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A willfully maintained ignorance of the reality of antipsychotic withdrawal syndrome 10/22/2012

Posted by ALT in Mental Health Research, Pharmaceuticals, Psychosis.
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9 comments

SCIENCE. (Read that with a deep, booming, authoritative voice)

SCIENCE has achieved an exalted level of infallibility in our society. Start a sentence with “researchers say…” and you’ll not be questioned.  We mortals can only look to our pantheon of data collectors with wonder and awe. We dare not question their pronouncements, percentages.

“Blessed are the 64.3% of all statistics that are made up on the spot, for they shall make your argument mighty.”

Here’s the thing about SCIENCE as a new religion: the way it’s framed, there’s no faith involved. You’re not asked to believe anything. Instead, you’re given data, objective facts, supposedly THE TRUTH as derived through the scientific process. Either you accept the truth, or you deny it. But you can’t argue with it; the facts don’t lie, do they?

The Facts Don’t Lie; Researchers Do

Lie.  That’s an inflammatory word, not to be used lightly. It means willful deceit.

But what do we call deceit achieved by willfully maintained ignorance? Is that a lie?

Whatever it’s called, that’s what I witnessed time and time again during my employment with the Research Scientists of Children’s Mental Health: careful avoidance of any idea that challenged their painfully constructed, government-funded, biopsychiatric house of cards. And it’s what I saw this morning, staring up at me from a press release about a new study in the New England Journal of Medicine.

HEADLINE: Some with Alzheimer’s better off staying on antipsychotics (study)

Essentially, the study found that abrupt discontinuation of Risperdal doubled the risk of “relapse” (defined as a return of psychotic/aggressive symptoms), when compared to continuation of Risperdal. In the “Conclusions” section, the authors write:

In patients with Alzheimer’s disease who had psychosis or agitation that had responded to risperidone therapy for 4 to 8 months, discontinuation of risperidone was associated with an increased risk of relapse.

Sounds like they just demonstrated that going off antipsychotics can lead to withdrawal symptoms. 

But here’s how principal investigator Dr. D.P.Devanand, who currently has disclosed financial ties to Janssen (makers of Risperdal), Novartis, and Eli Lilly (makers of Zyprexa), interpreted this data:

Caregivers should be aware of the increased mortality associated with these medications in people with dementia… [However] if a patient is taking an antipsychotic and doing reasonably well without any major side effects, they should stay on it.

- D.P. Devanand, principal investigator

Caregivers SHOULD be aware of the increased mortality associated with antipsychotics and dementia patients.  A black box warning issued by the FDA for antipsychotics risperidone, olanzapine, and aripirazole reads (in part) “Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo… These drugs are not approved for the treatment of patients with dementia-related psychosis.”

Caregivers should ALSO be aware of a long and scandalously illegal history of off-label promotion of these drugs to treat dementia when they were not and are not approved for this purpose. Fines for dementia-related off-label marketing prosecuted under the False Claims Act alone have totaled almost $2 billion. And who can forget Lilly’s clever sales pitch for the use of Zyprexa in nursing homes, “5 at 5”?

Lilly even devised a LTC sales slogan used nationwide – ‘5 at 5 pm,’ which was shorthand for dosing elderly [nursing home] patients with 5 milligrams of Zyprexa at 5 pm to keep patients calm throughout the night… It’s particularly disturbing that such a potent drug, with so many serious adverse side effects, was so blatantly abused in a vulnerable patient population whose health is already at risk. [A]t many nursing homes this potent antipsychotic was essentially used as a ‘chemical restraint’ for the elderly for whom Zyprexa had no other health benefit.

-Brian Kenney, attorney for the plaintiffs in Zyprexa whistleblower suit resulting in a $1.415 billion fine for off-label marketing

 ONE MORE THING caregivers should be aware of that Devanand et al. neglected to mention:

Antipsychotic Discontinuation Syndrome (IE, withdrawal)

When a person whose brain is accustomed to the presence of an antipsychotic agent abruptly stops ingesting that agent, discontinuation syndrome (withdrawal) is a very likely result. The brain attempts to maintain normal dopaminergic function in the presence of a dopamine-suppressing chemical (antipsychotic) – it does this by significantly enhancing dopaminergic activity.  When the chemical is removed from the equation, there is no longer a counterbalance for the dopamine-enhancing adjustment built up over time in the brain. This is the probable cause of antipsychotic withdrawal symptoms, which can include both psychosis and aggression.

Even in the case of gradual discontinuation of the drug, withdrawal may occur – but take it away abruptly, and you’re essentially guaranteed a display of withdrawal symptoms in a significant portion of the study population.

