The Evils Of Psychiatry: Truth About Bipolar,Depression, Abuse, DSM, & My Testimony (Video)
Severe Mood Dysregulation, Irritability, and the Diagnostic Boundaries of Bipolar Disorder in Youths
The American Journal of Psychiatry
Manic depressive disorder (bipolar disorder)
Modern psychiatry owes its intellectual framework to Kraepelin’s distinction between schizophrenia and manic depressive illness. This is now renamed bipolar disorder, the term used from here on. During Kraepelin’s time mental hospitals took whoever was sent to them; some got better but most didn’t. There was not that much attention to diagnosis other than perhaps distinguishing the learning disabled from the psychotic. Kraepelin noted that one group of patients alternated through several periods of profound disturbances – sometimes agitated and sometimes withdrawn and depressed. What distinguished them most from the schizophrenia patients (which he called ‘dementia praecox’) was that they made full recoveries between episodes and more of them eventually left hospital. It was the course of the illness rather than its symptoms that impressed him.
Bipolar patients can have all the same symptoms as in schizophrenia (hallucinations, delusions, thought disorder, etc.) although these occur only in the most severe forms of mania and depression. However these symptoms are accompanied by a profound disturbance of mood – either depression or elation. It is this elation that is called mania (or often hypomania).
The change in mood overshadows all else in this condition. In the depressed phase the patient suffers from severe depression and may be suicidal. In the elated phase the patient is overactive and bursting with confidence and energy. Hypomanic patients can be very destructive to themselves – spending money they haven’t got and behaving in an uninhibited manner (drinking too much, being sexually overactive without thought for the consequences, driving too fast, etc.).
The psychotic symptoms, where they occur, reflect the mood. If the patient is depressed hallucinations will be critical and persecuting, if elated the hallucinations praise and encourage.
Depressive delusions are usually of guilt and worthlessness and hypomanic delusions are expansive and grandiose: ‘I’m going to be asked to advise the president about foreign policy’, ‘My paintings are worth millions’.
In less extreme forms of hypomania patients can be very entertaining, often talking fast (‘pressure of speech’), punning and making humorous associations between ideas (‘flight of ideas’).
Many famous entertainers and artists have suffered from bipolar disorder and acknowledge that they get their inspiration when they are ‘high’. It can be difficult to be certain about diagnosis in some of the milder forms of hypomania because it usually lacks the ‘strangeness’ of the schizophrenic episode. The main disturbance is one of judgment – we would all like to spend more money or hope that our paintings are worth more than they are. Often the diagnosis needs friends and family members to be able to confirm that this is not how the person usually is. A rather flamboyant, flirty TV executive was brought to the clinic by her worried mother. The story was not, in itself, that remarkable – some rather torrid love affairs with work colleagues, recreational drug use in night clubs, and some incidences of rudeness to her boss and absences from work. There are lots of media people who conduct their lives like this. What was decisive was her mother’s description of how normally she was an over-conscientious, rather anxious woman and that this was completely out of character.
The mother was alert to the issue because her late husband had also suffered such episodes. Like schizophrenia, bipolar disorder also affects just under 1 per cent of the population, it runs in families, it starts in early adult life (though usually later than schizophrenia) and males and females are affected about equally. Although the elated phases are more dramatic depression is more frequent and persistent. The depressive phase of bipolar disorder is not easily distinguishable from the much more common disorder of clinical depression.
Treatment of psychotic disorders
Treatments in psychiatry, like any other branch of medicine, are evolving so fast that any description here would soon be out of date. A range of drugs have been developed since the 1950s (‘antipsychotics’ such as chlorpromazine, haloperidol, risperidone, clozapine, olanzapine) which are effective in settling patients during the acute phases of schizophrenia. Unlike earlier drugs like barbiturates these are tranquillizing rather than sedative. They calm the mind without making the patient fall asleep (they do often have drowsiness as a side effect but that is not their purpose).
Antipsychotics have revolutionized the treatment of acute psychotic episodes with calmer, shorter spells in hospital. Continuing on antipsychotics after recovery reduces the risk of further breakdowns, and most psychiatrists encourage schizophrenia patients to stay on them for many, many years (‘maintenance treatment’). Obviously this is not easy as all drugs have some side effects and nobody likes taking them endlessly. With support,
however, many patients do succeed in staying on them and suffer far fewer breakdowns.
Severe depressive episodes in bipolar patients can be treated either with antidepressants or, in extreme cases, with electro convulsive treatment (ECT). These are discussed below. There are also now a number of ‘mood stabilizers’ which are used in the maintenance treatment of bipolar disorder and significantly reduce the risk of breakdown. Drugs are certainly not the only treatments available for psychotic disorders but they are currently the cornerstone.
