years. The delusions were religious and grandiose in nature. He was a college graduate but was homeless living on the street in Philadelphia. He also had AIDS and the complication Kaposi sarcoma. His reason for being in the ED was "to preach". Dr. Hurford encourages him to come in for voluntary treatment but he refuses. At that point she ponders involuntary treatment but in the essay decides to discuss the patient's right to psychosis. Later we learn that she made the decision but has decided to analyze that decision in retrospect based on factors that she has encountered since.
One of those factors was the influence of a professional colleague who based on her own experience with psychosis and that colleague's mother's experience suggested that thoughts about living "in psychosis" and outside of psychosis need to be challenged. She basically states that the problem may be within the beholder rather than the identified patient. Following that logic, it makes sense to show up in an ED to preach while ignoring serious health problems. It also makes sense to make decisions about the person's "in psychosis" experience knowing so little about them. In my experience, nobody in the ED calls the parents or family of a 50 year old street person, to get a clear picture of how the psychosis has truly affected him. When I have treated these people on an inpatient unit and made those calls, I have never heard that the patient was well served by the psychosis. Not a single time. In many cases, family members were surprised to hear that person was still alive.
Dr. Hurford advances a number of other arguments that I call into question. She uses a very loose definition of insight as a "failure to accept an alternative view of reality". She turns this around to suggest that anyone who does not accept this premise (implicitly the treating physician) also lacks insight. I don't think that you can practice psychiatry and not be comfortable with alternative realities. I would suggest a more appropriate definition of insight as a decision-making process. Can I accurately assess how I am doing in the world? Am I making decisions in my best interest? Are those decisions consistent with my ability to survive? If I realize that I am not doing well can I get help? Pretty basic decisions. Not a question of lifestyle choices. To have a lifestyle you have to live. That is the kind of insight that I am used to dealing with.
Dr. Hurford discusses a case of a young patient with a psychotic disorder who stopped taking his medications and started using cannabis on daily basis. He dropped out of college and became progressively incoherent and then mute. She is concerned about traumatizing the patient by "enforcing" treatment even though he cannot "eat, sleep, and talk." I don't follow the logic that some treatment intervention - even basic detoxification from cannabis is somehow more traumatic than not eating, sleeping, or being able to communicate. How is that a preferred alternative existence?
At that point she digresses to a very brief overview of the usual comments about mental illness being only peripherally associated with violence and the lack of evidence that forced treatment led to fewer hospitalizations, arrests, or a better quality of life. She cites a meta-analysis of three randomized-controlled studies of more than 700 people. There are a lot of reasons why meta-analyses are not superior to the actual trial data. There are also a lot of reasons why truly clinical samples with these problems cannot be ethically randomized or included in the studies. There are also reasons why I would expect the entry points into these studies to be highly variable as well as the treatment resources that are involved. In Minnesota, we have 87 counties and the rule is that there are 87 interpretations of the commitment act for involuntary treatment. There are two corollaries operating here. The first is that the courts will be very liberal in terms of dropping commitments until something bad happens. At that point the pendulum swings back in the direction of more frequent commitment. The second is that only the wealthiest counties in the state can afford to provide adequate resources to treat the severely mentally ill. Even then there is no assurance that the counties that can afford it will actually provide the care. Some currently function like managed care companies and ration the care. They can end up rationing care and commitments in order to save the county money. The lack of evidence that forced care does anything may be more of an indictment of the lack of quality or consistency in delivering care and interpreting the law and rationing care more than anything. I have personally treated many times the number of people with forced treatment than in the meta-analysis and there is no doubt that the outcomes were better than with no treatment.
The outcome variables cited by Dr. Hurford are also dreadfully lacking compared with what can be seen routinely in clinical settings. They include very adverse outcomes in encounters with the police including getting shot, dying from a treatable illness, suicide, loss of relationships with spouses and children, loss of a job and income, and acute loss of life due to poor insight and judgment. In Minnesota, all that takes is going outside in the winter time without adequate protective clothing and you are dead or in the Burn Unit with frostbite.
