drugs


Schizophrenia is a fascinating set of phenomena, the study of which has launched a thousand ships including, arguably, my field, family therapy; many of the original family therapists left psychiatry to study schizophrenia (or, as the DSM would have me write it, Schizophrenia–capitalizing words gives them more authority, don’t you think?) as an interactive process. That is, if all behaviors make sense in their context, what context might make schizophrenic behavior necessary?

There was an almost violent backlash against this line of thinking, as it seemed to (and did, in many cases) blame mothers for their schizophrenic children–as in the unfortunate phrase “schizophrenogenic mother.” The conventional wisdom about schizophrenia these days reads like a pharmaceutical company press release, something like, “Schizophrenia is a biological disease of the brain which is at present incurable, but there are drugs which can help manage the symptoms, and if taken regularly can provide a decent quality of life.”

So schizophrenia is assumed to be a biological disease of the brain though it, like every other Mental Disorder, has no laboratory test that can detect its presence. The best we can do is a set of behavioral diagnostic criteria which, frankly, are a bit of a mess. You may notice as you read that different flavors of schizophrenia may have nothing or little in common with each other. Are they really the same “disease”? We don’t know.

We do have good evidence that you can inherit, in some fashion, a tendency for one of these constellations of behaviors. There is good evidence that environmental factors are also important, though they are not a big part of the mainstream discussion. We also have evidence that therapy helps in a lot of cases. There is some (hotly contested, I’m sure) evidence from the World Health Organization that unmedicated schizophrenics can eventually recover while those on medication do not. Here is a trailer for a moving documentary about two recovered women and the public perception of schizophrenia, called Take These Broken Wings. Also, consider checking out the documentary A Brilliant Madness, about John Nash, in which puts the lie to A Brilliant Mind, which showed Nash recovering with the help of psychopharmaceuticals.

The DSM says that schizophrenia may be overdiagnosed (or at least is diagnosed more often) in African- and Asian-American men, that it affects men differently than women (men tend towards the negative symptoms were women tend towards delusions and hallucinations), and that incidence rates are something like .5-1.5% of adults.

Here are a few terms that you’ll need to know to get through the criteria:

affective flattening: does not show emotion. Also, “affect” means “emotion” to scientists and people who like to talk like scientists.

alogia: lack of speech.

avolition: lack of motivation.

prodromal: symptoms coming early on in the course of a disease.

echolalia: repetition of others’ speech sounds.

echopraxia: repetition of others’ movements

And here are the diagnostic criteria, word-for-word, from the DSM-IV-TR, pp. 312-319:

Diagnostic criteria for Schizophrenia

A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g. frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction: For a significatn portion of the time since th onset of the distrubance, one or more major areas of functioning such as work, interpersonal relations, or self-care are mardekly below the level achieved prior to the onset (or when the onset is in childhood or adolewscence, faliure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: Continuou signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. Doring these prodromal or residual periods, the signs of the ditrubance may be manifested by only negative symptoms or two or more symptoms listen in Criterion A pressent in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):

Episodic With Interepisode Residual Symptoms (episodes are difined by the reemergence of prominent psychotic symptoms); also specify if: With Prominent Negative Symptoms

Episodic With No Interepisode Residual Symptoms

Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With Prominent Negative Symptoms

Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms

Single Episode In Full Remission

Other or Unspecified Pattern

Diagnostic criteria for 295.30 Paranoid Type

A type of Schizophrenia in which the following criteria are met:

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Diagnostic criteria for 295.10 Disorganized Type

A type of Schizophrenia in which the following criteria are met:

A. All of the following are prominent:

(1) disorganized speech

(2) disorganized behavior

(3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.

Diagnostic criteria for 295.20 Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumptions of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Diagnostic criteria for 295.90 Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Diagnostic criteria for 295.60 Residual Type

A type of Schizophrenia in which the following criteria are met:

A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

I know people who happily smoke pot, drink beer, and use other recreational drugs with no apparent concern, but who would not take an Ibuprofen because it’s bad for your liver. This confuses me. Yes, non-steroidal anti-inflammatory drugs are bad for your liver. So are many, many other mainstream drugs, like antidepressants and birth-control pills. (Here’s a list.)

But what is the reasoning that lets hippy-friendly drugs off the hepatotoxicity hook? It seems to be that these drugs are “natural” and so they are trustworthy, as if God wouldn’t make such righteous substances poisonous. This is not rational.

It’s true that there isn’t as much research on the hippy-friendly drugs as there is on medical drugs. The FDA makes pharmaceutical companies do a bunch of expensive research on the drugs trying to go the legitimate route, but they don’t get involved in the illegal stuff. There is some research, though, and we do know that even hippy drugs are made out of chemical compounds that the liver has to metabolize before we can pee them out. It is safe to assume that pot, acid, mushrooms, ecstasy, cocaine, and the rest of your recreational drug list are bad for your liver. (And alcohol, duh.)

I will happily support you in not taking over-the-counter pain meds, but if an Ibuprofin is a drop in the hepatotoxic-lifestyle bucket, your priorities confuse me. If you are willing to ingest any number of chemicals in order to feel good, why not ingest one or two more to feel a little less pain?

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), there is a mental disorder that is usually diagnosed in childhood or adolescence called Oppositional Defiant Disorder. It afflicts somewhere between 2-16% of people, more boys than girls before puberty, but equal numbers of boys and girls after puberty. Family therapists are not into giving medical-model diagnoses in general, but in many cases, a DSM diagnosis is the only way for a family to get their insurance companies to pay for them to get help. In one of my internship sites, for example, I will need to provide a DSM diagnosis after the first session with a family in order to get the clinic paid for our work. As I understand it, this is a common diagnosis for kids who are giving their parents and teachers a hard time.

