A new look at psychosis continued...
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.
Tyrrell: That's scandalous!
Bentall: There is also a bit of a scandal about the dosage of these drugs that are used. I think everybody in psychiatry knows about it and IÕve heard it discussed at conferences, but in a strangely detached way, as if this issue isn't really having an impact on patients' lives. The evidence is that you get no benefit whatsoever from doses above about 300mg per day of a chlorpromazine equivalent, and that's easy to work out for each of the main neuroleptics. If you go above that level, you get a massive increase in side effects but no added clinical benefit. And yet, it is still very common to find patients who are on much higher doses than that. We did a study of patients in the North West recently, which included recording their neuroleptic medication, and out of 200-odd patients we found that the median dose was about 600mg a day of chlorpromazine — in other words, double what the evidence says is the optimum dose. And there are plenty of people around who are taking more than a gram a day of chlorpromazine equivalent.
So there are people literally being poisoned by their psychiatrists. Of course, the paradox is that, by overprescribing medication in this way, psychiatrists actually deprive patients of benefits that they might otherwise get from the treatment.
Tyrrell: That's outrageous. And the only beneficiaries are the drug companies.
Bentall: Yes, they are beneficiaries. I give a lecture every year to our Masters students — we have a Masters in research methods and I give a lecture every year called "The science and politics of clinical trials" — and I say at the beginning that, if they don't feel less comfortable going to their doctor after this lecture, they've not been listening! I have lots of case studies of ways in which randomised controlled trials are subverted to give misleading results. So, for example, in the case of a newer atypical neuro-
leptic versus a typical neuroleptic, most trials have compared the new drug with an irrationally high dose of the old one, and they find that the atypical neuroleptics have a much better side-effect profile. Well, of course they do, because they have been compared to a toxic dose of the typical neuroleptics! I can't think that drug companies don't know what they've been doing, so it's a way of making a compound look good by comparing it to a wrong dose of a traditional one.
Tyrrell: Neuroleptics are supposed to be anti-psychotic but they don't address the psychosis at all, do they? Don't they just calm people down?
Bentall: Well, I don't think that's actually quite true; I think they are to some extent anti-psychotic. As I've said, in some patients, they have a very strong anti-hallucination and anti-delusion effect. But they also have quite a profound effect in calming manic patients down, which is a good thing because, if you've ever seen someone in a manic episode, it's pretty frightening. It's pretty frightening for them and it's also pretty frightening for everybody else around them.
It's important with psychiatric drugs not to throw the baby out with the bath water. There should be some people on anti-psychotic drugs, a lot fewer than are actually on them, and most of those who are on them should be on a lower dose. I would like to see the rational prescribing of psychiatric drugs. They are dangerous tools that have some benefits, if used carefully. But they're not used carefully.
Tyrrell: There's been some debate, particularly in America, I think, about whether psychologists should prescribe psychiatric drugs.
Bentall: I would welcome having a prescription pad. Most of my time is spent on research projects but I see patients one day a week, and it would be wonderful to be able to say, "I'll deal with the whole package, the medication as well as the psychological treatment". Equally important, it would give me un-prescribing rights. Then it would be possible to deliver a treatment for patients that actually matches their needs.
Tyrrell: Could you talk about your research on brief therapy interventions with psychotic patients?
Bentall: I've been involved in some randomised controlled trials for psychological treatment, which I think are methodologically extremely sound, compared to most drug trials. One of the major ones that I have been working on is the SoCRATES study (Study of Cognitive-Realignment Therapy in Early Schizophrenia), in which the principal investigator is Shon Lewis who, interestingly enough, is a psychiatrist. This is a large study of about 360 patients, 80 per cent of whom were having their first episode of psychosis, the rest their second episode. They were randomly assigned to three conditions: a brief CBT intervention, supportive counselling or treatment as usual — go to hospital and get pumped full of drugs.
Tyrrell: Counselling comes in many different models. I assume you are talking about the person-centred, so-called Rogerian model when you say supportive counselling?
Bentall: Rogerian, that's right. The therapy window was very, very short, just five weeks, and the study was extremely arduous to carry out. We had a team of three psychiatrists to do the follow-ups, who were blind to the treatment that the patients had received. They managed to follow up on 75 per cent of patients over 18 months, which in itself was quite an achievement, because it's a fairly itinerant population. The outcome of the study was, I suppose, in some ways a little disappointing. We had a significant benefit from both types of therapy and there was a greater benefit
from CBT but, while it was better being in psychological therapy than not, the clinical benefits were on average not as great as we would have liked.
We got a strong centre effect — there were three centres where the therapy took place. In one centre, there was almost no benefit from therapy; in another there was a very strong therapy effect; and the third fell in between. I guess that suggests that skill of the therapist is important — although we did supervise the therapists, who had the required level of competence on a cognitive therapy scale.