Right now we are in the midst of a sweeping cultural change that idealizes psychosis and suggests that hallucinogens and cannabis are therapeutic drugs. That will put the next generation or two of people with psychoses, mood disorders, and substance use disorders at risk for chronicity and every possible negative outcome. A point that should not be lost on anyone is how no care for psychosis is "cost-effective" care when the total impact on the patient is ignored. My point in writing this rebuttal is really advice for the people in these generations. Ask any psychiatrist treating you or your family member where they stand on this issue.
Especially if you value psychotic symptoms a lot less than your psychiatrist does.
George Dawson, MD, DFAPA
References:
1. Irene Hurford. Medicating A Prophet. New York Times. October 1, 2016.
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People arguing that delusions and hallucinations are just "another way of looking at things" deserved to be lumped together with the anti-vaxxers, climate change deniers, flat earthers,and people who really believe that the earth is just 6,000 years old. Those are the folks who are the people in an "alternate reality" that is not psychotic (since it's culturally shared) - but instead who are just really, really, really stupid.
ReplyDeleteR.D. Laing, who was nuts himself, had a treatment center in England that pushed for the use of hallucinogens in people with schizophrenia. One of his famous victims was one of the founders of the rock group Pink Floyd, Syd Barrett.
These people are causing deaths and destruction and we should in no case give creedence to their bull. Lord knows there's plenty of non-science in our field that really is bull - but not this nonsense.
This is an outgrowth of sixties anti-empirical, anti-Enlightenment, post-modern relativism that has created nothing but chaos in mental health and everywhere else it is applied.
ReplyDeleteI definitely don't want to fly in a post-modern jet, where physics can be what you want it to be.
By the way, climate change is a poor example, I would have said people who deny a rise in CO2 which is measurable. Temperatures increases are NOT following the hockey stick computer models. Climate change is a "science" controlled by fanatics never dissuaded by evidence. Climate skepticism isn't flat earth theory but many people inside academia have convinced themselves it is.
"King of Hearts" was a prototypical example of this kind of thinking, and while it was an enjoyable anti-war film, it's not a valid way of looking at the reality of mental illness.
This is off topic, but climate change in an excellent example. The computer models vary in terms of exactly when and how global warming will occur (as anyone familiar with computer models of complex phenomena would know), but not whether it will occur. In fact, it's already demonstrably occurring.
DeleteThere's a difference between people who question a prediction versus people who deny what has already factually happened.
ReplyDeletePlease, repetition by the columnists in the NY Times is not fact and there are many well credentialed skeptics:
http://www.businessinsider.com/the-ten-most-important-climate-change-skeptics-2009-7
Questioning global warming theories does not make one psychotic. Do you disagree? Is Richard LIndzen psychotic?
Science isn't determined by believing in computer models, but by making observations that confirm or deny the hypothesis. Hockey stick loses. Science also isn't determined by political shaming.
I think there is plenty of politics in science. Many people don't realize that default positions like consensus, expert opinion, reviews, even the sacred meta-analysis is always written from a perspective. It is not necessarily the truth.
DeleteSomebody jumped on me on another thread when I pointed out that even a third party backer like me has nobody to vote for in the election because the Green Party candidate is an anti-vaxxer. They suggested she was not. The reality is that her positions are so opaque (probable political strategy) that she tries to have it both ways and in the process suggests that vaccination policies and the programs themselves need scrutiny. In the end she tries to appeal to anti-vaxxers and vaccine supporters at the same time and it does not work for me.
I have not seen this confirmed anywhere, but the fact that human decision making depends on emotion probably has a lot to do with it. The fact that your ventral striatum lights up on an fMRI when you think you have made a good decision is probably a big part of that.
The other aspect that people lose sight of is that science itself is a process. There is no sacred book that contains all of the answers. Even Einstein had his skeptics. It was even more the case with Peter Higgs. In the end, the accumulating evidence proved them both to be correct.
The inconvenient problem with climate change is that there are major problems with waiting for conclusive evidence and making it a political discussion rather than a scientific one.
