‘A new look at psychosis.’ Ivan Tyrrell and Richard Bentall discuss patient-centred new approaches to the understanding and treatment of psychosis.

Ivan Tyrrell and Richard Bentall discuss patient-centred new approaches to the understanding and treatment of psychotic illness.

Tyrrell: You have written a huge book about psychosis, which you manage to make utterly readable and absorbing. There are lots of ideas arising from it that I want to discuss, and I’d like to start with a quote from your book, to set the scene. You are describing the modern psychiatric ward.

“With few exceptions, the psychiatric wards of today are located in general hospitals alongside surgical, medical and other types of services. Admissions to hospital are restricted to those who are floridly disturbed. Discharge back into the community is usually after a matter of weeks by which time, hopefully, the patient’s worst symptoms have been controlled by medication.

“Visiting such a ward, one sees patients with a variety of diagnoses aimlessly wandering around. Some talk out loud to their voices or charge around in a manic frenzy. However, on closer scrutiny, the overwhelming impression is one of inactivity and loneliness. Many patients sit in the ward lounge, silently smoking cigarettes, their faces glued to daytime television shows. The nurses, who now wear casual clothes instead of uniforms, spend most of their time in the nursing office, talking only to those patients who are most obviously distressed. The psychiatrists and psychologists are even less in evidence — patients on many wards see their psychiatrists for only a few minutes every week and the psychologists are almost entirely absent, confined by their own choice to outpatient clinics.

“There seems to be a lack of therapeutic contact between the patients and the staff. The patients are simply being ‘warehoused’ in the hope that their medication will do the trick.”

That’s a very damning description. As you go on to show, the success of psychiatric treatment today is little better than that achieved in the first decades of the 20th century, before the introduction of modern psychiatric drugs.

Bentall: It was meant to be a damning description. What I argue in my book is that we’ve been labouring under serious misunderstandings about the nature of madness for more than a century and that only by abolishing these misunderstandings can we hope to improve the lot of some of the most neglected and vulnerable people.

Tyrrell: You say, in effect, that modern psychiatry has been based on two completely erroneous ideas.

Bentall: Yes. The orthodox approach, which I think is so wrong, is based on two false assumptions: first, that madness can be divided into a small number of diseases, for instance schizophrenia and manic depression; second, that the ‘symptoms’ of madness cannot be understood in terms of the psychology of the person who suffers from them.

The German psychiatrist Emil Kraepelin is really the man who set psychiatry off in this wrong direction — the Kraepelinian paradigm remains almost unchallenged within the mental health professions, even today. It is the organising principle for psychiatric practice and research. It was Kraepelin’s idea that psychoses fell into a small number of discoverable types and that these could be independently identified by studying symptoms. Although his ideas were fiercely debated at the time, his system of diagnosis — on the basis of specific symptoms — was embraced by most clinicians.

Tyrrell: Interestingly, hints that the truth might lie elsewhere weren’t followed up. For instance, you write about the Swiss psychiatrist, Eugen Bleuler, who took the same basic approach as Kraepelin but refined some of his ideas, and introduced the concept of schizophrenia. In 1867 he took over the psychiatric clinic on an island in the Rhine. When a typhoid epidemic broke out in the village, he recruited some of his patients as nurses. He noted that they performed extremely well, prompting him to suggest that, in a general crisis, mental illness, far from dominating the life of the patients, could retreat into the background.

This is actually a far-reaching insight which we are still struggling to get orthodox psychiatrists and psychodynamic psychotherapists to see today — directing people’s attention outwards, off their own problems, helps break the cycle of their illness. Working as nurses gave people a sense of meaning and purpose, self respect, a degree of control, a chance to help others — all things which are crucial to mental health. But, alas, Bleuler didn’t make these connections, and what became emphasised in psychiatry was symptom classification.

Bentall: And the system doesn’t work. For a categorial system of diagnosis to work, patients must all fit the criteria for a particular diagnosis and not be able to fit the criteria for more than one disease, unless they are very unlucky indeed. That means more and more sub-categories are required, to try to accommodate everybody.