I think another interesting part of the data was that the supportive counselling group did quite well; the CBT group did better, but the supportive counselling group did quite well. Now, I've heard cynics, extreme advocates of biological psychiatry, describe this sort of counselling treatment as placebo control, but I don't think that is the right way to think about this. I think the simple story is that treating people with respect and being warm and human is quite important! The fact that supportive counselling did have this effect is a chilling reflection on the quality of routine care. I'm not saying supportive counselling doesn't require some skill, because it does, but it is an intervention that should be possible to deliver on a mass scale. So, it is striking that the treatment-as-usual patients were not getting that kind of support.
Tyrrell: The patients hadn't been put on drugs, presumably.
Bentall: They were on drugs. It just wasn't possible, for political reasons, to do a trial without drugs.
Tyrrell: Was that because drug companies were financing the—
Bentall: —No, no, it is just that you can't persuade NHS psychiatrists not to give patients drugs. But, also, a reasonable question to ask is, "Does the therapy produce added benefit above the drug treatment?" To which the answer is yes. As we had a very short therapy, it was quite amazing that we did have these effects after 18 months.
Tyrrell: Some people might wonder what is involved when you are using cognitive behavioural techniques with psychotic patients, who are effectively out of touch with normal reality.
Bentall: Well, I think that's a myth, really. I say to students that there is always an island of rationality in the maddest of patients.
Tyrrell: Absolutely! I quite agree. One thing I was struck by, though, when I looked in the index of your book, was that there was nothing much in it about the REM state, the rapid eye movement stage of sleep that is associated with most dreaming. J. Allan Hobson, professor of psychiatry at Harvard and one of the greatest sleep researchers, said in his book, The Chemistry of Conscious States, "If we can unveil the root cause of dreaming, we will have found the genesis of psychosis. Dreaming is not a model of psychosis, it is psychosis." What do you know about that?
Bentall: It's an old idea. It goes back to Jung, who described the psychotic patient as a dreamer awake. I'm not convinced by that!
Tyrrell: Well, my colleague, psychotherapist Joe Griffin, has put forward a theory that does appear to explain dreaming, and we are becoming more and more aware of a connection between dreaming and psychosis. We've worked with a few psychotic people — weÕve filmed working with them — and we notice many signs in their behaviour that could be explained by their being in the REM state while they are awake. For instance, you very often see rapid eye movement while they are talking. They are dissociated. The equivalent, in the REM state, of the catatonia seen in schizophrenia is that, when you are dreaming, you're paralysed. People with schizophrenia are reported to feel less pain. In dreaming, you don't experience pain, which is why the hypnotic state, which is also a REM state, is used for operations. I myself had an operation under hypnosis when I was 15, so I know that works! People hear voices —
Bentall: —You know there have been newer explanations for that, looking at the relationship between hemispheric activation and—
Tyrrell: —Yes, the right hemisphere is massively active. When people hear voices, the speech centres are activated, and that can be seen on brain scans.
Bentall: It's the left frontal areas in particular.
Tyrrell: But the point is that, when people are psychotic, they think the voices are alien, outside of themselves. What we think might be happening is this: the dream state, it is known, is the province of the right hemisphere and people aren't usually capable of left hemisphere thought when they
are dreaming, because they are locked into the metaphorical script of the dream. But if they are dreaming whilst awake, so to speak, there is still going to be some left hemisphere activity. Perhaps the only way the right hemisphere, which is dominant at the time, can make sense of these left brain thoughts is to create the metaphor of hearing voices. There is no language but metaphor for that part of the brain to use. So these voices become aliens, spies or strange influences from beyond, or from the government, and so on.
People totally believe in the reality of dreams when dreaming them, however crazy — you could be flying or talking to animals and in the dream it is totally real. It is only when you wake up that you think, "My God, I've had a really weird dream". But you believe in the reality at the time, in just the same way that psychotic people believe in their reality. But, because the dream has broken out of the REM state theatre, if you like, and it is now invading their waking reality, they will believe that with the same intensity that they believe in a dream. They can't make the distinction of knowing what's a dream and what isn't. Psychotic people don't say, "God, I've had an amazing dream".
Bentall: No, they don't. READ ON >>
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© Richard Bentall and HG Publishing (2003)
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This article first appeared in Volume 10, No, 3 (2003) of the Human Givens journal.
PROFESSOR RICHARD BENTALL holds the Chair in experimental clinical psychology at the University of Manchester.
Madness Explained is published by Allen Lane at £25.00.
IVAN TYRRELL is a psychotherapist, writer and lecturer who, with JOE GRIFFIN, developed the human givens approach
> You can find out more about psychosis and the new thinking on its causes at the following MindFields College events:
Understanding the mental health continuum Seminar
Psychosis: and positive strategies for Recovery Workshop
> The HGI ONLINE REGISTER of human givens practitioners, lists all fully qualified human givens therapists in private practice.
> More information, including all references, can be found in the following books, both by Joe Griffin and Ivan Tyrrell
Dreaming Reality: How dreaming keeps us sane or can drive us mad
Human Givens: A new approach to emotional health and clear thinking
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> Read more about schizophrenia here
> For a range of useful related publications including the above CD, visit:
www.humangivens.com
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> Read more about schizophrenia here |
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