I absolutely agree that the thing about science is that it is, of course, always open to refutation (and questioning, say, the validity of carbon dating doesn't make one psychotic either, but it does make one a sheep following leaders blindly). And there is a lot of politics, misleading studies with conclusions that don't match the data, and groupthink throughout science.
DeleteBut the polar ice sheets are indeed melting at an increasing pace, sea level is rising, Greenland is about to turn green again, average temperatures are at record historic highs and have been for several years, Co2 levels correlate with the changes, there are more extreme storms and droughts than ever, the Pentagon and the governments of almost every major country believe in it, and the vast majority of scientists who question it work for the fossil fuel industry. I suppose that could all be coincidental, but considering that isn't going to help the people of Vanuatu any time soon.
You believe Greenland is about to turn green. I just talked to some who went on a cruise there. It's not green.
ReplyDeleteThe majority of "scientists" on the DSM committee described 300 or so separate mental disorders. That doesn't make it true. Appeal to authority is no substitute for critical thinking. I agreed that CO2 levels are rising. They have risen in the past. The implications of that are controversial. I will gladly plan a vacation to Vanuatu in twenty years. And if we continue to deplete our Treasury chasing at this hysteria driven windmill, I might open up an offshore account.
How about actual data? Of course it's not green yet - still will take some years for the process scientists are actively monitoring, although it's happening way faster than they expected. Apparently you haven't seen the films. Have you seen what the Russians are doing to profit from the opening of the long sought after Northwest Passage that didn't used to exist?
DeleteHere you go:
Deletehttp://a-sceptical-mind.com/the-rise-and-fall-of-the-hockey-stick
This issue requires some investigation and not trusting Tom Friedman and Al Gore and Leo DiCaprio who are worse than Jenny McCarthy because their lifestyles make them colossal hypocrites.
Form a hypothesis and make a prediction. If the prediction fails, hypothesis is invalid.
http://www.accuweather.com/en/weather-blogs/climatechange/well-known-skeptic-says-climat-1/68474
Back to mental health...a real life example of the tragedy of not "judging" psychosis is evident on any trip to San Francisco, a city that is not run by Pat Buchanan and the Duck Dynasty clan. Mission St. looks like a heroin gallery and smells like an outhouse. But the city council will tell you over and over how enlightened they are.
You're absolutely right about San Francisco. The street people will die with their civil rights intact. I'm surprised they don't let patients with Alzheimers roam freely, since there's no such thing as mental illness according to them.
DeleteIt sounds like your standard of proof (that predictions have to be all correct, or else they are completely wrong. e.g, black and white thinking) is different for some issues than for others.
I think people have talked themselves into infinite tolerance which violates Popper's toleration paradox. The only mortal sin in a city like San Francisco is being judgmental. Using needles and urinating and screaming at strangers is just someone else's lifestyle that we have to get used to. Of course the citizens adapt by wearing headphones and avoiding eye contact, but that's not my idea of civilization.
ReplyDeleteWe certainly agree on the disaster of SF mental health policy. But moral vanity prevents the enlightened local pols from objectively looking at the mess they've made and thus they focus on their good intentions while the community crumbles and the seriously mentally ill die a slow suicide.
ReplyDeleteSaying you meant well and not owning up to an objective disaster is what a misbehaving child does. Why do we let them get away this?
As someone who has had "psychosis", I would like to write Yes, a doctor can/should forcibly hospitalize someone who is too delusional to function in society. Too delusional to understand that people do not want to hear them preach ( once they have been told no one wants to hear them).
ReplyDeleteBUT you miss the second part. Once you section them, they get angry at losing their freedom. Then and only then do you issue drugs, drugs you rename medicine.
The "antipsychotic" is not for psychosis but to get the patient to stop fighting their imprisonment.
The other example of the man who was not eating, yes maybe he should be sectioned and forced/encouraged to eat, but this leads to the slippery slope of people in the opposite condition of being morbidly obese, do you section them also for being too fat?
