Date: Thu, 11 Aug 1994 23:06:47 -0400 (EDT) From: Quinn D Rossander Subject: Demystifying Mental Illness To: ThisIsCrazy Demystifying Mental Illness Understanding and Reversing Disabling Socio-Psychological Reactions Nathaniel S. Lehrman, M.D. Former Clinical Director, Kingsboro Psychiatric Center, Brooklyn, NY Revised, July 14, 1994 Prepared for Alternatives '94 conference of National Mental Health Consumers' Self-Help Clearinghouse, Anaheim CA August 10-14, 1994. The term "mental illness" covers a multitude of sins, errors, peculiarities and disabilities. Sins, errors and peculiarities should not be considered illness, a term that should be reserved for reduced ability to function. Nor should crimes or bad habits. The umbrella use of the term to cover all these behaviors led Dr. Thomas S. Szasz to call "mental illness" a "myth." But mental disabilities have always existed, and have therefore always been a proper area for medical intervention. Those impairments of the ability to function are what we examine here as "mental illness." In the mid-1950's, Professor Howard Liddell of Cornell subjected young goats to unremitting stresses and noted the patterns of disordered response which then occurred. First the animals appeared inhibited, with their overall level of activity and usual level of curiosity greatly reduced. Someone familiar with psychological thinking would see them as depressed. If the stresses were continued, the goats developed a second level of reaction. Now they seemed behaviorally and emotionally disorganized: wildly overactive one moment and rigid the next; terribly frightened now and almost euphoric a little later. The same pattern of initial depression and subsequent disorganization was described clinically in human patients by Dr. Karl Menninger. He saw the first level as representing neurosis or partial disability, and the second as psychosis with total disability. (Total disability due to disorganization is commonly called acute schizophrenia.) While these states are illnesses, because of the disability involved, they are also reactions - reactions to unremitting stress which can occur in both animals and humans. They differ from most medical illnesses, however, in lacking visible tissue changes. All of us have minor episodes of depression and disorganization from which we recover without professional intervention. But the more [past stresses an animal or person has experienced, the greater the likelihood will be that relatively minor stress will produce a major disability. And, of course, the greater the current stress, the greater that likelihood will be also. _The Role of Stress_ The key role of stress in causing mental illness has been recognized for centuries, although its importance has gradually been hidden in and by American psychiatry over the past several years. During World War II, the diagnosis of military psychiatric casualties, which was based on a relatively small list of available diagnoses, always named the stress to which the soldier had been exposed and its magnitude, his predisposition (past psychological weaknesses) and his current incapacity. Years earlier, Dr. Adolf Meyer, later chairman of psychiatry at the Johns Hopkins School of Medicine, sought unsuccessfully to find connections between mental patients' brain pathology at autopsy and their symptoms, but he did find strong association between their symptoms and their life experiences - particularly those interpersonal failures experienced as stresses. The treatment methodology presented later in this paper was formulated by him. Over the past two decades, however, the role of stress as a causal factor in mental disability has been discounted increasingly, and has now almost completely disappeared from American psychiatric thinking as reflected in and shaped by its official Diagnostic and Statistical Manual of Mental Disorders (DSM). _The Initial Fluidity of Symptoms_ Dr. Michael Balint, the distinguished British psychiatrist, studying the interaction of general medical practitioners and their patients during the 1950's, noted how fluid patients' initial symptoms often were - especially when their complaints were the result of non-specific socio- psychological stresses rather than well-defined medical conditions. These patients complained one day of pain in one place, and another body part ached a week later: anxiety might be their most important symptom on Monday, depression on Tuesday and disorganization on Wednesday. Balint also described how doctor and patient gradually reached agreement on which symptoms were significant, and which not, as well as the stresses apparently behind them, and how diagnosis was based on the symptoms considered important. Many complaints for which patients seek medical help are, of course, the product of specific diseases provable by tissue examination and curable by particular medical or surgical interventions. Someone with severe pain below and to the right of his navel, accompanied by vomiting and low fever, may be suffering from appendicitis. If he is - and diagnostic skills concerning this condition are very high - his inflamed appendix would be removed surgically and microscopic examination of the removed tissue would confirm its responsibility for his original complaints - rather than their having been caused by an inflamed gall-bladder, for example, in which the clinical picture can be quite similar. Mental disabilities are very different. They are classified only in terms of symptoms: what the patient does, feels and complains of, and what we see of him and his behavior. Despite widespread assertions about "chemical imbalances" as causes, no such imbalance have ever been proved; they have really only been guessed at, with these guesses widely accepted as fact by dint of endless, uncontradicted repetition, actively assisted by the drug companies. No clearly defined organic or chemical patterns differentiate people with any of these mental disorders form others with different disorders or those without any. Menninger's classification involved only a small number of diagnostic entities, divided primarily between the neuroses with partial disability and the psychoses with total. The World War II military classification system, and the New York State Hospital's methodology over the decades which followed, were quite similar. Only since the American Psychiatric Association published its first DSM in 1952 has the number of different possible "diagnoses" risen out of sight: less than 100 in its first edition (DSM-I) and over 400 in its latest (DSM-IV). Obviously, much more psychiatric time will be spent today trying to determine the "correct" diagnosis than would have been required in years past. Many of the "disorders" listed there represent sins, errors and bad habits such as the "oppositional defiant disorder" diagnosed in repeatedly disobedient children, or the "disorder of written expression diagnosed of those with poor use of grammar, awful spelling and bad handwriting. But the DSM labels for genuine disabilities are equally faulty because of their over-specificity, which helps transform then into harmful, self-fulfilling prophecies. It is hardly scientific, or rational, to label as "schizophrenic" someone who is depressed on one day and anxious on another merely because he is disorganized the day the psychiatrist sees him. A psychiatric diagnosis emphasizes the symptoms associated with it and ignores those which are not. Schizophrenics will focus with their psychiatrists on their strange ideas, while tending to ignore their anxieties or depressed feelings. Should the treatment focus on the symptoms as representing a mysterious illness in itself, rather than as the understandable reaction to the patient's psychosocial stresses (now including doubts about his own sanity), the search for psychopathology can help create or aggravate it. And should the recrudescence of symptoms easily and automatically evoke the desire for medication to relieve them, the patient is far along the road to treatment-produced chemical dependency. _The Treatment of Mental Disabilities_ Stress evoked psychological symptoms can sometimes be overcome relatively easily by sympathetic listening and effective counseling. Listening and counseling of this sort will usually reduce symptoms even when it does not remove them altogether. We have already seen the fluidity of the symptoms which remain. Mental disabilities are therefore best treated early and competently, while their symptoms are still fluid and before maladaptive thought and behavioral patterns become congealed. Such maladaptive reorganizations often occur after the actual disorganization of acute schizophrenia and are usually called chronic schizophrenia. An acutely upset patient, who is wondering whether he is really hearing the voices detailing his own thoughts, may easily come to believe that he is indeed doing so if the doctor shows interest in the question, and seems to believe that he does. Had the patient been told early that he merely _thought_ he was hearing his own ideas as though they were coming from outside him, and that this was an error commonly made by upset people, he would have paid much less attention to the voices and they would then have disappeared relatively soon. The calming presence of someone who is not thrown by the patient's depression, panic or disorganization is the first step in treatment. The young goats disorganized by Liddell's stresses were greatly calmed when he introduced into their cage a mother goat which had not been subjected to any stresses. Such a calming presence in a human situation introduces hope. The central role of that emotion in all healing is recalled by the insistence of Ambroice Pare in the 16th century, "I bound the wounds, God healed them." Non-specific hope of this kind is necessary for treatment to start, but is not enough to carry treatment to a successful conclusion. Specific hopes must also be aroused - the patient's belief that his ability to cope will be aided by coming to understand the stresses to which he has been subjected, and improving his reaction to them. Recognizing his own contributions to this painful psycho-social situation and changing them, rather than retaining the maladaptive modes he may have acquired during his illness, will greatly enhance his chance of returning to normal living. The treatment of psychosis should therefore aim at helping patients understand why they became psychotic - their faulty interactions with those around them - and change both their psychotic thought and behavior patterns and their unsuccessful pre-psychotic modes of reacting. _Does Treatment Help or Harm?_ "The Potency of Psychotherapy," a paper I wrote 35 years ago, noted that this treatment modality was indeed powerful despite the absence then - which may still exist - of statistical proof of its effectiveness. Rather than treatment being important, I suggested that its helpful effects were cancelled by its harmful ones overall, resulting in the absence of any impact as shown by statistics. This concept is in agreement with my years of providing such treatment; the patients with whom I failed, a relatively small number, often seemed worse off after treatment than before. Psychiatry and psychology have long avoided facing the harm which their various treatment can produce. Any treatment in which patient and doctor agree at its conclusion that the patient is better will be helpful, at least in the short run, but long-term success depends on whether the patient has learned to correct his maladaptive responses. Counseling based on overt behavior and conscious thinking, founded on moral standards and aimed at healing both the patient's conflicts and his relationships with others, is therefore the modality most likely to succeed. This task can also be accomplished through psychoanalysis or psychoanalytically oriented psychotherapy, but there it takes much longer, and serious harm can arise from the way these modalities look for the childhood traumata allegedly behind current problems, rather than at the problems themselves. Medications, used briefly, can help calm the troubled, especially if its function is defined immediately as ameliorative rather than curative, its thinking-impairing qualities and side-effects are frankly acknowledged, and it is discontinued as soon as possible. Medication as the primary treatment modality, especially over long periods, is almost guaranteed to _prevent_ recovery by blurring the patient's already overloaded mind even further, thus making it even harder for him to address the overwhelming psychosocial problems which caused his initial breakdown. Comparison of the results of psychiatric hospitalization before the "psychopharmaceutical revolution" with those since it, show better treatment results before the increased dependency on only medications. And teaching patients to rely on prescribed medications, which they usually dislike, is seen by them as validating their use of street drugs, which they do like. That is why about half of those coming to psychiatric emergency rooms are also drug-abusers. _Summary_ "Mental illness" can be understood easily and accurately as different types of exaggeration of the reactions we all have. If we focus on the maladaptive reactions, and on the interactional stresses evoking them, we can help correct them. If we concentrate instead on labels, biology, chemistry and drugs, and the irreversibility these all imply, a self- fulfilling prophecy comes into play, leaving patients both disabled and drug-dependent. This file came from anonymous ftp sjuvm.stjohns.edu cd MADNESS The MADNESS ftp site is a service of MADNESS, an online discussion on LISTSERV@sjuvm.stjohns.edu Please credit the list if you copy this file.