So Devanand’s study really isn’t all that newsworthy. His data plainly shows that stopping the use of antipsychotics can cause a withdrawal reaction, which is what the FDA-approved label essentially already says – “To prevent serious side effects [read: withdrawal], do not stop taking ZYPREXA suddenly.” And a 2006 literature review summing up many antipsychotic discontinuation studies shows the same thing:

There is evidence to suggest that the process of discontinuation of some antipsychotic drugs may precipitate the new onset or relapse of psychotic episodes. Whereas psychotic deterioration following withdrawal of antipsychotic drugs has traditionally been taken as evidence of the chronicity of the underlying condition, this evidence suggests that some recurrent episodes of psychosis may be iatrogenic.

- Joanna Moncrieff, in “Does antipsychotic withdrawal provoke psychosis? Review of the literature on rapid onset psychosis (supersensitivity psychosis) and withdrawal-related relapse

Here’s the ground-breaking bit: Devanand and co-authors chose not to describe what they observed during the course of the study as “withdrawal” – that word is studiously avoided in the press release and abstract.* Rather, here’s how the results are characterized: the risk of “relapse” should antipsychotic medication be abruptly discontinued is evidence of the need for elderly patients to keep taking their Risperdal.

A classic case of willfully maintained ignorance.

Is it possible that Devanand and co-authors are ignorant of the concept of “withdrawal,” its causes, its symptomatology? Is it possible that they haven’t read the FDA-approved label for Risperdal, haven’t familiarized themselves with the scientific literature surrounding the discontinuation of antipsychotics, and are therefore innocent in their public charactarization of the results of their study as “relapse” best treated with continued use of Risperdal? Yes, it’s possible. It’s even likely that these authors averted their eyes from a mere glimpse of any such information, given the strong financial incentives and conflicts of interest disclosed in conjunction with the publication of this article.

But that’s a shaky foundation to build your innocence on.

The foolish man builds his house upon the sand; the wise man builds his house upon a rock. 

   


* I’d like to tell you the word “withdrawal” is entirely absent from the article itself (and I highly suspect it is!) but, even though this is a publicly funded National Institutes of Health study, the article is not freely available to the funders (we, the people) and I have been thwarted in my attempts to obtain it. Big bonus points if you send it to me.

Where have all the prophets gone? (Part Two) 06/19/2012

Posted by ALT in Philosophy/Spirituality, Psychosis.
Tags: , , , , , , , ,
3 comments

[read Part One here]

Ezekiel 37:1-14

(New International Version)

The hand of the Lord was on me, and he brought me out by the Spirit of the Lord and set me in the middle of a valley; it was full of bones. He led me back and forth among them, and I saw a great many bones on the floor of the valley, bones that were very dry. He asked me, “Son of man, can these bones live?”

I said, “Sovereign Lord, you alone know. ”

Then he said to me, “Prophesy to these bones and say to them, ‘Dry bones, hear the word of the Lord! This is what the Sovereign Lord says to these bones: I will make breath [in Hebrew, the word also means “spirit”]enter you, and you will come to life. I will attach tendons to you and make flesh come upon you and cover you with skin; I will put breath [spirit] in you, and you will come to life. Then you will know that I am the Lord. ’”

So I prophesied as I was commanded. And as I was prophesying, there was a noise, a rattling sound, and the bones came together, bone to bone. I looked, and tendons and flesh appeared on them and skin covered them, but there was no breath in them.

Then he said to me, “Prophesy to the breath; prophesy, son of man, and say to it, ‘This is what the Sovereign Lord says: Come, breath [spirit], from the four winds and breathe into these slain, that they may live.’” 10 So I prophesied as he commanded me, and breath entered them; they came to life and stood up on their feet—a vast army.

11 Then he said to me: “Son of man, these bones are the people of Israel. They say, ‘Our bones are dried up and our hope is gone; we are cut off.’ 12 Therefore prophesy and say to them: ‘This is what the Sovereign Lord says: My people, I am going to open your graves and bring you up from them; I will bring you back to the land of Israel. 13 Then you, my people, will know that I am the Lord, when I open your graves and bring you up from them. 14 I will put my Spirit in you and you will live, and I will settle you in your own land. Then you will know that I the Lord have spoken, and I have done it, declares the Lord. ’”

  

This was the text for the sermon I heard at the church of my childhood, a few weeks ago.  I had never encountered this story before, and it floored me.

What powerful imagery, and how relevant to our times!  A valley of dry bones, the people dead and desiccated, no breath to enliven them… until the Spirit reclaims them.  And I was struck – thunderstruck, really — by the fact that Ezekiel’s vision bears a striking resemblance to the visions experienced by many during a so-called “psychotic episode”: death and destruction, an Apocalypse, the voice of God, a rebirth.