I obviously disagree with you. First of all you seem to minimize the idea that "people don't want to hear them preach." I am personally familiar with many of these scenarios that involved confrontations with family members and/or the police where the outcomes were serious injury, death, and prolonged incarceration for the person with psychosis.
DeleteI don't "miss the second part". It is completely understandable to me that a person who believes they are preaching or God or the Antchrist sees absolutely no reason for being in the hospital. Why would a deity believe they needed to be hospitalized? What they fail to see is the risk involved.
I am also familiar with the usual antipsychiatry rap medicine = "drugs". Those medications or drugs are lifesaving for a number of people. I have talked with people 10, 30, and 30 years after I treated them with medications for acute episodes of psychosis who were working, had families and were successful in life. So I know a little about about that too.
Your argument about obesity and starvation makes no sense to me. It is a question of which one will kill you first. In that case of starvation it is generally dehydration that is the problem and it can kill you in about a week.
It is easy to take a rhetorical appraoch to these problems when you have no responsibility for what happens in these situations. That invariably falls to psychiatrists when the family as the last resource is gone.
But instead of laying it all on psychiatrists - I would encourage any interested group of people to take care of psychotic people are try to keep them out of the hospitals and off of civil commitment. They would do a service to overcrowded emergency departments and severely rationed psychiatric services.
My argument of obesity and starvation being judged by psychiatry is simple, if you (psychiatry) have to look after those who are starving, you also have to look after those are morbidly obese. Both lack "insight" into their behavior that is leading to their death. Who is lucky enough to be saved?
Delete(joking)
When I sell tobacco and my customer complains they are not feeling well when they stop smoking, I of course sell them more tobacco. They then feel better after smoking and everyone is happy.
Psychiatrist claim certain people are ill and need antipsychotics and give them to the ill/psychotic. The psychiatrist claim the person was psychotic BEFORE they gave them antipsychotics.
The problem is that after being given antipsychotics, the person usually has to take them for the rest of their life, for the fear of (fear)psychosis returning. What of instead, the doctor and patient waited out the first "psychosis" without medicine/drugs?
A doctor feels they have to do something for their patient, when doing NOTHING may be the correct treatment.
Assuming the patient is fed and clean and cared for.
Can a person ever be forgiven for being "psychotic"? Learn from their mistakes/ mistaken beliefs?
People don't need to be forgiven for being psychotic anymore than they need to be forgiven for having asthma. Psychosis is a no fault condition as far as psychiatrists go. Society is somewhat different in that the concept responsibility from crimes will not be forgiven. Contrary to popular belief the "not guilty by reason of insanity" defense rarely succeeds. If you have a drug induced psychosis - most states have disclaimers that say that crimes committed due to drug intoxication cannot be used a diminished capacity defense. In that context, psychiatrists are interested in keeping their patient out of contact with the criminal system.
DeleteOnly a small percentage of patients take antipsychotics "for the rest of their lives." The majority stop taking them within a few months. Many only need to take them for acute episodes especially if they are drug induced. That said taking a medication long term should not be a stigma for anyone who sees it as a stabilizing force in their lives.
You are missing the point again on starvation versus obesity. The only way that a person can be treated on an involuntary basis is an acute life threatening condition. Obesity is not an acute life threatening condition. Of course psychiatrists talk to patients about obesity and the complications.
People can learn from their mistakes - but in the case of people with psychotic disorders active learning needs to occur. I have treated most of the people I see with some form of psychotherapy with or without medications.
Nothing would make me happier than to see all of the people with psychosis adequately cared for with adequate food, housing, and medical care. That is the basis for my previous recommendation to you to have somebody provide those services. The problem is that it has been attempted in the past and did not work for untreated psychosis.
Like most people who criticize psychiatrists - you make it seem like we are out on the street hunting people down and bringing them to the hospital. The reality is that we see them after just about every bridge has been burned and they are in dire straits. I have seen far too many people after they have attempted suicide and survived it or after they were injured in a confrontation with the police. These are situations where nothing is the incorrect treatment because that is how they ended up in those situations.