Note that the word “often” is used to mean something like “more than usual,” so whichever kids who are most like this will qualify for this Disorder, as long as someone important believes that their behavior is significantly impairing their social or academic functioning. Note also that these symptoms could be occurring in just one setting (say, just at school) and the kid will still qualify for ODD, unlike the symptoms for ADHD, which have to occur in at least two settings to qualify for the diagnosis.

Outside of family therapy, ODD is very commonly treated with Ritalin for “comorbid” ADHD. Kids diagnosed with ODD are also fairly commonly given antidepressant and/or antipsychotic medication, on the guess that they have an underlying Mood Disorder or Bipolar Disorder, though there is little to no research on these medications for children, especially in combination.

The following is word-for-word from the DSM-IV-TR, page 102:

Diagnosis criteria for 313.81 Oppositional Defiant Disorder

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

(1) often loses temper

(2) often argues with adults

(3) often actively defies or refuses to comply with adults’ requests or rules

(4) often deliberately annoys people

(5) often blames others for his or her mistakes or misbehavior

(6) is often touchy or easily annoyed by others

(7) is often angry or resentful

(8) is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 or older, criteria are not met for Antisocial Personality Disorder.

Another unfortunately common situation I will have to assess for in the families I see (in addition to drug & alcohol abuse, domestic violence and many other things) is sexual or physical abuse. One of my texts (Patterson’s Essential Skills in Family Therapy: From the First Interview to Termination) estimates that 1 in 5 women and 1 in 9 men were sexually abused as kids. My other practicum text, Brock & Barnard’s Procedures in Marriage and Family Therapy, gives this list of indicators of abuse(p. 52):

The presence of an alcoholic parent

The family with poor mother-daughter connections/bonds

A mother who is very dependent either psychologically or physically as the result of illness or accident

A father who appears to be very controlling and possessive of his daughter(s)

An acting-out adolescent girl engaging in sexual promiscuity or suicidal gestures who is a frequent runaway or drug abuser

A child who appears to be very overresponsible and parentified in the family context

One thing I will have to assess in the families I see is possible drug/alcohol abuse, because substance abuse is pervasive, problematic, and interpersonal. One of my texts, Procedures in Marriage and Family Therapy, recommends using “objective” measures such as the Michigan Alcoholism Screening Test (25 items), or the MacAndrew Alcoholism Scale of the Minnesota Multiphasic Personality Inventory (49 items), to give weight to the assessment. However, it also says that there is a correlation of .89 (that’s very high) between answering yes to two or more of the following four questions  and alcohol abuse (p. 47):

1) Have you ever felt you ought to cut down on your drinking?

2)have people annoyed you by criticizing your drinking?

3) Have you ever felt bad or guilty about your drinking?

4) Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)?

Also, they list Heilman’s eight symptoms of alcoholism:

1) Thinking or talking a lot about drinking or getting high.

2) Increased tolerance. This is not a sign of health!

3) Drinking or taking a drug in a way that speeds up the onset of its effects.

4) Non-social use.

5) Drug/alcohol starts to seem like a medicine. Thoughts of drug/alcohol immediately upon a stressful event.

6) Blackouts. “How did I get home last night?”

7) Taking care to always have a supply of alcohol/drug.

8) Using more than planned.

Finally, Heilman says that anyone who answers yes to the question “Is your drinking ever different from what you would like it to be?” is very likely suffering from alcoholism (p. 48)

This is part 3 of a series of things I learned during my Bachelor’s degree in psychology that I thought should have been headlines in the mainstream news. If you missed them, here’s part 1 and part 2. Again, if you’re interested or skeptical, leave me a comment with a specific question and I’ll give you my references.

Egaz Moniz Was Given the Nobel Prize for Medicine in 1949 for Developing the Prefrontal Lobotomy: This “psychosurgery” involved slicing or scrambling the front part of the brain, and tended to produce more manageable behavior in “patients.”

40,000 Human Beings Were Lobotomized in the United States Between 1936 and 1977: These were men, women, and children with “illnesses” like schizophrenia, PTSD, depression, anxiety, homosexuality, criminal behavior, and being hard to manage.

Antipsychotic Thorazine Hailed as “Chemical Lobotomy”: Yes, this was meant as a compliment.

200,000,000 Prescriptions for Antidepressants in the US in 2007: That’s quite a few prescriptions.

80% of Antidepressant Prescriptions in the US Not Written by Psychiatrists: Consider that it may be a good idea to at least see a specialist in mental illness before taking psychotropic drugs or giving them to your kids.

Some Psychopharmaceuticals as Effective as Exercise in Treating Depression: But who wants to exercise when you’re depressed?

Sleep Deprivation the Most Effective Treatment For Depression, By Far: Never heard of this one? Maybe it’ll hit the news when someone figures out how to make money from sleep deprivation.

The World Health Organization Found That Schizophrenics Recover, But Only in Countries Without Easy Access to Psychopharmaceuticals: Schizophrenics can recover? Well, yes, it looks like they can. And yes, the WHO data shows a correlation, not necessarily causation, but an interesting correlation!

There is a saying among non-allopathic health care folks that goes, “You can’t heal what you can’t feel.” It’s the argument for not using analgesics unnecessarily: If you don’t really need it, don’t take a pain killer. It impairs your body’s ability to feel itself (by definition, right?) and that will impair your body’s ability to heal itself.

Is this true? Is there any evidence that taking a ibuprofin prolongs the whatever-it-is that’s causing your headache? That taking dextromathorphan makes your cough last longer? I understand that taking drugs can allow you to continue pushing your body, and that that could prolong a sickness. I understand that your liver has to deal with these chemicals, and that’s probably not good for it. But if all other things were equal–the same amount of rest and your liver is just fine, for example–would you get better faster if abstain from drugs than if you take them?

Next Page »