In The Far Side of Madness, John Perry proposes a series of interrelated archetypal images/ideas that consistently make an appearance in the psychotic process (though not necessarily in a linear fashion):

A. Center – A location is established at a world center or cosmic axis
B. Death – Themes of dismemberment or sacrifice
C. Return to beginnings
D. Cosmic Conflict – a battle between good and evil
E. Threat of Opposite
F. Apotheosis  – direct communication or identification with God
G. Sacred Marriage
H. New Birth
I. New Society/a New Age
J. Quadrated World – a fourfold structure of the world or cosmos

(from John Weir Perry’s Far Side of Madness)

Perry illustrates, with numerous case studies, the amazing regularity with which these features appear in psychotic processes.  Ezekiel’s vision contains many of them: death (dismemberment), cosmic conflict, apotheosis, new birth (the bones and flesh made alive), and quadrated world (breath “from the four winds”).  The book of Ezekiel, an account of Ezekiel’s seven visions from God, contains them all.

The idea that some [not all] psychotic processes are spiritual in nature, and serve (in part)* to convey a message from the divine, is an old one.  In fact, in many traditional cultures, it was and is the dominant interpretation of these experiences

But in our culture, the idea that psychosis/the visionary process has value for the individual experiencing it and the community to which he belongs is downright revolutionary!

On the micro level — the individual — it is valuable as

a self-healing process – one in which, specifically, the pathological complexes dissolve themselves. The whole schizophrenic turmoil is really a self-organising, healing experience.

-John Weir Perry, in this interview

But there is an analog at the macro level, the level of the community, that is equally important:

Our new understanding shows that the process of re-connection to the Unconscious [psychosis]…  is   nonetheless made up of the same stuff as seers, visionaries, cultural reformers and prophets go through. They also experience much of the same content, except that in their case it is specifically concerned, first and foremost, with the culture itself.

What’s more:

Any kind of therapy that deals with the psyche at this deeper level of the collective unconscious, one comes to the inevitable realisation that we are not going along in our psychic life, you know, just in a realm of interpersonal relationships. A very powerful culture such as ours projects huge patterns, huge conflicts and turmoils, and we all experience them, although we may not be conscious of their inner meaning at all.

In this sense, Humankind is still enormously alienated; the point is, it doesn’t happen just in Washington and Moscow – it happens within the psyche of the whole people…

This brings up the question of myth-form. You see, the big problems facing society are perceived in symbolic, mythic expression, and for this reason their resolution takes place on the symbolic, mythic level as well. If there’s work going on in a culture to reorganise itself, then it’s a process that must occur on both levels simultaneously: individuals will go through their personal visions, and collective spokesmen will express collective visions, which get worked out and implemented on a cultural level.

- John Weir Perry, in this interview**; emphasis added

Where have all the prophets gone?

Does this culture have problems of epic proportions facing it?  I would say: YES.  Are we in need of reorganization, a drastic reordering of priorities, some serious soul-searching?  Again, my opinion – YES.

And is it possible that somewhere in the vast expanse of humankind exists a visionary, one who will journey across an archetypal landscape and bring back to us a spiritual message, a breath of life to the dry bones of our culture of death?

Will we listen?

Or will we label (as psychotic) and medicate (with “anti-psychotics”) until that voice grows silent?


* They also serve as a process of self -reorganization, psychic re-invention.

** More from John Perry on these ideas in this excellent video interview, recently uploaded to YouTube (!):

Psychosis as a plastic process 05/10/2012

Posted by ALT in Psychosis.
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4 comments

Neuroplasticity – the idea that our brain is constantly changing, rearranging itself, adapting to the environment it is presented with and optimizing performance based on ever-changing stimuli, that it is, in short, a living thing – is finally getting some attention.  Though the concept has been around for, literally, centuries, mainstream neuroscience, stuck in its Cartesian ways, has been doggedly insisting that the brain is like a machine, with specified parts that function in an unchanging way.  “Once brain-damaged, always brain-damaged,” they say.  [Hmm… sounds familiar, doesn’t it?]

Never mind this couldn’t possibly be true.

This article describes just two of countless examples of a damaged brain reorganizing itself, regaining (or re-developing, to be more accurate) the lost functions in the process.  First, we read about Cheryl, who suffered complete loss of her vestibular function.  The vestibular function controls balance – without it, she felt like she was perpetually falling.  This went on for almost 10 years before a neuroplasticity-based therapy helped her regain almost all of it.  [Incidentally, this brain damage was the “side effect” of a drug she was prescribed after a routine surgery.] 