Compulsory treatment
Lack of insight can pose real risks of a psychotic patient harming him or others as he tries to flee or defend himself from perceived threats or persecution. Because of this impairment in judgment about the need for treatment, and the very real risks during psychotic states, psychiatry has been the one branch of medicine where the patient’s right to refuse treatment can be overruled. Provision for compulsory treatment is universal in psychiatric services and the overall principle seems generally accepted. The conditions under which it can be applied however (who imposes it, whether it is restricted to hospital care, whether there needs to be immediate risk of physical danger, etc.) vary enormously from country to country and reflect local values.
Compulsory detention for the severely mentally ill evolved before there were any effective treatments. It reflects recognition that mental illness is not simply deviance (‘mad’ not ‘bad’). Had it not been the case those at risk solely to themselves would have been left to their own devices and those presenting a risk to others would have been simply subject to the law. It was recognized in mental illnesses that the individual was changed from his normal self, and could change back. Detaining the patient served to protect him or her while the illness ran its course until they recovered (‘were restored to reason’). Of course not everyone did get better but enough did to sustain the hope and justify the humanitarian protective impulse behind detention.
Depression and neurotic disorders
Not all psychiatric disorders involve the same break with reality found in psychoses. In fact the majority of patients seen by psychiatrists do not suffer from psychoses but from less devastating disorders. Most of these are characterized by persisting high levels of depression and anxiety. They used to be lumped together under the title of ‘neuroses’ but the term has become unfashionable in psychiatry. However, it is a useful term, albeit rather vague, and one that most people understand so it will be used here. Neuroses cause distress and suffering to those who have them and may not be at all obvious to others. They vary greatly in severity and many patients are able to lead normal lives (marrying and working) while coping with them. Some, however, can be as disabling as the psychoses.
Depression
Depression is the commonest psychiatric disorder and affects about 15 per cent of us in our lifetime. The World Health Organization ranks it second to heart disease as a cause of lifelong disability worldwide. It appears to be becoming more common (particularly in the developed world), although some of this may be better detection, greater public awareness, and greater willingness to seek help. Luckily, with the advent of antidepressants and the development of more effective psychological treatments (e.g. cognitive behaviour therapy), it usually gets better fairly quickly. Most patients are treated by their family doctor and only the most severe get referred to psychiatrists. A proportion of depressed patients eventually become diagnosed as having bipolar disorder but here we focus on the ‘non-psychotic’ group.
Depression is usually experienced as a profound sense of misery, a loss of hope in the future, and often associated with self-doubt and self-criticism. Tension and anxiety are very common, sleep is disturbed, and patients lose weight and find themselves unable to concentrate properly or get on with things. Tearfulness and thoughts of suicide are common and aches, pains, and health worries frequent. In more severe cases patients report ‘feeling nothing’ (being cold and empty, unable to enjoy anything) rather than sadness. Patients may also take to alcohol or drugs as self-medication, which almost always makes things worse.
Depression differs from our normal periods of sadness by going on and on without relief, and the weight loss and poor sleep perpetuate it.
Depression is three times more common in women than men. Some people are constitutionally or temperamentally more at risk of developing it but it is clearly influenced by life circumstances. It is much more common in those living in poverty, those who are unemployed, live alone, have few friends or who have painful or disabling physical illnesses. Early loss of a mother and a difficult childhood are associated with an increased risk of becoming depressed as an adult. Depression is also more likely to follow from severe personal problems (relationship break ups, exam failure, job loss, etc.).
Helping people with depression almost always needs more than antidepressants (though these are very effective). Counseling, help to see a way forward, specific psychotherapy, and attention to ensuring a supportive social network are all needed. Understanding depression better has led to the recognition of just how important social networks and friendships are to people. These are not optional extras and few of us can survive without them. Providing such networks for young isolated mothers and their children in programmes such as Head Start in the US and Sure Start in the UK are national programmes that include strategies to prevent depression.
Most of us will experience some periods of depression in our lives with all of the features above. Most of us will get over them spontaneously and fairly quickly. Indeed, it is possible to think of depression as a necessary and useful human process – a period when we can work through loss, acknowledge it properly, and find a new balance. At such times it is appropriate to withdraw a bit into ourselves and some psychoanalysts consider the ability to be depressed as an essential step towards personal maturity. Certainly people who don’t seem ever to be depressed strike us as different or odd. Psychiatrists have spent years trying to make a clear distinction between ‘clinical depression’ and ‘normal depression’ and, frankly, have failed. The difference is more one of degree than genetics or symptom pattern. If it goes on and on, or if the symptoms become unbearable, it needs to be treated; if it gets better on its own after a few weeks, then great.
