Out of Its Mind

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Chapter One

The Unfinished Revolution

The era of Freud and the era of deinstitutionalization are ending. The era of neurobiology has begun and promises to revolutionize our understanding of the brain and its diseases. For those of us who are interested in mental illness, it is an exciting, perplexing, chaotic time, a time of crisis that demands confrontation.

--E. Fuller Torrey,

Out of the Shadows , 1997

Clearly, psychiatry is in crisis. Nobody denies that. Psychiatrists bemoan their field's fragmented, underfinanced services. Patients and coworkers worry about numerous foreign psychiatric residents who can barely speak English. And we can all see hordes of severely disordered people being consigned to homeless shelters and to prisons, while private hospitals commonly turn away such people and mental hospitals continue to shut down.

    So the question is not whether psychiatry confronts a crisis but what can be done about it. Our purpose here is to offer a sound answer. That answer isn't obvious, because an obvious answer would already be at hand. But it's clear enough if the background is filled in. So our first task is not to make proposals but to fill in that background--by explaining how psychiatry came to lose its way.

    A good place to start is with the coming of strong and effective psychiatric medication. That's because, from the days of Sigmund Freud to the present, few events in the history of psychiatry have sparked such drastic change as the emergence of psychiatric drugs. These drugs first made medical news in the 1950s, when millions of the mentally ill were still being warehoused in asylums and when Freudian psychoanalysis was coming to hold undisputed sway at most U.S. universities, mental hospitals, private offices, and clinics. Slowly, over several decades and in combination with certain questionable social theories about how easy mental illness was to treat, the new drugs changed all that. No matter that they did not cure but merely moderated target ills, or that they had disagreeable and dangerous side effects, or that their benefits were sometimes overstated, or that only some patients responded well to them. The plain fact is, they offered hope as nothing else in psychiatry ever had. They offered a real chance for large numbers of severely afflicted mental patients to have at least a semblance of normal life. So they were embraced with a mounting medical fervor that came to shake the field of psychiatry like an earthquake, trapping the Freudians in their own theoretical constructs, splitting open and dumping out the mental hospitals, and fracturing the entire field along fault lines still visible today.

    Unfortunately, the revolution thus unleashed was never finished. The Freudians became isolated and dethroned but unrepentant, while psychiatry wavered about what besides drugs should be stuck into the yawning therapy gap the dethroned Freudians left behind. But the insurance companies and HMOs that gained authority in the 1980s and 1990s didn't waver. They simply downsized psychiatry, replacing high-paid psychiatrists with low-paid therapists and counselors, and turning those psychiatrists they continued to employ into pill-pushers who hardly spoke with patients--to a point where the best medical school graduates no longer wanted to become psychiatrists.

    Blown hither and yon by these trends, the people with severe mental ills who had been psychiatry's chief wards fared poorly. Most were unceremoniously decanted out of America's mental hospitals, mainly in the 1960s and 1970s, and the doors of most mental hospitals were closed behind them--with assurances that better care in the form of community support services would be provided. With few exceptions, however, these community services failed to materialize, leaving the bewildered multitudes to their own devices. Small wonder, then, that many of the people abandoned in this fashion wound up in nursing homes or jails; or that we now have over two million Americans with severe but untreated mental ills; or that the plight of the severely disordered homeless on our streets has become a socially indefensible disgrace.

    More broadly, far greater multitudes with lesser ills are also treated poorly. That's because most therapists cannot prescribe drugs; most drug-prescribing psychiatrists have only brief contact with their patients; and communication between therapists and physicians, who are often engaged in turf wars, is poor or absent. So all too often the process of diagnosis, therapy, and drug prescription becomes fragmented, and patients seeking well-coordinated care find it does not exist.

    Meanwhile, ironically, the drugs that provided the impetus for all this have improved. They have become more versatile, less dangerous, and better able to treat a wider range of mental ills, including schizophrenia, manic depressive illness, depression, and many anxiety disorders. Beyond that, as shall be seen, we have made enormous strides in understanding how the brain works, how our drugs operate, what causes various kinds of mental illness, and what can be done to improve both drugs and treatment.