Tyrrell: Could you explain that a bit more?

Bentall: current Diagnostic and Statistical Manual — DSM-IV — there are five subtypes of schizophrenia; two milder forms of psychosis (schizophreniform disorder and brief psychotic disorder); schizo-affective disorder; delusional disorder; shared psychotic disorder; psychotic disorder due to a medical condition; substance-induced psychotic disorder; and, finally, the catch-all “psychotic disorder not otherwise specified”!
DSM-IV states that patients may not be diagnosed as suffering from schizophrenia if they also meet the criteria for schizoaffective disorder, major depression or mania.

Similarly, the criteria for bipolar disorder specify that the patient’s symptoms shouldn’t be better accounted for by schizoaffective disorder and must not be imposed on schizophrenia, schizophreniform disorder, delusional disorder or other psychotic disorders. But what researchers found when they tested the criteria was that 60 per cent of people who had met the criteria for one disorder had also met the criteria for at least one other at some time. They concluded that suffering from one disorder put people at greater risk of suffering from another.

Strangely, they didn’t discuss the possibility that their findings might reflect the inadequacies of the neo-Kraepelinian system! The most likely explanation for the strong associations observed between schizophrenia, depression and mania is that these diagnoses do not describe separate disorders.

Tyrrell: Absolutely! One of the central planks of your book is that the problems involved in categorising and ‘explaining’ schizophrenia and manic depression and so forth disappear if we look at the circumstances behind, and meaning of, people’s psychotic experiences. We need to listen to what they have to say about it themselves, and accept that there isn’t such a huge divide between people who have psychotic experiences, such as hearing voices or delusions, and those who don’t.

Bentall: You can’t consider the brain in isolation from the social world and the experiences people have. You can’t treat psychotic disorders without addressing patients’ psychological and social needs.

Tyrrell: Indeed. That’s what the human givens approach is all about.

Bentall: I would say that psychotic complaints invariably reflect concerns about the self or relationships with other people. Psychotically depressed people, for example, often believe that they are inadequate or guilty of imaginary misdeeds. Manic patients often feel they are superior to others and are capable of achievements that will amaze the world.

The delusional beliefs usually attributed to schizophrenia are particularly redolent with social themes: patients rarely profess bizarre ideas about animals or objects; they believe they themselves are being persecuted or denied recognition for some imaginary achievement or that they are adored by a particular celebrity or their doctor. The voices that psychotic people hear are often critical voices, telling them that they are worthless or they are doing something incorrectly. Michael Musalek, a psychiatrist at the University of Vienna, has suggested that psychotic symptoms reflect the core existential dilemmas experienced by ordinary people, and that really resonates with me.

Tyrrell: You provide lots of evidence to show the importance of social stresses and family stresses, which cause anxiety and depression, in the lead up to psychotic breakdown. And yet this has been so ignored by conventional psychiatry. I think that, if society were better able, psychotherapeutically, to deal with depression, anxiety disorders and trauma, we would have far fewer psychotic breakdowns in the first place, because — as you show in your book — it is almost like a continuum.

Bentall: I think that’s true.That comes out in the latest trial that we are doing, that we’ve just got the data for. This is a pilot study of using cognitive behavioural therapy (CBT) to prevent psychosis. We identified 60 people who are at ultra-high risk of psychotic breakdown because they are showing attenuated psychotic symptoms. Half of them were offered CBT and were monitored at monthly intervals to see how their symptoms developed. The other half were simply monitored without any psychological intervention.

We asked the treated patients to come up with a problem they wanted to work on, and, for the majority, the problems have concerned relationships with other people or mood problems. We had pre-set criteria for transition to psychosis and our initial results showed a significant difference between the groups in terms of reduction in numbers of people who became psychotic over a one-year follow-up period. Interestingly, we also found that the treated patients’ doctors were less likely to prescribe neuroleptic medication.

Tyrrell: Presumably, those who had the CBT, and were helped to think about relationships or other problems in a less negative or self-deprecating way, were the less likely to become psychotic?