I'm very tired, but I just wanted to say to Mark, that some people are glad for their medications. I hate the side effects, I really really do. But at least I'm not so psychotic that I might harm myself. I can live my life and work and be a productive member of society. If I decided to go off them, my doctor might disagree, but she's not going to force me to take them unless I get so unwell I'm a danger to myself.
DeleteNo one is forcing me to go to her appointments. No one is forcing the meds down my throat each day. And I've heard that many people, once stable go off their meds once out of hospital. No forcing at all.
Also they don't give out psych meds lightly, you've got to be ill to get them prescribed in the first place and ill enough to think you might need them to voluntarily swallow them.
And my doc tried to get me off antipsychotics twice, unfortunately I got sick, but she was very keen to get me off them as soon as possible.
And you think that being psychotic is just having odd beliefs. Apparently trying to argue with a psychotic individual is like banging your head against a brick wall. Some people can learn to live with their symptoms, but when very ill there is no 'learning' in the world that would work.
As the mother of a daughter living with schizophrenia, I want to thank Dr. Dawson for this well-informed and sensible rebuttal to Dr. Hurford's op-ed. I only wish that the New York Times would publish his much needed analysis of the dangerous notions informing the trends to 'respect' everyone's reality and, therefore, leave severely psychotic people to suffer untreated. I have noticed that the alternative movement, which supports this stance, is unconcerned about the hundreds of thousands of people with untreated smi who are now incarcerated, and dismisses them as people who 'chose' to do crimes.
ReplyDeleteWe're lucky, as American-Canadians, that we were living in Vancouver when our daughter became psychotic. She received involuntary treatment when she needed it, which has allowed her to live a stable life; she never wants to be left in untreated psychosis in the future. Sadly, the strong British Columbia Mental Health Act which has protected so many people I have come to know, is now under attack from human rights and disability groups opposed to involuntary treatment.
Mental Illness policy advocate D J Jaffe has also written a valuable critique of Dr. Hurford's article:
http://www.city-journal.org/html/policy-madness-14775.html
A great article. As a parent it horrifies me that professionals can even consider sentencing another person to a living hell which is what psychosis generally is if it is left untreated. Here in the UK too it is becoming accepted that people with severe mental illness are homeless, and ill. Campaigners talk about 'stigma' when the real problem is getting treatment over the long term.
ReplyDeleteIt is an interesting twist on stigma. In my most recent post - policy makers in the US argue that stigma prevents adequate treatment of the stigmatized. I agree with you that the real issue is adequate access to care. I think there is also an issue about how the term is used. It is typically discussed as general discrimination against the mentally ill or addicted by professionals or the public. The policy makers rationing the care are left out. It is the only severe medical problem where little to no care occurs or is justified as a human rights issue.
DeleteIn British Columbia, I have met parents, whose children could have access to the very helpful Early Psychosis Intervention programs we have had for many years, who don't understand the value of these free evidence-based services. This is because Canada, like the US, has inadequate public mental illness literacy programs. Many otherwise well-educated people have been swayed by the increasing influence of the kinds of views held by Mad in America. The perspectives of SAMHSA have a lot of influence in Canada and most recently can be seen in the kind of national recommendations for training peer support workers that were recently adopted; as in the US, these recommendations don't include offering people training to be peer workers any information on mental illnesses:
Deletehttp://www.huffingtonpost.ca/susan-inman/peer-mental-health-workers_b_9009252.html
Dear judyb,
DeleteI have tried to locate any organizations in the UK which represent families advocating for more sensible policies for helping people with psychotic disorders. Do these exist? We have the British Columbia Schizophrenia Society: http://www.bcss.org
Agree that a political organization is a very poor resource for setting public policy. SAMHSA is not much better in my opinion because it is also strongly influenced by politics. And let's face it - the US government is the largest single cause of rationing mental health and psychiatric services for the last 30 years.
ReplyDeleteWhy would anyone believe they are now going to "fix" the catastrophe that they have created?