    All of this suggests that the time has come to consolidate our gains and complete psychiatry's unfinished revolution. But old ways die hard. In World War I we had plenty of battlefield commanders yearning for horses instead of tanks, and we face a similar situation in psychiatry today. So we need to update and revive psychiatry.

    One way this should be done is with a new psychology--a psychology that will harness brain science knowledge to the task of advancing our understanding of the mind. As will be seen later, we have tried to frame such a psychology. In so doing, we have found that the "psychodynamic" psychology commonly used by psychiatrists today is useful in one way but deficient in another. It is useful because it stresses the dynamic nature of mental processes; but it is deficient in that it treats the mind or "psyche" like an independent entity not subject to scientific assessment.

    So how might we replace the term "psycho" in pyschodynamics? We could of course replace it with the word "brain." After all, we are using the term "brain science" throughout this book, rather than the more traditional "neuroscience," to refer to the study of neural processes, because scientific study of neural processes has long since passed the point where it is relegated to probing individual neurons and is now earnestly engaged in studying that vast mass of neurons we call the brain. Even so, the term "brain dynamics" seems awkward; and since the "neuro" prefix is still used freely in other terms like "neurology" and "cognitive neuroscience," we have chosen to call our new psychology "neurodynamics."

    Those aware of our devotion to brain science may suspect that neurodynamics will prove to be something of a Trojan horse--that we are really pressing for "more biomedicine" or "more drugs." They could hardly be more wrong. The truth is that psychiatry has developed something of a split personality, with some practitioners pushing pills at the behest of HMOs while others cling to outmoded forms of psychology divorced from medicine. As a result, psychiatry needs to renew itself by healing this rift, harmonizing its psychology with our growing knowledge of brain science, developing a comprehensive treatment system that will keep people with severe mental ills from being neglected, and overseeing sound treatment for others with lesser ills. This, as opposed to overzealous pursuit of impersonal biomedicine, is the right path to sound treatment.

    Anyone who doubts this fact need only recall that virtually all our psychoactive drugs are limited. They just treat symptoms. They don't cure the underlying disease. So even if the patient responds ideally, the best a drug can do is to banish or reduce the patient's symptoms. And if the patient stops taking the prescribed medicine--because of side effects, poor judgment, some personal crisis, reduced monitoring, or any other reason--the symptoms may return. Also, people vary a good deal and so do mental ills, creating a clear need to make decisions on an individual basis. As a result, the act of prescribing psychiatric drugs is not so much a science as an art: an art that needs to be interwoven with monitoring, therapy, the ups and downs of the ailment being treated, changes in the patient's situation, and various kinds of community and family support.

    Sadly, in the current era of managed care we commonly see only a parody of such enlightened treatment. For the HMOs and insurance companies have tended to assign therapy, the psychological side of patient care, to well-meaning but biologically unsophisticated psychologists and counselors. Intensifying the irony, many of these caretakers are steeped in psychodynamics or some other type of therapy divorced from medicine. So at some critical point the poor patient is apt to be shuttled back and forth between the two poles of psychiatry's split personality--from the pill-pusher's "mindless" pharmaceutical methods to the caretaker's "brainless" psychodynamic methods. Need we wonder why so many patients are lost to treatment?

    What deserves particular attention is not so much the shuttling around but the fact that vast numbers of patients fail to get the comprehensive care they need. As an example of this general problem, consider the case of someone we shall call Alice Morrisey, a businesswoman who consulted one of us (Allan Hobson) for help with a sleep problem. Her name, like those of all mental patients mentioned in this book, is fictitious. But her plight is not fictitious, and her story poignantly underlines the need for a coordinated program combining support for psychotherapy with versatile pharmacology, temporary hospitalization, and social services. Unfortunately, even for such high-functioning patients, programs of this sort are hard to find.

