schizophrenia or bipolar? (Melvin Konner, 1987)

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Becoming A Doctor: A Journey of Initiation in Medical School, Melvin Konner, M.D., United States: Penguin Books, 1987, pages 163-165:

“ . . . about just what sort of patient was schizophrenic. English psychiatrists had, for at least a generation, used the diagnosis much more restrictively than Americans had. They preferred to call most remitting forms of psychosis manic-depressive illness, also known as bipolar affective disorder.

The distinction was by no means academic. The treatment of choice for schizophrenia was the so-called major tranquilizers, like Thorazine, Stelazine, and Haldol. . . ”


“ . . . But, like most powerful treatments, the antischizophrenic drugs had powerful adverse effects. There were such immediate side effects as restlessness or spasms of the lips and tongue. These were transient and could usually be corrected by dosage adjustment, change of drug within the broad category, or addition of a second drug to control them. Much more serious were the so-called “tardive dyskinesias”---literally, late-appearing movement abnormalities. Resembling some aspects of Huntingtons’s disease and other disorders of movement, they ranged from the merely annoying to the incapacitating. They occurred in as many as 5 percent of patients treated for several years with antischizophrenic drugs, and eventually, perhaps, many more. And in a large proportion of these patients, they were permanent. Clearly then, if there were another effective treatment, every patient should have that option. . . ”


“ . . . John Brandt, along with a growing faction of other medical psychiatrists, thought that vast numbers of American schizophrenics had been misdiagnosed. His therapeutic strategy did not hinge on the sophistry of diagnostic labels. He simply thought that any person with a remitting psychosis deserved to fail a lithium trial before being exposed to the risks of long-term treatment with antischizophrenic drugs. Lithium was not without its problems. It had the very rare side effect of a potentially fatal abnormality of blood cell formation, and its therapeutic effect in generally depended on the maintenance of a blood level within a narrow range. Less would be ineffective, more would be toxic. This led to the major expense and inconvenience of a hospitalization for at least several weeks in order to establish the therapeutic blood level for a given patient and the doses needed to maintain it. These drawbacks had made American psychiatrists slow to adopt lithium. But it had, by the end of the 1970s, become accepted as the treatment of choice for manic-depressive illness. It had proved to reduce recurrences. Now the question was, who had schizophrenia and who had M.D.I.?

About Howard Cullen, John Brandt had no doubts. Cullen had a number of substantial periods of being well, he had depressions, and he had swings into elevated mood, including hypersexuality, during some of his psychotic breaks. These were features of manic-depressive illness, and his years of “schizophrenia” notwithstanding, he was a candidate for a lithium trial.

Following the protocol that was usual at Burdick, he was started on Haldol, a rapidly acting antischizophrenic. This was to be tapered off as the lithium level was built up. If his psychotic symptoms resolved after several weeks of therapeutic blood levels of lithium, he would stay on it permanently---with regular checks of vulnerable blood cells. He might never again have to be exposed to drugs with the risk of a permanent and crippling movement disorder. And the lithium should be at least as effective in preventing future psychotic breaks. . . ”

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This is just one doctor, and it's 1987 which is of course ages ago for medical science, but still, these are some good points.

And from a number of different things I've read, human biochem is both complicated and tends to be a somewhat different for different people. A medication which might work great for one person, may or may not work for someone else simularly situated. In a very respectful sense, it is trial and error. And it sure helps to have a doctor who has the time and willingness to listen.

Hopefully in the future we won't need anti psychotic drugs period. Things like project Soteria http://en.wikipedia.org/wiki/Soteria and stuff similar to what this man is doing http://www.youtube.com/user/bipolarorwakingup I think these can be helpful in prevention of relapse and even curing mild cases of mental illness. As for people with sever symptoms and even brain damage this new research is starting raise my hopes of finding a real cure. http://discovermagazine.com/2010/jun/03 ... :int=3&-C= I'm preying that this new research can be used somehow to save future generations from old treatment methods and maybe even the disease itself.

http://www.youtube.com/user/bipolarorwakingup

Okay, I watched and listened to this entire tape. And I certainly agree with the part at the end about the importance of social support and that growth can come from unlikely circumstances, specifically that growth can come from what is normally called 'mental illness.' Now, what I don't like is that this video seems to be as one-path as anything else, seems to be saying this is the only right way to do it. Instead, I believe there are a number of 'right' ways to do it, for different people, and also for the same person at different times in his or her life.

As an alternative, maybe Bill could have realized that other family members were also hurt at the loss of his Dad, and try and be there emotionally for them without overdoing it, also realizing that he himself would have to take alone time for himself and at largely unpredictable times.

Maybe his girlfriend Sue could have realized that he needs a little bit of spoken support, a goodly amount of unspoken support, and that he's going to need alone time and that it's okay.

And maybe Bill could have gotten involved in some social activity trying to make the world a better place, maybe not something as on the nose as a support group for people who've lost a parent relatively young, but maybe political activism, for example, on the landmine issue, that is, something else which builds connections at least potentially with fellow human beings, or maybe animal rescue which has both a combination of political activism and direct support, plus animals can be just pretty neat, they don't judge you, they appreciate you.

The story on the video is amazingly solitary.

And I don't like the example of Bill drinking and using drugs at a "party" and this leading to "total ego collapse" which is then viewed as a good thing. First off, a "party" is about peer pressure, someone different may be treated as a mascot, there's not enough track record of a real back and forth connection for them to be in favor of you and treat you as a real human being. In bad cases, parties and over-intoxication can lead to sexual assault and that's not so cool at all.