Next, there is Pedro, who suffered a stroke so severe it left him unable to speak and with half of his body paralyzed.  Through tremendous effort, Pedro and his son George designed a rehabilitation program that allowed him to slowly, ever-so-slowly re-learn nearly all of the skills he had lost. After a year, he was able to resume his job and worked their happily until retirement.  After his death, doctors did an autopsy of Pedro’s brain, only to discover a massive legion that had never healed – yet he had regained all of his lost functions.  His brain must have reogranized itself, redistrbuting the lost functions to areas unhurt by the lesion.

Doesn’t sound like something your standard machine could do.  Which most neuroscientists these days are begrudgingly conceding.

Of course, there are those desparate few who cling to the old ideas (Cartesian doctrine dies hard)…

Not a machine, you say?  Well how do you explain THIS?

[Lots more to be learned about neuroplasticity from this book, which I have just finished devouring and highly recommend.]

The Brain is Plastic, not Elastic

Note that the term is neuroplasticity.  Not neuroelasticity.  What’s the difference?

Something that is elastic can be stretched, but it will always come back to its original shape.  Like a rubber band. 

Don’t snap me!

Something that is plastic can also be stretched, but it then maintains its new shape.  And though you could manipulate it to return it to a semblance of the old shape, it would not be exactly the same… it never could be. 

I imagine that the brain activity is like Play-Doh… if you start out with a package of Play-Doh that is a square, and you then make a ball of it, it is possible to get back to a square.  But it won’t be the same square as you had to begin with… Even when a patient with a neurological or psychological problem is ‘cured,’ that cure never returns the patient’s brain to its preexisting state.

- Neuroscientist Alvaro Pascual-Leone, in the book The Brain that Changes Itself [emphasis added]

If the brain is plastic, the brain’s processes are plastic, too

Research has already shown this to be true for some processes.  Take, for example, memory.  Every time we recall an event, our brain literally rebuilds the memory.

I can recall vividly the party for my eighth birthday. I can almost taste the Baskin-Robbins ice cream cake and summon the thrill of tearing wrapping paper off boxes of Legos. This memory is embedded deep in my brain as a circuit of connected cells that I will likely have forever. Yet the science of reconsolidation suggests that the memory is less stable and trustworthy than it appears. Whenever I remember the party, I re-create the memory and alter its map of neural connections. Some details are reinforced—my current hunger makes me focus on the ice cream—while others get erased, like the face of a friend whose name I can no longer conjure. The memory is less like a movie, a permanent emulsion of chemicals on celluloid, and more like a play—subtly different each time it’s performed. In my brain, a network of cells is constantly being reconsolidated, rewritten, remade.

- Neuroscience journalist Jonah Lehrer, in this article (a very, very good read!)

Which brings me to my main point:

Psychosis is a plastic process

It seems that one of the fundamental premises of mainstream psychiatry is that the goal of treatment is to return the patient to the state of mind he or she was in before the psychotic break.  “Get back to normal,” they say. 

Not only would this truly be impossible (given that the brain is more like Play-Doh than a rubber band), but it may, in fact, be counterproductive to aim for it.  Psychosis can better be viewed as a transformative process, out of which a healthier human is born, “weller than well,” as they say.

In the new book Rethinking Madness, psychiatric survivor and clinician Dr. Paris Williams eloquently illuminates the point:

In the life sciences, it is common to think of living organisms as existing in a state of homeostasis, which is an organism’s resistance to change and its ability to maintain a stable internal environment. Mainstream psychol­ogy and psychiatry evidently draw from this model when attempting to return a psychotic individual to a state that is as close to his or her pre-psychotic state as possible. It has been suggested, however, that it is actually more accurate to con­sider organisms to be living in a homeodynamic state rather than a homeostatic one. The term homeodynamic suggests that “once a new stressor is encountered, the organism never returns to its previous dynamic state, but establishes a new dynamic balance appropriate to this newly integrated experience” …

In the context of psychosis, then, this concept suggests that it may be terribly problematic to attempt to return someone to their pre-psychotic condition rather than to support them in integrating their anomalous experiences as they move into an altogether new way of being in the world, an idea that is in very close accord with the recovery research. … [therefore] my working definition for full recovery is: “The condition of having achieved a homeodynamic balance in which the overall distress (and not necessarily the anomaly) of one’s subjective experiences is the same or less than that which preceded the psychosis.”

-Dr. Paris Williams in Rethinking Madness: Towards a Paradigm Shift in our Understanding and Treatment of Madness [emphasis added]

Ultimately, it’s up to each one of us to define “recovery” and “wellness” for ourselves – but I kind of like what Dr. Williams has done with the terms.

***

Click here to read a preview of the book Rethinking Madness.

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