Alice Morrisey's sleeping difficulties began in January 1997. Prior to seeing me intermittently (a total of nine times from December 1997 through May 1998), she had acted as the caretaker for an elderly man who was in poor health and who subsequently died. During her period of employment (October 1996-February 1997) she came into conflict with the man's son, whom she accused of elder abuse and of threatening her sexually and physically. She said that during one disagreement with him he came into the room in his underwear and showed her pictures of nude young women fondling each other. She claimed this incident had triggered both anxiety and insomnia in her because it challenged her integrity as a concerned caretaker and aroused fears of physical and sexual assault. Alice was so convinced that her sleep disorder was triggered by this encounter that she had brought suit against her employer.

    She reported waking up four to seven times per night, often in a sweat, following dreams that involved intense anxiety. The dreams' content varied but included the sensation of being nibbled by animals, a feeling of being pursued, fear of dying, and terror that the world was ending. People in the dreams included her mother, the old man she was taking care of, and the man's son. She said she often awoke to find her pillow wet with tears. By her account, the resulting lack of sleep caused lapses in her concentration, frequent daytime naps, and chronic fatigue. She also reported having anxiety attacks in the daytime, with palpitations and sweating.

    Alice's sleep disorder did not respond to supportive psychotherapy or to a wide array of drugs, including Ambien, Ativan, Buspar, Depakote, Prozac, Stelazine, and Trazodone. However, when she was seeing me on a semiregular basis she seemed to be holding her own despite the sleep and anxiety disorders.

    In order to understand her current crisis and to respond sympathetically, I became familiar with Alice's past history. She was born in 1941 and was the youngest of six children. Her mother was a stalwart Irish Catholic and her father was a painting contractor. She reported that she admired her father for his music and poetry but often had to rescue him from barroom blackouts and the DTs. A bright girl, she exhibited no obvious mental ills in her early years but was prone to anxiety. This flared up when she was 18, after she was involved in a car accident at college. On that occasion she was prescribed a sedative (glutethimide), to which she became temporarily addicted. Both of her parents died in the 1970s.

    Anxiety and conflict often surfaced in Alice Morrisey's relationships with men. Her first marriage lasted seven years, her second five. A third long-term relationship that endured for eight years ended in 1984. During her first marriage she had a daughter, Vanessa, who became a state beauty queen in 1988.

    Beginning around 1990, when she was 49 and menopausal, things took a downward turn. Her daughter married a man of whom she did not approve; her previously successful travel business started to fail; a three-year relationship with a man broke up; and two of her sisters and a brother became ill and died of cancer. In November of 1992 she was treated for anxiety at a teaching hospital near her home. At that time she reported the belief (a delusion) that her sisters were not dead.

    A short time later, in the winter of 1992-1993, she began acting grandiose, stopped eating, stopped taking medication, and became frankly psychotic. This was an understandable but regrettable development that might have been prevented had she been under the continuing care of a psychiatrist. Her behavior then got so bizarre that the local police arrested her. They found her to be confused and delusional and took her to a general hospital. According to her own account she was diagnosed there as having autism and schizophrenia, was placed on the drug Haldol (an antipsychotic used mostly against schizophrenia), and was discharged. Later, at a state psychiatric hospital, the diagnosis was changed to major depression, she was switched to Prozac (used mostly against anxiety and depression), and her condition gradually improved.

    After that she worked at a series of caretaker jobs and struggled unsuccessfully to return to her once-successful travel business. Around June 1996, following a move to another town, her psychosis resurfaced. This time her grandiose behavior and delusions included the paranoid belief that her friends were working for the FBI. She was committed to another state mental hospital for a month and then discharged, being seen intermittently by a psychiatrist for about a year thereafter. From the time of her discharge until her most recent hospitalization she functioned erratically on a daily dose of 200 mg of Tegretol (carbamazepine), a drug sometimes used for mood stabilization.

    A major problem for Alice was where to turn when she was discharged from hospitals. Not having any nearby siblings who could help her, she had developed several patron caretakers. There was a group of nuns she sometimes lived with; and a couple she had provided care for who were devoted to her; and an old alcoholic college friend married to a motel owner who would let her stay in the motel and work in the front office. Not having any money for an apartment, she would bounce around from one of these marginal living situations to another. It was in this context that she took the elder care job that precipitated her current crisis and resulted in her deciding to take legal action against her employer and to consult me.