I wish, instead maybe the example of a long hike with a new potential friend from his school in Arizona. A little bit of talking but mainly just hiking. And respectfully being in favor of each other and taking care of physical needs like staying hydrated. And the exhaustion from the long hike, and being able to see things in clarity with the setting sun, what artists sometimes call the golden hour, which might potentially lead to spiritual insights. Or not, and either way is perfectly okay.

Or, an example from my own life, I was living in Vermont and was driving down to Philadelphia where my sister was scheduled to get cancer treatment (we're not close and that kind of hurts too), I left later than I liked because I stayed up too late and then in the morning all this nickel and dime stuff and I couldn't get my s**t together. So I left around noon, but then around New York City, about six o'clock in the evening, maybe my Circadian clock was on the rise, and the sun was behind me so I could see very clearly in front of me. I felt I was driving very well and I think I was driving very well. And I kind of had this spiritual experience of acceptance of myself, acceptance of my sister, acceptance of the universe. And it really was pretty neat.

I think many psychiatrists are big egoists, and I am in favor of breaking the monopoly of psychiatry. On that, we probably agree.

Now, I generally take the approach of BOTH AND, which means I generally do favor medication, in combination with social support, the philosophic approach, the zen approach, acceptance, etc.

And for depression, a person has a choice, to either see a psychiatrist or a regular doctor like an internist or family practitioner.

For bipolar, I think someone still has a choice.

For schizophrenia, I don't know. I tend to think a person would probably have to go to a psychiatrist. Or a psychologist who refers the request for prescriptions. But maybe a person could see a sympathetic family practitioner, since there is a large component of respectful trial and error anyway.

Some psychiatrists are good, and some are lousy, and that's just the fact of the matter. If someone is happy with their psychiatrist, more power to them.

I've also had terrible experiences with psychologists and other so-called mental health professionals (cough, cough). When I was 17, this psychologist did not take my father's violence seriously. I think because it was relative minor (!) violence and he (idiot psychologist) did not want to be criticized by fellow professionals for full-court pressing a low grade case, something like that. Plus, I think he flat out did not like me, viewed me as a sarcastic teenager or something. And, he did a full day at the university and then saw me 7:00 at night as he was trying to "build" a private practice. He had previously seen my parents at the university where my Dad was a professor (my Dad is a CPA and taught some occasional courses).

Saw another psychologist when I was 23. I don't know, the guy was a pontificator and story teller who didn't really listen to me.

When I was 26, saw a psychiatrist at a university hospital, I think he was a young resident. He actually became huffy when I asked him to explain the medication. (I struggle variously with both depression and OCD. Have never taken medication but am now more open to the idea. In fact, I kind of do like the idea of medium step, feedback, another medium step, etc.)

I actually had more luck with a speech therapist when I was in my mid 30s who also acted as an informal counselor.

As far as this psychiatrist saying to you "Your such a pretty young women I just don't understand why would you want to die so badly?" And then he was disengaged as if you were wasting his time. Wow. I'm sorry that happened to you. My guess would be that it's the big dramatic method, like in the olden days when people used to believe that a treatment that was big and dramatic, or unpleasant, or painful, well, then it had to be effective, right? Well, actually, no. Of course not, doesn't necessarily make it effective at all. So, it's this big dramatic opening gambit on the doctor's part. And I'm thinking it works one out of five times, or less. And the times when it doesn't work, well, the doctor is then kind of stuck, isn't he? Hard to move on from there. Much better is to have a respectful conversation meeting a new person. And the doctor kind of goes at the person's pace. This would be so much better. The doctor might pitch an idea or two. But if the person's not interested, the doctor gracefully moves on. And that kind of common sense counseling and help is actually kind of rare.

And I've always been a serious person, was religious when I really tried Christianity in 8th and 9th grade, didn't fully work, very traumatic, some relief as I decided it probably wasn't true. But then the world didn't really open, not socially. Now, I take a goodly amount of Buddhism in a loosey goosey kind of way. I also have an interest in nature.

And yeah, after living on my own from '82 to 84 and again from 1985 all the way to 2008, I have been back living with my parents. And that has been damn difficult. I'm going to have to fight my way out and build up from lousy jobs, which I've never been good at. (Actually inverse relationship! A lousy, entry-level, "easy" job is actually harder because the social expectations and the BS that at times blurs to bullying, and the boredom. A "hard" job is actually easier)

Okay, with you probably (?) being bipolar and with the two suicide attempts, honest to gosh, I think you might be better off with an internist or family practitioner (doctor who used to just be called a general practitioner). A doctor who takes the approach, you want to try something like Zoloft or lithium, fine, or if it's not for you, that's fine, too. Who isn't so married to some treatment and so dogmatic about the whole thing. And maybe a dose of the zen approach, okay, a suicidal thought, well heck, it's just a thought, can watch the thing float in and out as it were with zen detachment. Well, maybe, perhaps, not such a bad skill to have in one's repertoire, and to be supplemented by other skills of course, sure, that kind of thing.

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And, as a young person, please think about really good jobs, starting with medicine, yes, really. And maybe not psychiatry at all, not that you have to pursue something that has bothered you personally, no rule like that at all, maybe something fun like infectious disease, or chronic kidney stuff or whatever, or the stuff you talk about which I really don't understand I got to tell you. But it sounds like you understand it and might be a field well worth pursuing. Or as a PhD in research, but I really you can get more done with an MD. (I also remember reading that just MDs publishing research or applying for grants were looked down upon, and that there are joint programs where a person can get an MD-PhD. If interested, take the initial steps and find out more. Organic chemistry, esp Organic II, is the classic weed out course.)

Or, even though I don't like the profession of law, it needs some good humanistic people. Or people in the middle who are open to better alternatives.

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And I definitely feel ideas like those presented by the poster of this video should be part of the discussion.