Bentall: That’s right. It was a relatively small study and we don’t know what will happen in two years’ time. We are currently discussing with the Medical Research Council the possibility of a bigger version.

Tyrrell: You make the point, and I couldn’t agree with you more, that psychotic phenomena are, above all, emotional phenomena. This is something we are always saying when talking about depression. People who are depressed seem flat but internally they are highly emotionally aroused. Similarly, you describe the case of a man diagnosed with schizophrenia where two doctors, two social workers and a psychologist who all knew him well described him as quite severely blunted in his emotions. But his diary, which his mother had, showed he was full of emotion — he talked about feeling pity and love and hurt and being cowardly and misunderstood and so forth.

Bentall: Yes, just because people aren’t emotionally expressive, it doesn’t mean they are not having emotions. In fact, flat affect, as it is called, is one of the severe side effects of neuroleptic medication, so it could even largely be down to that, not the illness at all.

Tyrrell: That brings me on to my next point. Neuroleptics.

Bentall: What’s striking about the story of the neuroleptics is that, in terms of efficacy in their effect on the so-called positive symptoms of schizophrenia (hallucinations and delusions), there has been no real improvement since the discovery of chlorpromazine, the first neuroleptic to be used on psychotic patients. There is no evidence that the new ‘atypical’ neuroleptics that are available today, and that have been pushed by drug companies at a huge expense to the British taxpayer, are any more effective than the older drugs.

Neuroleptics do have an effect on positive symptoms, and I believe that’s been proven, given the amount of trial evidence available. But they have many negative effects, which are also well understood. The old fashioned, so-called typical, neuroleptics, for example, produce side effects that are really dreadful: the patients have parkinsonian symptoms; they have a terrible inner sense of restlessness and depression; they get muscle dystonias, which are muscle spasms. In some cases they get tardive dyskinesia — pronounced involuntary movements of, for instance, the tongue, the lips and mouth, which can be very debilitating to people.

And these drugs also appear to have an extremely negative effect on people’s motivation, so that patients taking them often have what’s been described as a neuroleptic-induced deficit syndrome. So, although users may experience fewer positive symptoms, they’re also less able to achieve things in their lives.

Now, the new, or atypical, neuroleptics are being touted as much better because they don’t produce these side effects, but the truth is that they produce lots of other side effects. For example, if you take a drug like olanzapine, which is probably the most widely used neuroleptic in this country at the moment, massive weight gain is a serious problem. At least 50 per cent of people have sexual dysfunction and there is also a high risk of diabetes, so these drugs have pretty nasty side effects.

Tyrrell: Clearly, any benefits need to be balanced against all those side effects.

Bentall: Ah, but you also have to take into account that maybe a third of patients don’t get any benefits at all; they don’t get a reduction in positive symptoms, although they are still given the drugs and so still get the horrible side effects.

Tyrrell: So why do they keep on being prescribed the drugs?

Bentall: Psychiatrists tend to think the drugs are the only thing there are, therefore they must be prescribed, even if the patient is not getting any obvious benefit. I think patients should be asked if they want to take these drugs. The benefits and the side effects should be explained, and, if they do want to take them, they should be given a low-dose typical neuroleptic like chlorpromazine for three months. At the end of that time, a detailed account should be taken of the costs and benefits, and then the patients should decide if they want to continue or to try another drug. If the costs seem to be outweighing the benefits, then it makes sense to try another drug. If that doesn’t work after another three months, it makes sense to try an atypical neuroleptic. If that doesn’t work, then step four is to give up on the drugs. But that never happens.

You find, in Britain, that probably under five per cent of psychotic patients are not given neuroleptic drugs and they’re usually people who have been labelled as non-compliant: the people who have the guts to say firmly that they don’t want to go down that route. And they’re treated in a very pejorative way by the psychiatric establishment because of that. If taking a drug were based on an analysis of cost and benefits, you’d probably find just 50 per cent of patients would be on neuroleptic drugs.

Read the full article here: http://www.hgi.org.uk/archive/newlook-psychosis2.htm

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