    After May 1998, when her visits to me had ended, every so often she'd have anxiety-related troubles and would phone me. I would talk to her and try to piece things together as best I could. Obviously, this was a marginal arrangement. In July of 1998 she became very disorganized and was hospitalized briefly. Then, over a year later, in the fall of 1999, she lost contact with me altogether. In December 1999, after her lawsuit had been settled out of court, she became floridly psychotic--so psychotic that there was simply no talking to her. She was admitted to a general hospital just before Christmas, and was later transferred to a state mental hospital.

Alice Morrisey has clearly been suffering from a major affective (emotional) disorder with intermittent manic-psychotic episodes. However, her case has a number of striking features. To begin with, anyone who met her in a lucid period (I never saw her when she was psychotic) would be impressed. This lady ran a flourishing business. She was smart and industrious. Also, while she had long experienced anxiety-related difficulties, probably at least since her college days, her florid symptoms emerged very late, so late that she was never psychotic before the age of 50.

    Another unusual feature was her poor response to drags. Aside from her apparently favorable experience with Prozac in 1993, most of her other responses to psychiatric medications ranged from poor to nil. I'm not clear why she was never given lithium, the principal medication used against mania, but there are a lot of drags she either couldn't or wouldn't take. That probably goes a long way toward explaining why most of the drugs she did take, coming as they did from a restricted list of choices, seem to have done her little or no good.

    Another big problem was that she had no family nearby to look after her. Because today's psychiatric care is so badly organized, parents or siblings typically pick up the pieces, seeing that the care given more or less matches what's needed, and making sure the patient doesn't reach a point where he or she becomes suicidal, assaultive, homeless, or imprisoned--the usual fate of today's mentally ill people who hit bottom.

    But Alice Morrisey had no desire to fall through the cracks, and she had jury-rigged a social support network of her own that operated after a fashion. She also had good "insight" into her illness. That is, even when psychotic she appears to have understood that she needed help. So she always let herself be hospitalized, which at least kept her from being turned out to wander in the streets. Nevertheless, while she was outwardly compliant and even ingratiating, Alice's judgment was impaired even when she was free of psychosis, pointing to the possible existence of an underlying personality disorder.

Though Alice Morrisey's situation may improve, her recent history stands as a stern indictment of today's psychiatric care. In 1992-1993 she took three trips through hospital revolving doors before being put on a drag that seemed to help. And from 1993 onward it seems clear that she needed sound and coordinated diagnosis, pharmacology, therapy, and follow-up. Time and again she got one or another of these things but not all of them together.

    If she had managed to establish a sound, long-term relationship with a physician she trusted--one who knew how to use both drags and psychological techniques, and who was part of a cohesive system able to follow up her case--she might have avoided much of her later trouble. That doesn't mean that either drags or psychotherapy could have made her mental illness go away. That's too strong a claim for someone with what are almost certainly lifelong problems. But proper care could have helped her to stay functional.

    Even quite late, when she was seeing me on a semiregular basis, she was doing pretty well. Of course, I was merely being consulted for her sleep disorder. When her money ran short, she couldn't fix her car and couldn't come to Boston. And since then, obviously, she's gone from bad to worse. It's speculative to assume that we could have countered these processes just through weekly or biweekly office visits, though I think that's fairly likely. But in any case, that didn't happen. Instead, she didn't get what she thought she needed, she didn't get what I thought she needed, and she slid down the back stairs. Her distressing case shows why it is important to get long-term help from someone who understands both drugs and therapy, and also points up the urgent need for a strong support structure backing up the psychiatrist--one that will provide patients with medical monitoring, psychotherapy, case management, community support, and follow-up.

    A prime reason why effectively coordinated services like these are not the norm is simply that people with severe mental disorders lack clout. Poverty, incoherence, disorganization, and social stigma all tend to pull them down. And since they cannot do much to stand up for themselves, lawyers, sociologists, and others with their own agendas have in the past been free to concoct high-sounding social arguments that work against them. For similar reasons, politicians, administrators, and other social leaders tend to shun them--or what is worse, tend to uncritically accept ideas like the infamous "patients' rights" argument against commitment offered up by poorly informed lawyers and social scientists. With such things going on, it is easy to see why vast multitudes of the severely ill have been neglected.

