Trivializing the Suffering of Psychosis

If sick men fared just as well eating and drinking and living exactly as healthy men do…there would be little need for the science [of medicine].-Hippocrates

The 180-page report by the British Psychological Society (BPS), “Understanding Psychosis and Schizophrenia,” released November 27, 2014, is clearly a well-intended document.¹ According to the Executive Summary, the report concludes:

“. . . hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation; there is no clear dividing line between ‘psychosis’ and other thoughts, feelings and beliefs; for many people, though not all, experiences such as hearing voices or feeling paranoid are short-lived . . . [and] more generally, it is vital that services offer people the chance to talk in detail about their experiences and to make sense of what has happened to them."

I doubt that many psychiatrists would disagree with the general thrust of these claims, or with some of the report’s “feel good” generalities, such as “. . . each individual is unique and the only way to find out what will help a particular person is to explore their particular situation with them, and then support them to try things.” And, despite a decidedly jaundiced view of both psychiatric diagnosis and antipsychotic medication, the report acknowledges that “. . . many people find that ‘antipsychotic’ medication helps to make the experiences less frequent, intense or distressing.” Finally, to its credit, the report stresses that we “need to invest in prevention by taking measures to reduce abuse, deprivation and inequality.”

Unfortunately, the report also contains numerous straw-man arguments that I will not try to rebut here; for example, the notion that the term “schizophrenia” necessarily refers to a “brain disease.” On the contrary: the term “schizophrenia” is correctly applied to a generalized and pervasive condition of the person,* with dysfunctional manifestations in the cognitive, sensory, emotional, and behavioral realms. To be sure: schizophrenia is often associated with neuropathology, but that is neither necessary nor sufficient for the diagnosis, as the DSM-5 criteria make clear.

Moreover, some of the assumptions in the BPS report sound like caricatures of what knowledgeable psychiatrists actually believe or assert; for example, the report states, “It is often assumed that there is a straightforward dividing line between ‘mental health’ and ‘mental illness’ (normality and abnormality) and that discrete, identified disease processes (for example ‘schizophrenia’) are responsible for experiences such as hearing voices.” [Sec. 3.1]

I wish the report’s authors had specified who, exactly, “often assumes” such simplistic nonsense, since psychiatrists surely do not. Here, for example, is a quote from the DSM-5’s Introduction:

“The boundaries between normality and pathology vary across cultures for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cultures, social settings and families. Hence the level at which an experience becomes problematic or pathological will differ . . . [Moreover] although some mental disorders may have well-defined boundaries around symptom clusters, scientific evidence now places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors and possibly shared neural substrates.”

But in my view, the most serious failure of the BPS report is in the area where one might expect psychologists to excel; ie, in understanding the phenomenology of psychotic states and illnesses like schizophrenia. (The philosophical meaning of phenomenology denotes “the study of structures of consciousness as experienced from the first-person point of view”-Stanford Encyclopedia of Philosophy). Understanding the phenomenology of psychosis entails understanding how most persons see themselves and the world, when they experience putative psychotic symptoms, such as delusions of persecution, the belief that their thoughts are being controlled by an outside force, etc.

What is lamentably missing from the BPS report is any deep understanding of the psychic suffering occasioned by severe and enduring psychotic states, including but not limited to schizophrenia. Indeed, I believe the BPS’s attempt to “normalize” psychosis winds up trivializing the immense psychic pain and agony experienced by many persons diagnosed with schizophrenia and related disorders of reality perception.

For example, the report asserts, “Many of us hear voices occasionally, or have fears or beliefs that those around us do not share.” Well, yes-but this shallow and superficial description of the psychotic experience does scant justice to the nightmarish reality of severe psychotic states. It is a bit like saying to someone with advanced cancer, “Many of us experience very rapid cell growth occasionally, or have lumps or tumors that others do not have.”

Yes, the BPS report gives a perfunctory nod to the fact that, “Experiences such as hearing voices are real experiences for the person having them, and can lead to very real distress.” [3.4.1] But “distress” hardly captures the inner world of those with severe forms of psychotic illnesses. Terms like “agony,” “torment,” and “anguish” would be much closer to the mark, for many patients with severe psychotic illnesses.