Anxiety
Anxiety is fear spread thin. We’ve all experienced it and undoubtedly it is useful – a degree of anxiety is essential to keep us alert and get us to perform well – e.g. fear of failure gets us to work hard for exams. However psychological studies show that, while performance rises with anxiety up to a point, above a certain level our performance plummets. Anxiety disorders are probably about as common as depression but fewer people seek helping for them.
People with ‘Generalized Anxiety Disorder’ (GAD) are persistently over-anxious. Most of us experience similar anxiety levels from time to time, but in anxiety disorders it doesn’t settle. GAD is exhausting and sufferers can’t sleep, lose weight, and often can’t concentrate. If it goes on a long time they may become depressed.
Phobic disorders are more dramatic and noticeable. A phobia means an exaggerated fear. Most of us have a phobia – so-called simple phobias start in childhood and are constant through life.
Animal phobias are typical examples (spiders, mice, snakes). Mine is a height phobia – I can’t climb towers or go near cliff edges. Most people live with their simple phobias unless they begin to interfere seriously with life (e.g. a flying phobia in someone whose job begins to require frequent travel, a needle phobia in a woman who becomes pregnant and needs to have blood tests). Simple phobias are remarkably easy to cure by behavior therapy using ‘graded exposure’. You get used to the feared object by following a preset scheme increasing the exposure while monitoring your own anxiety (e.g. start with holding a picture of a spider then hold a small dead one, a larger dead one, a living one in a glass, a living one free, and then a tarantula!).
Most of the phobias seen by psychiatrists are not simple phobias. They are either agoraphobia or social phobia. These start in adult life, are not constant (they are worse in times of stress), and can be quite disabling. Agoraphobia is not fear of open spaces as many think, but of crowds and crowded places. It comes from the Greek word Agoros for market place, not the Latin word Ager for field. Agoraphobia affects women much more and is associated with panic attacks and often leads to staying in and avoiding crowds. It is this ‘avoidance’ that makes the disorder continues. Panic attacks are awful (racing heart, sweating, a dry mouth, and conviction that one is going to faint, wet oneself, or even die). It is no surprise that people exit the situation as fast as possible and avoid it. The pity is that if they stayed they would soon realize that panic is very short-lived (a matter of minutes, not hours) and fades on its own.
However when we rush off and the panic stops we become convinced that it was the getting away that stopped it and we don’t learn that we can ride out the panic. The memory of the last panic starts to get us anxious as we approach the situation again and this ‘fear of the fear’ increases the likelihood of another attack.
Treatment is usually based on behavior therapy, teaching the person how to stay with a panic attack and thereby reduce it. It is usually a bit more complicated than with simple phobias. Social phobia is an exaggerated anxiety on meeting people. There is some real controversy about whether this is a legitimate diagnosis or simply severe shyness, and particularly whether it should be treated with drugs. In social phobia the problem is usually one of avoidance rather than panic and the treatment involves counseling to help develop techniques for dealing with social situations.
Obsessive compulsive disorder
Most of us have experienced obsessional behavior as children – avoiding the cracks in the pavement to avoid catastrophic consequences is the commonest. Sportsmen and actors are notorious for such rituals – the tennis player who has to bounce the ball three times before serving, the leading lady who cannot play without something green in her costume. These superstitious behaviors’ have much in common with obsessive compulsive disorder (OCD). In this disorder the patient has to repeat activities or thoughts (classically hand washing or checking and counting rituals) a set number of times or in a set order to ward off anxiety or feared consequences. In the obsessional form (where there are often no external rituals) the problem is repetitive thoughts, often about awful outcomes (contamination with dirt or germs, or a fear of shouting out something blasphemous or offensive). The hallmark of OCD is that the thoughts or actions are repeated, resisted, and distressing. It isn’t a harmless superstition or quirk but can dominate and ruin lives. Compulsive cleaners, for instance, end up exhausted because they are never finished cleaning over and over again.
Obsessional ruminators can’t hold down a job because they are distracted with repeating their thoughts or counting and may wear out their partners as they seek constant reassurance about their worries.
OCD tends to be associated with specific personality traits – neat, tidy, conscientious. Most of us recognize obsessional features in ourselves and yet the full disorder seems so bizarre. Indeed, sufferers are often slow to seek help because they consider it so strange and incomprehensible – they are embarrassed by it. It has been subject to psychological over-interpretation and only recently have effective treatments been developed (behavior therapy and antidepressants in milder cases).