    Of course, anyone who seeks to change a situation should have a good grasp of what that situation is. So we will take time in the next chapter to describe today's mental health scene, focusing mainly on severe disorders and on people whose treatment has ranged from inadequate to nil. We will also focus on psychiatry's role in all this and will try to explain why, in the postasylum era, it has failed to protect its former charges.

    Part of the answer can be traced to psychiatry's old affair with Freudian psychoanalysis--a promising relationship that ultimately proved ill-suited to treating severe ailments. But it is unfair to simply blame the Freudians for what went wrong. So it is worth telling psychiatry's story: how it was originally tied to the state mental hospitals; how it emerged to embrace psychoanalysis: and how the future of psychoanalysis seemed so bright in the 1950s and 1960s that the best medical school graduates were attracted to psychiatry like bees to honey.

    We shall also see how the emergence of effective drugs joined up with several things--public distaste for the mental hospitals, waning confidence in psychoanalysis, and confusion about the nature of mental ills--to precipitate psychiatry's decline. We shall watch as psychiatry's pendulum swings from the brainless mind of Freud to the mindless brain of biomedicine. We shall assess the current crisis, how psychiatry operates, and rising public discontent with the way so many severely ill people are being treated. And we shall suggest that the prospects for reforming and reviving psychiatry are brighter than one might think--because the public wants sound treatment of mental ills; such treatment is now feasible if the gap between psychotherapy and biomedicine is bridged; and bridging that gap is precisely what a reformed psychiatry could do.

    Something that makes these prospects especially good is our growing knowledge of how psychiatric drugs actually work. For the antipsychotic drugs that began emerging in the 1950s (the so-called "neuroleptics") were quite specific. They did not simply "dope up" the recipient until he or she became compliant. Rather, they targeted particular diseases, or even particular groups of disease symptoms.

    Such specific effects were mysterious half a century ago, because the early neuroleptics were discovered by hit-or-miss research, and how they worked was uncertain. While not all this uncertainty has been banished, as time passed investigators came to realize that the drugs' specific effects reflected specific actions in the microscopic gaps (synapses) between nerve cells.

    Most nerve cells (neurons) depend on chemical transmitters to send messages across those synapses. A transmitter chemical, released into the gap by the sending neuron, crosses the synapse and "docks" on the other side at receptor sites designed to accept it, thereby providing communication across the gap. But some chemicals called neuromodulators do far more than this. Instead of transmitting momentary signals, they alter the receiving neuron's receptivity to further signals, thereby modulating that neuron's pattern of activity. What the neuroleptic drugs were doing was blocking some of the "docks" available to receive a particular neuromodulator called dopamine. The net effect was to tone down certain brain activities, including activities causing various psychotic symptoms.

    This model is worth noting, because most psychiatric drugs act similarly. That is, most of them promote or hinder passage of certain neuromodulators between neurons. This can be done various ways. It can be done by stepping up or reducing the amount of neuromodulator released into the synapse, or by changing the rate at which that chemical is broken down or removed from the synapse, or by blocking or otherwise changing the receptivity of docking sites on the receptor neuron.

    This last method--altering or blocking docking sites--seems especially promising for drug development right now because there are many different kinds of docking sites. Indeed, there seem to be five or more different sorts of docking sites per neuromodulator for most of the brain's many neuromodulators, with each type of docking site tending to be distributed differently within the brain. A particular psychiatric drug, such as Thorazine (chlorpromazine), tends to act at one or more specific docking sites while ignoring other sites, and that makes its effects differ from those of other drugs. What's even more encouraging is that many of the newer drugs alter multiple docking sites for several neuromodulators in varying degrees. So in theory, if we can learn enough about the brain, there is good reason to suspect we might develop an array of versatile drugs to offset mental disorders by influencing one or more selected docking sites in particular regions of the brain, much as a piano tuner can offset disorders of that instrument by tuning certain well-selected strings.

(Continues...)

Copyright © 2001 J. Allan Hobson and Jonathan A. Leonard. All rights reserved.