Of the handful of first-person quotes in the report (from those who suffer with psychotic symptoms), only one or two really capture the nightmarish world of severe schizophrenia and related psychoses. Thus, a man identified as “Graham” writes:

“I began to think that . . . my blood had been poisoned by evil spirits and that I was evil, and that there were spirits around me, warping my thoughts and changing my thoughts, and that was very frightening and I didn’t know what to do with it.” [Sec. 1.1]

Graham’s experience sounds relatively placid, compared with that of a patient described in Silvano Arieti’s classic work, Interpretation of Schizophrenia (from which the BPS authors could learn a great deal).² The patient had been institutionalized at King’s Park Hospital in Long Island, New York. Here is how he describes his experience of the other patients:

“The inmates, here, hate me extremely because I am sane . . . By the power of their imagination and daily and continuously, they create extreme pain my head, brain, eyes, heart, stomach and in every part of my body . . . they lift my heart and stomach and they pull my heart, and they stop it, move it, twist it and shake it and pull its muscles and tissues . . . By their imagination and their bodily mouvents [sic], they scare me continuously and by their imagination, they move the blood violently in every part of my body . . . they force me to sleep and awake as many times as they desire and they create my dreams . . . I am suffering daily, extremely, and without cessation, day and night, because they are continuously creating extreme pain in my eyes, brain, heart, and in every part of my body.”^2(pp404-405)

Now, that sounds a good deal like the kind of suffering I witnessed in literally hundreds of psychotic patients in the Massachusetts mental health system, over more than 20 years as a psychiatric consultant. One must wonder whether many of the BPS authors have had actual experience with such severely disturbed, hospitalized patients-little in the report would suggest this is the case. The report also fails to deal adequately with the profound incapacity and dysfunction associated with psychotic states of a prolonged nature. The report’s peculiar fixation on “voices”-the primary prism through which BPS chooses to views psychosis-is actually misleading, as auditory hallucinations are neither necessary nor sufficient for diagnosing schizophrenia; nor are they the strongest determinant of functional outcome in this illness. Indeed, a recent review concluded that:

“Cognitive dysfunction is a core feature of schizophrenia. Deficits are moderate to severe across several domains, including attention, working memory, verbal learning and memory, and executive functions. These deficits pre-date the onset of frank psychosis and are stable throughout the course of the illness in most patients. Over the past decade, the focus on these deficits has increased dramatically with the recognition that they are consistently the best predictor of functional outcomes across outcome domains and patient samples.”³[italics added]

Since the BPS report takes a rather pronounced anti-medication stance, as Dr Allen Frances⁴ has noted, it is important to state that these cognitive deficits in schizophrenia are known to precede the use of antipsychotic medication.⁵

In conclusion, while the BPS report has admirable goals, and makes some valid points as regards auditory hallucinations, it badly misses the mark in comprehending the suffering and incapacity of so many of our sickest patients. And let us be clear: it is precisely such suffering and incapacity that constitute the hallmark of what physicians, for millennia, have recognized as “disease.”⁶

*The thesis that the term “disease” ought to be predicated of persons or “people” was advanced by the late psychiatrist, Dr Robert E. Kendell. Thus, for Kendell, to speak of the mind or brain as “diseased” is to misunderstand the term “disease.” Of course, the brain may have cellular pathology-but disease is a global characteristic of the living human person or other organism. [See ref. 6 for details]

References:

1. Cooke A (Editor). Understanding Psychosis and Schizophrenia. British Psychological Society. https://www.bps.org.uk/system/files/user-files/Division%20of%20Clinical%20Psychology/public/understanding_psychosis_-_final_19th_nov_2014.pdf. Accessed December 22, 2014.
2. Arieti S. Interpretation of Schizophrenia, 2nd ed. New York: Basic Books; 1974.
3. Bowie CR, Harvey PD:.Cognitive deficits and functional outcome in schizophrenia. Neuropsychiatr Dis Treat. 2006;2:531–536.
4. Frances A. Pro and Con: The British Psychological Society Report on Psychosis. Psychiatric Times. December 19, 2014. http://www.psychiatrictimes.com/blogs/couch-crisis/pro-and-con-british-psychological-society-report-psychosis. Accessed December 22, 2014.
5. Saykin AJ, Shtasel DL, Gur RE, et al. Neuropsychological deficits in neuroleptic naive patients with first-episode schizophrenia. Arch Gen Psychiatry. 1994;51:124–131.
6. Pies RW. On myths and countermyths: more on Szaszian fallacies. Arch Gen Psychiatry. 1979;36:139-144.